What are the recommendations for managing postoperative pain at the surgical site?

Postoperative Surgical Site Pain Management

Multimodal analgesia combining acetaminophen, NSAIDs, and regional anesthetic techniques should be the foundation of postoperative surgical site pain management, with opioids reserved only as rescue therapy for breakthrough pain. 1

Core Pharmacological Strategy

First-Line: Non-Opioid Foundation

• Acetaminophen 1 gram IV every 8 hours should be initiated immediately postoperatively as the cornerstone analgesic, as it provides superior safety compared to other agents and significantly reduces opioid requirements. 1, 2

• NSAIDs should be added when contraindications are absent (no renal dysfunction, bleeding risk, or peptic ulcer disease), as they provide additive analgesia and further decrease narcotic consumption through different mechanisms of action. 1, 3

• COX-2 inhibitors (coxibs) may be substituted if traditional NSAIDs are contraindicated due to bleeding concerns, though cardiovascular risk must be assessed. 1

Second-Line: Adjuvant Medications

• Gabapentinoids (pregabalin 75-150 mg every 12 hours or gabapentin 300-600 mg every 8 hours) should be added for patients not achieving adequate analgesia with acetaminophen and NSAIDs alone, as they reduce central sensitization and provide opioid-sparing effects. 1, 2, 3

• Low-dose ketamine infusions can reduce opioid requirements in severe postoperative pain, though this requires appropriate monitoring. 3

Third-Line: Opioid Rescue Only

• Opioids must be minimized and used only as rescue therapy for breakthrough pain unresponsive to the multimodal regimen, as they worsen ileus, delay recovery, and increase adverse events. 1, 2

• Patient-controlled analgesia (PCA) provides superior pain control compared to continuous infusion when opioids are necessary. 3

• Short-acting opioids are preferred over long-acting formulations for postoperative pain. 3

Regional Anesthetic Techniques

Procedure-Specific Blocks

• Transversus Abdominis Plane (TAP) block provides significant pain reduction at 12 hours post-abdominal surgery and should be strongly considered for laparotomy or laparoscopic procedures. 3

• Rectus sheath block is recommended before laparoscopic abdominal procedures. 3

• Paravertebral block and erector spinae plane (ESP) block should be strongly considered for thoracic procedures, as they provide superior analgesia and reduce chronic pain development. 1

• Serratus anterior plane block can effectively reduce pain after thoracic surgery. 1

Neuraxial Techniques

• Thoracic epidural analgesia (TEA) attenuates surgical stress response, improves intestinal blood flow, reduces paralytic ileus incidence, and hastens recovery of bowel function, making it particularly valuable for major abdominal and thoracic procedures. 2

• Preservative-free dexmedetomidine added to local anesthetic in regional blocks enhances analgesia duration. 1

Pain Assessment Protocol

Preoperative Risk Stratification

• Identify high-risk patients preoperatively by assessing for preoperative pain (even distant from surgical site), chronic opioid use, anxiety (using APAIS scale), depression, and planned high-risk procedures (thoracotomy, sternotomy, breast surgery, procedures >3 hours duration). 1

• Surgical factors increasing chronic pain risk include repeat operations on previously operated sites due to nerve damage in scar tissue. 1

Postoperative Monitoring

• Pain must be assessed regularly using validated scales (Numerical Rating Scale, Visual Analog Scale, or Verbal Rating Scale) both at rest and during movement. 1, 3

• Reassess after each intervention at appropriate intervals based on the medication's expected onset of action. 3

• Monitor for neuropathic pain development using the DN4 scale, as early neuropathic pain predicts chronic postsurgical pain. 1

• For non-communicating patients, use modified FLACC scale (children) or ALGOPLUS scale (elderly). 1

Critical Pitfalls to Avoid

• Never rely on opioids as monotherapy, as this increases side effects (nausea, vomiting, sedation, ileus, respiratory depression) without providing superior analgesia compared to multimodal approaches. 1

• Do not delay pain assessment or treatment, as uncontrolled acute postoperative pain increases risk of chronic postsurgical pain, pneumonia, deep vein thrombosis, cardiovascular events, and depression. 1

• Avoid fluid overload, as this worsens intestinal function and delays recovery. 2

• Do not use nasogastric decompression routinely, as this can worsen gas-related symptoms and delay bowel recovery. 2

• Monitor high-risk patients closely for respiratory depression (age >70 years, first-time opioid users, sleep apnea, high BMI) when opioids are necessary. 1

Enhanced Recovery Considerations

• Early mobilization is mandatory to reduce pain, promote intestinal motility, and accelerate recovery. 2

• Chewing gum should be initiated as soon as tolerated to accelerate return of bowel function and reduce ileus duration. 2

• Preemptive analgesia before surgical incision reduces postoperative opioid consumption. 1

• Oral administration is preferred over IV when feasible and drug absorption can be reasonably assured. 1