Postoperative Pain Management in Enhanced Recovery Pathways

Figures & data

Table 1 Common Non-Opioid Modalities for Treatment of Postoperative Pain in Enhanced Recovery Pathways

Modality	Advantages	Disadvantages
Acetaminophen	● Reduced opioid requirements ● Improved pain control ● Generally well-tolerated ● Synergistic analgesic effect when combined with NSAIDs	● Hepatotoxicity with higher doses ● Caution in patients with liver dysfunction
Nonsteroidal anti-inflammatory drugs (NSAIDs)	● Reduced opioid requirements ● Improved pain control ● Synergistic analgesic effect when combined with acetaminophen	● Risk of gastrointestinal ulceration, bleeding, renal impairment, and cardiovascular adverse events ● Possible association with bone nonunion after spinal fusion ● Possible association with anastomotic leak after colorectal surgery
Gabapentinoids	● Reduced opioid requirements ● Improved pain control	● Benefits of questionable clinical significance ● Risk of sedation, visual disturbances, and respiratory depression ● Caution in patients with renal dysfunction ● Only available in oral formulations ● Optimal dosing regimen unclear
Alpha-2 agonists	● Reduced opioid requirements ● Improved pain control ● Can be used as adjuncts in regional anesthetic techniques	● Risk of sedation, hypotension, and bradycardia ● Limited evidence supporting use in postoperative setting ● Optimal dosing regimen unclear
Ketamine	● Reduced opioid requirements ● Improved pain control ● May reduce risk of opioid-induced hyperalgesia and opioid tolerance	● Risk of neuropsychiatric symptoms ● Caution in patients with cardiovascular disease, hepatic dysfunction, elevated intracranial and intraocular pressure, active psychosis, and pregnancy ● Optimal dosing regimen unclear
Intravenous lidocaine	● Reduced opioid requirements ● Improved pain control ● Decreased risk of ileus and shorter length of stay ● May be particularly beneficial after abdominal surgery	● Risk of toxicity requiring monitoring of plasma lidocaine levels ● Optimal dosing regimen unclear
Peripheral nerve blocks	● Reduced opioid requirements ● Improved pain control ● Faster postoperative recovery and decreased length of stay	● Risk of bleeding, nerve injury, infection, local anesthetic systemic toxicity, and various site-specific complications ● Risk of motor blockade and impaired postoperative mobilization after lower extremity surgery
Epidural analgesia	● Reduced opioid requirements ● Improved pain control ● Decreased risk of postoperative morbidity, particularly ileus and cardiopulmonary complications	● Risk of hypotension, urinary retention, motor blockade, backache, inadvertent dural puncture, neurological injury, infection, epidural hematoma, and local anesthetic systemic toxicity ● Usually avoided in patients with coagulopathy