All You Need To Know about Postoperative Pain

Whether you are a healthcare provider or an individual who is facing surgery, you need to know of the efforts that are dedicated to optimal pain management. Here you will find some valuable insights from The Journal of Pain in 2016. This taskforce of pain experts critically assess the various modalities and set the standard of care for pain management. I'll summarize below the 32 key recommendations and how you can implement them into your practice today. Or, if you are facing surgery yourself, you will be prepared to engage your surgeon and anesthesiologist in a conversation of how you will have your pain managed during and after your surgical procedure. In either position, we together can take a more intentional evidence-based approach to pain management.

Recommendation #1 Clinicians provide patient and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for management of postoperative pain, and document the plan and goals for postoperative pain management

What to do ---> communicate to patient and family about your plan and include multimodal strategies (medications perhaps but always some non-medication recommendations as well).

Recommendation #2 Parents (or other adult caregivers of children who undergo surgery) receive instruction in developmentally-appropriate methods for assessing pain as well as counseling on appropriate administration of analgesics and modalities

What to do ---> tell parents the signs that are utilized in assessment using the age-appropriate pain scales, such as the NIPS, PIPP, FLACC that might indicate the presence of pain. Here is a good resource.

Recommendation #3 Clinicians should conduct a preoperative evaluation including assessment of medical and psychiatric comorbidities, concomitant medications, history of chronic pain, substance abuse, and previous postoperative treatment regimens and responses, to guide the perioperative pain management plan.

What to do --->take a good history in a systematic way. Consider continuing at-home medications for mood, medical conditions to minimize deterioration in comorbid conditions. Identify how the presence of these conditions could impact perception of pain.

Recommendation #4 Pain management plan should be adjusted on the basis of adequacy of pain relief and presence of adverse events

What to do ---> Determine the patient's comfort goal. Assess for ability to meet functional goals. Be aware of adverse events related to pain management and adjust accordingly.

Recommendation #5 Use a validated pain assessment tool to track responses to pain management treatment.

What to do ---> Assessment tools should be validated tools and age-appropriate. Using consistent tools allows trends in pain to be tracked as one part of the efficacy of pain management. Tools include PIPP, NIPS, FLACC, NRS, FACES scales.

Check out my post about pain scales here

Recommendation #6 Offer multimodal analgesia with a variety of analgesic medications and techniques combined with non-pharmacologic interventions.

What to do ---> Aside from non-opioid and topical analgesics, assure you also consider use of non-medication strategies such as diaphragmatic breathing, distraction, relaxation, etc. These have an impact on stress hormones that affect pain. Check out my post here about these interventions for expected intense pain.

Recommendation #7 Consider transcutaneous electrical nerve stimulation (TENS) as an adjunct to other postoperative pain.

What to do ---> Involve physiatrists or physical therapists in the pain management plan. In some institutions, they are the ones to trial a TENS unit for the patient. Read this article for more information.

Recommendation #8 May consider acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments.

What to do ---> As the risk of these procedures are low, although there is some ambivalence as to the efficacy, I feel these should be considered to model to the patient that these may be helpful and effective pain management involves many small interventions that can be quite meaningful.

Recommendation #9 Consider the use of cognitive-behavioral modalities in adults as part of a multimodal approach

What to do ---> Mention that treatments such as guided imagery, other relaxation methods, hypnosis can be useful to help manage and cope with postoperative pain after surgery. When suggested by healthcare professionals, this can bolster the patients' consideration of such therapies as an adjunct.

Recommendation #10 Oral over intravenous administration of opioids for postoperative analgesia in patients who can use the oral route

What to do ---> If the gut works, use it. Follow your physician's instructions regarding the use of these medications. You may not be expected to finish the medications that have been prescribed for you.

Recommendation #11 Avoid using the intramuscular route for administration of analgesics for management of postoperative pain.

What to do ---> Intramuscular injection can be painful and prevent patients from accepting this therapy for pain treatment.

Recommendation #12 Intravenous patient-controlled analgesia (IV PCA) should be used when parenteral route is needed. Allows patient to safely titrate their need of pain medications.

What to do ---> When analgesia is needed for more than a few hours and can understand the concept of using the PCA device, PCA should be offered on the basis of evidence showing greater effectiveness and patient satisfaction. Administration by proxy should be avoided in adults but may be safely executed with children by a nurse proxy and appropriate cardiopulmonary monitoring.

Recommendation #13 Routine basal infusions are not recommended in opioid-naive adults.

What to do ---> Must consider each case individually. In the setting of appropriate use during the daytime hours, a night-time basal infusion may allow better analgesia without the patient needing to be awake and alert to push the button and treat their pain.

Recommendation #14 Provide appropriate monitoring of sedation, respiratory status and other adverse events in those patients receiving systemic opioids; be wary of potential for post-operative nausea and vomiting.

What to do ---> Consider proactive prescription of antiemetics to ensure availability at any time by patient.

Recommendation #15 Provide acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain

What to do ---> Consider these as-needed in those with mild pain but on a more scheduled basis for those with moderate to intense pain expected from a medical condition or surgical procedure.

Recommendation #16 Consider providing a preoperative dose of NSAIDs if there are no contraindications prior to a surgical procedure.

What to do ---> Consult your surgeons determine if this practice is supported.

Recommendation #17 Consider the use of gabapentin or pregabalin as a component of multimodal analgesia.

What to do ---> Weigh the risks and benefits of this modality. While gabapentin can be used safely, it should be started at a low dose, titrated slowly with vigilance to synergistic sedative effects when combined with other medications.

Recommendation #18 Consider intravenous ketamine as a component of multimodal analgesia in adults.

What to do ---> This article describes the use of ketamine in decreasing the incidence of persistent postsurgical pain.

Recommendation #19 Consider intravenous lidocaine infusions in adults who undergo open and laparoscopic abdominal surgery.

What to do ---> Check out this jour