Postoperative pain is a significant issue in the anesthesia provider’s management of patients. A survey mailed to 56 anesthesiologists stated that the principal endpoints they believed to be the most important to patients were postoperative incisional pain, nausea, vomiting, preoperative anxiety, and pain related to intravenous access placement. A key part of the recovery period is appropriate control of both pain during rest and pain with activity (incident pain). With the continued advances in anesthesia practice, anesthesiologists now have a growing armament to combat postoperative pain, including use of neuraxial anesthesia, nerve blocks, and perioperative analgesic medications. We will discuss some of the pharmaceutical interventions at the anesthesiologists’ disposal for the time after surgery.

Planning is an integral, and arguably the most important, component of anesthesia management. As anesthesiologists, our job frequently demands preventing an undesirable situation, like a postinduction hypotension, a difficult airway, patient’s movement at the time of skin incision, or postoperative nausea and vomiting. Similarly, postoperative pain management starts with pre-emptive analgesia. Pre-emptive analgesia is an antinociceptive therapy aimed at preventing both peripheral and central sensitization, thereby attenuating the postoperative amplification of pain. Regional anesthesia (both neuraxial and peripheral-nerve blockade) and even local infiltration for superficial procedures are excellent examples of pre-emptive analgesia. Preoperative use of certain nonsteroidal anti-inflammatory drugs (NSAIDs) (piroxicam, 20 mg, taken orally 2 hours before the procedure; intravenous ketorolac), antiepileptic drugs (gabapentin, 600 mg, taken orally 2 hours before the procedure) as well as intravenous opioids and receptor antagonists (ketamine) at the time of induction have all been shown to reduce postoperative analgesic requirements. The pre-emptive analgesic plan should be titrated according to the type of surgery and patients’ characteristics. Whenever possible, a multimodal approach should be used.

After adequate preventative steps have been taken, the next step is often dealing with postoperative pain. Opioids are the most commonly used medications under these circumstances. Titrations of morphine, fentanyl, dilaudid, etc. are often used as a first-line agent. Ethnicity (white race),
emergency surgery, major surgery, surgery lasting more than 100 minutes, and high pain score on arrival to the PACU are factors predictive of increased opioid requirements. Titration to effect is the goal; however, it is important to realize that the presence of pain does not prevent narcotic-induced respiratory depression, the most worrisome side effect of narcotics. Opioids also have other potential adverse effects, such as pruritis, nausea, vomiting, and constipation. The PACU anesthesiologist must always remain vigilant when administering any opioid dose. Patient-controlled analgesia (PCA) allows patients to determine the timing of analgesic doses and allows for improved titration of analgesia while minimizing patient anxiety. When used correctly, pain management may occur with less risk of side effects. Common intravenous (IV) PCA orders used at the Johns Hopkins Hospital are listed in Table 111.1.

NSAIDs can be used as part of an effective multimodal analgesia regimen. NSAIDS are beneficial postoperatively, because surgery causes both pain and inflammation. These medications can be divided into three groups: NSAIDs with predominantly analgesic effects (Naproxen, Ketorolac), NSAIDs that are mainly anti-inflammatory (oxicams), and those that confer both benefits (Diclofenac, Ketoprofen, Indomethacin). The one most often used in the PACU is Ketorolac (Toradol). It has been estimated that the use of Toradol in pain management may reduce opioid requirements by up to a third (range of 0% to 79%, depending on the type of surgery) and may improve the patient’s pain relief. Nonsteroidal medications have their own set of risk factors, including bleeding from platelet dysfunction, gastrointestinal (GI) upset, and renal impairment. These risks increase with higher dosages, prolonged therapy (more than 3 to 5 days), and, in susceptible patients (i.e., those with a history of GI bleeding or renal insufficiency). The newer class of selective COX-2 inhibitor nonsteroidals (celecoxib, rofecoxib, valdecoxib) was believed to have fewer side effects; however only celecoxib is still on the
market as the other two have been show to cause cardiac events in susceptible patients.