An Elephant's Knowledge: Chronic Post Surgical Pain
It was a busy Monday morning in theatres and I was already feeling anxious. My consultant was running late and Mrs Johnson, who was listed for a mastectomy was in tears. She said that her sister had had a mastectomy 8 years ago and that she had been in pain ever since; she was desperately worried the same thing would happen to her. I didn't know what to say when I noticed a little blue figure had sat down next to her and was trying to comfort her. "It sounds like what your sister had was Chronic Post Surgical Pain - how horrible" the Blue Elephant said. Whilst the nurse helped her get changed I asked the Blue Elephant a bit more about chronic post surgical pain. "Why do people get chronic pain after breast surgery?" "We aren't sure - it does seem to be linked to nerve damage in some cases but sometimes people have evidence of nerve disruption, without pain, and others no evidence of damage, but severe pain. There are definitely psychosocial risk factors; those with anxiety, or catastrophizing personalities, seem to have a higher prevalence. Younger people also seem to be more affected than the elderly and those clever scientists have found some genetic factors too." "Oh dear" I said. " Mrs Johnson has a history of anxiety and is only 42 years old! What am I going to do?" The Blue Elephant looked calmly at me and said, "Your job is to make sure that her acute post-operative pain is managed wel. Severe pain in the acute post-operative period is the most common and most important risk factor for CPSP. We think it happens as a result of central sensitization. Unfortunately no one analgesic regimen or nerve block has been shown to reduce the incidence." "What analgesia should I use then?" I asked. The Blue Elephant smiled - "You already know! The best approach is to provide a solid multimodal analgesic regimen. Attack the pain from al sides! Think about pre-emptive analgesia; local anaesthetics or regional anaesthesia; make sure she is given regular paracetamol and NSAIDs; load her with opiates and write her up for a PCA. You could also consider ketamine or gabapentin as these have been shown to be helpful in smal trials." I took a deep breath. "So that's al I can do? Multimodal analgesia?" "Yes. Don't forget to make sure her pain management is tip-top on the ward. Why don't you review her tomorrow and make sure that your analgesic regimen is keeping her comfortable? It would be worth letting the pain team know about her too so they can also help." With that, the Blue Elephant picked up his copy of the Times crossword with his trunk and pottered into Theatre 3. I went to find Mrs Johnson… Bruce, J and Quinlan, J. Chronic post-surgical pain. Reviews in Pain 2011;5(3):23-29 Macrae, W. Chronic post-surgical pain: 10 years on. BJA 2008;101(1):77-86 Editors: C Bantel & I Goodal Consultant Pain Specialists
Chelsea & Westminster NHS Foundation Trust;


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