Present-day challenges and future solutions in postoperative pain management: results from PainForum 2014

Figures & data

Table 1 Oxycodone routes of administration and doses used in Finnish hospitals

Patient ages (years)	IV bolus (dosing interval 10–15 minutes)	IV PCA (oxycodone 2 mg/mL, droperidol 0.05 mg/mL; lockout 6–10 minutes)	TM (dosing interval 15–30 minutes)	IR tablet PO or liquid PO (dosing interval 30–60 minutes)	CR tablet (BID)
12–17	0.05–0.1 mg/kg	0.02 mg/kg	5–10 mg	5–10 mg	10–20 mg
18–65	3 mg	1–2 mg	10 mg	5–10 mg	20 mg
>65 to <80	2 mg	1 mg	5 mg	5 mg	5–10 mg
>80	1 mg	1 mg	5 mg	5 mg	5 mg

Note: Copyright © 2012. Taylor & Francis Ltd. Kokki H, Kokki M, Sjovall S. Oxycodone for the treatment of postoperative pain. Expert Opinion on Pharmacotherapy. 2012;13(7):1045–1058. Reprinted by permission of the publisher (Taylor & Francis Ltd, http://www.tandfonline.com).⁴³

Abbreviations: BID, twice a day; CR, controlled release; IR, Immediate release; IV, intravenous; PCA, patient-controlled analgesia; PO, per oral (by mouth); TM, transmucosal.

Table 2 A brief summary of ASA guidelines for acute perioperative pain management

Area	Recommendations
Institutional policies and procedures	Training and education of health care providers Monitoring patient outcomes and documentation Monitoring patient outcomes at institutional level Round-the-clock availability of anesthesiologists for perioperative pain management based on standardized institutional policies and procedures Use of APS
Preoperative evaluation of the patient	Preoperative assessment and individualized plan (based on type of surgery, anticipated pain levels, underlying conditions, risk/benefit of various analgesics, and patient preferences) Physical examination and patient history
Preoperative preparation of the patient	Adjustments or continuations of any medications that should not be discontinued because of possible withdrawal symptoms Treatments to reduce preexisting pain Treatment to relieve anxiety Premedications as part of a multimodal pain management program Patient and family/caregiver education, including behavioral pain control techniques
Perioperative pain management	May include, but is not limited to, central regional opioid analgesia, PCA with systemic opioid agents, and peripheral regional analgesia The abovementioned modalities should be given preference over intramuscular opioids “as needed” Selections must reflect the expertise of the anesthesiology team and the capacity for safe application at the practice setting Exercise caution with continuous infusion modalities
Multimodal pain management	Whenever possible, multimodal analgesic techniques should be used, such as central regional blockade with local anesthetics Unless contraindicated, patients should receive round-the-clock NSAIDs, coxibs, or acetaminophen All dosing should optimize efficacy while minimizing the risk of adverse events The choice of medication must be individualized (agent, dose, route, and duration of therapy)

Note: There are varying levels of evidence for these steps.

Abbreviations: ASA, American Society of Anesthesiologists; APS, acute pain service; NSAIDs, nonsteroidal anti-inflammatory drugs; PCA, patient-controlled analgesia.

Table 3 Selected studies examining the use of specific postoperative protocols on specific variables

Study	Study design and population	Results	Comments
Vallano et al,^Citation67 study on the use of a protocol for postoperative analgesic use	101 surgical patients were evaluated before protocol and 108 after	Postoperative use of opioids, selection of first-choice opioids, and adequate analgesic doses increased significantly (P<0.05) after protocol	Regular administration of analgesics at predetermined intervals also increased after the protocol, but this was not significant (P=0.07)
Sauaia et al,^Citation68 study on adherence to postoperative pain management protocol and patient satisfaction in elderly patients	322 postsurgical patients at eight hospitals; patients ≥65 years. Patients were surveyed in first 24 hours after surgery and given a summary score; pain management variables were abstracted from their medical record and correlated using linear regression	62% reported severe postoperative pain but 87% were satisfied with their treatment. Worst pain intensity in first 24 hours was the most powerful predictor of patient satisfaction	Other predictors of patient satisfaction were younger age, male sex, preoperative education, type of surgery, shorter recovery room stay, oral analgesic, and morphine (vs other opioids)
Diby et al,^Citation69 study of postoperative pain protocol for cardiac surgery patients	Prospective quasi-experimental study of 133 cardiac surgery patients at one hospital. Study was done in three phases: baseline, 1 month after protocol was instituted, and then a reassessment at 6 months	With the protocol, pain intensity at rest, retrospective perception of pain intensity at rest, and the portion of patients with little to no pain all increased significantly. The portion of patients with sleep disturbances decreased from 68% to 35% (P=0.012)	There were no significant differences observed at 1 month and 6 months after the protocol was instituted
Miller et al,^Citation70 study of hospital LOS for colorectal surgery patients following implementation of a new recovery protocol	Data from 99 patients before implementation of a multimodal approach to perioperative care were compared with data from 142 following an enhanced recovery after surgery multimodal protocol was implemented	The new protocol resulted in significantly shorter LOS and fewer urinary tract infections (13% vs 24%, P=0.03) and lower readmission rates (9.8% vs 20.2%, P=0.02)	LOS was significantly reduced in both open and laparoscopic procedures (6 days vs 7 days, P=0.01 and 4 days vs 6 days, P<0.0001, respectively)
Jiang et al,^Citation71 pooled data analysis of PMDI for postoperative pain management in total knee or hip arthroplasty	Literature search on the effects of PMDI in patients undergoing total knee or total hip arthroplasty yielded 21 studies, data from which were pooled for analysis	Patients with PMDI had greater pain relief, consumed less opioids, had larger range of motion, and lower rates of postoperative nausea and vomiting than non-PMDI patients (placebo group)	Hospital LOS was similar in patients with or without PMDI

Abbreviations: LOS, lengths of stay; PMDI, periarticular multimodal drug injections.

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