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Dressings 107
instruments (Bak2018). The SFA will be well versed on strategies to reduce the risk of
wound contamination, including their own surgical handwash and patient skin prep-
aration including, pre- operative shaving and antiseptic skin cleansing. An SSI is con-
firmed in the presence of a ‘surgical wound with local signs and symptoms of infection,
for example, heat, redness, pain and swelling, and (in more serious cases) with
systemic signs of fever or a raised white blood cell count’ (NICE2020).
An SSI can delay healing and cause wound dehiscence. Antibiotics are the choice
of treatment for bacterial wound infections.
Pain
It is common in the early stages after surgery for the patient to experience localised
pain which, dependent upon the procedure, gradually reduces over several days. If
the patient continues to report localised pain after this time, or the pain worsens, then
this could indicate complications such as an SSI (Bak2018). See Chapter10 for more
information on pain management after surgery.
DRESSINGS
As stated above, the surgeon will select the dressing, however, the SFA must have an
awareness of the aim of dressings and the different types that are available. The ideal
wound dressing should have certain characteristics to assist wound healing (Britto
etal.2023): a dressing must maintain some moisture at the wound site but act as a
barrier against fluid or bacterial contamination. It may also be required to remove
excess exudate that might otherwise lead to wound maceration. It should adhere to
the skin but be able to be removed with minimal trauma and should be readily avail-
able and cost- effective.
There are a variety of dressings with differing properties and the SFA requires an
understanding of the aim of each type of dressings to ensure the correct type is being
applied. The properties of some common dressings are detailed here.
Self- Adhesive Absorbent Dressings
This type of sterile dressing, such as Mepore™, Melolin™, or Opsite Post- Op™, pro-
vides a low adhesive for fixation and easy removal of the dressing. It is flexible which
makes it comfortable for the patient. It will absorb a small amount of blood and other
exudate and is also water repellent. Self- adhesive dressings come in a range of sizes
that allow coverage and protection from contamination and are one of the most used
dressings to cover primary closed surgical wounds.
Soft Paraffin Gauze
Paraffin gauze, for example, Jelonet™, comes in sterile sheets and can easily be cut to
the desired shape of the wound without fraying. Its aim is to maintain a moist wound
108 Chapter 9 Wound Management
bed to aid healing and is only suitable for light to moderately exuding wounds as the
paraffin prevents absorbency (BNF2024). Paraffin gauze is a low- adherent dressing
and is, therefore, ideal for use on skin graft sites, lacerations and burns.
Alginates
Alginates consist of fibres derived from brown seaweed and come in a variety of sizes
and shapes including ribbons for packing wounds (e.g. Sorbsan™) and sheets for
laying on top of a wound (e.g. Kaltostat™). Alginates form a soft gel in contact with
wound exudate and can act as a haemostat; however, blood clots can cause this
dressing to adhere to the wound surface (BNF2024). A secondary dressing is needed
to ensure the alginate remains in place.
Negative Pressure Wound Therapy
Negative Pressure Wound Therapy, such as PICO™, applies sub- atmospheric pressure
to reduce inflammatory exudate and promote granulation tissue and is used on sur-
gical wounds where primary closure cannot be achieved due to active infection, skin
tension or oedema (Thompson and Marks2007).
Alternative pressure dressings, such as a wool pad or crepe bandage, may be
applied at the end of surgery to assist with haemostasis or eliminate any dead space to
prevent the formation of seroma or a haematoma (Bak2018).
CONCLUSION
The SFA may be expected to apply dressings after surgery and should therefore
ensure they work within their scope of practice when delegated this responsibility
following local and national wound management guidance. The SFA should be
aware of risk factors that can impact wound healing and be vigilant when assisting
with haemostasis and application of dressings. The SFA requires an understanding
of the dressings they may be asked to apply and an awareness of specialist services
in complex wound management.
REFERENCES
Bak, J.R. (2018). Wound healing, dressings, and drains. In: Alexanders Care of the Patient
in Surgery, 13e (ed. J. Rothrock). Missouri: Elsevier Saunders.
Baker, C.R., Reese, G., and Teo, J.T.H. (2010). Rapid Surgery. Chitester: Wiley.
Baranoski, S., Ayello, E.A., Niezgoda, J.A., and Langemo, D.K. (2020). Wound assessment,
Chapter six. In: Wound Care Essentials: Practice Principles, 3e (ed. S. Baranoski and
E.A. Ayello). Philadelphia: Wolters Kluwer Health.
BNF (2024). Alginate Dressings. London: BNF.
References 109
Britto, E.J., Nezwek, T.A., and Robins, M. (2023). Wound Dressings. Statpearls. https://
www.ncbi.nlm.nih.gov/books/NBK470199/ (accessed October 2022).
Campiglio, G., Klinger, F., Caviggioli, F. etal. (2022). Post- burn and keloid scar treatment
with adipose- derived stem cells in Kalaaji, A. In: Plastic and Aesthetic Regenerative
Surgery and Fat Grafting Clinical Application and Operative Techniques. Cham: Springer
International Publishing Chapter28.
Cox, J. (2019). Wound Care 101. Nursing 49 (10): 32– 39.
CPOC (2023). National safety standards for invasive procedures. [online]. The National
Safety Standards for Invasive Procedures (NatSSIPs) | Centre for Perioperative Care
(cpoc.org.uk) (accessed 06 September 2024).
Dealy, C. (2008). Wound Management. New Jersey: Wiley.
Doughty, D. and Sparks, B. (2016). Wound- healing physiology and factors that affect the
repair process. In: Acute and Chronic Wounds: Current Management Concepts, 3e (ed.
R. Bryant and D. Nix), 63– 81. Missouri: Elsevier.
Fuller, J. (2022). Surgical Technology. Principles and Practice, 8e. Missouri: Elsevier Saunders.
Holloway, S., Tate, S., Stechmiller, J., and Schultz, G. (2020). Acute and chronic wound heal-
ing, Chapter Five. In: Wound Care Essentials: Practice Principles, 5e (ed. S. Baranoski
and E.A. Ayello). Philadelphia: Wolters Kluwer Health.
Medicines Act (1968). Medicines Act C. 67.
NICE (2014) Obesity: identification, assessment and management. https://www.nice.
org.uk/guidance/cg189/chapter/Recommendations (accessed 15July 2024).
NICE (2019). Surgical site infections: prevention and treatment NICE guideline
[NG125]. https://www.nice.org.uk/guidance/ng125/chapter/Recommendat
ions#terms- used- in- this- guideline (accessed 11 August 2024).
NICE (2020). Surgical site infections: prevention and treatment. Recommendations | Surgical
Site Infections: Prevention and Treatment | Guidance|NICE. (accessed 27 April 2024).
PCC (2018). Position Statement: Surgical First Assistant. PCC.
Phillips, N. (2021). Berry and Kohn’s Operating Room Technique, 14e. Missouri: Elsevier.
Quick, C.R.G., Reed, J.B., Harper, S.J.F., and Saeb- Parsy, K. (2014). Essential Surgery
Problems, Diagnosis and Management, 5e. Edinburgh: Churchill Livingstone, Elsevier.
Singer, A.J. and Dagum, A.B. (2008). Current management of acute cutaneous wounds.
The New England Journal of Medicine 359: 1037– 1046.
Thompson, J.T. and Marks, M.W. (2007). Negative pressure wound therapy. Clinical Plastic
Surgery. 34 (4): 673– 684.
Tortora, G. and Derrickson, B. (2017). Principles of Anatomy and Physiology, 15e. New
Jersey: Wiley.
White, R. (2016). Acute versus chronic wounds: microbiological differences. In: Essential
Microbiology for Wound Care (ed. V. Edwards- Jones). Oxford: Oxford University Press.
111
Surgical First Assistant: The Essentials of Practice, First Edition. Editedby JulieQuick andMarkOwen.
© 2025John Wiley & Sons Ltd. Published 2025 by John Wiley & Sons Ltd.
CHAPTER 10
Pain Management
Felicia Cox and Nisha Bhudia
Royal Brompton & Harefield Hospitals, part of Guy’s & St Thomas’
NHS Foundation Trust, London, UK
INTRODUCTION
Pain is a distressing, subjective and complex phenomenon encountered by all
healthcare professionals in clinical practice. Effective pain assessment and
management by registered practitioners is an essential component in a patient’s peri-
operative journey. A structured assessment aims to identify probable causes and trig-
gers of pain and to guide appropriate interventions which can be varied and
multimodal. Pain may be acute or chronic and may persist even after injured tissues,
including bones, have healed. Both non- pharmacological and pharmacological treat-
ments may be employed to minimise the patient’s experience of pain and to improve
their functional capacity. Unrelieved pain has multiple adverse consequences. This
chapter will explore the definition of pain and the need to use a structured assessment
and will focus on pharmacological approaches to its management.
Defining Pain
Unlike other more clearly defined patient observations, there is no objective measure
of pain. Members of the perioperative team, including the SFA, are reliant upon the
patient’s self- report of pain although attempts have been made to measure pain objec-
tively; for example, intraoperatively using the surgical pleth index (Oh et al. 2024).
The experience of pain is unique to the individual and is a result of their previous
112 Chapter 10 Pain Management
experiences, employment status, family and social relationships. Repeated exposure
to painful stimuli, such as frequent cannulation, can result in increased sensitivity to
pain (Latremoliere and Woolf2009). This is known as central sensitisation and rein-
forces the need to manage acute pain effectively.
The International Association for the Study of Pain (IASP 2020) has recently
updated their comprehensive definition of pain as
‘an unpleasant sensory and emotional experience associated with, or resembling
that associated with, actual or potential tissue damage.’
The original definition (Merskey and Bogduk1994) excluded those unable to ver-
balise pain such as infants, people with a profound cognitive impairment and animals.
This revised definition is expanded by the introduction of six key points (Box10.1).
Classifying Pain
There are many ways to classify pain including duration, mechanism and features.
Pain may be categorised according to the cause (e.g. cancer or persistent post-
surgical pain) or by mechanism (such as peripheral or central sensitisation).
Box 10.1 Supplementary points toenhance
therevised definition ofpain.
• Pain is always a personal experience that is influenced to varying degrees
by biological, psychological and social factors.
• Pain and nociception* are different phenomena. Pain cannot be inferred
solely from activity in sensory neurons.
• Through their life experiences, individuals learn the concept of pain.
• A person’s report of an experience as pain should be respected.
• Although pain usually serves an adaptive role, it may have adverse effects
on function and social and psychological well- being.
• Verbal description is only one of several behaviours to express pain; inability
to communicate does not negate the possibility that a human or a nonhuman
animal experiences pain.
*Nociception is defined by IASP as “The neural process of encoding noxious stimuli”
which can be simplified as the sensory process of detecting tissue damage. Nociceptors
are the diverse group of receptors stimulated in this process (Juneja and Jaggar2009).
Source: IASP (2020)/International Association for the Study of Pain.
Introduction 113
Nociceptive pain results from damaged tissues, neuropathic pain results from nerve
damage or disease plus there is a new category of nociplastic pain. Nociplastic pain
arises from altered nociception with central sensitisation, despite no clear evidence
of actual or threatened tissue damage (IASP2020). However, this term is not widely
used in clinical practice.
Table10.1 outlines the characteristics of nociceptive and neuropathic pain. The
words that a patient uses to describe their pain can be useful in diagnosis.
Pain physiology can be broken down into four steps as illustrated in Figure10.1.
The site of action of analgesic medicines is identified.
1. Transduction: In response to an injury, a signal travels to the dorsal horn of
the spinal cord. Tissue injury causes the release of chemicals that stimulate
pain receptors (nociceptors). The signals travel via Aδ or C fibres to the
spinal cord.
2.
Transmission: In the spinal cord – the dorsal horn is the first relay station
where Aδ or C nerve synapses (connects) with a second- order nerve. The
second- order nerve travels up the opposite side of the spinal cord. The thala-
mus is the second relay station with connections to many parts of the brain
including the cortex, limbic system and the brainstem.
TABLE. Characteristics ofnociceptive andneuropathic pain.
Nociceptive pain Neuropathic pain
Subtypes Somatic–sharp,
stabbing pain usually
welllocalisedinthearea
ofinjury
Visceral–dull,heavyand
achingpainthatmay
occuroverawidearea
Painisusuallyexperiencedincombination
withasensorylossorgain.Itmaybe
associatedwithincreasedsympathetic
activity,forexample,changesintheskin
temperatureandsweating
Paindescribedasburning,stinging,
stabbingorelectricshocks
Duration Lessthanthreemonths
(acute)
Anyduration
Causes Stimulation of
nociceptorsinresponse
toinflammationor
damage,forexample,
aftersurgeryorafracture
Associatedwithinjuryordiseaseofthe
peripheralorcentralnervoussystem,for
example,phantomlimbpain
Management Paracetamol-based
multimodal analgesia
Non-steroidalanti-
inflammatorydrugs
Opioidtherapyforashort
duration
Poorresponsetoopioids.Considertheuse
ofadjuvants,forexample,anticonvulsant
therapy,forexample,pregabalinorNMDA
receptorantagonists,forexample,ketamine
Source: Adapted from Cox (2022).
114 Chapter 10 Pain Management
3. Modulation: The descending pathways modify (inhibit) the pain signals from
the periphery.
4.
Perception: Pain perception (the experience of pain) occurs in the brain.
Assessing Pain
Pain is influenced by a person’s previous experience of pain, physiological and
psychosocial factors together with culture, beliefs, expectations, mood and the ability
to cope (Hutchinson2020). Miller and Abu- Alhaija (2019) describe how different cul-
tures may have varied perceptions of and responses to an identical pain stimulus.
Greater pain sensitivity to painful (noxious) stimuli is reported in African Americans
and Asians compared to non- Hispanic white people (Kim etal.2019). Gender also
influences responses, as sex hormones alter sensitivity to pain by influencing pain
processing (descending) pathways (Mogil etal.2024).
Perception: Paracetamol, alpha-2 agonists,
COX-2 inhibitors, NMDA antagonists, opioids
Brain
Spinal cor
d
Periphery
Injury
Ascending
pathway
Descending
pathway
Dorsal hom
Dorsal root ganglion
Peripheral
nerve
Peripheral
noclceptors
Modulation: Paracetamol, anticonvulsants,
neuraxial opioids, NMDA antagonists
Transmission: Alpha-2 agonists,
COX-2 inhibitors, local
anaesthetics, opioids
Transmission: Anti-convulsants, local
anaesthetics, opioids
Transduction: COX-2 inhibitors, local
anaesthetics, NSAIDs
Pain
FIGURE. Physiology of pain and analgesia sites of action. Source: Reproduced from
Essential Pain Medicine with permission from University of Auckland.
Introduction 115
Tools
Pain assessment should be structured using a valid and reliable tool for the specific
patient population to aid the diagnosis of the type and possible cause of pain. The tool
should be easy to understand by staff and patients and should promote self- report of
pain. It can also be used to determine the effectiveness of any intervention (Cox2022).
Some simple questions to aid pain assessment are shown below. These questions will
be contained within pain assessment tools, but if you do not have access to a formal
tool, the PQRST mnemonic (below) can be used to focus the patient assessment.
Pain Assessment Questions Using PQRST
Provoking factors. What makes it worse?
Quality. What does it feel like?
Region/radiation. Where is your pain? Does it radiate?
Severity. How strong is your pain?
Timing. How long have you had it?
The choice of tool will be influenced by the required sensitivity and assessment.
Sensitivity is the ability to detect small, but meaningful clinical changes in pain inten-
sity and impact over time. A simple unidimensional tool (Figure10.2), for example, a
0– 10numerical rating scale where 0=no pain and 10=worst pain imaginable (see
an example below) is suitable in areas such as a post- anaesthesia setting when patients
can self- report.
Observational and behavioural assessment can also be utilised. Some examples
include in paediatrics the Face, Legs, Activity, Crying, Consolability (FLACC) behav-
ioural scale tool (Merkel etal.1997), the Critical Pain Assessment Observation Tool
(CPOT) in critical care (Gélinas and Johnston2007) and in older people the Bolton
pain assessment tool (Schofield etal.2018).
After surgery, the function should be used to guide analgesia provision (outlined
below), especially the use of opioids, rather than patient reported pain intensity (Levy
etal. 2018). Patients whose pain does not follow the expected trajectory should be
escalated to exclude a serious adverse event such as infection. The trajectory varies
between patients and their type of surgery.
0–10 numeric pain rating scale
0
No
pain
Moderate
pain
Worst
possible
pain
12345678910
FIGURE. 11- point numerical rating scale for pain.
116 Chapter 10 Pain Management
ExampleofaFunctionalActivityScale
1. No limitation: The patient is able to undertake the activity without limitation
due to pain (Levy etal.2021).
2.
Mild limitation: The patient is able to undertake the activity, but experiences
moderate to severe pain.
3.
Significant limitation: The patient is unable to complete the activity due to
pain or pain treatment- related adverse effects.
Managing Pain
This chapter focusses on acute pain and pharmacological interventions. There is
strong evidence that some patients are at high risk of poorly managed or persis-
tent pain. These include people who are opioid dependent, have drug dependence
syndrome (Quinlan and Cox 2017) or anxiety and depression (Darnall and
Cohen 2017). Schug and Bruce (2017) report that having pain prior to surgery or
poorly managed pain immediately after are risk factors for persistent post-
surgical pain.
The reverse pain ladder (Figure 10.3) is a useful reminder that as function
increases after an injury or surgery, analgesia should be reduced (the strongest such
as opioids first) and then stopped. All patients should receive regular paracetamol for
acute pain (Schug etal.2020, p.111).
← Maximum one week →
Discharge Immediate release
opioid for moderate to severe
pain (maximum five to seven
days) + paracetamol +/– NSAID
Paracetamol (avoid compound
analgesics) + PRN codeine, dihydrocodeine
or tramadol +/– NSAID
Paracetamol +/– NSAID
Time
Pain decreases and function improves with time.
FIGURE. Reverse pain ladder for managing acute pain.