New Advances in Acute Postoperative Pain Management
Purpose of Review
Postoperative pain remains one of the most common challenges following inpatient and outpatient surgeries. With our advances in modern medicine, pain following surgical procedures still remains a challenge, though significant accomplishments have been made over the past few decades. This article highlights some of the promising new advances and approaches in postoperative pain management.
Over the last decade, Enhanced Recovery after Surgery (ERAS) pathways and protocols are becoming the benchmark standards for enhancing postoperative recovery. Multimodal analgesia (MMA) is an essential component of such care. Further, in the wake of serious and persistent concern on the opioid epidemic in the USA, there has been a recent renewal of interest in non-opioid alternatives or adjuncts in controlling postoperative pain, often in the context of MMA. Intravenous (IV) acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), magnesium, ketamine, dexmedetomidine, liposomal bupivacaine, and newer neuraxial and peripheral regional techniques as well as patient-controlled modalities are gaining importance. Gabapentinoids have become popular but recent meta-analytic reviews have cast doubt on their routine use in perioperative settings. Among opioids, sublingual sufentanil, IV oxycodone, and iontophoretic transdermal fentanyl hold promise. Acupuncture and transcutaneous electrical nerve stimulation may be useful as adjuncts in MMA packages. Genetic testing, derivatives of herbal preparations, and an extended role of acute pain services may emerge as potential areas of importance in the future. There are, however, critical gaps in good quality evidence in many of the practice guideline recommendations.
In the era of opioid epidemic, several lines of evidence have emerged to support non-opioid-based drugs and approaches along with a few newer opioid formulations for postoperative pain management, although more research is needed to find the right balance of efficacy and safety.
KeywordsPain Postoperative Advances ERAS Management
Compliance with Ethical Standards
Conflict of Interest
Sukanya Mitra, Daniel Carlyle, Gopal Kodumudi, Vijay Kodumudi, and Nalini Vadivelu declare no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance.
- 2.Hall MJ, et al. Ambulatory Surgery Data From Hospitals and Ambulatory Surgery Centers: United States, 2010. Natl Health Stat Report. 2017(102):1–15.Google Scholar
- 4.Gramke HF, de Rijke JM, van Kleef M, Raps F, Kessels AGH, Peters ML, et al. The prevalence of postoperative pain in a cross-sectional group of patients after day-case surgery in a university hospital. Clin J Pain. 2007;23(6):543–8.Google Scholar
- 5.Hudcova J, et al. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev, 2006;(4):CD003348.Google Scholar
- 12.•• Pogatzki-Zahn EM, Segelcke D, Schug SA. Postoperative pain—from mechanisms to treatment. Pain Rep. 2017;2(2):e588. https://doi.org/10.1097/PR9.0000000000000588. An excellent recent review linking mechanisms of postoperative pain with the various treatment approaches.
- 14.Kang S, Brennan TJ. Mechanisms of postoperative pain. Anesth Pain Med. 2016;11:236–48.Google Scholar
- 16.•• Chou R, 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(2):131–57. The latest and comprehensive clinical practice guideline in this area. CrossRefPubMedGoogle Scholar
- 20.Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z. Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon rectum. 2013;56(5):667–78.Google Scholar
- 21.Holte K, Nielsen KG, Madsen JL, Kehlet H. Physiologic effects of bowel preparation. Dis Colon rectum. 2004;47(8):1397–402.Google Scholar
- 26.Jinnah AH, Smith BP, Perricelli BC. Comparison of two multimodal pain regimens used for postoperative pain control in total joint arthroplasty patients. J Surg Orthop Adv. 25(4):209–14.Google Scholar
- 28.• Kumar K, et al. A review of opioid-sparing modalities in perioperative pain management: methods to decrease opioid use postoperatively. Anesth Analg. 2017;125(5):1749–60. Another recent review with specific focus on non-opioid analgesics and procedures for postoperative pain management. CrossRefPubMedGoogle Scholar
- 29.Kaye AD, Cornett EM, Helander E, Menard B, Hsu E, Hart B, et al. An update on nonopioids: intravenous or oral analgesics for perioperative pain management. Anesthesiol Clin. 2017;35(2):e55–71.Google Scholar
- 31.Buvanendran A, Kroin J.S., Rajagopal A., Robison S.J., Moric M., Tuman K.J., Oral ketamine for acute pain management after amputation surgery. Pain Med. 2017. https://doi.org/10.1093/pm/pnx229.
- 32.Nielsen RV, Fomsgaard JS, Siegel H, Martusevicius R, Nikolajsen L, Dahl JB, et al. Intraoperative ketamine reduces immediate postoperative opioid consumption after spinal fusion surgery in chronic pain patients with opioid dependency: a randomized, blinded trial. Pain. 2017;158(3):463–70.Google Scholar
- 33.Kim NS, Lee JS, Park SY, Ryu A, Chun HR, Chung HS, et al. Oxycodone versus fentanyl for intravenous patient-controlled analgesia after laparoscopic supracervical hysterectomy: a prospective, randomized, double-blind study. Medicine (Baltimore). 2017;96(10):e6286.Google Scholar
- 37.• McNicol ED, et al. Single dose intravenous paracetamol or intravenous propacetamol for postoperative pain. Cochrane database Syst rev. 2016;(5):CD007126. Updated Cochrane review on intravenous paracetamol and its precursor in postoperative pain management. Google Scholar
- 39.Elia N, Lysakowski C, Tramer MR. Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials. Anesthesiology. 2005;103(6):1296–304.CrossRefPubMedGoogle Scholar
- 41.Wang X, Liu W, Xu Z, Wang F, Zhang C, Wang B, et al. Effect of dexmedetomidine alone for intravenous patient-controlled analgesia after gynecological laparoscopic surgery: a consort-prospective, randomized, controlled trial. Medicine (Baltimore). 2016;95(19):e3639.Google Scholar
- 43.Bellon M, le Bot A, Michelet D, Hilly J, Maesani M, Brasher C, et al. Efficacy of intraoperative dexmedetomidine compared with placebo for postoperative pain management: a meta-analysis of published studies. Pain Ther. 2016;5(1):63–80.Google Scholar
- 47.Eipe N, Penning J, Yazdi F, Mallick R, Turner L, Ahmadzai N, et al. Perioperative use of pregabalin for acute pain-a systematic review and meta-analysis. Pain. 2015;156(7):1284–300.Google Scholar
- 48.• 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(4):775–91. This recent analysis sobers our impression on the routine use of pregabalin in acute pain treatment. Google Scholar
- 49.• Fabritius ML, et al. Gabapentin for post-operative pain management—a systematic review with meta-analyses and trial sequential analyses. Acta Anaesthesiol Scand. 2016;60(9):1188–208. Along with the previous reference (no. 48), this analysis sobers our impression on the routine use of gabapentin in postoperative pain management. CrossRefPubMedGoogle Scholar
- 52.Weibel S, Jokinen J, Pace NL, Schnabel A, Hollmann MW, Hahnenkamp K, et al. Efficacy and safety of intravenous lidocaine for postoperative analgesia and recovery after surgery: a systematic review with trial sequential analysis. Br J Anaesth. 2016;116(6):770–83.Google Scholar
- 56.Melson TI, Boyer DL, Minkowitz HS, Turan A, Chiang YK, Evashenk MA, et al. Sufentanil sublingual tablet system vs. intravenous patient-controlled analgesia with morphine for postoperative pain control: a randomized, active-comparator trial. Pain Pract. 2014;14(8):679–88.Google Scholar
- 60.Ringold FG, Minkowitz HS, Gan TJ, Aqua KA, Chiang YK, Evashenk MA, et al. Sufentanil sublingual tablet system for the management of postoperative pain following open abdominal surgery: a randomized, placebo-controlled study. Reg Anesth Pain Med. 2015;40(1):22–30.Google Scholar
- 61.Minkowitz HS, Singla NK, Evashenk MA, Hwang SS, Chiang YK, Hamel LG, et al. Pharmacokinetics of sublingual sufentanil tablets and efficacy and safety in the management of postoperative pain. Reg Anesth Pain Med. 2013;38(2):131–9.Google Scholar
- 64.Kokki M, Franco MG, Raatikainen K, Välitalo P, Sankilampi U, Heinonen S, et al. Intravenous oxycodone for pain relief in the first stage of labour—maternal pharmacokinetics and neonatal exposure. Basic Clin Pharmacol Toxicol. 2012;111(3):182–8.Google Scholar
- 67.Langford RM, Chang KY, Ding L, Abraham J. Comparison of fentanyl iontophoretic transdermal system and routine care with morphine intravenous patient-controlled analgesia in the management of early postoperative mobilisation: results from a randomised study. Br J Pain. 2016;10(4):198–208.CrossRefPubMedPubMedCentralGoogle Scholar
- 68.Sanfilippo F, Conticello C, Santonocito C, Minardi C, Palermo F, Bernardini R, et al. Remifentanil and worse patient-reported outcomes regarding postoperative pain management after thyroidectomy. J Clin Anesth. 2016;31:27–33.Google Scholar
- 75.Naseem A, Harada T, Wang D, Arezina R, Lorch U, Onel E, et al. Bupivacaine extended release liposome injection does not prolong QTc interval in a thorough QT/QTc study in healthy volunteers. J Clin Pharmacol. 2012;52(9):1441–7.Google Scholar
- 78.McDermott AM, Chang KH, Mieske K, McAnena PF, Kinirons B, Abeidi A, et al. Aerosolized intraperitoneal local anesthetic for laparoscopic surgery: a randomized, double-blinded, placebo-controlled trial. World J Surg. 2015;39(7):1681–9.Google Scholar
- 79.Guay J, Kopp S. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev. 2016;1:CD005059.Google Scholar
- 80.• Brogi E, et al. Transversus abdominal plane block for postoperative analgesia: a systematic review and meta-analysis of randomized-controlled trials. Can J Anaesth. 2016;63(10):1184–96. An important meta-analysis of RCTs using this relatively newer approach for postoperative analgesia. CrossRefPubMedGoogle Scholar
- 81.Iyer SS, Bavishi H, Mohan CV, Kaur N. Comparison of epidural analgesia with transversus abdominis plane analgesia for postoperative pain relief in patients undergoing lower abdominal surgery: a prospective randomized study. Anesth Essays Res. 2017;11(3):670–5.CrossRefPubMedPubMedCentralGoogle Scholar
- 82.Zhao X, Tong Y, Ren H, Ding XB, Wang X, Zong JY, et al. Transversus abdominis plane block for postoperative analgesia after laparoscopic surgery: a systematic review and meta-analysis. Int J Clin Exp Med. 2014;7(9):2966–75.Google Scholar
- 83.Meissner W, Coluzzi F, Fletcher D, Huygen F, Morlion B, Neugebauer E, et al. Improving the management of post-operative acute pain: priorities for change. Curr Med Res Opin. 2015;31(11):2131–43.Google Scholar
- 91.McDonald J, Janz S. The Acupuncture Evidence Project. A comparative literature review: Australian acupuncture and Chinese Medicine Association Ltd., 2017.Google Scholar
- 95.Duan G, Xiang G, Guo S, Zhang Y, Ying Y, Huang P, et al. Genotypic analysis of SCN9A for prediction of postoperative pain in female patients undergoing gynecological laparoscopic surgery. Pain Physician. 2016;19(1):E151–62.Google Scholar
- 98.Zhu Q, Mao LN, Liu CP, Sun YH, Jiang B, Zhang W, et al. Antinociceptive effects of vitexin in a mouse model of postoperative pain. Sci Rep. 2016;6:19266.Google Scholar
- 100.Arruda APN, Ayala AP, Lopes LC, Bergamaschi CC, Guimarães C, Grossi MD, et al. Herbal medications for surgical patients: a systematic review protocol. BMJ Open. 2017;7(7):e014290.Google Scholar
- 101.• Zaccagnino MP, et al. The perioperative surgical home: a new role for the acute pain service. Anesth Analg. 2017;125(4):1394–402. An important suggestion to improve and expand the role of acute pain services to cover the entire perioerative period in a systematic pre-planned manner. CrossRefPubMedGoogle Scholar
- 102.•• Gordon DB, et al. Research gaps in practice guidelines for acute postoperative pain management in adults: findings from a review of the evidence for an American Pain Society Clinical Practice Guideline. J pain. 2016;17(2):158–66. A critical review that explored the clinical practice guidelines on acute postoperative pain management in adults to highlight many areas that need higher quality evidence to be garnered by future research. CrossRefPubMedGoogle Scholar