Association of Anaethetists: Peri-operative pain management in adults

Question 1

Goals of postoperative pain management

Answer 1

1. Provision of humanitarian pain relief
2. Promote recovery
3. Attenuation of the metabolic response to surgical stress
4. Promotion of restoration of function- drinking eating, mobilising etc.
5. Avoidance of persistent post-op opioid use
6. Avoidance of opioid-related adverse events- e.g. ventilatory impairment
7. Avoidance of harm from other analgesic strategies e.g. nerve damage from regional blocks
8. Reduce the risk of developing chronic post-surgical pain
9. Identify and manage chronic post-surgical pain

Question 2

Role of the inpatient pain team

Answer 2

• Ensure compliance with optimal perioperative pain management
• Educate staff
• Implement local guidelines
• Ensure appropriate patient information available

Question 3

Examples of multimodal analgesics

Answer 3

• Paracetamol
• Non-selective NSAIDs e.g. ibuprofen, diclofenac
• Selective NSAIDS e.g. Parecoxib
• a2-agonist- clonidine, dexmedetomidine
• NMDA antagonists- ketamine, magnesium
• Dexamethasone- effective analgesic and reduces rebound pain after regional anaesthesia
• a2-delta ligands- gabapentin, pregabalin
• Lidocaine

Question 4

Non-pharmacological analgesia

Answer 4

• Peri-operative education
• Avoidance of nocebo effect
• Mindfulness
• Physiotherapy
• TENS
• Acupuncture

Question 5

Pre-operative interventions for pain management

Answer 5

• Screening pre-op for modifiable risk factors for acute pain and chronic post-surgical pain e.g. anxiety, depression, frailty, use of opioids pre-op, weight, smoking, alcohol
• Expectation management and shared decision-making
• Consider supervised pre-op opioid tapering
• Identify those at risk of developing chronic post-op pain and MDT management

Question 6

Intra-operative interventions for pain management

Answer 6

• Analgesia should be multimodal and extend into the postoperative period
• Procedure-specific regional anaesthesia should be an essential element of multimodal analgesia where feasible
• Analgesic management should be patient and procedure-specific

Question 7

Post-operative interventions for pain management

Answer 7

• Anaesthetists should be available to support the provision of analgesia in recovery
• immediate-release opioids should be prescribed and given based on facilitating function rather than treating a unidimensional pain scale
• Avoid modified-release opioids routinely
• Lowest effective dose and oral routes, age-appropriate dosing
• Avoid co-administration with a sedative
• If opioids are used ensure sedation and vital signs are appropriately monitored
• Involvement of pain teams for patient not following expected pain trajectory or requiring advanced analgesic techniques

Question 8

Discharge interventions for pain management

Answer 8

• If prescribing opioids at discharge ensure discussion on risks of tolerance, dependence, addiction
• No greater than seven-day prescription
• Advice given on weaning and safe disposal of medications
• Avoid repeat prescriptions
• Avoid drug driving

Question 9

Pain in intensive care recommendations

Answer 9

• Assessment using behavioural pain scale or critical care pain observation tool
• Consider pain as a cause of agitation or delirium
• Any patients on an opioid infusion >72 hours should be monitored for signs of withdrawal
• Lowest possible opioid dose to achieve adequate analgesia should be used