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4
Surgical Audit
Types
Audit cycle
What to audit?
SU7.1: Describe the planning and conduct of surgical audit.
INTRODUCTION
Surgical audit can be defined as the systematic unbiased
review of surgical practice with the objective of
recognizing deficiencies and improving standards of
care. It involves critical analysis by peers and any lapses
or deficiencies detected during the course of the
treatment of the patient are listed. An audit should aim
at improving the standards laid down in the respective
departments. It should also aim at studying morbidity
and mortality. An audit is helpful in studying not only
the quality of services provided by the department but
is also useful to the individual surgeon to k
his/her own personal outcome data. Contributing to a
clinical database ensures that a surgeon’s own
performance is monitored continuously. It should be
compared to national data to ensure the accepted
standards are achieved.
Example 1: National database of laparoscopic
cholecystectomy shows that in about 3–4% of cases,
laparoscopic surgery needs to be converted to open
surgery. However, if a surgeon’s own data records show
more than 10% conversion rate, he needs to audit and
find out the reason behind this high failure rate. Thus,
an audit helps improve treatment policies, standard of
care and may be more economical.
Example 2: A hospital may have set certain standards
for thyroidectomy such as “identification of the recurrent
laryngeal nerve (RLN) should be done in all cases and
eep track of
What makes a good audit topic?
What is not an audit?
Steps of audit
that is the best method to avoid injuries to this nerve”.
Audit of recurrent laryngeal nerve paralysis after total
thyroidectomy would include a careful check of the
operative notes to see how many surgeons identified
the RLN at surgery and how many did not.
TYPES
Essentially, two types of audit may be encountered:
National audits and local/hospital audits. Both are
designed to improve the quality of care. National audits
should be driven by needs identified during the local
and hospital-based audits that are closest to the patient.
Recently an audit of treatment given to COVID-19
patients was done to check whether all the guidelines
given by the government were followed. Topics for
hospital-based audits are often identified at the departmental morbidity and mortality meetings, where issues
related to patient care are discussed. Tuberculosis is a
notifiable disease and it is a national issue. So, hospitals
can audit these types of cases. After report from the local
hospitals, a national audit can be designed to be completed by the local audit department and surgical teams.
Audit can also be categorised and used to study
different aspects of patient care. For example, an audit
of smoking behaviours of patients can be categorised
into: (a) Structure of care: Refers to the resources required,
e.g. the availability of a smoking cessation clinic in a
locality. (b) Process of care: Refers to the actions and
decisions taken by practitioners together with users, e.g.
waiting times for an appointment at the smoking
cessation clinic. (c) Outcome of care:
or behaviour response to an intervention, e.g. the
number of smokers who quit smoking for 1 year.
14
Measures the physical
Surgical Audit
15
AUDIT CYCLE
Important steps of audit cycle (audit process) are as
follows:
1. Define the audit question in a multidisciplinary team.
2. Identify the evidence and current standards or guidelines.
3. Design the audit to measure performance against
agreed standards based on strong evidence. One
needs to seek advice and ensure that institutions have
agreed to undertake the audit.
4. Define an agreeable timeline.
5. Conduct the audit.
6. Analyse results and compare performance against
agreed standards.
7. Undertake gap analysis:
a. If all standards are reached, reaudit after an agreed
interval.
b. If there is a need for improvement, identify possible
interventions such as training and agree with the
involved parties.
c. Implement the changes.
8. Allow sufficient time for changes to be included in
the new guidelines.
9. Reaudit, analyse and discuss whether the practice has
improved.
WHAT TO AUDIT?
Surgeons can decide about the topics based on the need/
requirement. It is a good idea to find out the common
surgical procedures done in the hospital and select a
topic related to the procedures. Some examples are
given below.
• Simple questions with straightforward outcomes:
Example: Did all patients receive antibiotic prophylaxis
prior to surgical incision?
• Simple measurements and interventions: Are all
patients appropriately assessed for possibility of deep
vein thrombosis (DVT) risks and received appropriate
prophylaxis during their hospital stay? How many
lymph nodes are removed after modified radical
mastectomy performed for carcinoma breast or
hemicolectomy for carcinoma colon.
• Audit anything that you are not certain about: Fluid
requirements in acute pancreatitis or non-operative
management of splenic injuries, etc.
WHAT MAKES A GOOD AUDIT TOPIC?
• Priorities in your hospital/department: For example:
Diabetic ulcer on the leg is common not only in our
hospital but also in India and it is a relevant topic.
• A topic in an area of medicine that interests you and
you may choose the topic.
• Re-audits of previous projects: If there is a previous
audit that was never re-audited and the loop was not
closed, then this is a good audit.
WHAT IS NOT AN AUDIT?
1. Comparison of treatment or interventions: Example:
Comparing antibiotics followed by drainage versus
antibiotics without drainage for breast abscess.
Outcomes of novel treatment: Example: Results of
2.
endoscopic cystogastrostomy.
3. Outcomes of novel service: Example: Role of CECT
scan in nutrition.
4. Pure research or service evaluation: Example: Finding
a new technique for hernia repair.
5. Census work
All these are considered original research work and
not an audit.
STEPS OF AUDIT
The audit process is divided into five official steps and
the cycle is only considered complete if all steps are
performed. The five steps of audit cycle are as follows:
Step 1: Define the standard to be reviewed—American
College or Royal College guidelines, or in sepsis—
Surviving Sepsis Campaign 2021 guidelines, etc. It is
important to consider local policies also.
Step 2: Decide what data to be collected? Who will
be collecting the data and is it retrospective or
prospective?
Step 3: Compare standard current practice with the
actual performance data collected from the department.
Evaluate how well the standards were met and if not,
identify reasons for this.
Step 4: Recommend a change, if required, agree to the
changes and then implement. Example: After an audit
from the hospital, it is found that when clindamycin
was used, ulcers healed faster in diabetic patients.
Step 5: Close the audit cycle loop—once the suggested
change is implemented, one cycle of audit is closed.
Section I • Basic Principles of Surgery
5
Principles and Steps of
Clinical Research in General Surgery
Principles of clinical research
Steps of clinical research
SU7.2: Describe the principles and steps of clinical research in
general surgery.
INTRODUCTION
The dictionary defines research as “the systematic
investigation into and study of materials and sources
in order to establish facts and reach new conclusions”.
The keywords in this definition are: (1) ‘Systematic
investigation’ meaning an orderly and methodical
investigation; (2) ‘Establish facts’ meaning that you are
collecting new data,
ing that you are adding to the already existing knowledge.
Clinical research is research in the field of health
sciences particularly clinical sciences. The National
Cancer Institute defines clinical research as follows:
“Research in which people, or data or samples of tissue
from people, are studied to understand health and
disease. Clinical research helps find new and better ways
to detect, diagnose, treat, and prevent disease. Types of
clinical research include clinical trials, which test new
treatments for a disease, and natural history studies,
which collect health information to understand how a
disease develops and progresses over time”.
We live in the era of evidenced-based surgery. Society
at large expects us to practice scientific surgery. As long
ago as 1853, Ruskin described the concept of science as
follows: “The work of science is to substitute facts for
appearances and demonstrations for impressions”. Any
field, including surgery, can claim to be scientific only
when the body of its knowledge is backed by reliable
and honest data that is collected and analysed in good
research studies. Thus it is essential that practicing
clinicians understand the principles that underlie
and (3) ‘Reach new conclusions’ mean-
Secondary research
scientific studies and comprehend the methodology
used in research projects. Further, understanding and
undertaking research projects bring with it several
advantages to the practicing clinician. These include
(1) gaining the respect of his/her fellow clinicians,
(2) better recognition in society, and (3) getting better
respect and compliance from his/her patients. Also,
various organisations are making it mandatory for its
members to have research publications before they can
progress in their careers.
PRINCIPLES OF CLINICAL RESEARCH
Clinical research is governed by several important
principles. Some of these principles are highlighted
hereunder.
1. Ethical conduct: The utmost importance must be given
to ethical conduct in carrying out clinical research. The
researcher must exercise total honesty and integrity.
The significant qualities of an ethical researcher was
laid out by Salter and has been listed in Key Box 5.1
The researcher must always have in mind the
physical and emotional comfort of the subject of
clinical research. The ethical principle of “do no
harm” must be the primary principle while undertaking research.
Key Box 5.1
Qualities of a Good Researcher (after Salter)
Integrity Inquisitive
Intelligence Innovative
Ingenuity Industrious
Initiative Incisive
16
Principles and Steps of Clinical Research in General Surgery
17
2. Usefulness to society: Clinical research must address
common clinical problems. It should try and answer
the controversies or difficult questions that a clinician
faces in everyday practice. It would be incorrect to
undertake research only for the sake of research and
publishing papers.
3. Propriety: The researcher must always show pro-
priety in whatever he/she does. This takes several
forms including financial regularity, communication
with his colleagues and his subjects, proper maintenance of records and transparency in sharing data
with others.
4. Address biases: The researcher must be careful to
make sure that biases or prejudices do not compromise the conclusions that are drawn from the data.
Several kinds of biases exist. The important ones are:
(1) Selection bias where the subjects in each of the
study groups are chosen in such a manner that the
results may be skewed; (2) Observer bias where the
person tabulating the end result may skew the results
deliberately or even unwittingly; and (3) Confounding
factor/s where an intervention or a condition other
than the one being studied may influence the outcome.
This essentially means that the researcher starts by
saying that the intervention proposed does not have an
influence on the outcome. If the data proves otherwise,
then a conclusion is drawn that the intervention is
indeed helpful. Continuing the above example, the null
hypothesis would be that the use of a drain would not
be useful after cholecystectomy.
Step 3. Draw up a protocol. A protocol is a detailed
document that describes several aspects of the study
including the aim of the study with the research
question, the methods that are being used to answer
this question and all the administrative issues that go
with the study. The protocol is required to make sure
that the researcher and his colleagues know exactly
what is to be done. The steps described in the protocol
are never violated. The important components of a
protocol are listed below:
Title that adequately describes the study and
3a. A
does enough to arouse the curiosity of the reader.
3b. Summary of the project. This is required to be
submitted for various approvals that are required
before the study is undertaken.
STEPS OF CLINICAL RESEARCH
Clinical research is undertaken in a systematic manner
involving several steps. These steps are summarised in
Fig. 5.1.
Step 1. Recognise a clinical problem and carry out a
literature search to understand what is known thus far
about the subject. Once this is determined, one can go
about asking a research question. An example of a
common clinical question would be whether a drain has
to be used after a cholecystectomy or not.
Step 2. Asking the correct research question and putting
forth a sensible hypothesis is an important step in
research. One talks of the ‘null hypothesis’ in research.
Fig. 5.1: Basic steps in clinical research
3c. Rationale of the study which describes the logic
behind undertaking the study, leading up to why a
particular research question had to be asked.
3d. Objectives of the study—lay down the research
questions in detail and explain the outcomes that are
going to be measured to get answers.
3e. Methods section of the protocol is the most
important part that describes in detail what is going
to be done. This has several subsections as under:
3e1. Subjects involved: Describes the characteristics
of the group of patients who are going to be studied
3e2. Sample size: Explains the number of patients
in the groups being studied. The sample size is
important to determine the ‘power’ of the study
and whether the conclusions of the study can be
applied to all the patients at large, or not.
3e3. Study design: Study design is the pre-eminent
component of a research project. A detailed
explanation of the various kinds of studies is
outside the purview of this chapter. Only the very
basic principles involved will be explained.
Choosing the appropriate study design for a given
research question is important. The value of the
research project and the conclusions drawn therefrom depend on the choice of a proper study
design.
Anecdotal experiences reported as case reports or
small numbers of patients (series) are of limited
Section I • Basic Principles of Surgery
18
Manipal Manual of Surgery
value because the information from these studies
cannot be realistically extrapolated to a population
in general.
Retrospective studies collect data from patients
who have already been treated or operated on.
These studies are not as valuable as prospective
studies because the methodology used is not
standardized, there may be several data points that
may be missing, and the interventions may vary
from one patient to another.
Prospective studies are a lot more reliable because
the methods employed, the interventions undertaken, the tests done and the collection of data are
all well controlled. The researcher can implement
further safeguards against biases in the form of
randomisation and blinding. Randomisation is a
process where the researcher has no role in
assigning the patients to the various study groups.
The allocation is generally done through computer
generated numbers. This process eliminates selection bias. Blinding is a process where the observer
who measures the outcomes of the study is not
aware of the intervention that has been undertaken
in the study subject. Blinding eliminates observer
bias.
The randomised controlled trial (RCT) is perhaps
the highest form of unbiased scientific study.
Conclusions drawn from an RCT are rated to have
the highest scientific value. However, it is not easy
to conduct an RCT with sufficient numbers of
patients particularly in surgical disciplines.
3e4. Interventions involve a detailed description of
the tests and procedures that are going to be
undertaken on the patients. These may be
biochemical or radiological tests. It also includes
interventions in the form of administration of the
study drug or an operative procedure. In the
example taken, one may consider measuring pain
through regular Visual Analogue Scale (VAS)
scores, get a chest X-ray to rule out atelectasis and
an abdominal ultrasound to detect collections.
3e5. Outcome measurements describe the endpoints
that are going to be measured in the study.
Defining the endpoints and determining the
correct metrics to measure them form an important part of the protocol. In the cholecystectomy
example, one can consider postoperative pain,
incidence of subhepatic collections, length of stay
in hospital, postoperative infection, incidence of
atelectasis as possible and points of the study.
Step 4. Obtain the necessary permissions from the
regulatory authorities/bodies. Armed with the protocol,
the researchers start with getting clearance from the
head of the unit/the head of the department and the
medical administrator. The protocol will then be
scrutinized by the scientific and ethical committees of
the institution. Once cleared by these committees, the
study has to be registered with an authority like the
Clinical Trial Registry of India.
Step 5. Conduct the study with honesty and diligence
and collect data.
Step 6. Analyse the data using the previously decided
set of statistical methods.
Step 7. Draw conclusions based on the analysis of the
data collected.
Step 8. Share the results and conclusions of the study
either in the form of a presentation read at a conference
or paper published in a good journal. It is quite possible
that the results of this study are so significant that one
might have to change ones’ clinical practice based on
the study. In the example given above, many studies
have shown that using a drain after a routine
cholecystectomy is actually not required at all.
SECONDARY RESEARCH
The processes described so far are considered to be
primary research. There is another form of research
called secondary research. Examples of secondary
research include systematic reviews, meta-analysis and
clinical guidelines. In secondary research, data from
several studies of primary research are collated and
conclusions are drawn to help clinicians carry out high
quality evidence-based practice.
Section I • Basic Principles of Surgery
6
Perioperative Care
Preoperative care
– Elective surgery
– Emergency surgery
SU1.3: Describe basic concepts of perioperative care.
The perioperative period is a term used to describe the
three distinct phases of any surgical procedure, which
include the preoperative phase, the intraoperative
phase, and the postoperative phase.
PREOPERATIVE CARE
Every patient presenting for surgery must be optimally
prepared before surgery to ensure best possible outcome
of surgery. Optimisation is done based on the urgency
of surgery, nature of the disease and presence of other
comorbidities.
Elective Surgery
There is sufficient time available for evaluation and
preparation of patients presenting for elective surgery.
Preoperative evaluation will consist of detailed history,
physical examination and investigations based on the
findings. There is no ‘routine’ investigation. All investigations must be tailored to the patient and the surgery. A
patient with no other comorbidity and minimum change
in his homeostasis may require no further preparation,
whereas some will require considerable preparation.
Examples:
• A patient may have pre-existing conditions unrelated
to surgery such as asthma, chronic obstructive
pulmonary disease, hypertension or diabetes. They
must be thoroughly evaluated and their condition
optimized prior to surgery.
stopped at least 4 weeks before surgery. Patients with
respiratory conditions and those presenting for major
Smoking should be
Intraoperative care
Postoperative care
thoracic or abdominal surgery may be advised
incentive spirometry and respiratory exercises to
improve their breathing ability.
• A patient with thyrotoxicosis must be made euthyroid
before thyroidectomy, a patient with phaeochromocytoma must have the hypertension well under
control before surgery.
• Nutrition: Nutritional support may be considered for
patients who are severely malnourished. Examples
may be carcinoma esophagus, achalasia cardia or a
few cases of intestinal fistulae. These patients should
receive seven or more days of enteral or parenteral
nutrition prior to surgery. Enteral nutrition has a
number of advantages such as preservation of gut
mucosa, decreased leakage of gut bacterial antigens,
reduction of inflammation, maintenance of immune
function and decreased hyperglycemia. Healing after
surgery is improved with better nutrition.
• Patients with coagulopathies or bleeding disorders may
be at increased risk for bleeding. They may require perioperative transfusion of blood products. Anti-platelet
drugs should be stopped 7 days before the procedure
unless they need to be continued. Low dose aspirin,
however, is usually continued. Refer to Key Box 6.1.
Key Box 6.1
Elective Surgery
1. Optimise pre-existing conditions: Control of diabetes,
hypertension, bronchial asthma
2. Functional status to be normal while operating on
thyroid and adrenals
3. Nutritional support
4. Tailor investigations to the patient’s condition and surgery
19
20
Manipal Manual of Surgery
Emergency Surgery
These surgeries can be broadly classified further into
surgeries for trauma and non-trauma.
• Urgent surgery: There is usually some time available
for optimization of these patients, say a few hours,
before surgery. For example, acute appendicitis,
intestinal obstruction, obstructed hernia, blunt
abdominal trauma. This time is utilized to treat them
with intravenous fluids to optimize blood volume,
correct electrolyte imbalance, administer antibiotics,
bronchodilators if asthmatic and to obtain investigations done such as echocardiogram. Most of abdominal
emergency cases need to have a nasogastric tube
inserted and urinary bladder catheterized
.
• Emergency surgery: Occasionally, some surgeries are
absolutely emergent and no time should be wasted
to optimize these patients. In these patients, evaluation, resuscitation, surgery and optimization happen
simultaneously. Examples: Life-threatening conditions
such as a patient with uncontrolled bleeding after
polytrauma, limb-threatening conditions such as
vascular injury.
Patient Preparation (Key Box 6.2)
Preoperative care also includes preparing the part for
surgery, marking the site and side and obtaining
informed consent (Follow WHO checklist). Consent
is taken after explaining to the patient, the nature of
surgery, anticipated outcome, possible complications
and postoperative course, possible need of postoperative intensive care and even mortality (as applicable
in those cases) in his own language. A witness to the
process of obtaining consent must also sign on this
document along with the patient and the surgeon.
• In addition, the patient must be referred to the
anaesthetist (pre-anaesthesia checkup) who will once
again evaluate the patient from his/her perspective,
obtain additional investigations as necessary and take
informed consent.
• All patients are kept fasting for solids and milk for at
least 6 hours and to clear fluids for at least two hours
prior to surgery. This is done to minimize the risk of
Key Box 6.2
Preparation of the Patient
1. Informed consent and signature
2. Clipping of the hair just before surgery
3. Mark the site—especially small lumps in the breast,
hernias, benign lumps
4. Nil per oral 6 hours for solids, and 2 hours for liquids
5. Follow anaesthesia orders. Give drugs prescribed by
Section I • Basic Principles of Surgery
anaesthetist
vomiting and pulmonary aspiration of regurgitated
gastric contents during anesthesia which can lead to
aspiration pneumonia.
• Instructions regarding premedication, investigations
(as required on the morning of surgery) and other
regular medications as prescribed by the anaesthetist
must be followed (Refer to Chapter 64 on
Anaesthesia
for further details).
INTRAOPERATIVE CARE (Fig. 6.1)
The intraoperative period is the most stressful part of
surgery and is the combined responsibility of the surgeon,
the anesthetist, nurses and the entire surgical team.
• On the day of surgery, the patient is wheeled into
the operation theatre, where his identity, surgery, site
and side, availability of blood products (as necessary),
fasting status and consent are once again checked
before beginning anesthesia. Antibiotics are given
within 30 minutes to an hour before commencement
of surgery.
• Once anaesthesia has been given, the anaesthetist
monitors the vitals of the patient while the surgeon
concentrates on the surgery. The maintenance of
depth of anaesthesia, administration of intravenous
fluids, blood products, analgesics, and maintenance
of physiology of the patient is the responsibility of
the anaesthetist.
• The surgeon undertakes the surgery with aseptic pre-
cautions, with an effort to minimize blood loss, tissue
damage and in a reasonable period of time. Once
surgery is done, the incision is closed after careful
count of the gauzes and instruments (done by the
nurse) so that nothing is left behind unintentionally
inside the patient’s body.
• Upon completion of surgery and emergence from
anaesthesia, the patient is shifted to the postanesthetic
care unit for further observation. The patient can then
be shifted to the ward after fulfilling discharge criteria
(hemodynamically stable with adequate oxygenation,
fully conscious, is able to void if not catheterized and
is pain free). The patients are shifted to high dependency units, if they have undergone major surgery
but are stable postoperatively. If the patient needs
postoperative mechanical ventilation or is hemodynamically unstable, then he is shifted to the
intensive care unit for further management.
POSTOPERATIVE CARE (Fig. 6.2)
Upon arrival in the recovery area, the surgeon and the
anaesthetist explain to the recovery nurse in charge of
the patient about the surgery, intraoperative events and
instructions for postoperative care (Key Box 6.3).
give
Perioperative Care
Fig. 6.1: Intraoperative care with monitoring vitals
Fig. 6.2: Postoperative care with monitoring of vitals
Key Box 6.3
Postoperative Care
1. Vitals: Airway, breathing, circulation and disposition
2. Analgesia
3. Fluid and electrolyte balance: Intake/output chart
4. Thromboprophylaxis—mobilisation of legs
5. Nutrition
6. Antibiotics
• ABCD: Monitoring and restoration to normal physio-
logy and function of organs [(A—airway, B— breathing,
C—circulation and D—disposition (consciousness)].
The patients are monitored closely and appropriate
management done till their vitals are normal.
21
• Pain relief: Adequate analgesia is important in the
postoperative period. This may include intravenous
paracetamol, opioids, nonsteroidal anti-inflammatory
drugs or regional analgesia depending on the nature
of the pain and severity.
• Fluid and electrolyte balance: The patients are
monitored closely postoperatively to ensure their
fluid and electrolyte status is normal. An intakeoutput chart is maintained for all patients who
have undergone major surgery. Their fluid input
(including blood products) is matched with output
(urine, blood loss and any other excessive secretions).
In the early postoperative period, one must remember that antidiuretic hormone (ADH) is released
which results in conserving of water. Aldosterone
secretion increases leading to reabsorption of sodium
and potassium secretion.
• Bowel movements: Patients who undergo laparo-
tomy have paralytic ileus, so it is common not to have
bowel movement for 2 to 3 days.
Once bowel sounds
are heard, the patient is given sips of water followed
by soft diet.
• Leg movements, both passive and active are done,
to minimize thromboembolic complications. They are
also prescribed thromboprophylaxis depending upon
the nature of the surgery.
• Nutrition: Patients who undergo gastrectomy, eso-
phageal surgeries and surgeries on intestines, may
require parenteral nutrition for a few days. Enteral
nutrition is resumed as early as possible.
• Preventing infection: In all contaminated and dirty
cases, antibiotics have to be continued for a period of
5 to 7 days. In cases of sepsis and septic shock, they
have to be continued for 14 days.
• Once the patients are stable, they are discharged
home with instructions for home care and follow-up.
Section I • Basic Principles of Surgery
7
Pain Management
The pain pathway
Assessment of pain
Routes of administration of analgesia
SU11.5: Describe principles of providing postoperative
pain relief and management of chronic pain.
INTRODUCTION
Pain is a sensation of discomfort associated with injury.
It can be acute or chronic. Acute pain (nociception) is
associated with tissue damage and an inflammatory
response, it is self-limiting and of short duration. Often
it does not involve neural tissue. Chronic pain, however,
persists long after the tissue damage is treated. Chronic
pain, on the other hand, is the pain which persists even
after 3 months of surgical illness. In surgical patients, it
can be due to postoperative pain, malignancies or
diseases such as chronic pancreatitis.
PRINCIPLES OF PROVIDING POSTOPERATIVE PAIN RELIEF
One of the main fears patients have about surgery is
the postoperative pain and it is only humane that this
is relieved. In addition, pain has adverse effects on
various systems of the body such as tachycardia,
hypertension, arrhythmias and rarely even myocardial
ischaemia and infarction. The patients may not breathe
properly leading to retained secretions because of
inadequate cough, atelectasis, pneumonia and respiratory failure. The hypertension can precipitate bleeding,
e.g. after thyroidectomy.
Pain relief can be given in many ways but it must be
tailored to the patient since pain medications have
adverse effects and hence, safety must be ensured at
all times. The pain prescription must contain clear
instructions regarding the name of the drug, dose, route,
Adverse effects of analgesic medication
Chronic pain
Adjuncts
frequency, monitoring required, treatment for known
side effects such as for nausea and vomiting and when
to call the duty doctor.
THE PAIN PATHWAY
Postoperative pain varies with the patient’s tolerance
to pain, type of surgery, anaesthetic and the site, and
extent of incisions given. The pain may be somatic,
visceral or both. It is important to understand how pain
is transmitted and appreciated by the body to treat it
effectively (Fig. 7.1).
Pain is produced in the injured tissue due to the
release of prostaglandins, serotonin, substance P and
acetylcholine which stimulate the peripheral nociceptors
(transduction). These stimulate the peripheral nerve
supplying the area and the impulses are transmitted
through it to the dorsal horn of the spinal cord
(transmission). These impulses then travel through the
ascending tracts to the thalamus (transmission) and the
sensory cortex where the pain is perceived (perception).
The perception of pain can be inhibited by stimulating
the descending inhibitory pathway and release of
inhibitory neurotransmitters such as GABA, glycine,
opioid peptides and norepinephrine (modulation).
Generally, acute postsurgical pain can be controlled by
addressing each component of this pain pathway and
hence it is called multimodal approach to pain control.
Transduction is reduced by local anaesthetic
infiltration (e.g. bupivacaine) and the use of nonsteroidal
anti-inflammatory drugs (Key Box 7.1). Transmission
through peripheral nerves can be blocked by nerve
blocks (transverse abdominis pain block for abdominal
surgery). Transmission through the spinal cord to
22
Pain Management
23
Fig. 7.1: Pain pathway, mechanisms of pain and medications that can be given to block each of these components
Key Box 7.1
Pain Mechanisms and Medications
Mechanism Medications
Transduction Local anaesthetic infiltration, NSAIDs
Transmission Local anaesthetics (nerve blocks,
epidural)
Perception Opioids, alpha2 agonists
Modulation Opioids, alpha2 agonists, NMDA
receptor antagonists
pain and 10 represents the most severe pain they can
imagine (Fig. 7.2). The patient can then be followed
up using the same scale to gauge whether severity of
Fig. 7.2: Numerical rating scale
the pain has changed or whether the analgesia
ascending pathways can be inhibited using epidural
analgesia. Opioids (morphine, fentanyl, tramadol,
nalbuphine) reduce perception. They also have a modulating effect on pain perception through their effects on
the µ receptors in the brain as well as spinal cord.
provided is sufficient. Pain score <3 is acceptable.
NRS of 10: Very severe pain: Ureteric colic, mesenteric
ischaemia or dissecting aneurysms, etc.
NRS 4–6: Moderate pain, e.g. acute cholecystitis or
appendicitis
NRS 2–3: Dull aching pain, e.g. hepatomegaly or
ASSESSMENT OF PAIN
• Pain is totally a subjective phenomenon. The patient
knows by his experience about nature of the pain and
other related features. Example: Any severe pain in
the abdomen results in vomiting. Thus, one can
deduce that the pain is severe. Each person may
respond differently to the pain. When a patient says
he has pain, he probably has pain and must be
believed. He can simply rate it as none, mild,
moderate or severe.
• Numerical rating score (NRS): In this, whenever the
patient has pain, he can be asked to rate the pain on
a scale numbering from 0 to 10, where 0 means no
splenomegaly
• Visual analogue scale (VAS): In this, the patient is
shown a 10 cm long scale, where one end represents
no pain and the other end (10 cm) represents very
severe pain (Fig. 7.3). However, unlike the NRS, the
patient is not shown any number in between and the
patient slides a rider across the scale to point out the
level of his pain. The numbers are present on a
continuous scale on the side facing the investigator
and can be in fractions also.
• Wong-Baker FACES scale: This scale consists of a
series of faces, where one end has a happy face
representing no pain and the other end, a face
Section I • Basic Principles of Surgery