What is a recommended regimen for postoperative pain management?

Recommended Regimen for Postoperative Pain Management

Multimodal pain management should always be considered to improve analgesia while reducing individual class-related side effects; a pharmacological step-up approach including major opiates when necessary should be adopted. 1

Basic Analgesic Regimen

• The foundation of postoperative pain management should include a combination of acetaminophen and NSAIDs or COX-2 selective inhibitors, administered pre-operatively or intra-operatively and continued postoperatively 1
• Acetaminophen should be administered at the beginning of postoperative analgesia as it is better and safer than other drugs, with typical dosing of 1g every 6 hours 1
• NSAIDs (when not contraindicated) should be used for moderate pain when used alone, and in multimodal analgesia to reduce morphine consumption and related side effects 1
• A single intra-operative dose of intravenous dexamethasone 8-10 mg is recommended for its analgesic and anti-emetic effects 1

Regional Analgesia Techniques

• Epidural and regional anesthesia is recommended in emergency general surgery, whenever feasible and if not delaying emergency procedures 1
• Single-shot fascia iliaca block or local infiltration analgesia is recommended, especially if there are contraindications to basic analgesics and/or in patients with high expected postoperative pain 1
• Patients with neuraxial anesthesia must be monitored and assessed adequately 1

Opioid Management

• Opioids should be reserved as rescue analgesics in the postoperative period 1
• For opioid-naïve patients requiring oxycodone, initiate treatment in a dosing range of 5 to 15 mg every 4 to 6 hours as needed for pain 2
• Patient-controlled analgesia (PCA) is recommended when IV route is needed in patients with adequate cognitive functions, starting with bolus injection in opioid naïve patients 1
• The intramuscular route should be avoided in postoperative pain management 1

Adjuvant Medications

• Small doses of ketamine (maximum dose of 0.5 mg/kg/h after anesthesia induction) are recommended in surgeries with high risk of acute pain or chronic postoperative pain, and in patients with vulnerability to pain 1
• Gabapentinoids can be considered as a component in multimodal analgesia, though systematic preoperative use is not recommended 1
• Coxib administration may be considered if there are no contraindications 1

Special Considerations

• For patients with obstructive sleep apnea syndrome (OSAS), reduce opioid use as much as possible to prevent possible cardiopulmonary complications 1
• Be aware that younger age and female gender could be risk factors for acute postoperative pain 1
• Pre-emptive acetaminophen reduces 24-hour opioid consumption and postoperative vomiting 3

Monitoring and Assessment

• Regular assessment of pain using validated pain scales is essential 1
• After a pain intervention is completed, reassess patients for both pain control and adverse reactions at appropriate intervals 1
• A combined nurse service with clinician supervision provides better outcomes in acute postoperative pain management 1
• When a significant change in worsening pain level is reported, reevaluate the patient for possible postoperative complications 1

Common Pitfalls and Caveats

• NSAIDs should be used cautiously in patients with colon or rectal anastomoses due to potential correlation with dehiscence and wound healing inhibition 1
• Avoid exceeding maximum toxic doses of local anesthetics, particularly for peri-prosthetic orthopedic infiltrations 1
• Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine should be avoided 1
• Caution is needed when using acetaminophen in patients with liver disease 1
• Avoid combining coxibs and NSAIDs as their combination seems to increase the incidence of myocardial infarction and affects kidney function 1