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Intraoperative Anesthesia Management Chapter 15 415
16
Postoperative Care and Pain
Management
Stephan Blumenthal, Alain Borgeat
Core Messages
✔
The necessity for careful postoperative assessment
of the different organ systems is self-evident
✔
Perioperative tachycardias are often combined
with ischemic episodes, and their treatment is
mandatory because of the high mortality of
perioperative myocardiac infarction
✔
Intensive insulin therapy can reduce morbidity
and mortality
✔
Following cervical spine surgery, perform air-

way assessment before extubation. Suction
drainage and close surveillance minimize the
risk of unrecognized bleeding
✔
Aggressive postoperative pulmonary care mini-
mizes the risk of respiratory complications
✔
Close neurological surveillance is mandatory to
detect deterioration
✔
Postoperative paralytic bowel dysfunction can
be ameliorated by thoracic epidural analgesia
✔
Spinal surgery is painful and a multimodal
approach for peri- and postoperative analgesia
is mandatory
✔
Opioid-related side-effects are independent of
the route of administration
✔
Administration of regional anesthesia (e.g., epi-
dural techniques) following complex spinal sur-
gery may be of great help
Postoperative Care
Major spinal surgery is
prone to complications but
can be minimized with
proper postoperative care
Despite advances in anesthesia care and surgical techniques, major surgery is
still prone to undesirable consequences [6] such as:

infection
thromboembolic complications
cardiorespiratory morbidity
cerebral dysfunction
postoperative nausea and vomiting
gastrointestinal paralysis
pain
fatigue
prolonged convalescence
The key pathogenetic factor in postoperative morbidity is the surgical stress
response with subsequent increased demands on organ function [6]. One of the
key issues for the anesthesiologist is to decrease this surgical stress response as
far as possible to limit its adverse effects.
Patients undergoing spinal surgery frequently have significant comorbidities
which can have a significant impact on the postoperative recovery. Surgery can
further compromise the organ system as a result of:
significant blood loss requiring mass transfusions
coagulopathy
Peri- and Postoperative Management Section 417
prolonged anesthesia with the problem of hypothermia
residual impaired pulmonary function
difficulties in acute postoperative pain management
Perioperative tachycardia
often is combined with
ischemic episodes
Even a single perioperative ischemic episode increases the risk of cardiac mor-
tality within the ensuing 2 years. Most of these ischemic events are clinically
silent and can only be detected with continuous ECG control. They are usually
combined with perioperative tachycardia, which can be either a cause of or a
reaction to ischemia. Treatment of a perioperative tachycardia is mandatory

since it corrects the imbalance between oxygen supply and oxygen consumption
and therefore has a cardioprotective effect.
Perioperative myocardiac
infarction has a high
mortality
P erioperative myocardiac infarction most often occurs during the first post-
operative day and has a mortality rate which remains high, although it decreases
with duration after surgery [25].
Intensive insulin therapy
can reduce morbidity
and mortality
Hyperglycemia and insulin resistance arecommoninpostoperativeandcriti-
cally ill patients, even if the patients have not previously had diabetes mellitus.
Intensive insulin therapy to maintain blood glucose at or below 6.1 mmol/l can
reduce morbidity and mortality, compared to a more conventional treatment
with insulin infusion only when blood glucose exceeds 11.9 mmol/l [28]. Since
diabetes mellitus is recognized as a risk factor of infection after spinal surgery [9,
14], appropriate insulin therapy may help to reduce the incidence of postopera-
tive wound infection as has been shown in the context of other operations [11].
Postoperative Ventilation or Extubation
Most spinal surgery patients, including those who have undergone posterior
fusion, can be extubated shortly after the procedure if preoperative pulmonary
function was acceptable. Extubation is also advantageous since the neurological
assessment is facilitated. However, residual narcotics or muscle relaxants can
lead to hypoventilation or apnea, especially in patients with an associated neuro-
muscular disease. The need for postoperative ventilation [23, 29] is determined
by patient and surgery related factors (
Table 1). Frequently, it is necessary only to
provide artificial ventilation for a few hours in the postoperative care unit, until
hypothermia and metabolic derangements have been corrected.

Table 1. Influences on the need for postoperative ventilation
Patient-related factors Surgery-related factors
presence of a preexisting neuromuscular disorder prolonged procedure (>5 h)
severe restrictive pulmonary dysfunction with a preopera-
tive < 35 % predicted vital capacity
congenital cardiac abnormality
right ventricular failure
obesity
exposing > 3 vertebral bodies
thoracic approach
blood loss >30 ml/kg
transfusion of large volumes of blood and fluid
hypothermia
Cervical Spine Surgery
Perform airway assessment
before extubation
At the conclusion of anterior cervical spine surgery, before extubation, it is advis-
able to perform a thorough airway assessment, in order to avoid a “can’t intubate,
can’t ventilate” situation. This can be done by direct laryngoscopy, fiberoptic
evaluation or by performing a cuff test.
Suction drainage and close
surveillance minimize the
risk of unrecognized bleed-
ing after anterior cervical
spine surgery
Postoperative bleeding after anterior cervical spine surgery can become a life-
threatening situation when reintubation is impossible due to the hematoma pres-
sure. In such cases, on-site emergency opening of the wound and reintubation or
tracheotomy is the only means to save the patient. We therefore recommend rou-
418 Section Peri- and Postoperative Management

tine suction drainage after anterior cervical spine surgery to minimize the risk of
this delirious complication and we keep these patients in the recovery room over-
night for surveillance.
Thoracic Spine Surgery
Anterior thoracic and thoracolumbar approaches usually require chest tube
placement. These drains should be checked regularly to ensure patency. Obstruc-
tion may lead to a pneumo- or hemothorax. This should always be considered as
a potential cause of postoperative respiratory distress.
Aggressive postoperative
pulmonary care minimizes
the risk of atelectasis
and pneumonia
Aggressive pulmonary care, including spirometry, physiotherapy and early
mobilization, is necessary to avoid postoperative atelectasis and pneumonia.
If prolonged periods of mechanical ventilation are necessary because of respi-
ratory insufficiency, the endotracheal tube should be replaced by a cuffed trache-
ostomy tube. This should be performed sooner rather than later if prolonged
ventilation is anticipated.
Hemodynamic Assessment
Continued hemorrhage remains a concern during the postoperative period and
careful monitoring is essential with regard to:
blood pressure
urine output
central venous pressure
wound drainage
Gravity suction drainage
and correction of hemo-
stasis reduce excessive
postoperative bleeding
If postoperative bleeding is considerable, removal of the vacuum can solve the

problem in the vast majority of cases. If coagulation abnormalities are suspected
from clinical findings, the hemostasis parameter should be checked.
Neurological Assessment
Neurological surveillance
is mandatory to detect
neurological deterioration
Surgeons prefer patients to be conscious and able to respond to commands
immediately after anesthesia for early neurological assessment [20]. Therefore,
postoperatively patients should be adequately analgo-sedated to allow neurolog-
ical evaluation, and motor control of the extremities should be possible at any
time. Neurological control should be performed regularly at short intervals to
detect neurological deterioration.
Magnetic resonance
imaging should be per-
formed to determine
thecauseofadenovo
neurological deficit
When such a finding is noted, an immediate investigation should be done to
determine the cause and reversibility of the process. When available, magnetic
resonance imaging should be performed to detect extrinsic spinal cord compres-
sion by bone, intramedullary swelling or hematoma.
After correction of severe spinal deformities, postoperative (late onset) neuro-
logical deterioration can arise because of interference with the circulation to the
spine leading to anterior spinal artery syndrome [26].
After anterior cervical fusion, recurrentlaryngealnerveinjuryhas been
reported [15]. Dissection involving levels T1–2 can result in a postoperative Hor-
ner syndrome caused by injury to the stellate ganglion [8]. A case of bilateral
phrenic nerve palsy as a complication of anterior decompression and fusion has
been described [10]. After iliac crest bone grafting, one has to be aware of possi-
ble neurological deficits involving the lateral femoral cutaneous, ilioinguinal and

superior cluneal nerves [19].
Postoperative Care and Pain Management Chapter 16 419
Gastrointestinal Function
Postoperative paralytic
bowel dysfunction can
be ameliorated by thoracic
epidural analgesia
Intraoperative irritation of sympathetic splanchnic nerves causes postoperative
paralytic bowel dysfunction, which can be made worse by activation of the sym-
pathetic system due to pain and the large amounts of opioids necessary for suffi-
cient analgesia. After major spinal surgery, a more rapid recovery of bowel func-
tion has been documented if postoperative analgesia is performed through a tho-
racic epidural catheter [2, 3].
Thromboembolic Prophylaxis
Low-molecular-weight
heparins prevent deep vein
thrombosis and thrombo-
embolic complications
Although deep vein thrombosis and thromboembolic complications occur after
spinal surgery at a lower rate compared to other orthopedic procedures, they can
contribute disproportionately to morbidity and mortality [7]. Patients undergo-
ing spinal surgery may be at increased risk of thromboembolic disease as a result
of prolonged surgery, prone positioning, malignancy, and extended periods of
postoperative recumbency. Appropriate preventive measures include the use of
compressive stockings, early mobilization and prophylactic administration of
low-molecular-weight heparins [22].
Postoperative Pain Management
Consequences of Pain
Postoperative pain after
spinal surgery can be severe

Pain management can be a major challenge after spinal surgery (see Chap-
ter
5 ). The alleviation of postoperative pain is primarily provided for hu-
manitarian reasons, but also to reduce nociception-induced responses, which
may adversely influence organ functioning and contribute to morbidity [16].
A common feature shared by all surgical patients is the widespread changes in
several biological cascade systems, including a predominance of catabolic
hormones, activation of cytokines, complement arachidonic acid metabolites,
nitric oxide, and free oxygen radicals, all of which may secondarily lead to
organ dysfunction and morbidity. Pain may obviously be considered as
another neurophysiological response to surgery but with its own secondary
effects on biological functions. Pain amplifies the metabolic response, auto-
nomic reflexes, ileus, and nausea and delays mobilization and feeding. Effec-
tive treatment of postoperative pain, therefore, results in modification of the
biological response to surgery, but the extent of modification is dependent on
the choice of analgesic technique [18].
Patients undergoing spinal surgery, particularly through a thoracic ap-
proach, may have a large incision extending over several dermatomes. Many
patients have preexisting chronic pain conditions, may be cognitively im-
paired (some have neuromuscular disorders), or may be very young. A multi-
modal approach to analgesia (see Chapter
5 ) is recommended [17], using an
appropriate combination of (
Table 2
):
Table 2. Multimodal analgesia
acetaminophen (paracetamol)
non-selective cyclooxygenase inhibitors
COX-2 inhibitors
opioids

local anesthetics
2
-agonists
ketamine
regional anesthesia techniques
A multimodal approach to
analgesia facilitates ambula-
tion and respiratory care
Adequate analgesia facilitates early ambulation and aggressive respiratory care,
which are important to decrease patient morbidity postoperatively.
420 Section Peri- and Postoperative Management
Non-narcotics
Acetaminophen and NSAIDs
exhibit an opioid-sparing
effect
Non-opioid analgesics (acetaminophen) and non-steroidal anti-inflammatory
drugs (NSAIDs) play a central role in the management of postoperative pain,
since they have shown an opioid-sparing effect, but there is little evidence for an
additive analgesic effect of two non-opioid analgesics.
Acetaminophen should not
begiveninpatientswith
impaired liver function
Acetaminophen can be part of a multimodal pain therapy without great risk,
with the exception of patients with impaired liver function. It has an additional
antipyretic potency.
Non-steroidal Drugs
Both non-selective cyclooxygenase inhibitors (NSAIDs) and the selective cycloo-
xygenase-2 (COX-2) inhibitors have been used successfully for pain therapy in
different orthopedic surgical contexts, including spinal surgery [21].
The use of non-selective NSAIDs may increase bleeding time by 30±35%,

cause gastritis and be associated with acute renal failure, particularly in the pres-
ence of hypovolemia and hypotension. COX-2 inhibitors have an analgesic effi-
cacy comparable to non-selective NSAIDs, but are associated with an absence of
antiplatelet activity and reduced gastrointestinal side effects. However, because
both COX-1 and COX-2 are present in the kidney, COX-2 inhibitors require the
same caution with their use regarding renal toxicity as non-selective NSAIDs,
and special caution is warranted not to further decrease an already impaired
renal function, especially in diabetic patients under concomitant ACE-inhibitor
therapy for blood pressure control.
The influence of these drugs on bone healing and bone-tendon healing is con-
troversial [12]. The results of experimental and animal studies with long-term
administration probably cannot be transferred to the perioperative setting when
these drugs are prescribed for a limited duration of some days.
Non-selective NSAIDs and
selective COX-2 inhibitors
should be used for a short
postoperative period
The concerns regarding increased cardiac risk following the long-term
administration of COX-2 inhibitors have to date only been demonstrated for
rofecoxib, which therefore has been withdrawn from the market. In our hands,
the use of NSAIDs and COX-2 inhibitors for up to 10 days after surgery has
become a standard of (our) care and does not seem to have noticeable side
effects.
Opioids
Subcutaneous or intramus-
cular opioid administration
exhibit a poorly predictable
time course for the
maximum analgesic effect
Opioids can be administered by different routes. The use of parenteral opioids

has been the mainstay of analgesia for all patients undergoing spinal surgery.
Subcutaneous or intramuscular administration has the major drawback of
uncontrolled absorption and distribution, unpredictable time to maximal
effect and unpredictable duration of action. Because of the aspects mentioned,
intravenous administration [con tinuous infusion and p atient-controlled anal-
gesia (PCA) devices with or without background infusions] should be pre-
ferred.
Opioids can also be given epidurally or intrathecally. The thecal sac is readily
accessible during spinal surgical procedures and intrathecal medication can be
injected with technical ease before wound closure. Early reports of the use of
intrathecal opioids for analgesia in children after spinal surgery and other major
surgeries have suggested that the use of morphine 20–30 mg/kg is associated
with excellent analgesia for up to 24 h. More recent studies suggest the optimum
dose of morphine to be 2±5 mg/kg, which provides a comparable analgesia for
24 h but with fewer side effects [5, 13].
Postoperative Care and Pain Management Chapter 16 421
Independently of the way they are administered, the use of opioids is associated
with side effects such as:
respiratory depression
nausea and vomiting
pruritus
urinary retention
sedation
ileus
Opioid-related side-effects
are independent of the
route they are administered
The latter gastrointestinal side-effect may be especially disadvantageous after
major spinal surgery, when some degree of paralytic ileus is common.
There is the possibility of reducing postoperative parenteral opioid consump-

tion by the administration of an oral slow release opioid formula, which is intro-
duced preoperatively [4]. Patients with cancer or other patients who have
received long-term opioids preoperatively by different routes (e.g., enteral, trans-
dermal) must be assumed to have acquired a degree of opioid tolerance and these
drugs should also be restarted as early as possible postoperatively.
Local Anesthetics
Administration of local
anesthetics through
epidural catheters allows
for excellent pain control
The use of local anesthetic agents alone or in combination with opioids by the
epidural route after spinal surgery has been described [27]. For scoliosis correc-
tion surgery with a dorsal or ventrodorsal approach, the use of continuous epidu-
ral analgesia with plain local anesthetic solution through one or two epidural
catheters placed intraoperatively by the surgeon has been shown to provide effi-
cient postoperative pain control with early recovery of bowel function, few side-
effects and a high patient satisfaction [2, 3].
Epidural analgesia with local anesthetic agents can make neurological assess-
ment difficult. Since the early postoperative period is critical for the appearance
of a postoperative neurological deficit, there is the possibility of performing anal-
gesia with a potent opioid (e.g., remifentanil) up to the first postoperative morn-
ing. After a thorough assessment of the neurological status, epidural analgesia
canbeintroduced.Theadministrationrateofthelocalanestheticcanbeguided
according to the level of motor and sensory blockade [2, 3].
Continuous administration
of local anesthetics
to the iliac crest after
bone grafting relieves
donor site pain
The continuous administration of local anesthetics to the iliac crest after bone

grafting through a catheter placed by the surgeon at the end of the procedure is
another new indication for these drugs [1].
N-Methyl-D-aspartate Antagonists
Low-dose ketamine
is helpful for acute
postoperative pain
TheroleoftheN-methyl-D-aspartate (NMDA) receptor in the processing of noci-
ceptive input has led naturally to renewed clinical interest in NMDA receptor
antagonists such as ketamine. It is a well-known general anesthetic and short-
acting analgesic which has been in use for almost three decades. The efficacy of
low-dose ketamine in the management of acute postoperative pain when admin-
istered alone or in conjunction with other agents via the oral, intramuscular, sub-
cutaneous, intravenous or epidural routes has been described and evidence sug-
gests that low-dose ketamine may play an important role in postoperative pain
management when used as an adjunct to local anesthetics, opioids or other anal-
gesic agents [24]. Low-dose ketamine is defined as a bolus dose of less than 2 mg/
kg body weight when given intramuscularly or less than 1 mg/kg body weight
when administered via the intravenous or epidural route. For continuous i.v.
administration, low-dose ketamine is defined as a rate of at most 20 μg/kg body
weight per minute.
422 Section Peri- and Postoperative Management
Ketamine may provide clinicians with a tool to improve postoperative pain man-
agement and to reduce postoperative opioid consumption and consecutively opi-
oid-related adverse effects. The S-enantiomer of this drug, which is not available
in all countries, has about a two times increased potency with a preferable side-
effect profile.
Recapitulation
Postoperative care. Patients for spinal surgery often
have significant comorbidities, and surgery imposes
further stresses of blood loss, mass transfusion, coa-

gulopathy, hypothermia, impaired pulmonary func-
tion and acute postoperative pain. Perioperative
tachycardia has to be treated since it is often com-
bined with ischemia, which increases the risk of pe-
rioperative myocardiac infarction.Intensivepost-
operative insulin therapy can reduce mortality. The
need for postoperative ventilation is suggested by
patient and surgical factors, but most spinal surgery
patients can be extubated shortly after the proce-
dure or need artificial ventilation only for a few
hours. Aggressive postoperative pulmonary care
helps to avoid atelectasis and pneumonia. Monitor-
ing of blood pressure, urine output, central venous
pressure, chest tubes and wound drainage is essen-
tial. Neurological assessment to detect neurologi-
cal deterioration is important, and immediate inves-
tigation (and when available magnetic resonance
imaging) should follow any suspicious finding. In-
traoperative irritation of sympathetic splanchnic
nerves, activation of the sympathetic system due to
pain and large amounts of opioids cause postopera-
tive paralytic bowel dysfunction. Preventive mea-
sures for thromboembolic disease include the ad-
ministration of low-molecular-weight heparins.
Postoperative pain management. A multimodal
approach to analgesia is recommended since ade-
quate analgesia allows early ambulation and ag-
gressive respiratory care. Non-opioid analgesics
haveshownanopioid-sparingeffect.Acetamino-
phen can be given without great risk. Non-selective

NSAIDs cannot be recommended for intraoperative
and early postoperative analgesia. COX-2 inhibitors
have analgesic efficacy comparable to non-selective
NSAIDs,butareassociatedwithanabsenceofanti-
platelet activity and reduced gastrointestinal side
effects, while requiring the same cautions regarding
renal toxicity as non-selective NSAIDs. Opioids are
potent analgesics and can be administered by dif-
ferent routes. Intravenous administration (continu-
ous infusion or patient-controlled) is preferred. In-
dependently of the way they are administered, their
use is associated with side effects such as respirato-
ry depression, nausea and vomiting, pruritus, uri-
nary retention, sedation, and gastrointestinal ileus.
Continuous local anesthetic agents through the
epidural route after spinal surgery have been shown
to provide efficient postoperative pain control with
early recovery of bowel function, few side effects
and high patient satisfaction. Continuous local an-
esthetic administration to the iliac crest after bone
grafting is another new indication for these drugs.
The efficacy and opioid-sparing effect of low-dose
ketamine in the management of acute postopera-
tive pain has been described. The S-enantiomer of
this drug has an increased potency with a preferable
side-effect profile.
Key Articles
van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlassela-
ers D, Ferdinande P, Lauwers P, Bouillon R (2001) Intensive insulin therapy in the criti-
cally ill patients. N Engl J Med 345:1359 – 67

It was proven for the first time in this prospective study of 1548 adults admitted to the
surgical intensive care unit that intensive intravenous insulin therapy to maintain blood
glucose at between 4.4 and 6.1 mmol/l can reduce mortality during intensive care and
during hospital stay, decrease the incidence of infectious complications and shorten
mechanical ventilation.
Kehlet H (1997)Multimodalapproachtocontrolpostoperativepathophysiologyand
rehabilitation. Br J Anaesth 78:606 – 17
The author demonstrates why no single technique or drug has been shown to eliminate
postoperative morbidity and mortality, and why multimodal interventions may lead to a
Postoperative Care and Pain Management Chapter 16 423