Guideline sources The following summarized guidelines for the evaluation and management of postoperative pain are prepared by our editorial team based on guidelines from the Global Alliance for Infection in Surgery (GAIS/WSES/AAST/SIAARTI 2022), the French Society of Anesthesia and Intensive Care (SFAR 2019), and the American Society of Anesthesiologists (ASA/APS/ASRA 2016). 1 2 3 Calculator Calculator Calculat Apfel score for postoperative na Behavioral observational pain sc Behavi Guidelines 1. Diagnostic investigations Preoperative assessment: As per SFAR 2019 guidelines: https://web.pathway.md/diseases/recrZF2RLIVT2nUyH 1/6 6/29/23, 11:22 PM Postoperative pain Pathway Identify the most vulnerable patients to pain preoperatively (with risks to develop severe postoperative pain and/or chronic postoperative pain) by focusing on preoperative pain, including pain even far from the operating site, the long-term consumption of opioids, and surgical and psychological factors such as anxiety or depression. E Use the APAIS tool to measure anxiety and/or the need for information during the preoperative period. E As per APS 2016 guidelines, obtain 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. B Pain assessment: As per WSES 2022 guidelines, obtain postoperative pain assessment at rest, and on movement if possible, to improve patient management after emergency surgery. B Show 2 more As per SFAR 2019 guidelines, identify postoperative risk factors for chronic postoperative pain by assessing for high-intensity postoperative pain (using a numerical scale), uncommon prolongation of postoperative pain, early neuropathic pain (using a DN4 scale), and signs of anxiety or depression. E Show 2 more 2. Medical management General principles (initiation of treatment): identify and treat postoperative pain as soon as possible and as best as possible in all patients. B Show 2 more General principles, adjustment of treatment: As per ASA/ASRA/APS 2016 guidelines, adjust pain management to ensure the greatest effect and the lowest side effects possible. B As per ASA/ASRA/APS 2016 guidelines: Adjust pain management plan based on the adequacy of pain relief and the presence of adverse events. B Use validated pain assessment tools to track responses to postoperative pain treatment and adjust the treatment plan accordingly. B Opioids: As per WSES 2022 guidelines, administer a major opioid for the treatment of moderate-to- severe pain unresponsive to other medications, if regional anesthesia techniques are not indicated. B Show 4 more As per SFAR 2019 guidelines, administer strong opioids (morphine or oxycodone), ideally PO, for severe postoperative pain or if weaker analgesics are not powerful enough to relieve pain. A As per APS 2016 guidelines, administer oral opioids for postoperative pain management. B https://web.pathway.md/diseases/recrZF2RLIVT2nUyH 2/6 6/29/23, 11:22 PM Postoperative pain Pathway Show 2 more Non-opioids, NSAIDs: As per AAST/SIAARTI/GAIS/WSES 2022 guidelines, administer acetaminophen and NSAIDs in multimodal analgesia, if not contraindicated. A Show 3 more As per SFAR 2019 guidelines: Administer nonselective NSAIDs or selective cyclooxygenase-2 inhibitors with morphine, if not contraindicated. A Do not use cyclooxygenase-2 inhibitors in patients with a history of PAD, stroke, or myocardial infarction. D Do not use nonselective NSAIDs for > 7 days in patients with PAD, stroke, or myocardial infarction. D Do not combine NSAIDs with curative doses of anticoagulant. D As per ASA/ASRA/APS 2016 guidelines, administer acetaminophen and/or NSAIDs as part of multimodal analgesia for postoperative pain management. A Non-opioids, gabapentinoids: As per AAST/SIAARTI/GAIS/WSES 2022 guidelines, administer gabapentinoids in multimodal analgesia, if not contraindicated. B As per ASA/ASRA/APS 2016 guidelines, consider administering gabapentin or pregabalin as a component of multimodal analgesia. B Non-opioids, IV ketamine: As per SFAR 2019 guidelines, administer small doses of ketamine intraoperatively in patients on general anesthesia in the following situations: surgery with a high risk of acute pain or chronic postoperative pain patients with vulnerability to pain, most particularly patients taking long-term opioids or addicted to opioids. A As per ASA/ASRA/APS 2016 guidelines, consider administering IV ketamine as a component of multimodal analgesia in adult patients with postoperative pain. C Non-opioids, IV lidocaine: As per SFAR 2019 guidelines, administer IV lidocaine infusion (1-2 mg/kg bolus followed by 1-2 mg/kg/hour) in order to decrease the level of postoperative pain and to improve recovery in adult patients undergoing major surgery (abdominal, pelvic, or spinal surgeries) not benefiting from regional analgesia. B As per ASA/ASRA/APS 2016 guidelines, consider administering IV lidocaine infusions in adult patients undergoing open and laparoscopic abdominal surgery, if not contraindicated. C Non-opioids (IV corticosteroids): consider administering IV dexamethasone 8 mg to reduce postoperative pain in adult patients. C Route of administration: As per WSES 2022 guidelines, prefer oral over IV route whenever feasible for the administration of analgesic drugs. B Show 2 more https://web.pathway.md/diseases/recrZF2RLIVT2nUyH 3/6 6/29/23, 11:22 PM Postoperative pain Pathway As per APS 2016 guidelines, prefer oral over IV route for opioid administration for postoperative analgesia, if possible. B Show 3 more Multimodal analgesia: As per WSES 2022 guidelines, consider administering multimodal pain management to improve analgesia while reducing individual class-related side effects. Adopt a pharmacological step-up approach including major opioids when necessary. B Show 2 more As per APS 2016 guidelines, administer multimodal analgesia, or use a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in adult and pediatric patients. A Management of nausea and vomiting: administer medications targetting dopaminergic pathways (haloperidol, risperidone, metoclopramide, prochlorperazine) for the management of nausea and vomiting. B Show 2 more Management of delirium: evaluate delirium using standardized assessment tools validated in critically ill patients whenever appropriate (such as CAM-ICU and ICDSC). B Show 2 more Management of respiratory distress: assess respiratory distress using standardized assessment tools and suggestive objective signs. Use a stepwise approach to the treatment of dyspnea. B Show 3 more Palliative care: consider offering palliation to achieve the control of all other related symptoms, such as nausea, vomiting, dyspnea, agitation, and delirium, in patients not amenable to surgical interventions or already operated on but not suitable for further interventions. B 3. Nonpharmacologic interventions Cognitive-behavioral therapy: consider offering cognitive-behavioral modalities as part of a multimodal approach in adult patients. C Alternative and complementary therapies: insufficient evidence to recommend for or against acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments. I 4. Therapeutic procedures Local and regional anesthesia: As per WSES 2022 guidelines, administer regional anesthesia in both adult and pediatric patients in site-specific surgeries. A Show 6 more As per SFAR 2019 guidelines, do not exceed the maximal toxic doses of local anesthetics, most specifically for peri-prosthetic orthopedic infiltrations and during associations of scar infiltrations and perinervous analgesic catheters. D https://web.pathway.md/diseases/recrZF2RLIVT2nUyH 4/6 6/29/23, 11:22 PM Postoperative pain Pathway Show 2 more As per APS 2016 guidelines, consider administering surgical site-specific local anesthetic infiltration for surgical procedures with evidence indicating efficacy. C Show 7 more Transcutaneous electrical nerve stimulation: consider offering transcutaneous electrical nerve stimulation as an adjunct to other postoperative pain treatments. C 5. Patient education General counseling: As per WSES 2022 guidelines, provide adequate education to patients and their families about the surgical and anesthesiologic treatment, options, plans, and aims of pain management, whenever possible. B As per APS 2016 guidelines, provide education to all adult and pediatric patients and primary caregivers on the pain treatment plan including tapering of analgesics after hospital discharge. B Show 2 more 6. Preventative measures Preemptive analgesia: As per WSES 2022 guidelines, consider administering preemptive analgesia to reduce postoperative opioid consumption. C As per SFAR 2019 guidelines, do not use gabapentinoids preoperatively for postoperative pain management. D As per APS 2016 guidelines, consider administering a preoperative dose of oral celecoxib in adult patients without contraindications. B 7. Quality improvement Hospital policies: ensure that facilities performing surgery have an organizational structure in place to develop and refine policies and processes for safe and effective delivery of postoperative pain control. B Show 2 more Studies 2002 MASTER Anaesthesia In high-risk status patients undergoing major abdominal surgery, epidural was not superior to control with respect to death or at least one postsurgical morbidity at 30 days. John R A Rigg et al. Lancet. 2002 Apr 13. https://web.pathway.md/diseases/recrZF2RLIVT2nUyH 5/6 6/29/23, 11:22 PM Postoperative pain Pathway References 1. Fr d ric Aubrun, Karine Nouette-Gaulain, Dominique Fletcher et al. Revision of expert panel's guidelines on postoperative pain management. Anaesth Crit Care Pain Med. 2019 Aug;38 4 405 411. Open 2. Roger Chou, Debra B Gordon, Oscar A de Leon-Casasola et al. 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. J Pain. 2016 Feb;17 2 131 57. Open 3. Federico Coccolini, Francesco Corradi, Massimo Sartelli et al. Postoperative pain management in non-traumatic emergency general surgery: WSES GAIS SIAARTI AAST guidelines. World J Emerg Surg. 2022 Sep 21;17 1 50. Open https://web.pathway.md/diseases/recrZF2RLIVT2nUyH 6/6