Post Operative Surgical Pain

The goal of postoperative pain control is to reduce the negative consequences of acute postsurgical pain and help the patient transition smoothly back to normal function. Traditionally, opioid analgesic therapy has served as the mainstay of treatment for acute postoperative pain. However, opioid misuse has led to increasing demands for more investigative efforts into developing pain treatment strategies that emphasize using a multimodal approach.

This activity explores the repercussions of inadequate pain control, emphasizing the increased risk of chronic pain and patient dissatisfaction. Learners grasp the significance of optimized postoperative pain control in improving immediate outcomes, reducing hospital stays, and enhancing overall patient satisfaction. By participating in this course, the interprofessional team enhances its competence in navigating the complexities of postoperative pain management, ultimately contributing to superior patient care and outcomes. Through collaborative efforts, the healthcare team ensures comprehensive care that addresses the multifaceted aspects of postoperative pain.

Objectives:

• Identify the indications and contraindications for postoperative pain control.

• Select the equipment, personnel, preparation, and technique needed for postoperative pain control.

• Review and evaluate the potential complications and clinical significance of postoperative pain control.

• Coordinate interprofessional team strategies for improving care coordination and communication to improve postoperative pain control and patient outcomes following surgery.

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Treatment Type:

Many preoperative, intraoperative, and postoperative interventions and management strategies are available and continue evolving to reduce and manage postoperative pain.  Below is a list of multimodal treatments for postsurgical pain:

• Systemic pharmacologic therapy

• Local, intra-articular, or topical techniques

• Regional anesthetic techniques

• Neuraxial anesthetic techniques

• Nonpharmacologic therapies (eg, cognitive modalities, physical therapy, transcutaneous electrical nerve stimulation)

Systemic pharmacologic therapy: Commonly used medications for postoperative pain control include opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, steroids, gabapentin or pregabalin, IV ketamine, and IV lidocaine. Intramuscular medications are discouraged. Oral administration of opioid medication is preferable over the intravenous route. However, during circumstances in which a parenteral route of medication administration is needed (eg, risk of aspiration, ileus), intravenous patient-controlled analgesia (PCA) is recommended. With PCA analgesia, avoid a basal infusion of opioid medication in opioid-naïve patients. Adding acetaminophen or NSAIDs is associated with reduced opioid consumption and better pain control than using opioids alone. Gabapentin or pregabalin are recommended for administration preoperatively, especially in opioid-tolerant patients, as they have been shown to reduce opioid requirements. Due to its extensive side effect profile, ketamine is only for major surgeries in highly opioid-tolerant or opioid-intolerant patients. Intraoperative IV lidocaine infusions have associations with a shorter duration of ileus and better analgesic control compared to placebo.

Local, intra-articular, or topical techniques: For targeted pain control, diverse methods, including peripheral nerve blocks, intra-articular anesthetic injections, anesthetic wound infiltration, and topical anesthetics, can be employed. Although these methods are not commonly used, their administration should be based on beneficial evidence.

Regional anesthetic techniques: A local anesthetic with or without the addition of IV opioid medication is an option for a fascial plane block, site-specific regional anesthetic injections, or, in some cases, epidural injections, depending on the type of procedure performed. An anesthesiologist typically performs these techniques under ultrasound guidance. Continuous IV medication (in drip form) is preferable to single-injection techniques in cases where postoperative pain is prolonged. Intrapleural analgesia is not recommended for pain control as there is little evidence to suggest benefits, and high systemic absorption within the pleural space increases the risk of drug toxicity.

Neuraxial anesthetic techniques: This typically involves an epidural injection with local anesthetic with or without the addition of IV opioid medication; this may also include the intrathecal (spinal) injection of opioid medicines. Epidural analgesia may be given as a continuous infusion or as patient-controlled analgesia. These techniques are routinely used in major thoracic and abdominal procedures, cesarean sections, and hip or lower extremity surgeries. They are especially beneficial in patients at risk for cardiac or pulmonary complications or prolonged ileus.

Nonpharmacologic therapies: Nonpharmacologic therapies used in pain control include cognitive and mechanical modalities such as transcutaneous electrical nerve stimulation.