Ciri-ciri Suami Yang Baik Menurut Islam

buat bakal suamiku ,

Sayang ... saya berdoa sayang dalam kalangan ini ... :)

1. Berkemampuan

sebagaimana hadis Nabi Riwayat Ahmad Bukhari dan Muslim dari Abu Hurairah yang bermaksud:

"Wahai permuda-pemuda; barang siapa diantara kamu bernikah, maka hendaklah ia bernikah, yang demikian itu amat menundukkan pandangan dan amat memelihara kehormatan, tetapi barang siapa yang tidak mampu, maka hendaklah berpuasa kerana puasa itu menahan nafsu." Mampu yang dimaksudkan, berupaya menyediakan tempat tinggal, saraan hidup yang kebiasaan, serta pakaian untuk menutup aurat. Seperti memberi makan dengan apa yang dia(suami) sendiri makan, memberi pakaian dengan apa yang dia sendiri pakai. Bukan bermaksud memberi pakaian lelaki kepadaisterinya, tetapi taraf kualiti sesuatu itu, yang diperuntukkan untuk dirinya, itulah yang diperuntukkan untuk isterinya juga. Maknanya lelaki yang bertanggung jawab. Perkara-perkara ini wajib dilaksanakan suami dan kegagalan menyempurnakannya boleh mendatangkan kesan buruk dan mudah berlaku perceraian.

2. Tidak Dayus

Sanggup menjadi pembela isterinya. Boleh dijadikan sebagai ganti ayah bonda. Sanggup melindungi wanita daripada segala bahaya dan kecelakaan yang menimpa kerana apabila seorang wanita rela dinikahi, bererti ia rela melepaskan dirinya daripada ayah bonda yang selama ini menjadi tempat pergantungan hidup. Kini berpindah kepada lelaki yang bakal menjadi suaminya.

3. Pandai menjaga darjat diri dan menepati janji

Apabila berkata dikota dan diamalkan. Selain daripada itu suami yang baik akan sentiasa mengajak isteri ke arah kebaikan, menjauhkan yang mungkar dan mendahului perbuatan itu.

4. Berkebolehan didalam urusan rumahtangga.

Kebolehan memasak, menjahit juga membasuh akan membantu kerana lelaki yang biasa membuat kerja begini, tidak akan membebankan isterinya membuat kerja rumah sekiranya isteri tiada kemampuan. Bukan dari jenis lelaki yang tidak bertimbang rasa, yang sentiasa memerintahkan isterinya itu dan ini tanpa mengira isterinya sakit atau kepenatan.(Bukan juga jalan kepada isteri itu untuk mengsambil lewakan layanannya kepada suami itu.)

5. Mempunyai penuh kepercayaan kepada perempuan dan tidak mudah bersangka buruk.

Biasanya apabila suami bertugas mencari nafkah maka isteri akan menjaga segala amanah harta dan anak di rumah. Sekiranya suami tidak mempunyai kepercayaan kepada isteri, ini bererti suami akan sentiasa menyangka buruk.

6. Rajin, berpemikiran luas dan tidak memakan harta perempuan.

Lelaki begini adalah ciri-ciri lelaki yang tidak pemalas, inginkan kemajuan serta tidak mengharapkan titik peluh isteri. Allah sangat tidak menyukai manusia yang hanya bertawakal dan menyerah diri tanpa usaha sedangkan kejayaan dicapai melalui usaha. (Sebenarnya secara peribadinya saya tidak berapa setuju dengan pendapat ini, kerana saya pernah berjumpa dengan kisah ini:[Khadijah ra. membuka isi hati kepada suaminya dengan ucapan: "Wahai Al-Amiin, bergembiralah! Semua harta kekayaan ini baik yang bergerak maupun yang tidak bergerak, yang terdiri dari bangunan-bangunan, rumah-rumah, barang-barang dagangan, hamba-hamba sahaya adalah menjadi milikmu. Engkau bebas membelanjakannya ke jalan mana yang engkau ridhoi !"

Dan sebagaimana Firman Allah SWT yang bermaksud: "Dan Dia (Allah) mendapatimu sebagai seorang yang kekurangan, lalu Dia memberikan kekayaan". (Adh-Dhuhaa: 8)] Dan seperti yang kita ketahui juga Khadhijah ra. telah menghabiskan hartanya demi membantu suaminya(Rasulullah s.a.w) dalam menegakkan Islam ini. Mungkinlah pendapat ‘memakan harta perempuan’ disini adalah sepertinya seorang suami yang tidak melakukan apa-apa dengan bersenang-senangan semata-mata. Dan menghabiskan harta isterinya dalam jalan sia-sia dan syahwat pula.)

7. Mudah memaafkan.

Sifat ini adalah sebahagian daripada sifat terpuji Rasullah ketika menegakkan agama Islam. Oleh itu suami bertanggungjawab sepenuhnya kepada isteri dan anak.

8. Datang daripada keturunan orang yang baik-baik lagi rajin beribadah.

Mempunyai akhlak dan budi bahasa mulia serta sangat menghormati orang tua, berpegangan agama lagi rajin beribadah dan tidak berpenyakit keturunan seperti gila atau penyakit merbahaya yang boleh membawa kepada kesengsaraan hidup.

Inilah serba sedikit pendapat-pendapat yang sempat saya kumpulkan. Tetapi apa yang lebih utama dari segala hujah itu tadi ialah Agamanya. Pilihlah yang beragama dan teguh dengan pegangan Islam ini. Tidak mengapa jika calon suami itu terkurang sedikit dari segi keduniaannya, tetapi lebih dari segi agamanya. Namun dalam mencari cirri-ciri suami yang baik itu, mari kita lihat juga ciri-ciri isteri yang baik itu bagai mana pula. Kerana tidak adil mengharapkan Allah menjodohkan kita dengan seorang lelaki yang baik akhlaknya sedangkan diri kita sendiri sangat memandang mudah pula pada yang demikian. Kerana Allah akan menjodohkan kamu sesuai dengan dirimu sendiri itu bagaimana.

surah An-Nur ayat 3, “Lelaki yang berzina tidak dinikahi melainkan dengan perempuan yang berzina atau perempuan musyrik dan perempuan yang berzina itu tidak dinikahi melainkan dengan lelaki yang berzina atau lelaki musyrik. Demikian itu terlarang kepada orang yang beriman.”

 

 

ikhlas ,

miss hano

25/6/2013 21:48

anesthesia general

hai ... here i am .. back with a lot of notes ... hihi , so .. for this section ~ i would like to share few words "perhaps" hihi ... regarding postoperative pain management ... take your time to read those articles . Thank You ^_^ MUAAHHH :)

Intrathecal morphine

February 10th, 2011 | Add a Comment

The intrathecal administration of opioids especially intrathecal morphine has emerged as a popular and effective form of postoperative pain control.

Intrathecal opioids are able to provide long-lasting analgesia after a single injection. They work by binding to the µ opioid receptors, which are located in the substantia gelatinosa of the dorsal horn of the spinal cord.

These receptors are concentration dependent and are typically not activated by systemic doses of opioids. Unlike intrathecal local anesthetics, intrathecal opioids provide analgesia without disrupting sensory, motor, or sympathetic functions.

Because of its hydrophilic properties and potent receptor affinity, preservative-free morphine (i.e., Duramorph or Astramorph) is the ideal opioid for intrathecal use.

The onset of analgesic effects is directly proportional to the lipid solubility of the opioid. Preservative-free morphine (along with hydromorphone and meperidine) has a relatively low lipid solubility and its onset of action is delayed for typically 20 to 40 minutes after administration.

The hydrophilic nature of the opioid also determines its duration of action. Preservative-free morphine is very hydrophilic and poorly lipid soluble, which extends its duration of analgesic effect up to 12 to 24 hours.

Because of its poor lipid solubility, intrathecal morphine remains in the cerebrospinal fluid (CSF) for a prolonged period of time. It is circulated through cerebral spinal bulk flow and eventually rises rostrally to supraspinal levels.

Intrathecal morphine, therefore, has bimodal analgesic effects. The first peak is soon after administration and is due to spinal opiate receptor binding. The second peak occurs 12 to 24 hours later and is due to supraspinal binding as the drug is circulated.

Compared with systemic dosing of morphine, intrathecal administration is effective in providing analgesia at a fraction of the systemic dose (0.25–0.5 mg) and thus has a much lower side-effect profile.

The side effects, however, are important to recognize and treat. Respiratory depression can be delayed up to 24 hours after administration and is due to the cephalad spread of intrathecal morphine to the opioid receptors in the medullary centers of the brain stem.

Thus, patients receiving intrathecal morphine must be closely monitored for up to 24 hours afterward for signs of respiratory depression.

Patients with postoperative pain despite having received intrathecal morphine present a management dilemma. Giving the patient additional systemic opioids must be done cautiously, as it may increase and potentiate the risk of respiratory depression.

Generally, patients who have received intrathecal morphine should not be placed on a patient-controlled analgesia machine and should be given only intermittent doses of short-acting narcotics until theintrathecal morphine analgesic effect occurs. Nonopioid analgesics can also be considered if not contraindicated after surgery.

Other intrathecal morphine side effects are similar to side effects of systemic morphine and include pruritus, nausea, vomiting, and urine retention. These effects are dose related and may be reversed with naloxone.

References

Raj PP, ed. Practical Management of Pain. 3rd Ed. St Louis: Mosby; 2000:180.

Rathmell JP, Lair TR, Nauman B. The role of intrathecal drugs in the treatment of acute pain. Anesth Analg 2005

Waldman SD, ed. Interventional Pain Management. 2nd Ed. Philadelphia: WB Saunders; 2001: 621 and 622

HERE... 

Pain Physician. 2007 Mar;10(2):357-66.

Drug-related side effects of long-term intrathecal morphine therapy.

Ruan X.

Source

Physician's Pain Specialists of Alabama, Mobile, AL, USA. xiuluruan@yahoo.com

Abstract

BACKGROUND:

The introduction of intrathecal opioid administration for intractable chronic non-malignant pain and cancer pain is considered as one of the most important breakthroughs in pain management. Morphine, the only opioid approved by FDA for intrathecal administration, has been increasingly utilized for this purpose. For over 3 decades, there have been numerous reports on the non-nociceptive side effects associated with ever increasing long-term intrathecal morphine usage.

OBJECTIVES:

To review the literature on side effects due to long-term intrathecal morphine therapy with discussions of alternate treatment options.

DESIGN:

English-language publications were identified through MEDLINE search and the bibliographies of identified articles were reviewed.

RESULTS:

Most side effects of intrathecal morphine therapy are dose dependent and mediated by opioid receptors. Common ones include nausea, vomiting, pruritus, urinary retention, constipation, sexual dysfunction, and edema. Less common ones include respiratory depression, and hyperalgesia. Catheter tip inflammatory mass formation is a less common complication that may not be mediated by opioid receptors.

CONCLUSION:

The utilization of intrathecal morphine administration for cancer and intractable non-malignant chronic pain represents an important leap forward in pain management. Yet, a wide variety of non-nociceptive side effects may also occur in susceptible patients. The side effects due to intrathecal morphine administration are mostly mediated by opioid receptors. Treatment usually involves the utilization of opioid receptor antagonist, such as naloxone. Patients considering intrathecal opioid pump therapy should be informed and advised about the possible side effects associated with long-term intrathecal morphine administration prior to placement of a permanent morphine infusion pump.


However ... in malaysia specifically our federal territory , we have provided pain management involving intrathecal morphine prior to obstetric patient in which only certain of the patient will having minor side effect ( should not be said side effect exactly) such as nauseated , vomiting , mild pruritus , or giddiness .By the way,  it will resolve in between 24 hours that we suggested the patient to drink a lot of water and encouraged early ambulation.   OH... oh... correct me if  i make some mistake... hihihi


Patient Controlled Analgesia 

Indications

• PCA is used for the management of moderate to severe pain when inadequate analgesia would result from oral analgesia or intermittent IV morphine boluses.

• The child must have the cognitive ability to understand the concept PCA and is willing to self-manage analgesia.

• Lack of normal hand function does not prevent patients from using PCA. A number of alternate handsets and a breath-triggered switch are available.

Contraindications to PCA

• If the child is unable to understand the concept of PCA or they do not wish to control their own analgesia, a nurse controlled opioid infusion would be more suitable.

Click to download PDF version (110 KB)

Prescription and program of PCA

• PCA is a specialised analgesia technique and is managed by CPMS. 
• Most patients are commenced on PCA in the recovery room. For other patients requiring PCA a referral needs to be made to CPMS by paging 5773(24 hours) and completing an inpatient consultation report sheet (MR2). The referrer needs to ensure that the patient's primary consultant has approved of CPMS involvement. 
• ONLY CPMS and Anaesthesia staff may prescribe PCA. For safety reasonsONLY Recovery or CPMS staff may program the PCA infusion pumps. 
• Morphine is the preferred opioid in most circumstances. Fentanyl or hydromorphone are alternative choices. Pethidine is NOT routinely used due to the concern for nor-pethidine toxicity. In some circumstances patients may have pethidine prescribed but this should only be for a short duration (generally less than 48 hours). 
• The PCA infusion is prescribed according to the guidelines on the Patient Controlled Analgesia attachment. This attachment is only valid if attached to a current medication chart (MR52). 
• If the prescription differs from the guidelines the designated box must be ticked.

PCA set up

• The PCA syringe must be prepared in accordance with RCH medication policy and labelled clearly with an intravenous additives label.

• PCA infusion pumps (Alaris P5000 PCA) must be used for all PCA infusions.

• The PCA infusion line should be clearly labelled with a blue IV opioid label at the 3-way-tap where the PCA line meets the maintenance line.

• 50 mL Braun Omnifix syringes are used for PCA, together with 180 cm minimum volume extension tubing.

• A 3-way-tap at the syringe end of the opioid infusion line is not required.

• The two authorised persons who make up each PCA syringe must sign the record of infusion on the Patient Controlled Analgesia attachment.

• Syringe and lines should be changed every 72 hours or more often depending on individual unit policy or the patient's medical condition.

• Keys for the PCA infusion pumps are kept with the ward drug keys on every ward. The operating theatre recovery room also has a set of PCA keys.

PCA delivery

• To avoid the IV occluding between PCA tries, the patient should have maintenance IV fluids (with a minimum infusion rate of 5 mL/hr) running through an infusion pump (IVAC or similar). No anti-reflux valves are required if an infusion pump is used. 
• The volume infused should be checked every hour and documented on the fluid balance chart. 
• The treatment for opioid overdose is the opioid antagonist naloxone (Narcan). Naloxone is available in the ward/unit drug cupboard and on the ward/unit resuscitation trolley. 
• The naloxone dose is available in 3 dose ranges: 1 microgram/kg for opioid induced pruritus and urinary retention 2 microgram/kg for excess sedation and 10 microgram/kg for resuscitation.

Concurrent drugs

• When opioid infusions are used, NO ORAL/ RECTAL/ INTRAVENOUS OR INTRAMUSCULAR opioids or sedative agents should be given without prior consultation with CPMS or an anaesthetist.

• Paracetamol, ketamine, local anaesthetics, tramadol and NSAIDs may be used concurrently with PCA infusions and may help to reduce opioid consumption and associated side effects.

Precautions

• If the patient is receiving other medication that may cause sedation (e.g. antihistamines, benzodiazepines or anticonvulsants), the patient may be at increased risk of sedation and respiratory depression. 
• Prolonged administration of opioid infusions and impaired liver and/or renal function may alter drug elimination with ALL opioids and possibly result in drug accumulation and toxicity.  
   
  • The morphine metabolite M3G causes CNS disturbances (including myoclonus and tremor) and the morphine metabolite M6G is a potent analgesic. Both these metabolites may accumulate in patients receiving long-term morphine infusions or patients with renal impairment. 
  • The hydromorphone metabolite H3G may accumulatein patients receiving long-term hydromorphone infusions orpatients with renal impairment. H3G can cause CNS disturbances (including confusion, tremor and agitation). 
  • Pethidine infusions may result in accumulation of the toxic metabolite
    nor-pethidine, which can cause CNS disturbances (including confusion, tremor and convulsions).
      
  • Prolonged fentanyl infusion may result in drug accumulation and potential increase in opioid related side effects. 
• Development of opioid tolerance with long-term administration of opioids may require the opioid dose to be increased. 
• Careful tapering of doses is important when weaning long-term opioids to avoid opioid withdrawal.

Parents and PCA

• It is important that the child's parents understand the concept of PCA, so they can support their child in its use.

• The child's parents must NOT push the PCA button for their child, but may encourage their child to use it as required.

Patient review

• CPMS reviews patients twice daily on week days and once daily on weekends and public holidays.

• If analgesia is inadequate or the patient is experiencing side-effects, CPMS must be called to review the patient.

• CPMS can be contacted at all times on pager 5773.

Observations

The following observations should be recorded on the general observation chart:

• Sedation score, respiratory rate and heart rate: 1 hourly until the PCA is ceased. [The need for less frequent observations for patients receiving long-term PCA should be discussed with CPMS.] It is important to accurately assess sedation during wake and sleep periods
• Pain score: 1 hourly while awake (using developmentally appropriate scale e.g. Wong-Baker Faces scale, Numeric scale, FLACC scale or PAT score).
    
• Vomiting score: 1 hourly  for the first 12 hours, then 4 hourly as indicated.
• Pulse oximetry: if indicated 

Indications for pulse oximetry: Pulse oximetry MUST BE implemented and used continuously in high-risk patients with: University of Michigan Sedation Scale (UMSS)  0 Awake and alert  1 Minimally sedated: may appear tired/sleepy, responds to verbal conversation and/or sound   2 Moderately sedated: somnolent/sleeping, easily aroused with light tactile stimulation or simple verbal command  3 Deep sedation: deep sleep, arousable only with deep or significant physical simulation  4 Unarousable  S Patient is sleeping  UMSS sedation score > 2 Significant cardiorespiratory impairment Sleep apnoea, snoring or airway obstruction Spot oximetry less than 94% SaO2 or patients receiving: Supplementary oxygen Concurrent sedative agents Clinical indicators for 'spot' pulse oximetry are: Tachypnoea or bradypnoea Respiratory distress Pallor or cyanosis or impaired oxygenation Confusion or agitation Hypotension Nurse concern

• PCA use: good and bad tries and total mg, recorded hourly. 
• The effectiveness of the analgesia should be recorded in the Nursing Progress notes or in the appropriate clinical pathway.

CPMS should be called if pain relief is inadequate after more than 5 good tries per hour for three hours.

Any observations outside normal values for age should be reported to CPMS +/- the primary treating team.

Complications

IF RESPIRATORY DEPRESSION OR OVERSEDATION IS SUSPECTED:

• CEASE the PCA
• CEASE all other infusions that could be contributing to sedation
• Attempt to rouse the patient
• Call 777 [MET team] if appropriate
• If apnoeic: administer bag & mask ventilation with 100% oxygen
• If breathing: maintain airway, monitor oxygen saturations and administer oxygen
  via face mask at 8 L/min
• Check circulation. If pulseless: commence chest compressions
• Administer naloxone per instructions on the attachment chart if opioid toxicity is suspected
• Call CPMS for urgent review

Ceasing the PCA

• The decision to cease the PCA should ideally be made in consultation with CPMS.

• Most patients self-wean off PCA, using it less as their pain decreases.

• Oral/rectal opioids may be administered immediately after the PCA is ceased.

• The date and time of ceasing the PCA must be recorded on the Patient Controlled Analgesia attachment chart.

• Any remaining opioid must be disposed of according to the RCH Drugs of Addiction policy.

• The PCA infusion pump must be returned to Recovery when it is no longer required.

akhirnya aku jatuh cinta....

*** entry kali ni mungkin agak bosan kott... yerlaa nk share pasal perasaan ...

Pada kala semua org sibuk dengan general election yg 13 ni... YEahhh yg penting Bn Mng...

Kami pulak sibuk membicarakan soal hati ... yerr... betul aku cemburu .. tapi tak dapat nak luahkan dgn kata.. kata... aku cuba jadi seorang yang positif ... dah bagus bler dia cerita his love story before ... its sadness ... and I am  jealous a bit sbb he still love that woman deep in his heart "he told me"...

Hmmm.... agak tragik la untuk aku nak buka hati lagi... takut... takut ... bila da sayang nanti .... the same thing will happen again ... I'm scared ...

Along cakap aku kena cuba ... but its my weakness .... having a heartbroken is painful. ... really hope ... hope that we will last forever ... we will getting to that stage ... I know he was a loyal man before ... but will he still be the same ? I'm wondering ...


Buat mse skang ni.... yeahh I think I love you ... but mungkin kah bila ur first love come back to you .... u will leave me ? Aku tanyer dia ... diam___________ then said " takla ... dah ada awak kan " ...but in his heart ?  I'm so sad ... huhuhu ...


Just ... what should I do for now ? ...sesungguhnya aku menyayangimu kerana Allah taala... e.j .




**************END*****************

Permata Hati

 

by Zaiful Ikhram (Notes) on Thursday, June 2, 2011 at 1:16am

 

 

Suara Hati Seorang Ikhwan
Suara Hati Seorang Ikhwan
untuk Seluruh Wanita Suci di Dunia
Wanita suci,
Mungkin aku memang tak romantis tapi siapa peduli?
Karena toh kau tak mengenalku
dan memang tak perlu mengenalku.
Bagiku kau bunga, tak mampu aku samakanmu dengan
bunga terindah sekalipun.
Bagiku manusia ialah makhluk yang terindah,
tersempurna & tertinggi.
Bagiku dirimu salah satu dari semua itu,
karenanya kau
tak membutuhkanpersamaan.

Wanita suci,
Jangan pernah biarkan aku manatapmu penuh,
karena akan membuat ku mengingatmu.
Berarti memenuhi kepalaku dengan
inginkanmu.
Berimbas pada tersusunnya gambarmu
dalam tiap dinding khayalku.
Membuatku inginkanmu sepenuh hati,
seluruh jiwa,
sesemangat mentari.
Kasihanilah dirimu jika harus hadir dalam khayalku
yg masih penuh Lumpur.
Karena sesungguhnya dirimu terlalu suci.

Wanita suci,
Berdua menghabiskan waktu denganmu
bagaikan mimpi tak berujung.
Ada ingin tapi tak ada henti.
Menyentuhmu merupakan ingin diri, berkelebat selalu,
meski ujung penutupmu pun tak berani kusentuh.
Jangan pernah kalah dengan mimpi & inginku karena
sucimu kaupertaruhkan.
Mungkin kau tak peduli
Tapi kau hanya menjadi wanita biasa
di hadapanku bila kau kalah.
Dan tak lebih dari wanita biasa.

Wanita suci,
Jangan pernah kautatapku penuh
Bahkan tak perlu kaulirikkan matamu
untuk melihatku.
Bukan karena aku terlalu indah,
tapi karena aku seorang yg masih kotor.
Aku biasa memakai topeng keindahan
pada wajah burukku, mengenakan pakaian sutra emas.
Meniru laku para rahib,
meski hatiku lebih kotor dari Lumpur.
Kau memang suci,
tapi masih sangat mungkin kau termanipulasi.
Karena kau toh hanya manusia-hanya wanita.

Wanita suci,
Beri sepenuh diri pada dia sang lelaki suci yg
dengan sepenuh hati membawamu kehadapan Tuhanmu.
Untuknya dirimu ada, itu kata otakku,
terukir dalam kitab suci, tak perlu dipikir lagi.
Tunggu sang lelaki itu
menjemputmu, dalam rangkaian khitbah & akad yg indah.
Atau kejar sang lelaki suci itu,
karena itu ialah hakmu, seperti dicontohkan ibunda Khadijah.
Jangan ada ragu, jangan ada malu,
semua terukir dalam kitab suci.

Wanita suci
bariskan harapanmu pada istikharah
sepenuh hati ikhlas.
Relakan Allah pilihkan lelaki suci
untukmu, mungkin sekarang / nanti,
bahkan mungkin tiada sampai kau mati.
Mungkin itu berarti dirimu terlalu suci untuk
semua lelaki di fana saat ini.
Mungkin lelaki suci itu menanti di istana kekalmu,
yg kaubangun dengan segala kekhusyu'an tangis do'amu.
Wanita suci
Pilihan Allah tak selalu seindah inginmu,
tapi itu pilihan-Nya.
Tak ada yg lebih baik dari pilihan Allah SWT.
Mungkin kebaikan itu bukan pada lelaki yg terpilih
itu, melainkan pada jalan yang kaupilih,
seperti kisah seorang wanita sudi di masa lalu yg
meminta ke-Islam-an sebagai mahar pernikahannya.
Atau mungkin kebaikan itu terletak pada keikhlasanmu
menerima keputusan Sang Kekasih Tertinggi.
Kekasih tempat kita memberi semua cinta & menerima cinta
dalam setiap denyut nadi kita.

Acute Pain Service

Article 1 :

Methodology


A. Definition of Acute Pain Management in the Perioperative Setting  , acute pain is defined as pain that is

present in a surgical patient after a procedure. Such pain may be the result of trauma from the procedure or

procedure related  complications. Pain management in the perioperative setting refers to actions before,

during, and after a procedure that are intended to reduce or eliminate postoperative pain


before discharge.
  APS (Acute Pain Service ) Guideline Purpose: 

(1) facilitate the safety and effectiveness of acute pain management in the perioperative setting;

(2) reduce the risk of adverse outcomes;

(3) maintain the patient’s functional abilities, as well as physical and psychologic

well-being; and

(4) enhance the quality of life for patients with acute pain during the perioperative period. Adverse outcomes

that may result from the undertreatment of perioperative pain  include (but are not limited to)

thromboembolic and pulmonary complications, additional time spent in an intensive care

unit or hospital, hospital readmission for further pain management, needless suffering, impairment of health-

related quality of life, and development of chronic pain. Adverse outcomes associated with the management

of perioperative pain include  (but are not limited to) respiratory depression, brain or other  neurologic

injury, sedation, circulatory depression, nausea, vomiting, pruritus, urinary retention, impairment of bowel 

function, and sleep disruption. Health-related quality of life  includes (but is not limited to) physical,

emotional, social, and  spiritual well-being.


*Patients with severe or concurrent medical illness such as


sickle cell crisis, pancreatitis, or acute pain related to cancer

or cancer treatment may also benefit from aggressive pain

control. Labor pain is another condition of interest to anesthesiologists.

However, the complex interactions of concurrent

medical therapies and physiologic alterations make it

impractical to address pain management for these populations

within the context of this document.    

Recommendations for Preoperative Preparation of the Patient.

Patient preparation for perioperative pain management should include appropriate adjustments or

continuation of medications to avert an abstinence syndrome, treatment of preexistent pain, or preoperative

initiation of  therapy for postoperative pain management.

Anesthesiologists offering perioperative analgesia service should provide, in collaboration with others as

appropriate,patient and family education regarding their important roles in achieving comfort, reporting pain,

and in proper use of the recommended analgesic methods. Common misconceptions  that overestimate the

risk of adverse effects and addiction  should be dispelled. Patient education for optimal use of

patient-controlled analgesia (PCA) and other sophisticated  methods, such as patient-controlled epidural

analgesia  might include discussion of these analgesic methods at the  time of the preanesthetic evaluation,

brochures and videotapes  to educate patients about therapeutic options, and discussion  at the bedside

during postoperative visits. Such education  may also include instruction in behavioral modalities

for control of pain and anxiety.

IV. Perioperative Techniques for Pain Management

Perioperative techniques for postoperative pain management

include but are not limited to the following single modalities:

(1) central regional (i.e., neuraxial) opioid analgesia;

(2) PCAwith systemic opioids; and

(3) peripheral regional analgesic techniques, including but not limited to intercostal blocks,

plexus blocks, and local anesthetic infiltration of incisions.

Central regional opioid analgesia: Randomized controlled trials report improved pain relief when use of

preincisional  epidural or intrathecal morphine is compared with  preincisional oral, intravenous, or

intramuscular morphine

(Category A2 evidence).36–39 RCTs comparing preoperative

or preincisional intrathecal morphine or epidural sufentanil

with saline placebo report inconsistent findings regarding

pain relief 
(Category C2 evidence).40–43 RCTs comparing

preoperative or preincisional epidural morphine or

fentanyl with postoperative epidural morphine or fentanyl

are equivocal regarding postoperative pain scores

(Category C2 evidence).44,45

Meta-analyses of RCTs46–54 report improved pain relief

and increased frequency of pruritus in comparisons of

postincisional epidural morphine and saline placebo

(Category A1 evidence); findings for the frequency of nausea or

vomiting were equivocal

(Category C1 evidence). Meta-analyses of RCTs comparing postincisional epidural morphine

with intramuscular morphine report improved pain relief

and an increased frequency of pruritus

(Category A1 evidence). 49,55–59

One RCT reports improved pain scores and

less analgesic use when postincisional intrathecal fentanyl is

compared with no postincisional spinal treatment

(CategoryA3 evidence).60

One RCT reports improved pain scores when postoperative

epidural morphine is compared with postoperative epidural

saline

(Category A3 evidence).61
Meta-analyses of RCTs62–70 report

improved pain scores and a higher frequency of pruritus

and urinary retention when postoperative epidural morphine is

compared with intramuscular morphine

(Category A3 evidence);

findings for nausea and vomiting are equivocal

(Category C2 evidence).

Findings from RCTs are equivocal

regarding the analgesic efficacy of postoperative epidural

fentanyl compared with postoperative IV fentanyl

(Category C2 evidence)71–74;

meta-analytic findings are equivocal

for nausea and vomiting and pruritus

(Category C1 evidence).72–76

PCA with systemic opioids: Randomized controlled trials

report equivocal findings regarding the analgesic efficacy of

IV PCA techniques compared with nurse or staff-administered

intravenous analgesia  (Category C2 evidence).77–80   
 V. Multimodal Techniques for Pain Management

Multimodal techniques for pain management include the

administration of two or more drugs that act by different

mechanisms for providing analgesia. These drugs may be

administered via the same route or by different routes.   SEE EXAMPLES OF CASE :   http://www.penncancer.org/pdf/NETs%20and%20Surgery_Karakousis.pdf     Appendix 1: Summary of

Recommendations

I. Institutional Policies and Procedures for Providing

Perioperative Pain Management

• Anesthesiologists offering perioperative analgesia services should

provide, in collaboration with other healthcare professionals as

appropriate, ongoing education and training to ensure that hospital

personnel are knowledgeable and skilled with regard to the

effective and safe use of the available treatment options within the

institution.

Educational content should range from basic bedside pain

assessment to sophisticated pain management techniques (e.g., epidural analgesia, PCA, and various regional anesthesia techniques)

and nonpharmacologic techniques (e.g., relaxation,

imagery, hypnotic methods).

For optimal pain management, ongoing education and training

are essential for new personnel, to maintain skills, and

whenever therapeutic approaches are modified.

• Anesthesiologists and other healthcare providers should use standardized,

validated instruments to facilitate the regular evaluation

and documentation of pain intensity, the effects of pain therapy,

and side effects caused by the therapy.

• Anesthesiologists responsible for perioperative analgesia should

be available at all times to consult with ward nurses, surgeons, or

other involved physicians.

They should assist in evaluating patients who are experiencing

problems with any aspect of perioperative pain relief.

• Anesthesiologists providing perioperative analgesia services

should do so within the framework of an Acute Pain Service.

They should participate in developing standardized institutional

policies and procedures.II. Preoperative Evaluation of the Patient

• A directed pain history, a directed physical examination, and a

pain control plan should be included in the anesthetic preoperative

evaluation.

III. Preoperative Preparation of the Patient

• Patient preparation for perioperative pain management should

include appropriate adjustments or continuation of medications to

avert an abstinence syndrome, treatment of preexistent pain, or preoperative

initiation of therapy for postoperative pain management.

• Anesthesiologists offering perioperative analgesia services should

provide, in collaboration with others as appropriate, patient and

family education regarding their important roles in achieving

comfort, reporting pain, and in proper use of the recommended

analgesic methods.

Common misconceptions that overestimate the risk of adverse

effects and addiction should be dispelled.

Patient education for optimal use of PCA and other sophisticated

methods, such as patient-controlled epidural analgesia,

might include discussion of these analgesic methods at the

time of the preanesthetic evaluation, brochures and videotapes

to educate patients about therapeutic options, and discussion

at the bedside during postoperative visits.

Such education may also include instruction in behavioral

modalities for control of pain and anxiety.

IV. Perioperative Techniques for Pain Management

• Anesthesiologists who manage perioperative pain should use

therapeutic options such as epidural or intrathecal opioids, systemic

opioid PCA, and regional techniques after thoughtfully

considering the risks and benefits for the individual patient.

These modalities should be used in preference to intramuscular

opioids ordered “as needed.”

• The therapy selected should reflect the individual anesthesiologist’s

expertise, as well as the capacity for safe application of the

modality in each practice setting.

This capacity includes the ability to recognize and treat adverse

effects that emerge after initiation of therapy.

• Special caution should be taken when continuous infusion

modalities are used because drug accumulation may contribute

to adverse events.   V. Multimodal Techniques for Pain Management

• Whenever possible, anesthesiologists should use multimodal pain

management therapy.

Unless contraindicated, patients should receive an aroundthe-

clock regimen of NSAIDs, COXIBs, or acetaminophen.

Regional blockade with local anesthetics should be considered.

• Dosing regimens should be administered to optimize efficacy

while minimizing the risk of adverse events.

• The choice of medication, dose, route, and duration of therapy

should be individualized VI. Patient Subpopulations

• Pediatric patients

Aggressive and proactive pain management is necessary to

overcome the historic undertreatment of pain in children.

Perioperative care for children undergoing painful procedures

or surgery requires developmentally appropriate pain assessment

and therapy.

Analgesic therapy should depend upon age, weight, and comorbidity,

and unless contraindicated should involve a multimodal

approach.

Behavioral techniques, especially important in addressing the

emotional component of pain, should be applied whenever

feasible.

Sedative, analgesic, and local anesthetics are all important components

of appropriate analgesic regimens for painful procedures.

Because many analgesic medications are synergistic with sedating

agents, it is imperative that appropriate monitoring be used during

the procedure and recovery.

• Geriatric patients

Pain assessment and therapy should be integrated into the

perioperative care of geriatric patients.

Pain assessment tools appropriate to a patient’s cognitive abilities

should be used. Extensive and proactive evaluation and

questioning may be necessary to overcome barriers that hinder

communication regarding unrelieved pain.

Anesthesiologists should recognize that geriatric patients may

respond differently than younger patients to pain and analgesic

medications, often because of comorbidity.

Vigilant dose titration is necessary to ensure adequate treatment

while avoiding adverse effects such as somnolence in this

vulnerable group, who are often taking other medications (including

alternative and complementary agents). • Other subpopulations

Anesthesiologists should recognize that patients who are critically

ill, cognitively impaired, or have communication difficulties

may require additional interventions to ensure optimal

perioperative pain management.

Anesthesiologists should consider a therapeutic trial of an analgesic

in patients with increased blood pressure and heart rate or

agitated behavior when causes other than pain have been excluded.

Appendix 2: Methods and Analyses

A. State of the Literature

For these updated Guidelines, a review of studies used in the

development of the original Guidelines was combined with studies

published subsequent to approval of the original Guidelines

in 2003.* The scientific assessment of these Guidelines was

based on evidence linkages or statements regarding potential relationships between clinical interventions and outcomes. The

interventions listed below were examined to assess their relationship

to a variety of outcomes related to the management of acute

pain in the perioperative setting.

Institutional Policies and Procedures for Providing Perioperative Pain

Management

Education and training of healthcare providers

Monitoring of patient outcomes

Documentation of monitoring activities

Monitoring of outcomes at an institutional level

24-h availability of anesthesiologists providing perioperative

pain management

Acute pain service

Preoperative Evaluation of the Patient

A directed pain history (e.g., medical record review and patient

interview to include current medications, adverse effects, preexisting

pain conditions, medical conditions that would influence a

pain therapy, nonpharmacologic pain therapies, alternative and

complementary therapies)

A directed physical examination

Consultations with other healthcare providers (e.g., nurses, surgeons,

pharmacists) Preoperative Preparation of the Patient

Preoperative adjustment or continuation of medications whose sudden

cessation may provoke an abstinence syndrome

Preoperative treatment(s) to reduce preexisting pain and anxiety

Premedication(s) before surgery as part of a multimodal analgesic

pain management program

Patient and family education

Perioperative Techniques for Pain Management

Epidural or intrathecal analgesia with opioids (vs. epidural placebo,

epidural local anesthetics, or IV, intramuscular, or oral opioids)

Patient-controlled analgesia with opioids:

IV PCA versus nurse-controlled or continuous IV

IV PCA versus intramuscular

Epidural PCA versus epidural bolus or infusion

Epidural PCA versus IV PCA

IV PCA with background infusion of opioids versus no background

infusion

Regional analgesia with local anesthetics or opioids

Intercostal or interpleural blocks

Plexus and other blocks

Intraarticular opioids, local anesthetics or combinations

Infiltration of incisions

Multimodal Techniques (Epidural, IV, or Regional Techniques) Two or more analgesic agents, one route versus a single agent, one route

Epidural or intrathecal analgesia with opioids combined with:

Local anesthetics versus epidural opioids

Local anesthetics versus epidural local anesthetics

Clonidine versus epidural opioids

IV opioids combined with:

Clonidine versus IV opioids

Ketorolac versus IV opioids

Ketamine versus IV opioids

Oral opioids combined with NSAIDs, COXIBs, or acetaminophen

versus oral opioids Two or more drug delivery routes versus a single route

Epidural or intrathecal analgesia with opioids combined with IV,

intramuscular, oral, transdermal, or subcutaneous analgesics versus

epidural opioids

IV opioids combined with oral NSAIDs, COXIBs, or acetaminophen

versus IV opioids

Nonpharmacologic, alternative, or complementary pain management

combined with pharmacologic pain management versus

pharmacologic pain management

Special Patient Populations

Pain management techniques for pediatric patients

Pain assessment techniques

Dose level adjustments

Avoidance of repetitive diagnostic evaluation (heel sticks) for neonates

Pain management techniques for geriatric patients

Pain assessment techniques

Dose level adjustments

Painmanagementtechniques for other special populations (e.g., cognitively

impaired, critically ill, patients with difficulty communicating)

Pain assessment methods specific to special populations

Pain management techniques specific to special populations

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