A c u t e Pa i n Ma n a g e m e n t

David M. Dickerson, MD

KEYWORDS
 Acute pain management  Multimodal analgesia  Multimodal pain management
 Ambulatory surgery  Outpatient surgery

KEY POINTS
 The cost to the patient and society of uncontrolled postoperative pain and chronic post-
surgical pain requires a focus on prevention and effective multimodal intervention.
 The ambulatory anesthesiologist should be skilled at regional anesthesia and the applica-
tion of continuous peripheral nerve catheters.
 The ambulatory surgical setting should make these techniques and their implementation
possible.
 Effective communication in the perioperative period among the patient, nursing staff, and
providers is necessary for rapid assessment and treatment of a patient’s pain.
 The cost of maintaining a formulary with multiple analgesic drug classes and supplies and
equipment for regional anesthesia may be offset by revenue in an outcomes-based reim-
bursement model.

INTRODUCTION

Acute postsurgical pain poses treatment challenges for the anesthesiologist, chal-
lenges augmented by the ambulatory surgical setting. The “fifth vital sign,” pain, has
become a focal point and continues to be a primary determinant of delayed discharge,
unanticipated admission, and quality of recovery.1–5 Although the prevalence of un-
controlled postoperative pain, frequently moderate to severe, has been characterized,
the continued cost of uncontrolled pain has led to publication of practice guidelines for
its control.6 Most recently, the American Society of Anesthesiologists practice guide-
lines for acute pain management establish a paradigm for the more frequent and spe-
cific use of multimodal analgesia (MMA) (Table 1).7
This article updates acute pain management in ambulatory surgery and proposes a
practical three-step approach, the “three I’s” (Box 1), for reducing the impact and inci-
dence of uncontrolled surgical pain. By identifying at-risk patients, implementing
MMA, and intervening promptly with rescue therapies, the anesthesiologist may

Disclosure: No conflicts or relationships to disclose.

Department of Anesthesia and Critical Care, University of Chicago Medicine, 5841 South Maryland
Avenue MC4028, Office O-416, Chicago, IL 60637, USA
E-mail address: ddickerson@dacc.uchicago.edu

Anesthesiology Clin - (2014) -–-

http://dx.doi.org/10.1016/j.anclin.2014.02.010 anesthesiology.theclinics.com
1932-2275/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
2 Dickerson

Table 1
American Society of Anesthesiologists practice guidelines for acute pain management in the
perioperative setting

Recommendations
Institutional  Anesthesiologists should provide ongoing, up-to-date education and
policies training on the safe and effective use of available treatment options
within the institution. Including:
 Basic bedside pain assessment
 Nonpharmacologic techniques
 Sophisticated pain management techniques (eg, regional anesthesia)
 Providers should use standardized, validated instruments for the regular
evaluation and documentation of pain intensity, therapeutic response,
and side effects.
 Anesthesiologists responsible for perioperative analgesia should be
available at all times to assist in the evaluation and treatment of periop-
erative pain.
 Standardized, institutional policies and procedures should be developed
and an integrated approach used for pain management by an
anesthesiologist-led acute pain service.
Preoperative  A directed pain history, directed physical examination, and pain control
preparation plan should be included in the anesthetic preoperative evaluation.
of the patient
Perioperative  Anesthesiologists who manage perioperative pain should use therapeutic
techniques options, such as central regional opioids, systemic opioid PCA, or periph-
eral regional techniques after an analysis of the risk/benefit ratio for the
individual patient.
 The therapy implemented should reflect the individual anesthesiologist’s
expertise and a respect for the capacity for safe application of the modality
in the specific practice setting. This includes the ability to recognize and
treat adverse effects from the therapy.
Multimodal  Whenever possible, anesthesiologists should use multimodal pain man-
techniques agement therapy, regional block should be considered.
for pain  Unless contraindicated, patients should receive an around-the-clock
management regimen of COXIBs, NSAIDS, or acetaminophen.
 Dosing regimens should optimize efficacy and minimize adverse events.
 Specific medication, dose, route, and duration of therapy should be
individualized.

Abbreviations: COXIB, cyclooxygenase-2 inhibitor; NSAID, nonsteroidal anti-inflammatory drugs;

PCA, Patient-Controlled Analgesia.
Adapted from American Society of Anesthesiologists Task Force on Acute Pain Management.
Practice guidelines for acute pain management in the perioperative setting. Anesthesiology
2012;116:255–6; with permission.

Box 1
Planning for pain: the three “I’s”

Identify patients at risk for uncontrolled postoperative pain

Implement effective preventative multimodal analgesia
Intervene with rescue regional analgesia, additional opioids, or nonopioid agents
 Acute Pain Management 3

improve outcomes, reduce cost, and optimize the patient’s experience and quality of
recovery.

IDENTIFY: RISK STRATIFICATION, PREPROCEDURAL PLANNING

The preanesthetic assessment identifies a history of uncontrolled postsurgical pain,

intolerance or contraindications to analgesics, contraindications to regional anes-
thesia, and presence of preoperative pain or anxiety.7 Several patient and surgical
characteristics predispose to moderate or severe postoperative pain (Box 2).8–12 Iden-
tifying a high-risk cohort preoperatively warrants prompt initiation of MMA. Com-
prehensive MMA may impact the patient’s quality of recovery, prevent discharge
delay or unanticipated admission, and reduce the risk of chronic postsurgical pain
(Box 3).13–22
Katz23 suggested controlling pain throughout all phases of the perioperative period
and not just the period of surgical intervention.24 Uncontrolled postdischarge pain
can lead to unanticipated admission, defined as readmission within 24 hours of sur-
gery, and greater risk for chronic postsurgical pain. For these reasons, the anesthe-
siologist should assist the surgical team in planning postdischarge multimodal
analgesic regimens for the most immediate and intense period of surgical pain.
Appreciation of the multitude of neural pathways involved in nociceptive afferent
neurotransmission is the foundation for a targeted, comprehensive multimodal
approach (Table 2). Preoperative blocking of the afferent injury barrage during and
after surgery prevents the induction of central sensitization, lowering postoperative
pain and analgesic requirements.

IMPLEMENT: MMA, REGIONAL ANESTHESIA

Multiple days of effective analgesia minimizing adverse effects can be accomplished

with continuous peripheral neural blockade (cPNB). A single-shot PNB reduces opioid
exposure, improves patient comfort and circulation to the anesthetized extremity, re-
duces time in recovery, increases patient satisfaction, and lowers rates of adverse
events.25 Catheter-based continuous techniques have similar benefit.4,26 Compared
with single-shot PNBs, cPNBs are associated with better pain control and the need
for decreased opioid analgesics, resulting in less nausea. Chronic pain after surgery

Box 2
Preoperative predictors of moderate-to-severe postoperative pain

 Increased preoperative pain

 Increased preoperative anxiety
 Younger patients
 Female gender
 Surgery type
 Appendectomy
 Cholecystectomy
 Hemorrhoidectomy
 Tonsillectomy
 Duration of surgery
4 Dickerson

Box 3
Preoperative predictors of the development of chronic postsurgical pain

 Increased preoperative pain

 Increased preoperative anxiety
 Increased postoperative pain
 Female gender
 Surgical type

also is decreased and patient satisfaction is augmented.27,28 cPNBs can be safely

placed at multiple sites with proved analgesic efficacy for a multitude of ambulatory
surgeries (Table 3).29 The cost and risks of these techniques must be weighed in
the context of the benefit to the patient during the first postoperative days. Some

Table 2
Pathway approach to multimodal analgesia

Peripheral vs
Central Nervous
Site of Action Analgesic Agent Receptor Target
Peripheral afferent Peripheral 1/ Local anesthetic Sodium channel (free
blockade, inhibition central (wound infiltration) nerve endings of
of central peripheral)
hyperexcitability Local anesthetic Sodium channel
(peripheral nerve (peripheral afferent
block) neuron)
Local anesthetic Sodium channel (central
systemic infusion and peripheral)
Inflammation Peripheral and Acetaminophen, Cox-II, cannabinoid
reduction (reduction central paracetamol
in proinflammatory NSAIDs Cox-I, Cox-II
mediators, Dexamethasone Cox-II
decreased afferent
neurotransmission)
Afferent slowing Peripheral and Gabapentanoids Calcium-channel
central (Lyrica, gabapentin)
Spinal and supraspinal Central Opioids Opioid receptors
modulation
Antinociceptive Membrane Benzodiazepines GABAa
interneuron stabilization SNRI/TCA (chronic use) Norepinephrine
activation reuptake, serotonin
reuptake
Pronociceptive Central (dorsal Ketamine, NMDA receptor
interneuron horn of spinal dextromethorphan,
blockade cord) levorphanol,
methadone
Descending inhibition Central Tizanidine, clonidine, Alpha-2 in locus
dexmedatomidine ceruleus

Abbreviations: Cox, cyclooxygenase; GABA, g-aminobutyric acid; NMDA, N-methyl-D-aspartate;

NSAID, nonsteroidal anti-inflammatory drugs; SNRI, selective norepinephrine reuptake inhibitor;
TCA, tricyclic antidepressant.
 Acute Pain Management 5

Table 3
Indications for continuous nerve blocks in orthopedic procedures and trauma

Doses for Initial Bolus

Followed by Continuous
Surgical Procedure or Site of Injury Continuous Block Infusion
Total shoulder arthroplasty, shoulder Interscalene 20 mL ropivacaine 0.5%
hemiarthroplasty, rotator cuff repair, 5–10 mL$h 1 ropivacaine
shoulder arthrodesis, “frozen” shoulder 0.2%
physical therapy, biceps surgery, proximal
humerus fractures
Distal humerus fractures, elbow arthroplasty, Supraclavicular, 20 mL ropivacaine 0.5%
elbow arthrodesis, radius fractures and infraclavicular, 5–10 mL$h 1 ropivacaine
surgery, ulna fractures and surgery, wrist axillary 0.2%
arthrodesis, reimplantation surgery
Breast surgery Thoracic 15 mL ropivacaine 0.5%
paravertebral via catheter
(T4-5) 5–10 mL$h 1 ropivacaine
0.2% via catheter
Total knee arthroplasty, anterior cruciate Femoral nerve 20 mL ropivacaine 0.5%
ligament reconstruction, patella repair, 5–10 mL$h 1 ropivacaine
knee active and passive physical therapy 0.2%
Total knee arthroplasty, posterior cruciate Femoral 1 sciatic 6–12 mL ropivacaine
ligament reconstruction 0.2%–0.5%
3–8 mL$h 1 ropivacaine
0.1%–0.2%
Tibia fracture and repair, fibular fracture and Sciatic or 5–10 mL ropivacaine
repair, ankle fusion, subtalar fusion, total popliteal 0.2%–0.5%
knee arthroplasty, hallux valgus repair 3–8 mL$h 1 ropivacaine
0.1%–0.2%
Ankle fusion, total ankle arthroplasty Femoral or 20 mL ropivacaine 0.2%
saphenous 1 5–10 mL$h 1 ropivacaine
sciatic 0.1%

Adapted from Chelly JE, Ghisi D, Fanelli A. Continuous peripheral nerve blocks in acute pain man-
agement. Br J Anaesth 2010;105(Suppl 1):i88; with permission.

procedures and patients, however, are not suitable for regional anesthesia because of
contraindication or surgical site. These patients should still receive local anesthetic
infiltration at incision sites.

IMPLEMENT: MMA, PHARMACOTHERAPY

Much emphasis has been placed on MMA to improve the quality of recovery,
decrease length of postanesthesia care unit stay, and potentially reduce the opioid
requirement.1–3,30–33 Opioid-sparing methods help to reduce delayed discharge, pre-
vent unanticipated admission, and potentially alter the rates of cancer recurrence or
metastasis.34–36 The American Society of Anesthesiologists practice guidelines pro-
vide a framework for incorporating nonopioid medications perioperatively.7 The selec-
tion of the type and number of specific nonopioid agents should be evidence-based
and directed toward minimizing risk and maximizing benefit.
Several studies support preoperative initiation of nonsteroidal anti-inflammatory
drugs (NSAIDs), yet the necessary dose, route, frequency, and duration are unclear.
The potent inhibition of prostaglandin synthesis by NSAID therapy may have analgesic
6 Dickerson

benefits that must be weighed against the potential renal, cardiovascular, gastrointes-
tinal, and bleeding risks.37–39 Whether or not NSAIDs impair bone healing is
controversial.40
Among its potent antiemetic effects, dexamethasone also may contribute to
postoperative pain relief and reduce opioid consumption.41,42 a2-Agonists, ketamine,
b-blockers, local anesthetics, and acetaminophen can improve postoperative pain
management (see Table 1).43–50 When acetaminophen and an NSAID were combined,
the benefit was synergistic. When not contraindicated, these agents should be admin-
istered concurrently for maximal benefit.51
The efficacy of preoperative gabapentinoids in reducing postoperative pain has
been evaluated in randomized controlled trials and meta-analyses. Most studies
demonstrated a reduction in postoperative pain scores, but there was discrepancy
in the reduction of opioid consumption; postoperative nausea and vomiting; and other
adverse effects, such as sedation, dizziness, or visual disturbances.52–55
Because preoperative anxiety correlates with severe postoperative pain, anxiolysis
may be another target for intervention. A 1200-mg dose of gabapentin significantly
reduced preoperative anxiety and pain catastrophization in highly anxious patients
compared with placebo.56 In a recent, randomized, double-blind study, preoperative
coadministration of midazolam and diclofenac resulted in significant reduction of pain
scores and postoperative nausea and vomiting compared with diclofenac alone for
hernia repair surgery performed with general anesthesia.57

IMPLEMENT: NONPHARMACOLOGIC TECHNIQUES

Nonpharmacologic techniques may influence patient stress, anxiety, and pain. Intra-
operative music has been shown to reduce opioid consumption and increase patient
comfort after gynecologic surgery.58 Transcutaneous electrical nerve stimulation and
other complementary therapies offer additional patient comfort.59

INTERVENE: RECOVERY ROOM RESCUE

If preoperative and intraoperative interventions fail to produce patient comfort, the

anesthesiologist must first rule out superimposed medical issues in a timely fashion
(eg, anginal chest pain, pneumoperitoneum-related shoulder or abdominal pain).
Assuming surgical pain, the anesthesiologist must implement a treatment algorithm
to promptly intervene in hopes of improving the patient’s comfort and preventing
potential discharge delay or admission. Application of other classes or doses of non-
opioid analgesics and additional opioids should be initiated while the possible need for
a neuraxial block is evaluated.

SUMMARY

The cost to the patient and society of uncontrolled postoperative pain and chronic
postsurgical pain requires a focus on prevention and effective intervention. The ambu-
latory anesthesiologist should be skilled at regional anesthesia and the application of
continuous peripheral nerve catheters.
The ambulatory surgical setting should make these techniques and their implemen-
tation possible. For rapid assessment and treatment of a patient’s pain, communica-
tion in the perioperative period among the patient, nursing staff, and providers is
necessary. The cost of maintaining a formulary with multiple analgesic drug classes
and supplies and equipment for regional anesthesia may be offset by revenue in an
outcomes-based reimbursement model.
 Acute Pain Management 7

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