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123
Perioperative Pain
Management
AClinical Guide
AlaaAbd-Elsayed
KristopherSchroeder
Editors
Perioperative Pain Management
Alaa Abd-Elsayed · Kristopher Schroeder
Editors
Perioperative Pain
Management
A Clinical Guide
Editors
Alaa Abd-Elsayed
Department of Anesthesiology
University of Wisconsin
Madison, WI, USA
Kristopher Schroeder
Department of Anesthesiology
University of Wisconsin
Madison, WI, USA
ISBN 978-3-031-67647-5 ISBN 978-3-031-67648-2 (eBook)
https://doi.org/10.1007/978-3-031-67648-2
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse
of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply,even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or
the editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
If disposing of this product, please recycle the paper.
To my two beautiful children Maro and
George
To all patients in pain
To all authors who contributed to this book
Alaa Abd-Elsayed
Each of the authors of this text sacrificed
significant pieces of themselves and their
time to create something that will benefit
their colleagues and patients. Our families
and social networks share in this sacrifice as
we spend time away from them seeking to
create a product that will resonate and
provide substantial clinical benefit. To all
those impacted—thank you! Your patience,
love, and support remain critical to each of
us as we strive to balance clinical, academic,
and home responsibilities. Carrie, Cora,
Evie, and Rose—this is my opportunity to say
thank you and I love you!
Kristopher Schroeder
https://t.me/med1917
Preface
Perioperative pain management was, at one time, existed in a real of simplicity
that was simultaneously woefully inadequate. Patients were subjected to extensive
surgical procedures with scant regard for limiting the size of incisions, and pain
managementwasprovidedmostlybyopioidanalgesics.Forward-thinkingphysicians
might consider broadening pain management with acetaminophen or a non-steroidal
anti-inflammatoryagent but, in many cases, patients remained fastedandthese agents
were therefore infrequently viable options. Regional anesthesia was practiced by a
select group of wizards facile in the palpation of opaque bony or muscular landmarks
and reliant on pops, clicks, and subtle changes in resistance to accurately site local
anesthetics near a limited number of analgesic targets. Patients subjected to these
regimens, frequently required prolonged hospitalizations, and often realized chronic
painthatimpactedtheirabilitytoreturntofullfunctionalstatus and enjoy a reasonable
quality of life.
In the background, the medical profession was misled and inadvertently harmed
itself through prescribing outpatient opioids at alarming rates and manufacturing
patients with significant tolerance to those opioid receptor agonists that were the
cornerstone of postoperative pain management. Recently, in an effort to mend those
patients so negatively impacted by our collective opioid prescribing habits, partial
opioid receptor agonists or full antagonists are frequently prescribed and these agents
effectively mute the postoperative analgesic efficacy of our traditional opioid stal-
warts. Our patients have become frustrated by our lack of success with postoperative
analgesia and our healthcare colleagues share in this frustration. Too frequently,
patients will be de-humanized and labeled as “chronic painers” by colleagues
frustrated and exhausted by our collective failed efforts at managing these patients.
Fortunately,this is aproblem that is not without solutions and collaborative efforts
to mitigate surgical insults, manage pain, and recognize the patient’s critical role
in analgesic management have started to move the needle and make an impactful
difference in the postoperative recovery of our patients. Our surgeons have worked
diligently to limit the scope of their surgical procedures and now laparoscopic and
robotic procedures can substantially diminish the extent of surgical wounds and
dramatically hasten recovery. In addition, enhanced recovery protocols have ushered
vii
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viii Preface
in an era of reduced perioperative inflammation and dramatically decreased the
impact of surgery on postoperative functional recovery. Even our analgesic arma-
mentarium has been substantially bolstered as we now haveintravenouspreparations
of most drugs and an expanded array of medications that impact pain at a diverse
array of receptors. Regional anesthesia, once the domain of the wizard, has been
brought down from Mount Olympus, and improvements in ultrasound technology
and training haveallowed for an expanded pool of healthcare professionals trained to
deliveryeffectiveregional anesthesia. In addition, these same advancements in ultra-
sound imaging have ushered in an era of anatomical exploration, and novel analgesic
targets have emerged that provide targeted regional anesthesia in areas previously
spared by traditional techniques. Finally, the traditional walls between “acute” and
“chronic” pain have started to erode as clinicians have increasingly recognized the
blurred boundaries between these two practices.
In conjunction with these advances in technology, there has been a collective
recognition of the benefits to be realized through collaboration and thoughtful peri-
operative planning. Anesthesia preoperative clinics, interventional pain physicians,
psychiatrist, primary care providers, physical therapists, and surgical team members
all play vital roles in ensuring that patients are optimized for surgery and that the
patient is an engaged member of the team. The ease of communication and collabo-
ration among these groups has neverbeen more accessible, ensuring that all available
analgesic modalities are mobilized for patients facing challenging pain management
scenarios.
We are all simultaneously fortunate that the present and near future offer tanta-
lizing options for improved and extended analgesia. Extended-release local anes-
thetic preparations, cryoneurolysis, and peripheral nerve stimulation are but a few
of the technologies and approaches that each of us may soon offer to our patients.
Beyond these technologies, an enhanced recognition of the benefits to be realized
through collegial collaboration remains an important consideration when treating
challenging patients that may offer the promise of improved clinician wellbeing
through strengthened supportive networks.
Undoubtedly, this work is challenging and occasionally unrewarding. However,
the impact that might be realized through improvements in patient care and a
diminished community opioid burden make the effort more than worthwhile.
Madison, USA Alaa Abd-Elsayed, MD, MBA, MPH, CPE, FASA
Kristopher Schroeder, MD, FASA
https://t.me/med1917
Contents
Introduction
Perioperative Pain Management- Introduction ....................... 3
David L. Snyder, Girgis Girgis, and Alaa Abd-Elsayed
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Foundations
General Principles of Perioperative Pain Management ................ 9
Tyler Speaks, Margeaux Epner, Sandra Chavez-Carmona, James Kim,
and Anthony T. Machi
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2 Contemporary Principles of Perioperative Pain Management . . . . . . . . . 11
3 Types of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
4 NeurophysiologyofPain ........................................ 14
5 Transduction .................................................. 14
6 Transmission .................................................. 15
7 Modulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
8 Perception .................................................... 16
9 PainAssessment ............................................... 16
10 Treatment of Perioperative Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
11 Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
12 Non-opioid Pharmacologic Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
13 OpioidandOpiateTherapies ..................................... 20
14 Non-pharmacologic Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
15 TreatmentSummary ............................................ 21
16 Role of Pain Management in ERAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
17 EmergingTherapies ............................................ 22
18 Peripheral Nerve Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
19 Cryoneurolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
20 Oliceridine—BiasedLigand ..................................... 25
21 Transient Receptor Potential Vanilloid 1 Channel Agonists . . . . . . . . . . . 26
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x Contents
22 Extended-Release Local Anesthetic Formulations . . . . . . . . . . . . . . . . . . . 26
23 Local Anesthetic Adjuvants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
24 Summary ..................................................... 28
25 Key Takeaways of Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Patient/Surgical Risk Factors for Chronic Pain and Opioid
Dependency ....................................................... 37
Whitney Carter, Chelsea-Ann Patry, Andrew Mendelson,
and Lynn Kohan
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2 ChronicPost-surgicalPain ....................................... 38
3 CPSPRiskFactors ............................................. 39
4 CPSPPrevention/CPSPTreatment ................................ 39
5 Opioid Dependence and OUD Background . . . . . . . . . . . . . . . . . . . . . . . . 43
6 Opioid Dependence Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
7 Opioid Dependence Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
8 OUD/Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
9 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
The Implications of the Opioid Epidemic for the Treatment
of Perioperative Pain .............................................. 53
Nan Xiang, Denise Courtney, Shivana Ramsingh, Rebecca Donald,
and Sudheer Potru
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2 Opioid Risk Tool—OUD (ORT–OUD) . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Genetics of Acute Pain ............................................. 73
Danial Shams
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
2 AnatomyofPainPathways ...................................... 74
3 Heritability of Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
4 Candidate Genes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
5 FutureDirections .............................................. 80
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Pain Management Consent Considerations .......................... 83
Elizabeth Wilson and Kristopher Schroeder
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
2 Historical Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3 Consent ....................................................... 85
4 Unique Consent Circumstances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
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Contents xi
Perioperative Pain Management: Miscellaneous (Monitoring, Risk
Assessment) ....................................................... 95
Edwin Amirianfar, Alexander Bautista, and Alaa Abd-Elsayed
1 Elderly ....................................................... 95
2 Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
3 OpioidUseDisorder ............................................ 97
4 Cannabis Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
5 Assessment ................................................... 101
6 VAS .......................................................... 101
7 Numerical Rating Scale (NRS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
8 Oswestry Disability Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
9 Functional Pain Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
10 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
11 KeyTakeawayPoints ........................................... 104
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Review of Eras Pain Management Protocols ......................... 107
George Yacoub, Clara Nemr, and Alaa Abd-Elsayed
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
2 Preoperative ERAS Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
3 ERAS Guidelines: Multimodal Analgesia for Perioperative Care . . . . . . 109
4 Intrathecal Morphine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
5 ThoracicEpiduralAnalgesia ..................................... 110
6 Transversus Abdominis Plane Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
7 ErectorSpinaePlaneBlock ...................................... 111
8 Lidocaine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
9 Acetaminophen and NSAIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
10 Gabapentinoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
11 Glucocorticoids and Dexamethasone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
12 NMDA Receptor Antagonists and Ketamine . . . . . . . . . . . . . . . . . . . . . . . 115
13 Central α-2 Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
14 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Preoperative Preparation for Regional Anesthesia .................... 123
Melanie Donnelly and Peter W. Coleman
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
2 Discussion .................................................... 124
3 PatientOutcomes .............................................. 125
4 Regional Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
5 Modality of Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
6 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
7 KeyTakeaways ................................................ 130
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
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