Optimizing postoperative pain management

R. MICHAEL RITCHEY, MD

ostoperative pain management is an impor- incidence of chronic pain after breast surgery, thora-

P tant but seemingly undervalued component of

perioperative care. Over the past decade, med-
ical societies, governmental agencies, and
accrediting bodies such as the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO)
cotomy, and inguinal hernia repair.3

■ CONVENTIONAL THERAPIES
Acetaminophen: Safe, but watch the total dose
have paid increasing attention to the management of Acetaminophen is considered a weak analgesic com-
all types of pain, including postoperative pain. pared with other therapies. It has a ceiling effect for
Despite this increased focus, the literature suggests analgesia. Although it is considered safer than non-
that many patients continue to experience significant steroidal anti-inflammatory drugs (NSAIDs), aceta-
postoperative pain. A nationwide survey of 250 minophen has an upper-level dose above which
patients who had undergone surgery in the previous 5 patients are at increased risk for liver toxicity. The rec-
years revealed that 82% reported postoperative pain, ommended maximum dosage in adults is 4,000 mg/day.
and 86% of those who reported postoperative pain When acetaminophen is used postoperatively in
had moderate, severe, or extreme pain.1 It is clear that combination with opioids, approximately 20% less
we have not yet won the battle against postoperative morphine is required to achieve an equivalent level of
pain, and it is imperative that we bring every weapon analgesia; however, there does not appear to be a con-
at our disposal to the front. comitant reduction in opioid-related side effects,
This review will discuss potential consequences of including nausea and vomiting.4
postoperative pain and briefly outline some manage- NSAIDs: May reduce opioid-related side effects
ment options, including intravenous patient-controlled In appropriate patients, NSAIDs are excellent anal-
opioid analgesia (IV PCA). gesics for the postoperative period. A recent meta-
■ CONSEQUENCES OF POSTOPERATIVE PAIN analysis found that NSAID administration decreased
postoperative nausea and vomiting by 30%, most
Inadequately controlled pain can cause postoperative likely because of decreased opioid requirements.5
morbidity, prolong recovery time, delay return to nor- Potential side effects of NSAIDs include increased
mal living, and decrease satisfaction with care. risks of bleeding (particularly gastrointestinal), gastro-
Inadequate pain management increases the use of intestinal ulceration, and adverse renal effects.
health care resources, thereby increasing total health
care costs.2 Opioids: The gold standard
Postoperative pain may be a factor in the develop- Opioids are the gold standard of postoperative anal-
ment of chronic pain. In a literature review looking at gesia despite their undesirable side effects. They are
chronic pain as an outcome of surgery, the severity of the mainstay of treatment for moderate to severe pain
postoperative pain was positively correlated with the and can be given by virtually any route. If not for the
many adverse effects associated with opioids—some
From the Division of Anesthesiology, Critical Care Medicine, of them potentially serious—the search for other
and Comprehensive Pain Medicine, Cleveland Clinic therapies would be much less necessary.
Foundation, Cleveland, OH.
Address: R. Michael Ritchey, MD, Department of General ■ NONTRADITIONAL THERAPIES
Anesthesiology, Cleveland Clinic Foundation, 9500 Euclid
Avenue, E31, Cleveland, OH 44195; [email protected]. Ketamine: Excellent analgesia at very low doses
Disclosure: Dr. Ritchey reported that he has no financial rela- Ketamine is an N-methyl D-aspartate (NMDA)
tionships that pose a potential conflict of interest with this article. receptor antagonist. This spinal cord receptor facili-
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 RITCHEY

tates the development of pain sensitization and has an type of postoperative pain management. In a study
influence on the development of opioid tolerance. involving patients undergoing rotator cuff surgery,
Subanesthetic doses of ketamine have been shown to nerve block anesthesia (interscalene brachial plexus
decrease opioid requirements, decrease pain scores, blockade) was compared with general anesthesia.9
and possibly prevent the development of opioid toler- One half of the patients received general anesthesia
ance.6 Ketamine, however, has significant adverse followed by bupivacaine (0.25%) wound infiltration
psychotomimetic effects, which limit its usefulness. and the other half received interscalene brachial
plexus block (0.75% ropivacaine). Compared with
Gabapentin: Analgesic and anxiolytic the group randomized to general anesthesia, patients
Gabapentin is a gamma-aminobutyric acid (GABA) assigned to receive the interscalene block had less
analog, but it does not act through the GABA-ergic pain, had less nausea and vomiting, were discharged
system. Its exact mechanism of analgesia is unknown. earlier, were more satisfied with their overall therapy,
Gabapentin was originally approved as an anticon- and were more likely to accept the same therapy if
vulsant but has been found to be effective in the they needed surgery again. Four patients in the group
treatment of chronic neuropathic pain. receiving general anesthesia required admission post-
Gabapentin also has been shown to be effective as operatively because of intractable pain.
a postoperative analgesic as well as an effective anxio- The placement of peripheral nerve catheters is an
lytic. Premedication with gabapentin was studied in option that potentially allows for extended analgesia
patients undergoing arthroscopic anterior cruciate lig- in an outpatient setting. An appropriate infrastruc-
ament repair.7 Twenty-five patients received placebo ture must be in place, which includes thorough
and an equal number were given a single preoperative patient education and around-the-clock availability
dose of 1,200 mg of gabapentin. Patients who of staff for questions and issue resolution.10
received gabapentin had a reduction in preoperative
anxiety scores, required less postoperative morphine, ■ INTRAVENOUS PATIENT-CONTROLLED
had less pain postoperatively, and had greater range of OPIOID ANALGESIA
motion during postoperative physical therapy than IV PCA continues to be a popular choice for postop-
the control group. erative pain control. With IV PCA, after an appro-
priate loading dose to achieve analgesia, the patient
■ ADVANCED OPTIONS FOR PAIN MANAGEMENT titrates the dosage to his or her comfort level. This
Epidural analgesia: method attempts to solve the problem of the wide
Efficacious, but more difficult to manage variability in response to opioids among patients. A
In an overview of randomized trials, Rodgers et al sought systematic review of trials in which opioid-based
to determine reliable estimates of the effects of spinal or PCA was compared with the same opioid given intra-
epidural anesthesia on postoperative morbidity and muscularly, intravenously, or subcutaneously showed
mortality.8 A correlation was found between the use of that IV PCA improved analgesia and was the pre-
these forms of anesthesia and a reduction in the risks ferred route of administration.11
of all-cause mortality, deep vein thrombosis, pul- Nevertheless, IV PCA is not appropriate for all
monary embolism, blood loss, respiratory depression, patients, particularly those who may not have the
transfusion requirements, and pneumonia. mental capacity to use it advantageously. Older
Continuous epidural analgesia is one of the most patients in particular tend to have less success using
effective options for postoperative analgesia. this mode of analgesia. Patients must be actively
Problems with the technique center around the managed for IV PCA to be effective; it cannot be a
intense labor requirements to manage it and safety “set and forget” therapy.12
issues associated with thromboprophylaxis therapy. Three opioids are typically used for IV PCA: mor-
phine, fentanyl, and hydromorphone. Meperidine
Peripheral nerve blocks and catheters: has fallen out of favor.
Extended-duration analgesia at home? Morphine is the most commonly used opioid, and it
Peripheral nerve blocks of the upper and lower is well tolerated at low doses in patients with liver dys-
extremities are useful for postoperative pain relief function. However, it has a renally excreted active
and, in appropriate situations, as the main anesthetic metabolite, morphine-6-glucuronide, which can accu-
for surgery. mulate in patients with renal insufficiency and can
Extremity surgery is particularly amenable to this increase the risk of sedation and respiratory depression.
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 P O S T O P E R AT I V E PA I N M A N A G E M E N T

TABLE 1 TABLE 2
Equianalgesic opioid doses A typical PCA program for morphine
for intravenous patient-controlled analgesia
Dose: 1 mg (0.5–2 mg)
Morphine 2 mg
Lockout: 6 min (5–12 min)
Fentanyl 20 µg
Hourly limit: 10 doses (5–10)
Hydromorphone 0.2 mg
Basal rate: 0 mg/hr (0–2 mg/hr)
Clinician (nurse-activated) dose

PCA = patient-controlled analgesia

Fentanyl is another commonly used opioid in IV
PCA. It has a rapid onset and a short duration of
action. It has no active metabolites and can be used istered by the patient’s nurse (nurse-activated dose)
safely in patients with significant renal or hepatic when breakthrough pain occurs.
dysfunction.
Hydromorphone also has no active metabolites. It ■ MULTIMODAL ANALGESIA
is five to eight times as potent as morphine and may
have fewer side effects. Multimodal analgesia is a “shotgun” approach to
Opioid dosing for IV PCA. Equianalgesic opioid postoperative analgesia. It relies on different classes of
doses for IV PCA have been established (Table 1), analgesics acting at different sites. Using a variety of
permitting easy interchangeability between opioids. analgesics at lower doses potentially provides effec-
Meperidine has a renally excreted active metabo- tive analgesia while minimizing adverse effects of the
lite, normeperidine, which has a very long half-life individual therapies.15 An example of multimodal
and can accumulate even in patients who have nor- analgesia would be the treatment of a patient who has
mal renal function. Normeperidine causes neurologic had a total knee replacement with a continuous lum-
side effects such as shakiness, tremors, myoclonus, bar epidural utilizing a local anesthetic combined
jitters, and seizures. A retrospective review of the with an opioid. In addition, the patient may receive a
medical records of 355 patients showed that as the scheduled dose of an NSAID as well as acetamino-
dose and duration of meperidine increased, so did the phen. Local therapy such as ice might also be applied.
incidence of side effects and neurologic complica-
tions.13 The authors found a 2% incidence of central ■ MANAGING INADEQUATE ANALGESIA
nervous system excitation in the patients who were As stated earlier, IV PCA is not a “set and forget”
using the highest dosages (600 mg/day) for the therapy. Some patients do not attain effective anal-
longest duration of time. They recommended that if gesia and must be evaluated and managed in an
meperidine is used for IV PCA, the dosage should be expedient manner. Table 3 provides a list of steps to
limited to a maximum of 10 mg/kg/day for no more manage a patient who is not responding favorably to
than 3 days. Meperidine is not used for IV PCA at your efforts.
The Cleveland Clinic.
Evaluate
Example of an IV PCA program for morphine First, evaluate the patient to determine the location
Table 2 presents a standard PCA program for mor- of the pain and to assess for signs of a possible emerging
phine administration in adults at our facility, with process (ie, vital signs, physical exam, urine output).
ranges for lower and upper limits. The demand dose Assess the patient’s intravenous site for evidence of
(patient-activated dose) of morphine is usually started infiltration or disconnection. Determine whether the
at 1 mg. The interval between available doses (lock- patient is using the PCA appropriately, which can be
out interval) is 6 minutes. We limit the number of assessed by reviewing the PCA flow sheet and by
patient-activated doses to a maximum of 10 per hour. interrogating the PCA pump. If re-educating the
For opioid-naïve patients, we do not initiate a con- patient does not result in increased use of the pump,
tinuous infusion, as it has been shown to increase the an alternative to PCA should be provided, such as
incidence of respiratory depression.14 It is important around-the-clock opioid administration by the nurse
to provide readily available doses that can be admin- or, in some situations, continuous IV opioid infusion.
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 RITCHEY

All of these therapies rely on frequent assessments of

adequacy of analgesia and monitoring for possible TABLE 3
Approach to the patient
sedation and respiratory depression.
who has received inadequate analgesia
Reassess
After making the assessment, attempt to improve the Evaluate patient
patient’s condition by administering additional doses Reassess program
of opioid (such as morphine 2 to 4 mg IV push). If the Increase dose
patient is actually self-administering more than 3
Add basal dose
doses per hour and is still uncomfortable, increasing
the demand dose by 50% to 100% and/or adding a Change narcotic
continuous infusion is appropriate. The easiest way to Consider adjunct medications
add an infusion is by starting with a low dosage (mor- Consider pain management consult
phine 1 mg/hr). If not already prescribed, an adjunc-
tive medication such as an NSAID or acetaminophen
is reasonable. Changing to an alternative opioid can
be beneficial, as some patients respond better to one
opioid than another. ■ MANAGING OPIOID-DEPENDENT PATIENTS
Consult Mitra and Sinatra have published a useful review of
Finally, if the patient’s pain is still uncontrolled, consid- perioperative pain management in the opioid-
er obtaining a pain management consult. A pain man- dependent patient.16 Many of the concepts present-
agement consultant is usually more comfortable aggres- ed in this section have been described in their
sively dosing opioids as well as adding nontraditional review.
therapies. The consultant may be able to provide Besides illicit use and use for cancer pain, opioids
advanced pain management options such as peripheral are being used more frequently for noncancer-relat-
nerve blockade and epidural analgesia. Finally, he or she ed pain. Patients with noncancer (“benign”) pain
will be able to help with the transition to oral analgesics. frequently use long-acting opioids, sometimes at
alarmingly high doses. As a result, more patients are
■ TRANSITIONING TO ORAL ANALGESICS coming to the operating room with a significant tol-
erance to opioids, and often suffer excruciating pain
The transition from IV PCA to oral analgesics can postoperatively because they are routinely relatively
result in therapeutic failure and decreased patient underdosed. If possible, a pain management consult-
satisfaction if dosages are inadequate and dosing ant should be involved with these patients’ care
intervals are improper. These outcomes are particu- from the beginning.
larly a possibility for patients who have been on Very few opioid-dependent patients are truly
chronic opioid therapy prior to surgery (see the fol- addicted. They are tolerant to opioid effects, however,
lowing section). A recommended approach to handle and can have a physical dependence to opioids.
this transition is the scheduled dosing of an aceta- Tolerance and physical dependence are not equiva-
minophen/opioid combination such as 2 tablets of lent to addiction.
acetaminophen 325 mg/oxycodone 5 mg every 4
hours for 24 to 48 hours, depending on the patient’s Prevent withdrawal
level of pain. This schedule will help reduce the The first step in managing the opioid-dependent
delays inherent in as-needed dosing strategies. patient is to prevent opioid withdrawal. Patients
Early in the transition period, extra medication should be instructed to take their morning dose of opi-
should be readily available in case the initial therapy oids on the day of surgery. Consider the patient’s pre-
is inadequate. A pure oral opioid, such as oxycodone, operative opioid use to be the baseline requirement. If
and/or an NSAID (if not already prescribed as a the patient will be NPO after surgery, convert this
scheduled medication) is appropriate (eg, oxycodone dose into an equivalent continuous intravenous infu-
5 to 10 mg orally every 4 hours as needed). With more sion. It is important to remember (but is often forgot-
painful procedures, an additional IV opioid as needed ten) that this baseline infusion only covers the
is appropriate (eg, morphine 2 to 4 mg IV every 4 patient’s preoperative requirements. The patient’s post-
hours as needed for breakthrough pain). surgical requirements will have to be added to the
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 P O S T O P E R AT I V E PA I N M A N A G E M E N T

baseline. These patients often require doses of anal- appreciate these aspects may result in unnecessary
gesics that make any practitioner nervous. increases in analgesic doses.

Reduce opioid requirement when possible Transition to oral opioids

(but maintain baseline requirements) Opioid-tolerant patients often require an increase in
Using a multimodal approach is beneficial when their baseline oral opioid requirements in the several
managing an opioid-dependent patient. Local anes- days following surgery. Increases of 30% to 50% are not
thetic infiltration by the surgeon, ketamine infusion, unusual. Dosages can be tapered back to their baseline
clonidine patch, acetaminophen and NSAIDs, mus- requirements over a 1- to 2-week period. If the surgery
cle relaxants, anxiolytics, peripheral nerve block, and actually resulted in a decrease of their preoperative pain,
epidural analgesia should be used when appropriate. further weaning may be possible. Weaning of opioids is
a gradual process and should be carried out with the
Do not rely solely on pain scores assistance of a physician knowledgeable in this process.
when assessing analgesic efficacy
Opioid-dependent patients and patients with ■ SUMMARY
chronic pain routinely report high pain scores The quality of postoperative pain management can be
regardless of their overall condition. They may improved. Although many safe and effective thera-
report a verbal pain rating of 8 out of 10, but then pies exist, their utilization varies considerably
say they are feeling fairly well. Looking at as many between and within institutions. Major challenges
objective signs as possible when assessing their include the appropriate prescribing of analgesic ther-
overall progress is important. Diet intake, ambula- apies and the timely response to suboptimal pain con-
tion, ability to cough and breathe deeply, and trol. Patients’ satisfaction with their analgesic care
resumption of “normal” activities (such as smoking) may depend less on how well their pain is controlled
are all important aspects of recovery, and failing to and more on the attentiveness of their caregivers.
■ REFERENCES from overview of randomised trials. BMJ 2000; 321:1493–1497.
9. Hadzic A, Williams BA, Karaca PE, et al. For outpatient rotator
1. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain cuff surgery, nerve block anesthesia provides superior same-day recov-
experience: results from a national survey suggest postoperative pain ery over general anesthesia. Anesthesiology 2005; 102:1001–1007.
continues to be undermanaged. Anesth Analg 2003; 97:534–540. 10. Ilfeld BM, Enneking FK. A portable mechanical pump providing
2. Joshi PG, Ogunnaike BO. Consequences of inadequate postopera- over four days of patient-controlled analgesia by perineural infusion
tive pain relief and chronic persistent postoperative pain. at home. Reg Anesth Pain Med 2002; 27:100–104.
Anesthesiol Clin North Am 2005; 23:21–36. 11. Walder B, Schafer M, Henzi I, Tramer MR. Efficacy and safety of
3. Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A patient-controlled opioid analgesia for acute postoperative pain. A
review of predictive factors. Anesthesiology 2000; 93:1123–1133. quantitative systematic review. Acta Anaesthesiol Scand 2001;
4. Remy C, Marret E, Bonnet F. Effects of acetaminophen on mor- 45:795–804.
phine side-effects and consumption after major surgery: meta-analy- 12. Etches RC. Patient-controlled analgesia. Surg Clin North Am
sis of randomized controlled trials. Br J Anaesth 2005; 94:505–513. 1999; 79:297–312.
5. Marret E, Kurdi O, Zufferey P, Bonnet F. Effects of nonsteroidal 13. Simopoulos TT, Smith HS, Peeters-Asdourian C, Stevens DS.
antiinflammatory drugs on patient-controlled analgesia morphine side Use of meperidine in patient-controlled analgesia and the develop-
effects: meta-analysis of randomized controlled trials. Anesthesiology ment of a normeperidine toxic reaction. Arch Surg 2002;
2005; 102:1249–1260. 137:84–88.
6. Himmelseher S, Durieux ME. Ketamine for perioperative pain 14. Dawson PJ, Libreri FC, Jones DJ, et al. The efficacy of adding a
management. Anesthesiology 2005; 102:211–220. continuous intravenous morphine infusion to patient-controlled
7. Menigaux C, Adam F, Guignard B, Sessler DI, Chauvin M. analgesia (PCA) in abdominal surgery. Anaesth Intens Care 1995;
Preoperative gabapentin decreases anxiety and improves early func- 23:453–458.
tional recovery from knee surgery. Anesth Analg 2005; 15. Jin F, Chung F. Multimodal analgesia for postoperative pain con-
100:1394–1399. trol. J Clin Anesth 2001; 13:524–539.
8. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative 16. Mitra S, Sinatra RS. Perioperative management of acute pain in
mortality and morbidity with epidural or spinal anaesthesia: results the opioid-dependent patient. Anesthesiology 2004; 101:212–227.

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