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Perioperative AnalgesiaEdit

Perioperative analgesia encompasses the strategies used before, during, and after surgery to relieve pain, enable early mobilization, and minimize medication-related harms. In modern practice, this field is defined by a balance: providing sufficient analgesia to permit recovery while limiting exposure to drugs that carry risks, particularly opioids. The approach draws on a mix of pharmacology, regional anesthesia, and care pathways designed to shorten hospital stays and improve outcomes. See pain management and enhanced recovery after surgery for broader context on pain control and perioperative care pathways.

The shift toward multimodal analgesia reflects a broader preference for evidence-based, patient-centered care that weighs effectiveness, safety, and cost. Rather than relying on a single drug class, clinicians combine multiple modalities that target different pain pathways. This philosophy has become a cornerstone of many institutional protocols and is a core component of ERAS programs, which aim to streamline recovery, reduce complications, and improve patient satisfaction. See multimodal analgesia for a deeper dive into the pharmacologic strategy and its rationale.

Core principles

Pharmacologic options

  • Opioids: Effective for acute postoperative pain but associated with risks such as respiratory depression, constipation, delirium, and potential for dependence. Clinicians increasingly apply opioid-sparing techniques and limit exposure through protocols and alternative analgesics. See opioid.
  • Non-opioid analgesics: NSAIDs and acetaminophen form the backbone of many protocols, often used in scheduled, around-the-clock fashion to lower opioid needs. NSAIDs carry their own risks (gastrointestinal, renal) that must be weighed against benefits, especially in certain patients. See nonsteroidal anti-inflammatory drugs and acetaminophen.
  • Adjuvants: Gabapentinoids, ketamine, lidocaine infusions, and alpha-2 agonists like dexmedetomidine may enhance analgesia or reduce opioid requirements in selected patients. See gabapentinoids, ketamine, lidocaine, and dexmedetomidine.
  • Local infiltration and wound blocks: Local anesthetics infiltrated at the surgical site or delivered via continuous wound catheters can provide targeted relief with few systemic effects. See local anesthetic and local infiltration analgesia.

Regional and neuraxial techniques

  • Neuraxial anesthesia: Epidural or intrathecal administration of analgesics can provide powerful, segmental pain relief for abdominal, thoracic, and lower-extremity surgeries, often enabling faster recovery when used appropriately. See neuraxial anesthesia.
  • Peripheral nerve blocks: Targeted blocks (e.g., femoral, interscalene, adductor canal) can significantly reduce pain after specific procedures and lower opioid needs. See peripheral nerve block.
  • Wound infiltration and catheter techniques: Localized analgesia given via wound infiltration or catheters complements systemic analgesia and regional blocks. See local infiltration analgesia.

Controversies and debates

  • Opioid-sparing versus adequate pain relief: Proponents of opioid-sparing regimens emphasize safety, addiction risk mitigation, and shorter hospital stays. Opponents warn against under-treating pain, which can impede mobilization and satisfaction. The balance is dynamic and patient-specific, with ongoing evaluation of outcomes such as length of stay, complication rates, and readmissions. See opioid and pain management.
  • Non-opioid effectiveness and safety: NSAIDs and other non-opioids reduce opioid exposure but raise concerns in patients with ulcers, renal impairment, or cardiovascular risk. The debate centers on selecting the right agents, doses, and timing for each patient. See NSAIDs and acetaminophen.
  • Regional anesthesia risks and benefits: While neuraxial and peripheral blocks can enhance recovery, they carry risks such as hypotension, nerve injury, or rare complications. The decision to employ these techniques hinges on procedure type, patient risk, and institutional expertise. See neuraxial anesthesia and peripheral nerve block.
  • Equity in analgesia: Advocates argue for addressing biases and ensuring access to effective pain control across populations; critics caution that improper emphasis on identity-based metrics could erode clinical focus or risk misattribution if not grounded in robust data. From this perspective, emphasis should remain on outcomes and evidence, with careful analysis of how disparities arise and how best to address them. See racial disparities in pain management.
  • Policy, cost, and patient autonomy: Governmental and institutional policies aim to curb overprescribing and ensure safety, but some argue they can impede clinician judgment or patient access in certain contexts. The practical view stresses evidence-based protocols that maximize value, minimize harm, and respect patient choices. See healthcare costs and patient autonomy.

Implementation in practice

  • Preoperative assessment: Risk stratification, discussion of goals, and planning for analgesia that aligns with anesthesia and surgical plans. See preoperative assessment.
  • Intraoperative management: Judicious use of regional techniques, multimodal pharmacology, and vigilant monitoring to control pain while limiting side effects. See intraoperative care.
  • Postoperative care: Protocol-driven analgesia with escalation or de-escalation based on pain scores, mobility milestones, and recovery trajectory. Early involvement of physical therapy and nutrition often accompanies ERAS pathways. See postoperative care and enhanced recovery after surgery.
  • Disparities and monitoring: Hospitals increasingly collect data on pain control, opioid use, and patient-reported outcomes to identify gaps and improve practice. See healthcare disparities.

See also