7 Principles to Improve Perioperative Pain Management

Whether you are a provider taking care of patients after a surgical procedure or YOU are the individual having surgery, there are some key components of optimal pain management.

Check out the article here

Although it is important to reduce the unnecessary use of opioid medications in the surgical population, there also remains an opportunity to address the inconsistencies and fragmentation of the current paradigm of pain care. This is a topic of great importance to me and I even published a journal article describing the current difficulties. Check out that article here

As Dr Mariano et al addressed in his article, 'to date there has been no large-scale, multisociety collaborative effort involving all specialties involved in surgical care to develop common guidelines for perioperative pain management'. To this end,

Guiding Principles

Principle 1 - A thorough preoperative evaluation should be conducted including:

- medical and psychological conditions

- concomitant medications

- history of chronic pain (or presence of baseline pain and rating)

- substance use disorder (or risk factors for such)

- previous postoperative treatment regimens and responses

Principle 2 - Clinicians should use a validated pain assessment tool to track responses to postoperative pain treatments and adjust treatment plans accordingly. I've blogged about these scales in the past. You can check it out here.

Briefly, the pain scales include the following:

Numeric Rating Scale (NRS) - the classic '0 through 10' pain scale. Self-report.

FLACC - an observational behavioral scale. An acronym for 'Faces, Legs, Activity, Cry, Consolability'.

FACES scale - a self-report scale for younger children

PIPP - Premature Infant Pain Profile (observational)

NIPS - Neonate Infant Pain Score (observational)

Principle 3 - Clinicians should offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with non-pharmacological interventions, for the treatment of postoperative pain in adults.

These modalities include first-line agents such as acetaminophen and NSAIDs like ibuprofen or ketorolac. Non-pharmacologic modalities such as ice, heat, acupuncture, acupressure, cognitive behavioral therapy, diaphragmatic breathing, and others can provide an added benefit and address various aspects of the pain experience. With procedures or conditions associated with moderate or intense pain, on occasion opioids might be a reasonable consideration weighing the risks and benefits. Regional anesthetics and local anesthetic agents can provide additional discomfort and minimize the need for systemic medications while improving mobility.

Principle 4 - Clinicians should provide patient and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for managing postoperative pain, and document the plan and goals for postoperative pain management.

In other words, although there may be some general principles to delivering an optimal pain management plan, individual patient variations and responses to treatment need to be considered. This means as providers, we should remain reassuring but flexible in what other modalities we might suggest. There is both an art and a science to this practice but something every provider can learn.

Principle 5 - Clinicians should provide education to all patients (adult) and primary caregivers on the pain treatment plan, including proper storage and disposal of opioids and tapering of analgesics after hospital discharge.

To provide education to your patients, one must first have the education themselves. Pain is something that affects every human being and therefore we are all responsible for assisting in pain management, in some form or another. Blogs like this one, and several others such as Pedia Pain Focus, ChildKind International are committed to providing education to all interested individuals. Your parents will thank you for your curiosity and interest in soothing their discomfort.

Principle 6 - Clinicians should adjust the pain management plan based on adequacy of pain relief and presence of adverse events. I would also add that our pain management plan should focus on the patient being able to meet their functional goals in physical therapy, activities of daily living, and other desired activities.

So talk to your patients about their response to treatment. Do they feel the plan is effective? Do they have problematic side effects such as nausea, sleepiness, dizziness? Sometimes some minor adjustments in medication dose can make a big difference and get your patients more functional.

Principle 7 - Clinicians should have access to consultation with a pain specialist for patients who have inadequately controlled postoperative pain or are at high risk of inadequately controlled postoperative pain at their facilities (eg, long-term opioid therapy, history of substance use disorder).

So reach out to a pain medicine colleague for some additional advice. The Society for Pediatric Pain Management is a great resource. You might check out their member group and determine if you know of a colleague willing to provide some general guidance. This is a particular interest of mine, learning of the challenges others are facing and making some suggestions that can improve the quality of pain management. There is no shame to reaching out for a different idea. We're all in this together to help our patients. Feel free to drop a question into the forum for some additional advice or contact me offline.

Future Directions

This consortium established with representatives from several specialties is a good first formal step for aiming toward a common goal of equitable pain management. However, there is much more to be done in this regard. I have spoken frequently of the barriers to optimal pain care and, towards this goal, have proposed the development of a smartphone app for use by the provider at the bedside to serve as a checklist for medications and modalities to be considered. The goal would be, using the app, to develop a solid pain management plan in 5 minutes for any post-surgical patient as well as offering a reading list of articles that provide evidence for the efficacy of these modalities. A smartphone app would have widespread reach, encouraging providers to utilize the resources available to them to deliver the highest quality of pain management possible. Sure, thousands of individuals receive world-class pain management, while several-fold more individuals suffer needlessly.

Next Steps

I am currently revising my PreEmpt Pain app for a more streamlined user experience. I have always been fascinated in a systems approach to pain management, while being mindful of the patient variability that exists. My goal is to introduce an intuitive, step-by-step process that can be implemented quickly to effectively manage acute pain. The framework below is my private conceptualization of the process and conditions to be considered. As a trainee, I myself struggled with the complexity of pain management. I strive to put the tools of the experts into your hands for better understanding and communication with your patients. So stay tuned for an update and access to the app.

Does your affiliated institution have a formal process in place to address pain management? Share your thoughts in the comments. Are you a patient who has had good pain management in the hospital? Are there particular actions or education providers have done for you that have been particularly helpful? We want to know your thoughts and about your experience.