New guidelines for management of postoperative pain have just been published jointly by several specialty societies (Chou 2016). The guidelines aim to use multimodal analgesic techniques so that use of opioids might be minimized.
There are 32 specific recommendations in all and the guidelines really focus on multimodal techniques that target different mechanisms of actions in the peripheral and central nervous systems.
Education of the patient should begin preoperatively and be specifically tailored to individual patients, taking into account medical, psychological and social factors. Such preoperative planning may help to reduce opioid consumption, anxiety, requests for sedation and ultimately reduce length of stay. Such educational interventions can range from single episodes of face-to-face instruction or provision of written materials, videos, audiotapes, or Web-based educational information to more intensive, multicomponent preoperative interventions including individualized and supervised exercise, education, and telephone calls. Such sessions should take into consideration health literacy, the language and cultural context of the patient/family, and allow sufficient time for asking questions. Though the timing of such preoperative sessions is uncertain, they should be far enough in advance to allow for discontinuation of certain medications prior to surgery and to avoid withdrawal syndromes from some medications.
The panel does recommend TENS (transcutaneous electrical nerve stimulation) and cognitive behavioral therapy (CBT) as potential nonpharmacologic adjuncts for pain management but found the evidence insufficient to recommend acupuncture, massage, or cold therapy.
The panel recommends use of oral, rather than intravenous, opioids where possible and also recommends avoidance of intramuscular analgesics. Where parenteral analgesia is needed the panel recommends use of intravenous patient-controlled analgesia (PCA) if the patient is a good candidate but recommends against a basal dose of opioids during PCA in opioid-naïve patients.
One overarching theme is use of multiple different analgesics to maximize efficacy of pain control while minimizing adverse effects. The panel recommends that clinicians provide adults and children with acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain in patients without contraindications and clinicians should consider giving a preoperative dose of oral celecoxib to adult patients if no contraindications. Other pharmacological considerations are use of oral gabapentin or pregabalin, IV ketamine, and IV lidocaine infusions for some procedures.
Other interventions in multimodal pain management may include surgical site-specific local anesthetic infiltration for surgical procedures with evidence indicating efficacy and use of topical local anesthetics in combination with nerve blocks for procedures like circumcision.
Surgical site-specific peripheral regional anesthetic techniques should be considered in adults and children for procedures with evidence indicating efficacy and use of continuous, local anesthetic-based peripheral regional analgesic techniques should be considered when the need for analgesia is likely to exceed the duration of effect of a single injection.
Neuraxial analgesia should be offered for major thoracic and abdominal procedures, particularly in patients at risk for cardiac complications, pulmonary complications, or prolonged ileus. But neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine should be avoided. Appropriate monitoring should be in place for those receiving neuraxial analgesia.
Each facility performing surgery should have an organizational structure in place to develop and refine policies and processes for safe and effective delivery of postoperative pain control.
There should be access to consultation with a pain specialist for patients with inadequately controlled postoperative pain or at high risk of inadequately controlled postoperative pain (eg, opioid-tolerant, history of substance abuse). And appropriately trained and credentialed physicians should be available for monitoring patients for whom neuraxial analgesia or continuous peripheral blocks are used.
Importantly, there should be adequate education of patients, parents, families, other caregivers and primary care physicians about appropriate tapering of analgesia after discharge from the hospital.
Overall, this is a comprehensive and well thought out guideline that summarizes the evidence from the literature and has practical recommendations for management of postoperative pain.
Also, the American Academy of Pediatrics has recently published its recommendations for critical elements for the pediatric perianesthesia environment (Polaner 2015). It does have a short section on perioperative pain management and has recommendations for monitoring infants whose immature respiratory control centers leave them vulnerable to effects of anesthesia and other drugs and those with obstructive sleep apnea.
Both guidelines do not specify who should provide the
preoperative planning and education. The American Society of Anesthesiologists
has good discussions on the
“Perioperative Surgical Home” and a recent abstract presented at the ASA annual meeting showed how a perioperative surgical home improves quality and reduces costs (Harrison 2015). But, logically, such planning and education should also be multidisciplinary. So a perioperative home staffed by anesthesiologists, nurses, physician extenders, and surgeons from specific departments may make sense. Such might also include pain specialists and clinical pharmacists to help deal with complex cases.
Chou R, Gordon DB, de Leon-Casasola OA, et al. Guidelines on the Management of Postoperative Pain. Management of Postoperative Pain: A Clinical Practice Guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. The Journal of Pain 2016; 17(2): 131-157
Polaner DM, Huck CS. AAP (American Academy of Pediatrics). Critical Elements for the Pediatric Perioperative Anesthesia Environment. Pediatrics 2015; 136(6): published online November 30, 2015
ASA (American Society of Anesthesiologists). Perioperative Surgical Home.
Anesthesiology 2015 from the American Society of Anesthesiologists (ASA): Abstract A1031. Presented October 24, 2015
As reported in: Harrison L. Perioperative Surgical Home Improves Quality, Reduces Costs. Medscape Medical News 2015; November 02, 2015