All You Need To Know about Postoperative Pain
Updated: Jan 15
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 journal article.
Recommendation #20 Consider local infiltration of local anesthetics for surgical procedures. These often require fewer resources and are less labor-intensive and can be greatly beneficial in improving pain after a surgical procedure.
What to do ---> Be aware of the adverse effects of local anesthetic use and the treatment for local anesthetic toxicity. Check out this paper.
Recommendation #21 Consider use of topical local anesthetics in combination with nerve blocks before circumcision.
What to do ---> Consider the adverse effects of some local anesthetics in children under the age of 3 months.
Recommendation #22 Intrapleural analgesia with local anesthetics is not recommended for pain control after thoracic surgery.
Recommendation #23 Consider regional anesthetic techniques in patients undergoing surgeries associated with moderate or intense pain.
What to do ---> Communicate that these modalities help to target various receptors responsible for the perpetuation of pain. Regional anesthetic techniques are part of a multimodal program to decrease use of opioids and minimize adverse side effects of the various agents.
Recommendation #24 Use continuous, local anesthetic-based peripheral regional analgesic techniques when the need for analgesia is likely to exceed the duration of effect of a single injection.
What to do ---> Communicate that catheter-based regional anesthetic techniques will prolong the analgesia after a procedure associated with more intense pain and will ultimately improve mobility, respiratory mechanics, and healing.
Recommendation #25 Consider the addition of clonidine as an adjuvant for prolongation of analgesia with single-injection peripheral neural blockade.
Recommendation #26 Offer neuraxial analgesia for major thoracic and abdominal procedures, particularly those at risk for cardiac complications, pulmonary complications, or prolonged ileus.
Recommendation #27 Avoid neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine in the treatment of postoperative pain.
Recommendation #28 Provide appropriate monitoring of patients who have received neuraxial interventions for perioperative analgesia.
What to do ---> Assure you are aware of your institutions policies regarding this monitoring.
Recommendation #29 There should be an established organizational structure in place to develop and refine policies and processes for safe and effective delivery of postoperative pain control.
What to do ---> Seek out opportunities to improve upon the delivery of perioperative pain management in quality control projects or critical assessment of your practice.
Recommendation #30 Clinicians should have assess to advanced pain specialists for those patients with inadequately-controlled postoperative pain or those at high risk such as opioid-tolerant individuals, those with history of substance abuse)
What to do ---> Establish a network of providers that can assist you in these challenging situations. The Society for Pediatric Pain Medicine is a great resource and encourages membership from all specialties towards the goal of improved pain management practice and education. Check out their website here
Recommendation #31 In facilities where neuraxial analgesia and continuous peripheral nerve blocks are performed, understand the policies and procedures that support their safe delivery
What to do ---> Familiarize yourself with these medications and the safety protocols
Recommendation #32 Provide education to all patients and primary caregivers on the pain treatment plan including tapering of analgesics after hospital discharge.
What to do ---> Involve patients and their caregivers in the pain management plan while in the hospital to ease the transition to hospital discharge. Provide a contact number so the patient can ask questions if needed after hospital discharge.
Check out the full journal article here.
This is an exhaustive list of the modalities and practices that should be considered. Knowledge of these modalities is important for physicians, nurses, all healthcare providers, and patients as well as their caregivers.
My app aims to remind providers of some of these considerations to the available treatments are offered to patients. I believe we need tools that will remind us in a systematic way of all the treatments we can provide to patients and that we have the knowledge to speak with patients as to all the efforts we are putting into pain management. (Check out The App page of this website to launch the app).
If you have thoughts or comments about this article, I would love to hear from you.
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