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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
This narrative review presents key considerations and of Anaesthetists propelled an expansion in multidisci-
approaches in the management of postoperative pain in plinary IPSs across the UK. This was in response to an
adults. acknowledgement that postoperative pain management
was inadequate, having ‘not advanced significantly for
Methods
many years’12 . The rising prominence of perioperative
Th Cochrane Library, PubMed and Google Scholar pain management was mirrored globally with campaigns
databases were searched for literature on the assessment including ‘Pain as the 5th vital sign’28 . Standards for ser-
and treatment of postoperative pain after breast, upper vice provision are set out by the Faculty of Pain Medicine
gastrointestinal, lower gastrointestinal and endocrine in Core Standards for Pain Management Services in the UK 29
surgery using combinations of the following Medical and by the Royal College of Anaesthetists in Guidelines
Publication of the joint working party report Pain after Effective pain management is underpinned by assessment
Surgery12 by the Royal College of Surgeons and College and timely response. Self-reporting subjective pain scales
represent the standard of acute pain assessment, allow- and is an acceptable target for patients40,41 . Severe pain
ing patients to report pain using a unidimensional scale should be responded to as a matter of urgency, using a
of numbers or words. Commonly used to evaluate pain structured, multimodal analgesic approach, with frequent
intensity, the visual analogue scale, verbal rating scale and reassessments until comfort is attained.
numerical rating scale are valid, reliable and appropriate
for use in monitoring postoperative pain in patients who Pharmacological management of postoperative
are able to self-report35 . However, unidimensional scales pain
fail to describe the patient experience fully, for example,
ability to tolerate pain or its impact on functional recovery. No perfect analgesic drug exists. Evidence supporting the
Postoperative pain is often not isolated to the surgical site, use of drugs with a low number needed to treat (NNT)
predominantly small trials, mostly containing fewer than caution should be employed in their use, particularly in
50 patients, found that its use was associated with decreased patients with preexisting drug abuse81 .
postoperative morphine consumption at 24 and 48 h, along
with decreased pain intensity. Although the benefits are 𝛂-2 agonists
thought to be somewhat offset by dose-dependent adverse The α-2 receptor agonists clonidine and dexmedetomidine
effects, including hypersalivation, nausea and vomiting, can be administered orally (clonidine only), intravenously,
and psychotomimetic effects such as vivid dreams, blurred intrathecally, perineurally or via a transdermal patch, and
vision, hallucinations, nightmares and delirium72 , there have been used both during and after operation. Although
was a non-clinically significant reduction in nausea and they are associated with reduced opiate use and duration
vomiting and little difference compared with controls in of nerve blocks, their benefit is offset by sedation and
terms of central nervous system side-effects71 . Ketamine hypotension82 – 84 . In view of the haemodynamic effects,
Epidural Reduced pain and requirement for co-analgesics Technique-related: backache, postdural puncture
Improved respiratory function headache, neurological injury, epidural haematoma,
Reduced pulmonary, thromboembolic, failure
cardiovascular, ileus and surgical stress response Epidural local anaesthetic-related: hypotension,
sensory deficits, motor weakness, urinary retention,
Can be continued after operation
toxicity
Epidural opioids: nausea, vomiting, pruritus, respiratory
depression
Attachment to drug delivery equipment
Although there is a paucity of evidence, the most recent are opiates, including morphine, buprenorphine, diamor-
meta-analysis90 considering three RCTs examining the phine, hydromorphone, tramadol and fentanyl, the former
use of cannabinoids for acute postoperative pain favoured causing greater respiratory depression. Less common
placebo over tetrahydrocannabinol or nabilone in all trials. adjuncts include clonidine which, when used in neurax-
ial blocks, blocks the sympathetic outflow93 . Compared
Regional analgesia with IVPCA opioids, pain is modestly improved with EA
following intra-abdominal surgery, with a statistically,
Regional anaesthesia delivers analgesic drugs, usually
but non-clinically, significant reduction in pain scores at
local anaesthetic, with or without an adjunct, directly to
rest94 . However, use of EA may enhance the trajectory
the peripheral nerves. Table 1 outlines commonly used
towards DrEaMing. The combination of tolerance of
regional analgesia techniques. Use of regional anaesthesia
solid food plus defaecation predicts recovery of gastroin-
reduces the risk of PPSP compared with conventional
testinal transit95 , and EA reduces paralytic ileus while
analgesia. For thoracic epidural analgesia after thora-
increasing food tolerance by reducing nausea, vomiting
cotomy, the odds ratio is 0⋅52 (95 per cent c.i. 0⋅32 to
and pain96 . The analgesic failure rate is higher for EA
0⋅84; P = 0⋅008); for various regional analgesia techniques,
including paravertebral, nerve blocks and local infiltration than IVPCA opioids (120 versus 34 in 1000 respectively),
in breast surgery, the odds ratio is 0⋅34 (0⋅19 to 0⋅60)91 . and EA is more likely to be associated with need for
interventions for hypotension (120 versus 17 per 1000)94 .
Continuous central neuraxial block The technique has a risk of complications. The pessimistic
Continuous central neuraxial block or EA has many ben- estimate of permanent harm associated with all EA is
efits across a range of surgical procedures. There is level 17⋅4 (95 per cent c.i. 7⋅2 to 27⋅8) per 100 000 and that
1 evidence for improved analgesia at rest, and reduced of paraplegia or death is 6⋅1 (2⋅2 to 13⋅3) per 100 00026 .
incidence of ileus, pulmonary complications, surgical Furthermore, although the risk of developing an epidu-
stress response, negative nitrogen balance and other anal- ral haematoma remains small, appropriate precautions
gesic requirements92 . Most epidural formulations include should be taken in patients taking antiplatelets and/or
a local anaesthetic infusion. Commonly used adjuncts anticoagulant medication97 . Current ERAS guidelines53
for elective colorectal surgery recommend thoracic EA resulted in significantly less postoperative requirement for
for open surgery but not for laparoscopic procedures. morphine at 24 h. A more recent meta-analysis104 of 310
Recommendations appear surgery-specific, as thoracic EA adult patients identified that pain scores at rest in the first
is recommended as first line in ERAS pathways for patients 24 h were the same as those for EA (mean difference 0⋅5, 95
undergoing oesophagectomy55 . However, local anaesthetic per cent c.i. 0⋅1 to 1⋅0; P = 0⋅10), with a reduced incidence
infiltration of wounds has higher-level evidence reported of hypotension and shorter hospital stay. Different surgical
for gynaecological ERAS pathways54 . specialties vary in their ERAS guidelines with respect to
truncal blocks; for example, ERAS guidelines for periop-
Intrathecal analgesia erative care in gynaecological/oncological surgery recom-
This technique involves use of a local anaesthetic which mend incisional local anaesthetic injection over TAP blocks
or thoracic EA54 , whereas TAP blocks are strongly rec-
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