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Review

Acute postoperative pain management

C. Small1 and H. Laycock2
1
Warwick Clinical Trials Unit, University of Warwick, Coventry, and 2 Department of Anaesthetics, Pain Medicine and Intensive Care, Imperial College
London, London, UK
Correspondence to: Dr H. Laycock, Department of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, Chelsea and Westminster
Hospital Campus, 369 Fulham Road, London SW10 9NH, UK (e-mail: h.laycock@imperial.ac.uk)

Background: Acute postoperative pain is common. Nearly 20 per cent of patients experience severe pain
in the first 24 h after surgery, a figure that has remained largely unchanged in the past 30 years. This
review aims to present key considerations for postoperative pain management.
Methods: A narrative review of postoperative pain strategies was undertaken. Searches of the Cochrane
Library, PubMed and Google Scholar databases were performed using the terms postoperative care,
psychological factor, pain management, acute pain service, analgesia, acute pain and pain assessment.
Results: Information on service provision, preoperative planning, pain assessment, and pharmacological
and non-pharmacological strategies relevant to acute postoperative pain management in adults is
presented, with a focus on enhanced recovery after surgery pathways.
Conclusion: Adequate perioperative pain management is integral to patient care and outcomes. Each
of the biological, psychological and social dimensions of the pain experience should be considered and
understood in order to provide optimum pain management in the postoperative setting.
Paper accepted 22 November 2019
Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.11477

Background hospital sites across the UK. It highlighted that 48 and

Acute pain occurs following tissue injury associated with
surgery and should resolve during the healing process. This
normally takes up to 3 months, after which pain is consid-
ered to be chronic or persistent1 . Pain is a multidimen-
sional experience, personalized to each patient. Differences
in pain experience are influenced by biological response,
psychological state and traits, and social context2 – 4 . The
aetiology of acute postoperative pain is multifactorial. Sur-
gical procedures cause injury to tissues. The surgical injury
triggers a myriad of responses in the pain matrix, from
sensitization of peripheral and central pain pathways to
feelings of fear, anxiety and frustration5 . Although pain
decreases over the first few days after surgery in the major-
ity of patients, some experience a static or ascending trajec-
tory in pain and analgesic requirements6 .
The prevention and alleviation of postoperative pain
are core responsibilities for healthcare professionals7 .
However, a considerable proportion of patients experi-
ence undesirable levels of postoperative pain. In a 2016
cross-sectional observational study8 of over 15 000 UK
patients undergoing surgery, 11 per cent reported severe
pain and 37 per cent reported moderate pain in the first
24 h. The Perioperative Quality Improvement Programme
(PQIP) 2017–2018 annual report9 included data from 79
19 per cent of patients reported moderate or severe pain
respectively at the surgical site within 24 h of surgery, and
these data were replicated in the most recent 2018–2019
publication10 . These data are not confined to the UK.
A German prospective cohort study11 of 50 523 patients
reported that up to 47⋅2 per cent of patients experienced
severe pain (numerical rating scale score at least 8) in the
first 24 h after surgery; however, this varied depending on
the type of surgery performed. Furthermore, moderate-
to-severe pain continues over the extended postoperative
recovery phase6 . This is despite inpatient pain services
(IPSs), and improvements in the awareness and manage-
ment options available for postoperative pain. Recent data
show little change from those reported in 1990 by the
joint working party of the Royal College of Surgeons and
College of Anaesthetists in a document entitled Pain after
Surgery12 .
Patients report concern about pain occurring after
surgery13,14 . The intensity and duration of pain expe-
rienced increase the likelihood of patients developing
chronic or persistent postsurgical pain (PPSP)15 – 17 ,
which results in longer-term psychological, social and
economic adversity18,19 . Optimum prevention and relief
of postoperative pain are critical on both humanitarian
grounds and for efficient health service delivery7,20 – 22 .

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Acute postoperative pain management
This narrative review presents key considerations and
approaches in the management of postoperative pain in
adults.
Methods
Th Cochrane Library, PubMed and Google Scholar
databases were searched for literature on the assessment
and treatment of postoperative pain after breast, upper
gastrointestinal, lower gastrointestinal and endocrine
surgery using combinations of the following Medical
Subject Heading (MeSH) terms: postoperative care, psy-
chological factor, pain management, acute pain service,
analgesia, acute pain and pain assessment. Screened articles
included all those describing adult acute hospital inpatient
populations and published in the English language. A total
of 1162 study titles and abstracts were screened, with 64
selected for further review. Articles related to cardiac, tho-
racic, transplant, orthopaedic, trauma and neurosurgery
were not included, unless they described novel or unique
principles not covered in the included study populations.
Additional articles identified by review of original article
reference lists were included.
Pain as a priority in health services research
Improving quality of care is a strategic priority for health-
care services. Quality performance indicators measure a
myriad of outcomes that extend beyond simply evaluating
survival23 , with a burgeoning understanding of the impact
that poorly managed acute pain has on health resource
use22 . Pain management is part of the complete perioper-
ative care package and is a core component of enhanced
recovery programmes24,25 . In the UK, data regarding
postoperative pain are routinely collected and analysed,
for example the National Audit Project26 reported com-
plications related to neuraxial blocks, and the PQIP9,10
reports pain scores in postanaesthetic recovery. Individ-
ualized pain management is listed as one of the top five
national improvement opportunities to influence the care
of surgical patients in both the 2017–2018 and 2018–2019
reports. Pain management was highlighted as critical to
achieve DrEaMing (Drinking, Eating and Mobilizing) on
day 1 after surgery9,10 . Adequate perioperative pain man-
agement is therefore core to patient care and outcomes.
It is hoped that large, prospective epidemiological studies
can demonstrate the effectiveness of pain management
techniques and provide insight into rare complications27
to help guide practice.
Service provision
Publication of the joint working party report Pain after
Surgery12 by the Royal College of Surgeons and College
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e71
of Anaesthetists propelled an expansion in multidisci-
plinary IPSs across the UK. This was in response to an
acknowledgement that postoperative pain management
was inadequate, having ‘not advanced significantly for
many years’12 . The rising prominence of perioperative
pain management was mirrored globally with campaigns
including ‘Pain as the 5th vital sign’28 . Standards for ser-
vice provision are set out by the Faculty of Pain Medicine
in Core Standards for Pain Management Services in the UK 29
and by the Royal College of Anaesthetists in Guidelines
for the Provision of Anaesthesia Services for Inpatient Pain
Management 201930 . Roles of the IPS include: supervision
of postoperative pain management interventions, such as
continuous regional anaesthesia; management of patients
with uncontrolled pain; education; research; and quality
improvement. The formulation of each IPS varies between
centres. UK data suggest that many services fail to meet
the core standards set and this represents an area for
development to improve pain management31 .
Preassessment and planning
Optimum pain management should start before surgery.
All patients should undergo a preoperative assessment that
includes a section on pain management. This allows plan-
ning of optimal pain management techniques and facilitates
early discussions to help alleviate fear of postoperative
pain13,14 . It also identifies patients with preexisting com-
plex pain, allowing implementation of patient education,
preoperative interventions, early specialist management
and allocation of resources, as such patients present partic-
ular challenges, especially those already taking high-dose
opioids in the community. It also enables forward plan-
ning for patients with existing co-morbidities who may
be unsuitable for traditional pharmacological approaches
owing to an increased risk of side-effects32 . Discussion
of postoperative pain management at preoperative assess-
ment aims to optimize patient satisfaction and reduce
adverse effects33 . Common phenotypes and conditions
predict poor postoperative pain control and increased opi-
oid intake, including: younger age; female sex; smoking;
depression; anxiety; sleep disorders; negative affectivity;
preoperative pain; use of preoperative analgesia; and sur-
gical factors including type of surgery (major, emergency
or abdominal) and its duration4,34 . Many of these factors
are also associated with the development of PPSP16 .
Assessment and response
Effective pain management is underpinned by assessment
and timely response. Self-reporting subjective pain scales
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represent the standard of acute pain assessment, allow-
ing patients to report pain using a unidimensional scale
of numbers or words. Commonly used to evaluate pain
intensity, the visual analogue scale, verbal rating scale and
numerical rating scale are valid, reliable and appropriate
for use in monitoring postoperative pain in patients who
are able to self-report35 . However, unidimensional scales
fail to describe the patient experience fully, for example,
ability to tolerate pain or its impact on functional recovery.
Postoperative pain is often not isolated to the surgical site,
but includes other locations, such as a sore throat following
tracheal intubation or at injection sites8 . The whole pain
experience should be evaluated. Although one approach is
for patients to mark pain locations on body maps, reporting
individual pain intensity scores for each site, this is imprac-
tical for regular pain assessments required in the postop-
erative environment. Multidimensional tools validated for
use with chronic pain, such as the Brief Pain Inventory,
lack validation in the postoperative setting. Newer tools,
such as the Clinically Aligned Pain Assessment (CAPA)
tool36 , which guides clinical conversations to cover com-
fort, change in pain, pain control, functioning and sleep,
may improve assessment of pain in the perioperative period
but require further evaluation.
Pain in patient groups unable to self-report is often
underestimated. For patients with severe dementia or those
unable to verbalize, standardized objective assessment tools
have been designed and validated. The Pain in Advanced
Dementia (PAINAD) and Dolopus-2 tools are recom-
mended for individuals with severe cognitive impairment37 ,
and the Critical Care Pain Observation Tool (CPOT) or
Behavioural Pain Scale (BPS) for patients unable to verbal-
ize in critical care38 . In rare circumstances where even these
measures are unsuitable, surrogate measures of pain can be
used, such as opiate consumption. It is now recognized that
cardiorespiratory parameters are unreliable for evaluation
of pain in any setting, so their use in the immediate recov-
ery phase, when patients may be unable to verbalize during
recovery from general anaesthesia, is not recommended39 .
Trends in pain assessment scores over time and the
relationship between pain and activity or immobility
are more helpful than isolated pain scores. Additional
information regarding the nature of the pain, whether
visceral, nociceptive or neuropathic, can also help guide
treatment. The context surrounding surgery can influence
acceptable pain levels for patients, such as whether the
procedure was emergency or elective. The perioperative
journey requires regular discussions to set appropriate
pain goals, which may change over time. However, there
is some evidence that a target of ‘no worse than mild pain’
reduces the occurrence of severe pain in the trauma setting
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C. Small and H. Laycock
and is an acceptable target for patients40,41 . Severe pain
should be responded to as a matter of urgency, using a
structured, multimodal analgesic approach, with frequent
reassessments until comfort is attained.
Pharmacological management of postoperative
pain
No perfect analgesic drug exists. Evidence supporting the
use of drugs with a low number needed to treat (NNT)
is limited by data that pertain to specific patient popula-
tions, using a single-dose study design in the initial few
hours of postoperative recovery42,43 . Postoperative pain
management should represent more than pharmacolog-
ical therapies. For major abdominal surgery, traditional
approaches such as epidural analgesia or opioid based
intravenous patient controlled analgesia (IVPCA) are
associated with superior pain control, however fail to
translate into improved recovery or reduced morbid-
ity when compared with pain management strategies
used within an enhanced recovery after surgery (ERAS)
pathway24 . The requirement for delivery systems and
co-administration of intravenous fluids and oxygen with
IVPCA and epidurals is thought to impede patients
reaching the desired state of DrEaMing23 . Postoperative
analgesia is an essential component of most ERAS path-
ways; when implemented effectively they are successful in
improving patient outcomes44 . They advocate the use of
multimodal analgesia and encourage use of opiate-sparing
techniques including regional analgesia where possible45 .
Multimodal analgesia involves choosing drugs that act on
different parts of the anatomical pain pathways. In general,
analgesic medications act by inhibiting ascending pain sig-
nals, either in the periphery or centrally in the spinal cord
and brain, and facilitating descending inhibitory spinal
pathways. This leads to decreased nociceptive transmission
and interpretation of these signals as pain by higher neuro-
logical centres. Drugs with different mechanisms of action
are then combined to produce synergistic effects, allowing
use of lower doses, thus reducing the burden of side-effects
from single-drug strategies46 . The combinations have core
components according to the type of surgery performed.
Publications from the PROSPECT (PROcedure-SPECific
Pain ManagemenT)47 collaboration of surgeons and anaes-
thetists provide practical evidence-based summaries on
procedure-specific pain management. However, these need
to be tailored to each patient, accounting for additional
factors such as preexisting analgesic use, co-morbidities,
pharmacogenomics, epigenetics, drug interactions and
tolerance32,48 . Evidence regarding drugs useful in multi-
modal strategies is outlined below.
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Acute postoperative pain management e73

Paracetamol if there is an association, it trends towards non-selective

NSAID use61 – 63 . Guidance continues to recommend
Inclusion of paracetamol in multimodal analgesic strategies
consideration on an individual-patient basis as additional
produces opioid-sparing effects. A statistically significant
side-effects need to be evaluated, such as increased risk
reduction in mean cumulative 24-h morphine consump-
of thromboembolic events, gastrointestinal bleeding and
tion is observed with paracetamol compared with placebo
worsening of cardiac failure.
after major surgery49 . The most recent Cochrane review50
of RCTs of single-dose oral analgesic for acute postopera- Opioids
tive pain in adults reported a NNT of 3⋅6 (95 per cent c.i.
3⋅2 to 4⋅1) with 1 g paracetamol, which improved on com- Opioids have long been the cornerstone treatment for
bination with other analgesics, such as 400 mg ibuprofen, moderate and severe acute pain. There is, however,
60 mg codeine and 10 mg oxycodone (NNT 1⋅5, 2⋅2 and tension between their benefit and threat to optimal post-
1⋅8 respectively). When given prophylactically, intravenous operative recovery. In the immediate postoperative phase,
opioid-related adverse events (ORADE) were reported in
paracetamol is associated with reduced postoperative nau-
10 per cent of a surgical cohort of 135 379 patients, and
sea and vomiting, postulated to be due to superior pain
were more common in older men with higher ASA fitness
control51 . A significant concern regarding paracetamol use
grades, those with multiple comorbidities, and patients
relates to the development of hepatotoxicity; however, cur-
with a history of alcohol or drug abuse. ORADE were
rent data suggest this is unlikely to develop at therapeutic
associated with an increase in duration of hospital stay of
doses52 . Therefore, the inclusion of paracetamol as part of a
1⋅6 days64 . Continuation of opioids beyond the postoper-
multimodal strategy is likely to be useful in improving pain
ative hospital stay represents a risk. In the USA, a survey65
relief and reducing doses of other analgesic medications.
of patients receiving chronic opioid therapy revealed that
27 per cent were first started on opioids after surgery and
Non-steroidal anti-inflammatory drugs a recent systematic review66 found that fewer than half of
opioid prescriptions issued after surgery are used by the
Non-steroidal anti-inflammatory drugs (NSAIDs) are
patient following discharge, highlighting a potential source
endorsed by the ERAS Society for use as part of a mul-
for diversion and misuse of opioid supply. Patients who
timodal analgesic strategy53 – 57 . NSAIDs are reported
are already on opioids or benzodiazepines, or diagnosed
to reduce IVPCA morphine consumption after major
with substance use or another mental health disorder, are
surgery49 . Concerns remain regarding the risk of compli-
at greatest risk of prolonged postoperative use67 .
cations, including acute kidney injury and anastomotic leak.
Patients taking opiates before surgery are not only at
Two observational studies58,59 explored NSAID-associated
increased risk of uncontrolled pain, but also have a higher
postoperative complications. The first study58 consid-
burden of ORADE, especially respiratory depression and
ered 1503 patients undergoing elective or emergency
sedation68 . In this group, multimodal analgesic strategies
gastrointestinal resection, and reported a risk-adjusted
are of particular importance to aid effective analgesia, min-
reduced incidence of postoperative complications follow-
imize increased opioid use and attenuate opioid-induced
ing NSAID use (odds ratio 0⋅72, 95 per cent c.i. 0⋅52
hyperalgesia68 . However, these patients risk withdrawal if
to 0⋅99), although this was predominantly owing to a
their normal dose of opioids is not continued at a baseline
reduction in minor complications with high-dose NSAID
level, so accurate records of their preadmission opioid dose
use58 . The second observational cohort study59 of 9264
are essential. In these circumstances, IVPCA opioids can
patients undergoing elective or emergency gastrointestinal
be helpful, but patients often require background infu-
surgery reported that use of NSAIDs was not associated
sions and may need higher bolus doses than opioid-naive
with major complications, acute kidney injury or post-
patients owing to opioid tolerance68,69 . Other strategies
operative bleeding after propensity score matching and
to mitigate harm include opioid rotation/switching, use
adjusting for confounding factors. Despite risk adjustment,
of additional techniques such as regional analgesia, and
these data are limited by selection bias, in that NSAIDs
ensuring that a ‘reverse analgesic ladder’ is used on dis-
are more likely to be administered to healthier patients.
charge to return the patient to their preadmission opioid
The most recent Cochrane review60 of perioperative
regimen in a stepwise manner69,70 .
NSAIDs concluded that their effects on renal function
remain uncertain, in part owing to a lack of evidence
Ketamine
regarding the safety of NSAIDs in the perioperative phase.
There continues to be inconclusive evidence regarding The most recent Cochrane review71 of perioperative
anastomotic leak; more recent evaluation suggests that, ketamine use for acute postoperative pain in over 130

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e74
predominantly small trials, mostly containing fewer than
50 patients, found that its use was associated with decreased
postoperative morphine consumption at 24 and 48 h, along
with decreased pain intensity. Although the benefits are
thought to be somewhat offset by dose-dependent adverse
effects, including hypersalivation, nausea and vomiting,
and psychotomimetic effects such as vivid dreams, blurred
vision, hallucinations, nightmares and delirium72 , there
was a non-clinically significant reduction in nausea and
vomiting and little difference compared with controls in
terms of central nervous system side-effects71 . Ketamine
is also thought to reduce the likelihood of transition to
PPSP73 . Currently it is not recommended as a routine part
of most ERAS postoperative pain strategies. However,
its inclusion in a multimodal strategy may be effective in
patients with escalating opioid requirements.
Gabapentinoids
Gabapentinoids are effective analgesics in most inflam-
matory and postoperative pain animal models, but their
effects in human models appear variable74 . Gabapentinoids
act on ascending and descending pathways, influencing
both the nociceptive and affective components of pain.
Most commonly used to manage chronic neuropathic pain,
their use in the perioperative phase rose to prominence
following interest in their preemptive use to prevent PPSP.
Synthesis of small trials suggested that they may be pro-
tective against the development of PPSP73,75 . Evidence
regarding the incidence of acute neuropathic postoperative
pain and pharmacological management is scarce; use of
gabapentinoids in these circumstances appears sensible
based on chronic pain data. However, a systematic review76
published in 2007 reported that gabapentin and pregabalin
reduced opioid consumption in the early postoperative
period, leading to their inclusion in strategies to manage
generalized postoperative pain. Subsequent studies have
focused on either perioperative gabapentin or pregabalin
use for postoperative pain after specific surgical proce-
dures. Evidence also varies based on whether these drugs
are given before or after operation, making decisions
regarding their use difficult. Although gabapentin and
pregabalin are recommended in the clinical practice guide-
lines of the American Pain Society48 for use as part of
a multimodal strategy for postoperative pain, systematic
reviews and meta-analyses77,78 for each drug found that
their use was associated with minimal opioid-sparing
effects and an increased risk of adverse events. There are
growing concerns about their associated risks, in particular
abuse, community fatalities and diversion79 . In April 2019,
they were recategorized as class C drugs in the UK80 , and
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C. Small and H. Laycock
caution should be employed in their use, particularly in
patients with preexisting drug abuse81 .
𝛂-2 agonists
The α-2 receptor agonists clonidine and dexmedetomidine
can be administered orally (clonidine only), intravenously,
intrathecally, perineurally or via a transdermal patch, and
have been used both during and after operation. Although
they are associated with reduced opiate use and duration
of nerve blocks, their benefit is offset by sedation and
hypotension82 – 84 . In view of the haemodynamic effects,
postoperative α-2 agonist infusion would necessitate
admission to a high-dependency area in most UK centres.
Magnesium
There is level 1 evidence that intravenous magnesium, as
an adjunct to morphine analgesia, has an opioid-sparing
effect and reduces pain scores85 . The studies included in
this systematic review and meta-analysis used bolus doses
(mostly 30–50 mg/kg) alongside an intraoperative lower
dose or short postoperative infusions of magnesium (up to
48 h after surgery). In addition, two small RCTs86,87 sug-
gested that intravenous magnesium extends the duration
of sensory block with spinal anaesthesia, and reduces sub-
sequent postoperative pain and opioid requirements.
Intravenous lidocaine
Recovery outcomes within the DrEaMing paradigm have
been examined in the recent Cochrane review88 of con-
tinuous intravenous perioperative lidocaine infusion for
postoperative pain and recovery in adults. Of 68 included
RCTs, 42 involved abdominal surgery and were evaluated
as low quality with varying dosing regimens (between 1
and 5 mg per kg per h). The authors concluded that there
was insufficient evidence to demonstrate improvements in
postoperative pain, or resolution of ileus, nausea, vomiting
or side-effects compared with placebo, usual care or tho-
racic epidural anaesthesia (EA). Current ERAS guidelines
for elective colorectal surgery include perioperative lido-
caine infusions. However, these guidelines are based on
the previous, now superseded, Cochrane review89 which
inferred more benefit from intravenous lidocaine. There
is currently uncertainty regarding the use of intravenous
lidocaine to aid postoperative analgesia. There are a num-
ber of studies ongoing and publications that may change
this conclusion are awaited.
Other agents
There has been recent interest in the use of cannabis-based
drugs in acute as well as chronic pain management.
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Acute postoperative pain management e75

Table 1 Advantages and disadvantages of regional analgesic techniques

Technique Advantages Disadvantages

Epidural
Intrathecal (spinal)
Peripheral trunk blocks (e.g.
transversus abdominis
plane and rectus sheath)
Paravertebral
Wound infiltration
Reduced pain and requirement for co-analgesics
Improved respiratory function
Reduced pulmonary, thromboembolic,
cardiovascular, ileus and surgical stress response
Can be continued after operation
Reduced pain and systemic opioid requirements
Reduced pain and systemic opioid requirements in
the immediate postoperative period
Catheter insertion allows continued block in
postoperative phase
Reduced pain and systemic opioid requirements
Lower risk of pulmonary complications for patients
undergoing thoracotomy
Catheter insertion allows continued block in
postoperative phase
Levels of analgesia comparable to those of epidural
analgesia, with reduced incidence of hypotension
Reduced pain and systemic opioid requirements in
immediate postoperative phase
Easily administered
Technique-related: backache, postdural puncture
headache, neurological injury, epidural haematoma,
failure
Epidural local anaesthetic-related: hypotension,
sensory deficits, motor weakness, urinary retention,
toxicity
Epidural opioids: nausea, vomiting, pruritus, respiratory
depression
Attachment to drug delivery equipment
Nausea and vomiting
Pruritus and respiratory depression if opioids used
Fails to address visceral pain
Local anaesthetic toxicity
Risk of perforation of the peritoneum with possible
damage to visceral structures on insertion
Hypotension possible
Vascular or pleural puncture on insertion
Short-term efficacy

Adapted from Wick et al.45 .

Although there is a paucity of evidence, the most recent
meta-analysis90 considering three RCTs examining the
use of cannabinoids for acute postoperative pain favoured
placebo over tetrahydrocannabinol or nabilone in all trials.
Regional analgesia
Regional anaesthesia delivers analgesic drugs, usually
local anaesthetic, with or without an adjunct, directly to
the peripheral nerves. Table 1 outlines commonly used
regional analgesia techniques. Use of regional anaesthesia
reduces the risk of PPSP compared with conventional
analgesia. For thoracic epidural analgesia after thora-
cotomy, the odds ratio is 0⋅52 (95 per cent c.i. 0⋅32 to
0⋅84; P = 0⋅008); for various regional analgesia techniques,
including paravertebral, nerve blocks and local infiltration
in breast surgery, the odds ratio is 0⋅34 (0⋅19 to 0⋅60)91 .
Continuous central neuraxial block
Continuous central neuraxial block or EA has many ben-
efits across a range of surgical procedures. There is level
1 evidence for improved analgesia at rest, and reduced
incidence of ileus, pulmonary complications, surgical
stress response, negative nitrogen balance and other anal-
gesic requirements92 . Most epidural formulations include
a local anaesthetic infusion. Commonly used adjuncts
are opiates, including morphine, buprenorphine, diamor-
phine, hydromorphone, tramadol and fentanyl, the former
causing greater respiratory depression. Less common
adjuncts include clonidine which, when used in neurax-
ial blocks, blocks the sympathetic outflow93 . Compared
with IVPCA opioids, pain is modestly improved with EA
following intra-abdominal surgery, with a statistically,
but non-clinically, significant reduction in pain scores at
rest94 . However, use of EA may enhance the trajectory
towards DrEaMing. The combination of tolerance of
solid food plus defaecation predicts recovery of gastroin-
testinal transit95 , and EA reduces paralytic ileus while
increasing food tolerance by reducing nausea, vomiting
and pain96 . The analgesic failure rate is higher for EA
than IVPCA opioids (120 versus 34 in 1000 respectively),
and EA is more likely to be associated with need for
interventions for hypotension (120 versus 17 per 1000)94 .
The technique has a risk of complications. The pessimistic
estimate of permanent harm associated with all EA is
17⋅4 (95 per cent c.i. 7⋅2 to 27⋅8) per 100 000 and that
of paraplegia or death is 6⋅1 (2⋅2 to 13⋅3) per 100 00026 .
Furthermore, although the risk of developing an epidu-
ral haematoma remains small, appropriate precautions
should be taken in patients taking antiplatelets and/or
anticoagulant medication97 . Current ERAS guidelines53

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for elective colorectal surgery recommend thoracic EA
for open surgery but not for laparoscopic procedures.
Recommendations appear surgery-specific, as thoracic EA
is recommended as first line in ERAS pathways for patients
undergoing oesophagectomy55 . However, local anaesthetic
infiltration of wounds has higher-level evidence reported
for gynaecological ERAS pathways54 .
Intrathecal analgesia
This technique involves use of a local anaesthetic which
acts during surgery to decrease stress responses, and
co-administration of a long-acting opioid, such as mor-
phine or diamorphine, which has continued analgesic
effects for up to 24 h. Spinal anaesthesia/analgesia has high
efficacy and a low complication rate, with a pessimistic
estimate of 2⋅2 (95 per cent c.i. 1 to 4⋅4) per 100 000
for permanent harm and 1⋅2 (1 to 3⋅2) per 100 000 for
paraplegia or death26 . When used as part of an ERAS pro-
gramme, intrathecal analgesia is associated with reduced
opioid consumption after laparoscopic colonic resection98
and abdominal surgery for gynaecological malignancy99 ,
and lower pain scores100 . However, its impact on dura-
tion of hospital stay appears inconclusive98,99 . The main
concerns surround risk of delayed respiratory depression
in the first day after operation. However, the technique is
recommended in the most recent ERAS guidelines53 for
laparoscopic colorectal surgery53 .
Abdominal wall blocks
In the past decade, new abdominal truncal blocks, includ-
ing transversus abdominis plane (TAP) and rectus sheath
blocks, have grown in popularity101 . The TAP block pro-
vides analgesia by blocking the seventh to 11th intercostal
nerves (T7–T11), the subcostal nerve (T12), and the ilioin-
guinal and iliohypogastric nerves (L1–L2). These blocks
can be administered as a single dose, or as an infusion
for more long-lasting benefit. They can be placed under
direct vision using ultrasound imaging or laparoscopically.
Truncal blocks generally contain a local anaesthetic, with
or without an adjunct. The majority of research evaluat-
ing adjuncts originates from limb blocks, and details are
beyond the scope of this article. However, in general, mor-
phine and fentanyl do not improve the quality of analgesia
but increase side-effects, whereas dexamethasone, cloni-
dine and ketamine can prolong the duration of analgesia
but are all associated with unwanted side-effects owing to
systemic absorption93 .
Equivalence or superiority in terms of analgesic provision
has been shown, but variation in techniques limits ability
to synthesize study data in a meta-analysis102 . A 2010
Cochrane review103 concluded that single-shot TAP blocks
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C. Small and H. Laycock
resulted in significantly less postoperative requirement for
morphine at 24 h. A more recent meta-analysis104 of 310
adult patients identified that pain scores at rest in the first
24 h were the same as those for EA (mean difference 0⋅5, 95
per cent c.i. 0⋅1 to 1⋅0; P = 0⋅10), with a reduced incidence
of hypotension and shorter hospital stay. Different surgical
specialties vary in their ERAS guidelines with respect to
truncal blocks; for example, ERAS guidelines for periop-
erative care in gynaecological/oncological surgery recom-
mend incisional local anaesthetic injection over TAP blocks
or thoracic EA54 , whereas TAP blocks are strongly rec-
ommended as part of multimodal analgesia in minimally
invasive colorectal surgery53 .
Non-pharmacological techniques
Non-pharmacological interventions to aid the manage-
ment of postoperative pain can be used throughout the
perioperative phase. These are often cheap and easy
to implement. Preoperative strategies include patient
education and psychological interventions105 , such as
cognitive behavioural therapy. Distraction techniques,
including music, aromatherapy, canine therapy and virtual
reality have been used during and after operation, and have
shown greatest benefit in patients with anxiety106 – 110 . In
the postoperative setting they can be used as part of a
self-management programme, increasing patient indepen-
dence and autonomy111 . Many such therapies have been
established in the treatment of chronic pain. Owing to
concerns over the side-effect burden of tradition pharma-
cotherapies, they are becoming increasingly investigated
in all settings including acute postoperative pain.
Overview
Adequate management of postoperative pain is a core
determinant of the patient achieving DrEaMing status.
Each of the biological, psychological and social dimensions
of the pain experience should be considered and under-
stood in order to provide optimum pain management in the
postoperative setting. Recognition of the biopsychosocial
phenotypes at increased risk of difficult-to-manage postop-
erative pain and development of PPSP will enhance strati-
fication of resource use and aid in decision-making around
balance of pharmacological benefit and risk.
Acknowledgements
C.S. is currently a National Institute for Health Research
Academic Clinical Lecturer. H.L. is a Clinical Lecturer
funded partly by a Horizon 2020 project grant from the
European Union and Health Education England.
Disclosure: The authors declare no conflict of interest.
www.bjs.co.uk BJS 2020; 107: e70–e80

Acute postoperative pain management
References
1 Schug SA, Lavand’homme P, Barke A, Korwisi B, Rief W,
Treede R-D et al.; IASP Taskforce for the Classification of
Chronic Pain. The IASP classification of chronic pain for
ICD-11. Pain 2019; 160: 45–52.
2 Papaioannou M, Skapinakis P, Damigos D, Mavreas V,
Broumas G, Palgimesi A. The role of catastrophizing in the
prediction of postoperative pain. Pain Med 2009; 10:
1452–1459.
3 Schreiber KL, Zinboonyahgoon N, Xu X, Spivey T,
King T, Dominici L et al. Preoperative psychosocial and
psychophysical phenotypes as predictors of acute pain
outcomes after breast surgery. J Pain 2019; 20: 540–556.
4 Yang MMH, Hartley RL, Leung AA, Ronksley PE, Jetté N,
Casha S et al. Preoperative predictors of poor acute
postoperative pain control: a systematic review and
meta-analysis. BMJ Open 2019; 9: e025091.
5 McMahon SB, Koltzenburg M, Tracey I, Turk DC. Wall
and Melzack’s Textbook of Pain (6th edn). Elsevier:
Philadelphia, 2013.
6 Chapman CR, Donaldson GW, Davis JJ, Bradshaw DH.
Improving individual measurement of postoperative pain:
the pain trajectory. J Pain 2011; 12: 257–262.
7 Brennan F, Carr DB, Cousins M. Pain management: a
fundamental human right. Anesth Analg 2007; 105:
205–221.
8 Walker EMK, Bell M, Cook TM, Grocott MPW,
Moonesinghe SR; Central SNAP-1 Organisation; National
Study Groups. Patient reported outcome of adult
perioperative anaesthesia in the United Kingdom: a
cross-sectional observational study. Br J Anaesth 2016; 117:
758–766.
9 National Institute of Academic Anaesthesia (NIAA) Health
Services Research Centre. Perioperative Quality Improvement
Programme Annual Report 2017–18. NIAA: London, 2018.
10 National Institute of Academic Anaesthesia (NIAA) Health
Services Research Centre. Perioperative Quality Improvement
Programme Annual Report 2018–19. NIAA: London, 2019.
11 Gerbershagen HJ, Aduckathil S, van Wijck AJM, Peelen
LM, Kalkman CJ, Meissner W. Pain intensity on the first
day after surgery: a prospective cohort study comparing 179
surgical procedures. Anesthesiology 2013; 118: 934–944.
12 Royal College of Surgeons of England and College of
Anaesthetists. Pain after Surgery. Royal College of Surgeons:
London, 1990.
13 Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative
pain experience: results from a national survey suggest
postoperative pain continues to be undermanaged. Anesth
Analg 2003; 97: 534–540.
14 Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL.
Incidence, patient satisfaction, and perceptions of
post-surgical pain: results from a US national survey. Curr
Med Res Opin 2014; 30: 149–160.
15 Kehlet H, Jensen TS, Woolf J. Persistent postsurgical pain:
risk factors and prevention. Lancet 2006; 367: 1618–1625.
© 2020 BJS Society Ltd
Published by John Wiley & Sons Ltd
13652168, 2020, 2, Downloaded from https://bjssjournals.onlinelibrary.wiley.com/doi/10.1002/bjs.11477 by Cochrane Philippines, Wiley Online Library on [09/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
e77
16 Chapman CR, Vierck CJ. The transition of acute
postoperative pain to chronic pain: an integrative overview
of research on mechanisms. J Pain 2017; 18:
359.e1–359.e38.
17 Glare P, Aubrey KR, Myles PS. Transition from acute to
chronic pain after surgery. Lancet 2019; 393: 1537–1546.
18 Sinatra R. Causes and consequences of inadequate
management of acute pain. Pain Med 2010; 11: 1859–1871.
19 Joshi GP, Ogunnaike BO. Consequences of inadequate
postoperative pain relief and chronic persistent post-
operative pain. Anesthesiol Clin North Am 2005; 23: 21–36.
20 Cousins MJ, Brennan F, Carr DB. Pain relief: a universal
human right. Pain 2004; 112: 1–4.
21 Hernandez-Boussard T, Graham LA, Desai K, Wahl TS,
Aucoin E, Richman JS et al. The fifth vital sign:
postoperative pain predicts 30-day readmissions and
subsequent emergency department visits. Ann Surg 2017;
266: 516–524.
22 Atchabahian A, Andreae M. Long-term functional
outcomes after regional anesthesia: a summary of the
published evidence and a recent Cochrane review. Refresh
Courses Anesthesiol 2015; 43: 15–26.
23 Levy N, Mills P, Mythen M. Is the pursuit of DREAMing
(drinking, eating and mobilising) the ultimate goal of
anaesthesia? Anaesthesia 2016; 71: 1008–1012.
24 Hughes MJ, Ventham NT, McNally S, Harrison E,
Wigmore S. Analgesia after open abdominal surgery in the
setting of enhanced recovery surgery: a systematic review
and meta-analysis. JAMA Surg 2014; 149: 1224–1230.
25 Oliveira RA, Guatura GMGBDS, Peniche ACG, Costa
ALS, Poveda VB. An integrative review of postoperative
accelerated recovery protocols. AORN J 2017; 106:
324.e5–330.e5.
26 Cook TM, Counsell D, Wildsmith JAW; Royal College of
Anaesthetists Third National Audit Project. Major
complications of central neuraxial block: report on the
Third National Audit Project of the Royal College of
Anaesthetists. Br J Anaesth 2009; 102: 179–190.
27 Elkassabany NM, Memtsoudis SG, Mariano ER. What can
regional anesthesiology and acute pain medicine learn from
‘big data’? Anesthesiol Clin 2018; 36: 467–478.
28 Max MB. Quality improvement guidelines for the treatment
of acute pain and cancer pain. JAMA 1995; 274: 1874.
29 Faculty of Pain Medicine. Core Standards for Pain
Management Services in the UK . Faculty of Pain Medicine:
London, 2015.
30 Royal College of Anaesthetists. Guidelines for the Provision of
Anaesthetic Services (GPAS) 2019. Royal College of
Anaesthetists: London, 2019.
31 Rockett M, Vanstone R, Chand J, Waeland D. A survey of
acute pain services in the UK. Anaesthesia 2017; 72:
1237–1242.
32 Sultana A, Torres D, Schumann R. Special indications for
opioid free anaesthesia and analgesia, patient and procedure
related: including obesity, sleep apnoea, chronic obstructive
pulmonary disease, complex regional pain syndromes,
www.bjs.co.uk BJS 2020; 107: e70–e80

e78
opioid addiction and cancer surgery. Best Pract Res Clin
Anaesthesiol 2017; 31: 547–560.
33 Tumber PS. Optimizing perioperative analgesia for the
complex pain patient: medical and interventional strategies.
Can J Anaesth 2014; 61: 131–140.
34 Ip HYV, Abrishami A, Peng PWH, Wong J, Chung F.
Predictors of postoperative pain and analgesic consumption:
a qualitative systematic review. Anesthesiology 2009; 111:
657–677.
35 Breivik H, Borchgrevink PC, Allen SM, Rosseland LA,
Romundstad L, Hals EKB et al. Assessment of pain. Br
J Anaesth 2008; 101: 17–24.
36 Twining J, Padula C. Pilot testing the clinically aligned pain
assessment (CAPA) measure. Pain Manag Nurs 2019; 20:
462–467.
37 Schofield P. The assessment of pain in older people: UK
national guidelines. Age Ageing 2018; 47(Suppl 1): i1–i22.
38 Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter
AJC, Pandharipande PP et al. Clinical practice guidelines
for the prevention and management of pain, agitation/-
sedation, delirium, immobility, and sleep disruption in adult
patients in the ICU. Crit Care Med 2018; 49: e825–e873.
39 Pereira-Morales S, Arroyo-Novoa CM, Wysocki A, Sanzero
Eller L. Acute pain assessment in sedated patients in the
postanesthesia care unit. Clin J Pain 2018; 34: 700–706.
40 Moore RA, Straube S, Aldington D. Pain measures and
cut-offs – ‘no worse than mild pain’ as a simple, universal
outcome. Anaesthesia 2013; 68: 400–412.
41 Aldington DJ, McQuay HJ, Moore RA. End-to-end
military pain management. Philos Trans R Soc Lond B Biol Sci
2011; 366: 268–275.
42 Gray A, Kehlet H, Bonnet F, Rawal N. Predicting
postoperative analgesia outcomes: NNT league tables or
procedure-specific evidence? Br J Anaesth 2005; 94:
710–714.
43 Moore RA, Derry S, Wiffen PJ, Banerjee S, Karan R,
Glimm E et al. Estimating relative efficacy in acute
postoperative pain: network meta-analysis is consistent with
indirect comparison to placebo alone. Pain 2018; 159:
2234–2244.
44 Ripollés-Melchor J, Ramírez-Rodríguez JM,
Casans-Francés R, Aldecoa C, Abad-Motos A,
Logroño-Egea M et al.; POWER Study Investigators
Group for the Spanish Perioperative Audit and Research
Network (REDGERM). Association between use of
enhanced recovery after surgery protocol and postoperative
complications in colorectal surgery: the Postoperative
Outcomes Within Enhanced Recovery After Surgery
Protocol (POWER) Study. JAMA Surg 2019; 154:
725–736.
45 Wick EC, Grant MC, Wu CL. Postoperative multimodal
analgesia pain management with nonopioid analgesics and
techniques. JAMA Surg 2017; 152: 691–697.
46 Kehlet H, Dahl JB. The value of ‘multimodal’ or ‘balanced
analgesia’ in postoperative pain treatment. Anesth Analg
1993; 77: 1048–1056.
© 2020 BJS Society Ltd
Published by John Wiley & Sons Ltd
13652168, 2020, 2, Downloaded from https://bjssjournals.onlinelibrary.wiley.com/doi/10.1002/bjs.11477 by Cochrane Philippines, Wiley Online Library on [09/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
C. Small and H. Laycock
47 Lee B, Schug SA, Joshi GP, Kehlet H; PROSPECT
Working Group. Procedure-specific pain management
(PROSPECT) – an update. Best Pract Res Clin Anaesthesiol
2018; 32: 101–111.
48 Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg
JM, Bickler S, Brennan T 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; 17: 131–157.
49 Maund E, McDaid C, Rice S, Wright K, Jenkins B,
Woolacott N. Paracetamol and selective and non-selective
non-steroidal anti-inflammatory drugs for the reduction in
morphine-related side-effects after major surgery: a
systematic review. Br J Anaesth 2011; 106: 292–297.
50 Moore RA, Derry S, Aldington D, Wiffen PJ. Single dose
oral analgesics for acute postoperative pain in adults – an
overview of Cochrane reviews. Cochrane Database Syst Rev
2015; (9)CD008659.
51 Apfel CC, Turan A, Souza K, Pergolizzi J, Hornuss C.
Intravenous acetaminophen reduces postoperative nausea
and vomiting: a systematic review and meta-analysis. Pain
2013; 154: 677–689.
52 Dart RC, Bailey E. Does therapeutic use of acetaminophen
cause acute liver failure? Pharmacotherapy 2007; 27:
1219–1230.
53 Gustafsson UO, Scott MJ, Hubner M, Nygren J,
Demartines N, Francis N et al. Guidelines for perioperative
care in elective colorectal surgery: Enhanced Recovery
After Surgery (ERAS®) Society recommendations: 2018.
World J Surg 2019; 43: 659–695.
54 Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G,
Altman A, Meyer LA et al. Guidelines for perioperative care
in gynecologic/oncology: Enhanced Recovery After
Surgery (ERAS) Society recommendations – 2019 update.
Int J Gynecol Cancer 2019; 29: 651–668.
55 Low DE, Allum W, De Manzoni G, Ferri L, Immanuel A,
Kuppusamy M et al. Guidelines for perioperative care in
esophagectomy: Enhanced Recovery After Surgery
(ERAS®) Society recommendations. World J Surg 2019; 43:
299–330.
56 Thorell A, MacCormick AD, Awad S, Reynolds N,
Roulin D, Demartines N et al. Guidelines for perioperative
care in bariatric surgery: Enhanced Recovery After Surgery
(ERAS) Society recommendations. World J Surg 2016; 40:
2065–2083.
57 Temple-Oberle C, Shea-Budgell MA, Tan M, Semple JL,
Schrag C, Barreto M et al. Consensus review of optimal
perioperative care in breast reconstruction: Enhanced
Recovery After Surgery (ERAS) Society recommendations.
Plast Reconstr Surg 2017; 139: 1056e–1071e.
58 STARSurg Collaborative. Impact of postoperative
non-steroidal anti-inflammatory drugs on adverse events
www.bjs.co.uk BJS 2020; 107: e70–e80

Acute postoperative pain management
after gastrointestinal surgery. Br J Surg 2014; 101:
1413–1423.
59 STARSurg Collaborative. Safety of nonsteroidal
anti-inflammatory drugs in major gastrointestinal surgery: a
prospective, multicenter cohort study. World J Surg 2017;
41: 47–55.
60 Bell S, Rennie T, Marwick CA, Davey P. Effects of
peri-operative nonsteroidal anti-inflammatory drugs on
post-operative kidney function for adults with normal
kidney function. Cochrane Database Syst Rev 2018;
(11)CD011274.
61 Kverneng Hultberg D, Angenete E, Lydrup M-L,
Rutegård J, Matthiessen P, Rutegård M. Nonsteroidal
anti-inflammatory drugs and the risk of anastomotic leakage
after anterior resection for rectal cancer. Eur J Surg Oncol
2017; 43: 1908–1914.
62 Huang Y, Tang SR, Young CJ. Nonsteroidal
anti-inflammatory drugs and anastomotic dehiscence after
colorectal surgery: a meta-analysis. ANZ J Surg 2018; 88:
959–965.
63 Modasi A, Pace D, Godwin M, Smith C, Curtis B. NSAID
administration post colorectal surgery increases
anastomotic leak rate: systematic review/meta-analysis. Surg
Endosc 2019; 33: 879–885.
64 Shafi S, Collinsworth AW, Copeland LA, Ogola GO,
Qiu T, Kouznetsova M et al. Association of opioid-related
adverse drug events with clinical and cost outcomes among
surgical patients in a large integrated health care delivery
system. JAMA Surg 2018; 153: 757–763.
65 Callinan CE, Neuman MD, Lacy KE, Gabison C, Ashburn
MA. The initiation of chronic opioids: a survey of chronic
pain patients. J Pain 2017; 18: 360–365.
66 Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL.
Prescription opioid analgesics commonly unused after
surgery: a systematic review. JAMA Surg 2017; 152:
1066–1071.
67 Lanzillotta JA, Clark A, Starbuck E, Kean EB,
Kalarchian M. The impact of patient characteristics and
postoperative opioid exposure on prolonged postoperative
opioid use: an integrative review. Pain Manag Nurs 2018;
19: 535–548.
68 Quinlan J, Cox F. Acute pain management in patients with
drug dependence syndrome. Pain Rep 2017; 2: e611.
69 Huxtable C, Roberts L, Somogyi A, Macintyres P. Acute
pain management in opioid tolerant patients: a growing
challenge. Anaesth Intensive Care 2011; 39: 804–823.
70 Kumar K, Kirksey MA, Duong S, Wu CL. A review of
opioid-sparing modalities in perioperative pain
management. Anesth Analg 2017; 125: 1749–1760.
71 Brinck E, Tiippana E, Heesen M, Bell RF, Straube S,
Moore RA et al. Perioperative intravenous ketamine for
acute postoperative pain in adults. Cochrane Database Syst
Rev 2018; (12)CD012033.
72 Aroni F, Iacovidou N, Dontas I, Pourzitaki C, Xanthos T.
Pharmacological aspects and potential new clinical
© 2020 BJS Society Ltd
Published by John Wiley & Sons Ltd
13652168, 2020, 2, Downloaded from https://bjssjournals.onlinelibrary.wiley.com/doi/10.1002/bjs.11477 by Cochrane Philippines, Wiley Online Library on [09/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
e79
applications of ketamine: reevaluation of an old drug. J Clin
Pharmacol 2009; 49: 957–964.
73 Chaparro LE, Smith SA, Moore RA, Wiffen PJ, Gilron I.
Pharmacotherapy for the prevention of chronic pain after
surgery in adults. Cochrane Database Syst Rev 2013;
(7)CD008307.
74 Chincholkar M. Analgesic mechanisms of gabapentinoids
and effects in experimental pain models: a narrative review.
Br J Anaesth 2018; 120: 1315–1334.
75 Clarke H, Bonin RP, Orser BA, Englesakis M,
Wijeysundera DN, Katz J. The prevention of chronic
postsurgical pain using gabapentin and pregabalin: a
combined systematic review and meta-analysis. Anesth
Analg 2012; 115: 428–442.
76 Tiippana EM, Hamunen K, Kontinen VK, Kalso E. Do
surgical patients benefit from perioperative
gabapentin/pregabalin? A systematic review of efficacy and
safety. Anesth Analg 2007; 104: 1545–1556.
77 Fabritius ML, Geisler A, Petersen PL, Nikolajsen L,
Hansen MS, Kontinen V et al. Gabapentin for
post-operative pain management – a systematic review with
meta-analyses and trial sequential analyses. Acta Anaesthesiol
Scand 2016; 60: 1188–1208.
78 Fabritius ML, Strøm C, Koyuncu S, Jæger P, Petersen PL,
Geisler A et al. Benefit and harm of pregabalin in acute pain
treatment: a systematic review with meta-analyses and trial
sequential analyses. Br J Anaesth 2017; 119: 775–791.
79 Office for National Statistics. Number of Drug-Related
Deaths Involving Gabapentin or Pregabalin With or Without An
Opioid Drug, England and Wales, 2017; 2018. https://www.
ons.gov.uk/peoplepopulationandcommunity/birthsdeaths
andmarriages/deaths/adhocs/009142numberofdrugrelated
deathsinvolvinggabapentinorpregabalinwithorwithoutano
pioiddrugenglandandwales2017 [accessed 6 October 2019].
80 Mayor S. Pregabalin and gabapentin become controlled
drugs to cut deaths from misuse. BMJ 2018; 363: k4364.
81 Evoy KE, Morrison MD, Saklad SR. Abuse and misuse of
pregabalin and gabapentin. Drugs 2017; 77: 403–426.
82 Grape S, Kirkham KR, Frauenknecht J, Albrecht E.
Intra-operative analgesia with remifentanil vs.
dexmedetomidine: a systematic review and meta-analysis
with trial sequential analysis. Anaesthesia 2019; 74:
793–800.
83 Jessen Lundorf L, Korvenius Nedergaard H, Møller AM.
Perioperative dexmedetomidine for acute pain after
abdominal surgery in adults. Cochrane Database Syst Rev
2016; (2)CD010358.
84 McEvoy MD, Scott MJ, Gordon DB, Grant SA, Thacker
JKM, Wu CL et al.; Perioperative Quality Initiative (POQI)
I Workgroup. American Society for Enhanced Recovery
(ASER) and Perioperative Quality Initiative (POQI) joint
consensus statement on optimal analgesia within an
enhanced recovery pathway for colorectal surgery: part
1 – from the preoperative period to PACU. Perioper Med
2017; 6: 8.
www.bjs.co.uk BJS 2020; 107: e70–e80

e80
85 De Oliveira GS, Castro-Alves LJ, Khan JH, McCarthy RJ.
Perioperative systemic magnesium to minimize
postoperative pain. Anesthesiology 2013; 119: 178–190.
86 Kahraman F, Eroglu A. The effect of intravenous
magnesium sulfate infusion on sensory spinal block and
postoperative pain score in abdominal hysterectomy. Biomed
Res Int 2014; 2014: 236024.
87 Kumar M, Dayal N, Rautela RS, Sethi AK. Effect of
intravenous magnesium sulphate on postoperative pain
following spinal anesthesia. A randomized double blind
controlled study. Middle East J Anaesthesiol 2013; 22:
251–256.
88 Weibel S, Jelting Y, Pace NL, Helf A, Eberhart LH,
Hahnenkamp K et al. Continuous intravenous perioperative
lidocaine infusion for postoperative pain and recovery in
adults. Cochrane Database Syst Rev 2018; (6)CD009642.
89 Kranke P, Jokinen J, Pace NL, Schnabel A, Hollmann
MW, Hahnenkamp K et al. Continuous intravenous
perioperative lidocaine infusion for postoperative pain and
recovery. Cochrane Database Syst Rev 2015; (7)CD009642.
90 Aviram J, Samuelly-Leichtag G. Efficacy of cannabis-based
medicines for pain management: a systematic review and
meta-analysis of randomized controlled trials. Pain Physician
2017; 20: E755–E796.
91 Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao
JY, Johnson M et al. Local anaesthetics and regional
anaesthesia versus conventional analgesia for preventing
persistent postoperative pain in adults and children.
Cochrane Database Syst Rev 2018; (6)CD007105.
92 Nimmo SM, Harrington LS. What is the role of epidural
analgesia in abdominal surgery? Contin Educ Anaesth Crit
Care Pain 2014; 14: 224–229.
93 Emelife PI, Eng MR, Menard BL, Myers AS, Cornett EM,
Urman RD et al. Adjunct medications for peripheral and
neuraxial anesthesia. Best Pract Res Clin Anaesthesiol 2018;
32: 83–99.
94 Salicath JH, Yeoh EC, Bennett MH. Epidural analgesia
versus patient-controlled intravenous analgesia for pain
following intra-abdominal surgery in adults. Cochrane
Database Syst Rev 2018; (8)CD010434.
95 van Bree SHW, Bemelman WA, Hollmann MW,
Zwinderman AH, Matteoli G, El Temna S et al.
Identification of clinical outcome measures for recovery of
gastrointestinal motility in postoperative ileus. Ann Surg
2014; 259: 708–714.
96 Guay J, Nishimori M, Kopp S. Epidural local anaesthetics
versus opioid-based analgesic regimens for postoperative
gastrointestinal paralysis, vomiting and pain after abdominal
surgery. Cochrane Database Syst Rev 2016; (7)CD001893.
97 Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK,
Kopp SL, Benzon HT et al. Regional anesthesia in the
patient receiving antithrombotic or thrombolytic therapy:
American Society of Regional Anesthesia and Pain
Medicine evidence-based guidelines (third edition). Reg
Anesth Pain Med 2010; 35: 64–101.
© 2020 BJS Society Ltd
Published by John Wiley & Sons Ltd
13652168, 2020, 2, Downloaded from https://bjssjournals.onlinelibrary.wiley.com/doi/10.1002/bjs.11477 by Cochrane Philippines, Wiley Online Library on [09/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
C. Small and H. Laycock
98 Wongyingsinn M, Baldini G, Stein B, Charlebois P,
Liberman S, Carli F. Spinal analgesia for laparoscopic
colonic resection using an enhanced recovery after surgery
programme: better analgesia, but no benefits on
postoperative recovery: a randomized controlled trial. Br
J Anaesth 2012; 108: 850–856.
99 Kjølhede P, Bergdahl O, Borendal Wodlin N, Nilsson L.
Effect of intrathecal morphine and epidural analgesia on
postoperative recovery after abdominal surgery for
gynecologic malignancy: an open-label randomised trial.
BMJ Open 2019; 9: e024484.
100 Koning MV, Teunissen AJW, Van Der Harst E, Ruijgrok
EJ, Stolker RJ. Intrathecal morphine for laparoscopic
segmental colonic resection as part of an enhanced recovery
protocol: a randomized controlled trial. Reg Anesth Pain Med
2018; 43: 166–173.
101 Chakraborty A, Khemka R, Datta T. Ultrasound-guided
truncal blocks: a new frontier in regional anaesthesia. Indian
J Anaesth 2016; 60: 703–711.
102 Sanderson BJ, Doane MA. Transversus abdominis plane
catheters for analgesia following abdominal surgery in
adults. Reg Anesth Pain Med 2018; 43: 5–13.
103 Charlton S, Cyna AM, Middleton P, Griffiths JD.
Perioperative transversus abdominis plane (TAP) blocks for
analgesia after abdominal surgery. Cochrane Database Syst
Rev 2010; (12)CD007705.
104 Baeriswyl M, Zeiter F, Piubellini D, Kirkham KR,
Albrecht E. The analgesic efficacy of transverse abdominis
plane block versus epidural analgesia. Medicine (Baltimore)
2018; 97: e11261.
105 Powell R, Scott NW, Manyande A, Bruce J, Vögele C,
Byrne-Davis LM et al. Psychological preparation and
postoperative outcomes for adults undergoing surgery
under general anaesthesia. Cochrane Database Syst Rev 2016;
(5)CD008646.
106 Poulsen MJ, Coto J. Nursing music protocol and
postoperative pain. Pain Manag Nurs 2018; 19: 172–176.
107 Cepeda MS, Carr DB, Lau J, Alvarez H. Music for pain
relief. Cochrane Database Syst Rev (2)CD004843.
108 Dimitriou V, Mavridou P, Manataki A, Damigos D. The
use of aromatherapy for postoperative pain management: a
systematic review of randomized controlled trials.
J Perianesth Nurs 2017; 32: 530–541.
109 Cooley LF, Barker SB. Canine-assisted therapy as an
adjunct tool in the care of the surgical patient: a literature
review and opportunity for research. Altern Ther Health
Med 2018; 24: 48–51.
110 Mosso Vázquez JL, Mosso Lara D, Mosso Lara JL, Miller I,
Wiederhold MD, Wiederhold BK. Pain distraction during
ambulatory surgery: virtual reality and mobile devices.
Cyberpsychol Behav Soc Netw 2019; 22: 15–21.
111 Mordecai L, Leung FHL, Carvalho CYM, Reddi D,
Lees M, Cone S et al. Self-managing postoperative pain
with the use of a novel, interactive device: a proof of
concept study. Pain Res Manag 2016; 2016: 9704185.
www.bjs.co.uk BJS 2020; 107: e70–e80