Preoperative patient evaluation and planning is integral to perioperative pain management. Proactive individualized planning is an anticipatory strategy for postoperative analgesia that integrates pain management into the perioperative care of patients. Patient factors to consider in formulating a plan include type of surgery, expected severity of postoperative pain, underlying medical conditions (e.g., presence of respiratory or cardiac disease, allergies), the risk-benefit ratio for the available techniques, and a patient’s preferences or previous experience with pain. A preoperative directed pain history, a directed physical examination, or consultations with other healthcare providers, should be included in the anesthetic preoperative evaluation. ASA section II Preoperative evaluation of the patient.

Psychological aspects of acute pain

Pain is an individual, multifactorial experience influenced, among other things, by culture, previous pain experience, belief, mood and ability to cope. Pain may be an indicator of tissue damage but may also be experienced in the absence of an identifiable cause.

Psychological factors that influence the experience of pain include the processes of attention, other cognitive processes (eg memory/learning, thought processing, beliefs, mood), behavioural responses, and interactions with the person’s environment.

The degree to which pain may interrupt attention depends on factors such as intensity, novelty, unpredictability, degree of awareness of bodily information, threat value of pain, catastrophic thinking, presence of emotional arousal, environmental demands (such as task difficulty), and emotional significance.

Preoperative anxiety has been shown to be associated with higher pain intensities in the first hour after a variety of different operations; anxiety and moderate to severe postoperative pain are, in turn, predictors of postoperative anxiety. ANZCA, chapter 1, section 1.2

General patient information and advice

Regardless of the type of surgical procedure, pre-operative discussions between the patient and their anaesthesiologist and surgeon should cover specific topics to ensure that the patient knows what to expect and what is expected of them. It is important to involve the patient in optimising their general medical condition as many patients undergoing surgery have significant co-morbidity. In advance of admission to hospital, the patient should visit their primary care physician or be referred to the appropriate hospital specialist – to stabilise their treatment for other medical conditions and to optimise their analgesic medication prior to surgery. Educational resources, such as www.youranaesthetic.info, can inform patients about their forthcoming anaesthetic procedure and provide specific advice about the different anaesthetic and pain relief techniques for surgery. PROSPECT: patient advice and assessment

Program on Postoperative Pain Management

Postoperative pain management depends on the type of anaesthetic technique employed.

For postoperative management to be successful, the following points should be addressed:

• plan for either inpatient or ambulatory surgery.
• information and training in the use of pain assessment tools after surgery, for example, visual analogue scores.
• a realistic expectation of the intensity and duration of postoperative pain.
• demonstration and training in pain management techniques that require patient involvement (e.g. intravenous patient-controlled analgesia, patient-controlled epidural analgesia).
• information about the medication to be used after hospital discharge for management of pain and postoperative nausea. PROSPECT: patient advice and assessment

Summary

As part of the pre-operative evaluation, patients should be informed about a pain control plan and have realistic expectations of the intensity and duration of postoperative pain they will experience.

Supplementary reading

1. Long LS, Shapiro WA, Leung JM. A brief review of practical preoperative cognitive screening tools. Can J Anaesth. 2012 Aug;59(8):798-804.