|Year : 2019 | Volume
| Issue : 2 | Page : 54-61
Outline for setting up acute postoperative pain service for Indian Hospital
Rashid M Khan, Aziz Haris, Abdullah Al-Jadidi, Naresh Kaul
Department of Anesthesia, Pain and ICU, Khoula Hospital, Muscat, Sultanate of Oman
|Date of Submission||13-May-2019|
|Date of Decision||18-May-2019|
|Date of Acceptance||06-Jun-2019|
|Date of Web Publication||7-Aug-2019|
Dr. Naresh Kaul
Department of Anesthesia, Pain and ICU, Khoula Hospital, Muscat
Sultanate of Oman
Source of Support: None, Conflict of Interest: None
Majority of Indian hospitals still lack the provision of acute postoperative pain relief service. In other parts of the world, field of acute pain management strategy has witnessed a surge in its implementation. Today, acute pain has begun to be recognized not merely as a distressing symptom but also as a precursor of chronic, debilitating pain. This development warrants that we in India address this issue on an urgent basis through the use of analgesic/narcotic combination via parenteral/oral/rectal route as well as by performing regional blocks, to meet the interpatient variability and available facility. In this review article, we have provided the organization and function of acute pain service (APS) program that can be adapted to a wide spectrum of Indian hospitals. We have outlined the role of APS team including the use of easily available analgesic/narcotic drug combinations for various categories of Indian hospitals dealing with different grades of surgical conditions, including those hospitals that are not sufficient in resources and funding. This article has also tabulated possible regional block techniques with their indications for treating acute postoperative pain in combination with parenteral/oral/rectal analgesics/narcotics in the more developed Indian hospitals. Staffing and equipment requirements have also been outlined.
Keywords: Acute pain service, organization, regional anesthesia
|How to cite this article:|
Khan RM, Haris A, Al-Jadidi A, Kaul N. Outline for setting up acute postoperative pain service for Indian Hospital. Indian J Pain 2019;33:54-61
| Introduction|| |
Acute postoperative pain is a feeling of distress, suffering, or agony, caused by the stimulation of specialized nerve endings that have been damaged or cut during the surgery. Its purpose is chiefly protective. It acts as a warning that tissues have been damaged and informs the sufferer to remove or withdraw from the source. Acute pain is of short duration that gradually resolves as the injured tissues heal. Acute pain is distinct from chronic pain and is relatively more sharp and severe. The current evidence shows that unrelieved postoperative pain leads to chronic pain conditions.
A relatively recent survey from a medically advanced country like the United States of America showed that approximately 86% of patients experienced pain after surgery. Of these, 75% had moderate-to extreme pain during the immediate postsurgical period. 74% continued to experience these levels of pain after discharge. Despite heightened awareness and clinical advancement in pain management, there has been little improvement in postsurgical analgesia as measured by this survey. Situation in India is still grim.
Acute perioperative pain may start from the time of hospital admission to the first 72 h after the surgery, which varies in intensity due to subjective variations and nature of the surgery. Adequate pain management perioperatively provides good postoperative analgesia and is associated with less morbidity and mortality. On the other hand, unrelieved postoperative pain may not only delay the recovery and discharge process but also can potentially lead to chronic pain conditions. The solution to this problem lies in setting up of the acute pain service (APS) based on evidence-based approach within the available resources in the region with accountability.,
We must realize that acute postoperative pain is usually predictable, and hence, it is essential that we provide effective pain education to the patient in terms of its multiple causes and effects of pain. We must reassure a patient that there is a range of treatments available to him/her. This pain education has been shown to reduce patients' distress, anxiety, and depression besides improving functional status and results in lesser narcotic requirement.
It has been shown that properly implemented APS reduces length of hospital stay, lowers re-admission rate and helps in speedy recovery. It also improves quality of life, enhances productivity, and results in decreased costs for patients and the healthcare system., The last is especially important in the Indian context of hospitals, as they are almost always cash strapped and can ill afford prolonged hospital stay of the patient due to unrelieved pain.
Unfortunately, APS is a poorly organized sector in Indian hospitals. In a relatively recent survey conducted by Jain et al. in 2015, it was observed that anesthesiologists cater to postoperative pain relief in 45% of Indian hospitals, and in the rest, surgeons were responsible for pain relief in the wards. In the same survey, it was noted that in those who provided APS, 50% of them did not have any written pain protocols and 60% did not perform any regular measurement of pain. Only 30% of the Indian patients received adequate postoperative pain relief. In India, like in other countries, anesthesiologist is usually the lead physician who works closely with the paramedical staff and decides the analgesic modality, managing side effects, and patient safety.
In Thailand, situation is nearly similar and a survey in 2009 noted that intramuscular (IM) injections were the preferred route of analgesic administration in the postoperative period as per orders of the operating surgeons, quite like the situation prevailing in most Indian hospitals.
It is time that India adopts an APS to cater to acute postoperative pain. A broad outline of such a service that can be adapted to different categories of Indian hospitals is therefore essential and is the need of hour. In this article, we have divided Indian hospitals into three categories that already exist or needs setting up of an APS:
Category 1 hospitals
In this category of hospitals, consulting specialists (full- or part-time) run clinical service for inpatients along with nursing and technical staff. Majority of average Indian private hospitals and subdistrict hospitals fall in this category. Only 1–2 on-call anesthesiologists are available or willing to run APS with 2–3 nursing staff members based only on oral/parenteral analgesics or narcotics without regional block services.
Category 2 hospitals
In these hospitals, there is departmentalized clinical service inclusive of full-fledged major departments such as surgery, medicine, orthopedics, gynecology and obstetrics, and anesthesia and critical care to name a few besides adequate nursing and technical staff backup. Most Indian district hospitals and well-developed large private hospitals belong to this category. In these categories of hospital, there are facilities as in category 1 hospital plus facility to provide top-up services via epidural or wound catheter that has been placed in the operation theater. However, for a safe and efficient APS, especially epidural service in this category of hospital, the presence of a 24-h floor anesthesiologist is a must.
Category 3 hospitals
These hospitals provide teaching/training services with accredited residency training program in addition to advance clinical service. All medical colleges and metro/cosmopolitan hospitals would fit into this category. These institutions have access to ultrasonography-aided nerve or plexus blocks (continuous or intermittent top-ups) and/or patient-controlled analgesia (PCA) with a team of trained dedicated personnel (anesthesiologists/physicians and nurses). Obviously, the size of the team shall depend on the workload. In category 3 hospitals, a team of dedicated healthcare personnel who are responsible for assessment, patient monitoring, and treatment of pain besides noting the side effects of pain medications run APS. This is done on a 24-h basis.
Assessment of pain is the first step in its effective management in all the three categories of hospitals. The measurement and treatment of pain must be appropriate for each patient. Self-reporting by the patient is a major component of comprehensive pain assessment. It is generally performed using a numeric rating scale. One such scale is the defense and veterans pain rating scale (DVPRS) that has partly been modified and shown in [Table 1].
Modified DVPRS can be used initially for pain assessment and then to follow-up to see the efficacy of pain relief after treatment in most adult patients. This numeric rating scale can help to modify administration of analgesics/narcotics and local anesthetic depending on the response, including the impact of pain on patient's activity, sleep, mood, and stress besides gauging intensity of pain.
For children and noncooperative adult patients, it is preferred to use faces pain scale and neurobehavioral scales [Figure 1]and neurobehavioral scales [Table 1].
| Category 1 Hospitals|| |
In many of category 1 hospitals, due to acute shortage of anesthesiologists, there may be none to run the APS. However, postoperative patients still deserve to have a realistic approach to acute postoperative pain management. In these hospitals, one of the cornerstones of the APS services has been the evolution of specialized acute pain nurses. Many hospitals have used nurse-initiated APS with excellent result when anesthesiologist-based APSs were not available., APS nurses fulfill a critical role in standardizing pain assessment and treatment protocols, as well as in educating patients and serving as bedside nurses in acute pain management programs. However, there should be availability of 1–2 anesthesiologists who can be consulted over the phone.
In category 1 hospitals, multimodal approach should be adopted using basically nonsteroidal anti-inflammatory drugs/other analgesics via intravenous (IV) or IM approach.
Acute postoperative pain management in category 1 hospital should be based on the grade of surgery. This has been partly adapted from Milewska et al.'s 2013 guidelines on recommendations for acute pain management with modifications to suite the Indian subcontinent. All drugs recommended in this guideline are freely available even in small towns of India. The recommendations are as follows:
Grade I surgery
In this category are included patients who are to undergo or have undergone (but not limited to) minor orthopedic, general, or gynecological surgery done in daycare or main theater having postoperative pain that is <4 on the numeric rating scale.
- Before surgery: Adopting preemptive analgesia is recommended by using one or more drug combination keeping paracetamol as the basal drug:
- Paracetamol 1 g IV or 1–2 g per rectal, ± in combination with one of the following:
- Pregabalin 150-300 mg or gabapentin 600-1200 mg orally 2 h before anesthesia
- Ketoprofen (50–100 mg IV) or dexketoprofen (25–50 mg IV).
After surgery (again keeping paracetamol as basal drug):
- Paracetamol 1.0 g IV or orally every 6 hourly (maximum 4 g per day in adults) ± in combination with one of the following IV or per oral route:
- Diclofenac 75 mg 8–12 hourly (unless risk of bleeding exists)
- Ketoprofen 25–50 mg every 6–8 hourly
- Ibuprofen 400 mg every 8 hourly
- Naproxen 250–500 mg every 8 hourly
- Pregabalin 75-100 mg every 8hourly or gabapentin 300-600 mg every 8 hourly.
Note: Before the beginning of surgery, the line of incision should be infiltrated with 1% lidocaine (10–20 ml) or 0.25% bupivacaine (5–10 ml) as a preemptive analgesia. Repeat the surgical site infiltration with local anesthetic at the end of the procedure.
Grade II surgery
This includes patient who are to undergo or have undergone surgical procedures (but not limited to) laparotomies without disturbing the integrity of gastrointestinal tract (open cholecystectomy, nephrectomy as few examples), orthopedic procedures (excluding operative procedures on pelvis, thorax, spine, and neurosurgery), urology, and gynecology. Postoperative pain level in these patients is often >4 and generally lasts for 2–3 days.
- Before surgery: as in Grade I surgery
- After surgery: Same medication as suggested in Grade I surgery.
In addition, local infiltration of the surgical site should be done as recommended above for Grade I surgery.
However, these patients may still have some breakthrough pain and need supplementation with one of the following, repeated at 10–15-min interval to a maximum of 2–3 doses, under strict nursing supervision:
- Pethidine 20–25 mg IV
- Tramadol 10–20 mg IV
- Morphine 1–2 mg IV
- Buprenorphine transdermal patch (10–20× μg/h release).
After 2–3 days of surgery, nonopioid analgesics may be used as recommended under Grade I surgery and opioids discontinued.
Grade III surgery
Under this are included patients who are to undergo or have undergone surgical procedures (but not limited to) spine and thoracic surgery and pelvic orthopedic or intraperitoneal procedures. Intensity of pain in this grade of surgery is likely to be of a greater magnitude.
- Before surgery: as in Grade I surgery
- After surgery
- Opioids as intermittent IV (in doses as for breakthrough pain in Grade II surgery) or nursing supervised infusions. These may be pethidine, morphine, or buprenorphine. It is essential for patient's satisfaction that the pain of grade III surgery is effectively controlled by narcotic while initiating the analgesic regimen mentioned below.
- Pregabalin 100 mg every 8 hourly or gabapentin 600 mg every 8 hourly
- Paracetamol 1.0 g IV or orally every 6 hourly (maximum 4 g per day in adults) ± one of the following:
- Diclofenac 75 mg 8–12 hourly IM or IV (unless risk of bleeding exists)
- Ketoprofen 25–50 mg every 6–8 hourly
- Dexketoprofen (25–50 mg) every 8–12 hourly
- Ibuprofen 400 mg every 8 hourly
- Naproxen 250–500 mg every 8 hourly.
Local infiltration of the surgical site should be done as recommended above for Grade I surgery.
However, these patients may still have some breakthrough pain when they have proceeded to nonnarcotic analgesic regimen and need supplementation with one of the following, repeated at 10–15 min interval to a maximum of 2–3 doses, under strict nursing supervision:
- Pethidine 20–25 mg IV
- Tramadol 10–20 mg IV
- Morphine 1–2 mg IV
- Buprenorphine transdermal patch (10-20× μg/h release).
Polytrauma patients or those who have undergone surgery on more than one body cavity have a greater intensity pain that also lasts significantly longer. These patients need anesthetist-supervised pain-relieving strategies that may vary from patient to patient and need to be tailored on an individual basis according to available medications, equipment, and expertise.
Note: The entire dose schedules stated above are as for adult patients only.
In those Indian hospitals that have no or limited access to opioids, one can rely on the readily available ketamine. Its low-dose infusion has shown to provide good postoperative pain relief with little adverse side effects. King in 2005 has reported the successful use of low-dose ketamine for postoperative analgesia when working with Médecins Sans Frontières (Doctors without Borders) in the Ivory Coast.
Stubhaug et al. in 1997 have recommended a preincisional bolus of 0.5 mg racemic ketamine followed by a 24-h infusion of 120 μg/kg/h and then of 60 μg/kg/h for 48 h to reduce the hyperalgesia associated with the incision site.
| Category 2 Hospitals|| |
In addition to pain-relieving strategy outlined for category 1 hospitals, wherever epidural or surgical site catheter infusion service is provided in this category of hospitals, resuscitation equipment, oxygen, and appropriate drugs must be readily available. In addition, epidural infusions should be labeled “for epidural use only.” A safe rule for infusion service is to administer the lowest possible effective concentration of local anesthetic. This helps to preserve motor function, which improves patient satisfaction and aids early detection of neurological complications.
Blood pressure, pulse rate, and respiratory rate should be recorded every 15 min for 1 h and then every 30 min for the next 2 h. Thereafter, all patients should be monitored for heart rate, blood pressure, respiratory rate, sedation score, temperature, and degree of motor and sensory block on an hourly basis for the first 24 h and then reduced to 2 hourly. Pain score (at rest and on movement or deep breathing) should be recorded as per the numeric scale and infusion rate adjusted accordingly. Motor movement can be used for measuring the motor block during epidural infusion service. Motor block and sensory level should be recorded hourly for the first 2 h and then 4 hourly until catheter is removed. It may have to be more frequent if epidural rate is changed or clinically indicated.
Epidural catheter or any other infusion lines should be clearly labeled. Name of drug, its concentration and infusion rate should be clearly documented with instruction for re-adjustments of dose, if required. In addition, there should be an IV infusion line running throughout the infusion period. There must be a detailed handover of information during change of shift duties about patients who are receiving epidural analgesia. It is important that all patients receiving epidural analgesia should be in proximity to the nurses' station. This ensures close supervision.
In case of syringe or any other infusion pump, the loading of solution should be done under aseptic technique. Appropriately trained staff must administer bolus injections and postbolus monitoring of the patient is required immediately after the injection.
After the administration of each bolus dose, the patient should be closely observed every 15 min for next 1 hour to ensure patient is in a stable condition.
Needless to say that meticulous records must be kept of the monitoring as well as epidural or other catheter infusion rate, total amount used, and inspection of catheter insertion site. Patient on epidural infusion should always be assisted when getting out of bed.
When the catheter infusion service is no more desired or needs to be terminated for any cause, epidural catheter should be removed with due consideration particularly if patient is receiving anticoagulant. A period of 10–12 h should have elapsed after the last dose of low-molecular-weight heparin. After removal, catheter tip should be inspected for its integrity and documented. The next dose of low-molecular-weight heparin may be administered 2 h after the catheter removal. In case patient is receiving warfarin, International Normalized Ratio should be <1.5 before catheter removal. In either case, close monitoring of patient's neurological status should continue for next 24 h after the removal for catheter.
| Category 3 Hospitals|| |
In category 3 hospitals, regional blocks play an important role in postoperative pain management besides using parenteral and oral routes for analgesic/narcotic administration as stated under category 1 hospitals. Adequately trained personnel administer these blocks. An adequately trained personnel in regional blocks is one who has had a formal training in an accredited institute and performs 20–25 regional procedures of various forms each year. However, it is not enough to have a trained regional anesthesiologist/physician alone to conduct regional anesthesia service as part of APS. There should be other staff members including nurses who are willing to support the system for running a safe APS. The team should comprise of at least 2–3 trained anesthesiologists/physicians and equal number of dedicated nursing staff member with training in acute pain management to cope up with the APS keeping in mind that some of the team members shall be on leave. This team should not only provide APS but should also be responsible for follow-up of all patients who have received regional techniques and conduct audits to improve upon the APS.
Equipment needed at category 3 level of acute pain service
This includes a regional anesthesia cart (RAC) with the following equipment:
- Different sizes of insulated block needles for peripheral nerve blocks
- Nerve stimulator
- Preparation and sterilization kits
- Local anesthetics and narcotics (morphine, fentanyl)
- Emergency medications to resuscitate a patient in case of a mishap
- Ultrasound machine to perform real-time nerve blockade.
The availability of a “block room” is desirable as it will expedite patient flow in operation theatre (OT) without wastage of OT time, shall contain stock of all necessary equipment and medications in an RAC that will be needed, have monitors, and help in resident/interested personnel teaching.
APS in category 3 hospitals should follow the six tenets of good service laid down by Upp et al. in 2013. These tenets are as follows:
- Dedicated provider of APS should be available around-the-clock for consultation or intervention in cases of severe acute pain
- APS team should carry out regular pain assessment at rest and with movement
- ”Mobilization and rehabilitation” of the patient should be done in consultation with surgeons and ward nurses
- There should be ongoing continuing medical education of ward nurses on safe, appropriate, and cost-effective analgesia
- Equally important is to educate the patient on available pain treatment options, benefits, adverse events, and realistic analgesic goals
- Regular auditing of APS performance regarding cost-effectiveness and patient satisfaction with analgesic techniques.
Regional block services offered in this category of hospital have been found to offer several advantages. These include better postoperative pain relief, reduction of the incidence of deep vein thrombosis, besides early ambulation. It is also noted to decrease the incidence of postoperative nausea and vomiting that is so commonly noted with postoperative narcotic medications.,,
Intrathecal narcotics are effectively used as part of multimodal analgesia. It improves patient satisfaction and reduces the overall requirement of analgesics. Unlike local anesthetics with intrathecal narcotics, there is no loss of motor, proprioception, and sympathetic innervation. Narcotics should be used for providing analgesia wherever subarachnoid block is practiced and can also be used along with general anesthesia in major abdominal and thoracic surgery. Fentanyl and sufentanil have shorter duration of action and are useful in immediate postoperative period and help in smooth transition to parenteral analgesia. Intrathecal morphine provides analgesia for up to 24 h but has potential of causing respiratory depression in dose-dependent manner. Duration of analgesia, time to peak respiratory depression and clinical dose range have been shown in [Table 2].
Dose less than 200 μg of morphine do not cause respiratory depression, but a higher dose mandates respiratory monitoring for first 24 h postsurgery. Due to this reason, it is not recommended for day surgery. Preservative free preparation should be used.
Serious side effects of intrathecal morphine include respiratory depression, sedation, and bradycardia. Nonserious side effects include pruritus, nausea and vomiting, sweating, delayed gastric emptying, constipation, headache, persistent hiccups, priapism, and nystagmus.
It is important to identify and avoid intrathecal morphine in patients who are at increased risk of respiratory depression such as patients with obstructive sleep apnea, obesity, opioid sensitivity, concurrent use of opioids, and patients with poor respiratory reserve.
Epidural anesthesia and analgesia
Epidural is a standard technique to provide anesthesia and analgesia in varied procedures. It provides good quality analgesia in the perioperative period when drugs are given as continuous infusion. Drugs can also be given as intermittent boluses to provide analgesia with interval time as per the duration of action of agent used. When providing analgesia using epidural catheter, one should strictly adhere to protocol for patients on antiplatelet drugs and anticoagulants. Commonly used local anesthetic drugs for epidural analgesia and anesthesia is shown in [Table 3].
|Table 3: Commonly used local anesthetic drugs for epidural analgesia and anesthesia|
Click here to view
Initial loading dose
- Lumbar epidural 1–2 ml per se gment
- Thoracic epidural 0.7 ml per se gment
- Caudal 3 ml per se gment.
Lumbar region epidurals
Loading dose should be administered in 3–5 ml bolus at 3–5 min interval. This permits time to assess patient's response and avoid complications.
- For surgical anesthesia, loading dose up to 20 ml of 2% lidocaine with 1:200000 epinephrine or 15 ml of 0.5% bupivacaine
- For analgesia alone, loading dose of bupivacaine or levobupivacaine or ropivacaine is 10 ml of 0.2%–0.25% solution.
Larger dose is recommended if low concentration is used up to 20 ml of 0.0625%–0.125% bupivacaine or equipotent dose of ropivacaine.
In maintenance dose, continuous infusion of 4–15 ml of bupivacaine or levobupivacaine (0.1%) or ropivacaine (0.1%–0.2%) should be infused titrated to response.
In case of intermittent blousing, one-third to one-fourth of initial loading dose at timed interval as per the duration of local anesthetic action.
Thoracic region epidurals
It is mainly used for providing analgesia and not as sole anesthetic technique. Aim while establishing segmental block is to minimize hemodynamic changes and respiratory impairment.
Initial dose of 3–6 ml of 0.125%–0.25% bupivacaine or 0.1%–0.2% ropivacaine is given.
Maintenance dose of 3 ml every 30 min is given till desired response is achieved.
In case narcotics are to be added to infusion, fentanyl 2 μg/ml or hydromorphone 20μg/ml is recommended.
In selected cases, placing catheter at two levels provides epidural analgesia. Always watch for total spinal and signs of local anesthetic toxicity along with other minor complications.
Indications for lumbar and thoracic epidurals include (but not limited to):
- Lumbar epidural: It is useful for perioperative analgesia in following surgeries: hip and knee surgery, lower segment Cesarean section, labor analgesia, hysterectomy, pelvic floor procedures, laparotomy, prostatectomy, urologic surgery, amputation, revascularization surgery of the lower limb, pheochromocytoma, aorto-femoral bypass, and nephrectomy
- Thoracic epidural: It is useful for perioperative analgesia in following surgeries: thoracotomy, thoracic aneurysm repair, thymectomy, video-assisted thoracoscopic surgery, esophagectomy, gastrectomy, pancreatectomy, hepatic resection, cholecystectomy, major bowel resection, modified radical mastectomy, breast augmentation surgery, and abdominoplasty.
| Regional Blocks|| |
Regional blocks provide good-quality perioperative analgesia and significantly reduce the requirement of analgesics. Some surgeries can be performed in blocks alone, but most of the blocks are given along with general anesthesia to manage postoperative pain. Infusion of local anesthetic can be given in few blocks to maintain analgesia in the postoperative period using fixed-dose elastometric pumps or routine infusion pumps. Various blocks with their indications have been shown in [Table 4].
|Table 4: For infusion - 0.1%-0.25% bupivacaine and levobupivacaine and 0.1%-0.2% ropivacaine via catheter at the rate of 3-7 ml/h|
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Patient should be instructed to protect the blocked area or limb and not to bear weight or drive.
- For establishing block: Lignocaine 1.5%–2% to a maximum dose of 5 mg/kg without adrenaline and up to 7 mg/kg with 1:200,000 adrenaline and bupivacaine 0.5% to a maximum dose of 2.5 mg/kg
- For infusion: 0.1%–0.25% bupivacaine and levobupivacaine and 0.1%–0.2% ropivacaine via catheter at the rate of 3–7 ml/h.
| Patient-Controlled Analgesia|| |
The more privileged category 3 hospitals generally have access to PCA system. All IV PCA pumps contain the following modes: initial loading dose, demand dose, lockout interval, total dose in specific period, and background infusion rate. Morphine is generally the first choice for use with PCA for acute postoperative pain relief. Other narcotic agents that have been successfully used for postoperative pain relief including sufentanil, fentanyl, and tramadol. Opioid-based PCA is occasionally beset with problems such as nausea and vomiting, body itching, respiratory depression, sedation, confusion, and urinary retention.
The normal PCA setting for morphine pumps is demand dose 1-2 mg and lockout period of 5-10 min with a continuous basal infusion of 0-2mg/h.
PCA setting, when fentanyl is used as the narcotic analgesic, includes a demand dose of 20-50 g and lockout period of 5-10 min with a continuous basal infusion of 0-60 g.
When tramadol is used for PCA, the demand dose is generally set as 10-20 mg and lockout time of 5-10 min with a basal infusion ranging between 0-20 mg.
In case local anesthetics are used with epidural PCA, the following dose concentration schedule is to be followed:
- Bupivacaine 0.05–0.125%
- Levobupivacaine 0.05–0.125%
- Ropivacaine 0.1–0.2%.
For each of the above local anesthetic agents, the demand dose is 2-4 ml; lockout period is of 10-20 min with a continuous basal infusion ranging from 4-10 ml/h.
Much work remains to be done in India in relation to managing acute postoperative pain. The new undergraduate and postgraduate curriculum that is being upgraded by the Medical Council of India must emphasize appropriate pain education. It should also be made mandatory for all health-care professionals. A multidisciplinary team should be instituted for successful pain management in all India hospitals. Pain education should be included in examinations of undergraduate and postgraduate health-care students for competency and incorporated into continuing education programs. It is time that Indian hospitals adopt pain as the fifth vital sign on the chart such as blood pressure, temperature, pulse rate, and respiratory rate.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]