Book Review

Postoperative Pain Management

N Engl J Med 1993; 329:973-974September 23, 1993

Article

Postoperative Pain Management
Edited by F. Michael Ferrante and Timothy R. Vadeboncouer. 689 pp., illustrated. New York, Churchill Livingstone, 1993. $74.95. ISBN: 0-443-08766-0

The field of postoperative pain management is rapidly developing a body of specialized knowledge for practitioners to use in improving the quality of patient care. This textbook is an excellent guide to the new advances in postoperative pain management. Its reasonable length and price will appeal to both individuals and institutions, and it will be useful for all practitioners and trainees concerned with postoperative and acute pain.

The preface outlines the philosophy behind this new approach to pain management. “Balanced analgesia” is the use of pharmacologic and regional-anesthetic techniques to blunt or abolish the physiologic processes involved in pain nociception. Since we do not have a single drug that will block pain in all patients, for all types of operations, and without side effects, a multimodal approach tailored to the patient and the operation makes sense. This emerging practice promises to affect outcome, facilitate early mobilization, and shorten convalescence.

The first chapter covers postoperative pain from an epidemiologic perspective. It deals with the problem of the intramuscular administration of a fixed dose on an as-needed basis. This practice does not account for the individual variability in analgesic requirements and does not ensure consistent, effective delivery of drugs. Concern about respiratory depression and the potential for addiction still limits the pain therapy given to patients. Epidemiologic studies have shown an even lower standard of effective pain treatment in children.

Subsequent chapters are organized along traditional lines, with an excellent one on the peripheral and central nervous system pain-transmission pathways. A chapter on the neuroendocrine response to postoperative pain makes the interesting point that reduction of the surgical stress response depends on the surgical site and the methods used for pain management. For example, the combined regional and pharmacologic technique for lower-extremity and abdominal operations can completely block the surgical stress response, whereas the same analgesia may not block the endocrine stress response to upper-abdominal and thoracic operations, even though the patient may be free of pain after the operation. This may be due to visceral autonomic, vagal, and phrenic afferent pathways that are not completely blocked by these techniques. Thus, analgesia does not always ensure reduction of stress hormones, and stress hormone levels may not be an accurate final measure of the outcome of analgesic techniques.

The chapter on the autonomic nervous system presents the anatomy and physiology well but could have outlined the clinical correlates of the role of the sympathetic nervous system in difficult postoperative pain states. For example, a patient with severe constant burning or aching pain that appears to be resistant to narcotics may have a component of sympathetically maintained pain. An understanding of the current concepts of sympathetic pain and treatment would help the reader to diagnose and treat these difficult problems.

The final group of chapters reviews the treatment of postoperative pain according to regions of the body and procedures. Pain after cesarean section differs from pain after orthopedic, thoracic, and abdominal procedures. These chapters are a first step in the standardization of the knowledge base and clinical approaches to these different problems and the systematic, cost-effective improvement of postoperative pain management. The final chapters address the financial aspects of postoperative pain management, nursing, and the organization of an acute-pain service, with helpful sample forms from the Brigham and Women's Hospital clinical practice.

This textbook can best be summarized by a quotation from testimony presented to the Agency for Health Care Policy and Research on the management of acute postoperative pain: “The pain results from the surgical procedure, but postoperative pain has its own diagnosis, its own treatments, its own side effects, its own specialists.” If improved outcome and patient satisfaction can be demonstrated by large-scale, prospective outcomes studies, the next clinical challenge will be to ensure the widespread application of these analgesic techniques as an integral part of high-quality care. This excellent textbook will help the practitioner toward this goal.

Alan M. Harvey, M.D.
Baystate Medical Center, Springfield, MA 01199