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Perioperative Pain Management:
Miscellaneous (Monitoring, Risk
Assessment)
Edwin Amirianfar, Alexander Bautista, and Alaa Abd-Elsayed
Abstract Managing pain in the perioperative period is imperative, but careful
consideration must be taken into account in order to properly, yet safely, admin-
ister medications to treat pain. Factors to consider for patients who are receiving
both opioid and non-opioid pain medications, include age, chronic medical condi-
tions, opioid naivety/tolerance Bethell et al. (Pharmacoepidemiol Drug Saf 29:504–9,
2020 [1]). Therefore, it is imperative to understand a patient’s medical history in order
to achieve adequate pain relief, while also creating a customized treatment plan to
mitigate side effects.
Keywords Monitoring
· Assessment · Risks · Pain management · Pain scale ·
Cannabis use · Opioid use disorder
High Risk Patients
1 Elderly
The elderly population, defined as patients over the age of 65, are at elevated risk for
the development of a number of postoperative complications including an increased
risk of postoperative delirium and functional decline [2, 3]. With advances in medical
E. Amirianfar (
B
) · A. Bautista
Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville,
KY, USA
e-mail: Edwin.Amirianfar@louisville.edu
A. Bautista
e-mail: alexander.bautista@louisville.edu
A. Abd-Elsayed
University of Wisconsin-Madison, AnesthesiologyMadison, USA
e-mail: abdelsayed@wisc.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_7
95
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96 E. Amirianfar et al.
management and surgical techniques, this patient population is now exposed to
surgery more often than in the past with over 310 million surgeries performed per
year [4].
With aging, functional changes occur in multiple organs that should be consid-
ered when prescribing medications to address pain. Functional changes occur that
can affect the respiratory, cardiovascular, gastrointestinal, and renal systems [5].
Furthermore, metabolism and body mass composition are also affected in the aging
population [5]. Aging impacts body mass composition through increases in total
body water and reductions in lean body mass. This can affect the volume of distri-
bution for medications as hydrophilic drugs will have a smaller apparent volume
of distribution while lipophilic drugs will have an increased volume of distribution
with a prolonged half-life [5, 6]. Drug absorption is also affected by aging, including
a reduction in first-pass metabolism, which can lead to increased plasma concen-
trations of drugs (i.e. opioids) [5]. Furthermore, hepatic changes, either as a result
of liver disease or normal aging, can also affect metabolism, including reductions
in cytochrome P450 activity in the liver, which can alter first-pass metabolism and
significantly increase bioavailability [5]. Aging also affects the respiratory system,
where structural changes include a loss of lung elastic recoil, increased chest wall
rigidity and a decrease in t he force generation from respiratory muscles, which leads
to a reduction in pulmonary function [7]. The changes in lung function play a role in
the elderly population as they are more prone to the adverse effects of many of these
pain medications.
Due to the age-related changes seen in the elderly, opioid monotherapy should
be utilized with caution because the risk of adverse events associated with elevated
opioid doses may be increased in these patients [8]. Multimodal analgesia utilizes
various medication classes with different mechanisms of action to adequately control
pain, while also limiting the adverse events associated with any particular analgesic
class [9]. These multimodal analgesic medications include acetaminophen, NSAIDs,
gabapentinoids, and ketamine. [9] Regional anesthesia, which includes both periph-
eral nerve blocks and neuraxial anesthesia, is another mode of analgesia that can
assist with managing pain in the perioperative period in elderly patients. Periph-
eral nerve blocks consist of identifying a peripheral nerve and infiltrating it with an
anesthetic agent with the goal of blocking transmission and inhibiting pain signaling
[10]. Neuraxial anesthesia is the placement of local anesthetic in the proximity of
the central nervous system and includes spinal, epidural, and caudal anesthesia [11].
Neuraxial anesthetics work by blocking nerve signal connections to the spinal cord to
prevent the transmission of pain and also prevent spinal reflex inhibition of diaphrag-
matic and gastrointestinal function thereby hastening the return of bowel activity
following surgery [8]. Peripheral and neuraxial anesthesia are considered safe in
the elderly population and have shown that they are associated with decreased pain
scores, a decreased need for postoperative analgesic medications, earlier ambulation,
earlier return of bowel function, and improved mental status [2]. Common procedures
where regional anesthesia can be used include thoracotomy, colectomy, and a variety
of extremity procedures including joint arthroplasty or fracture repair [2]. Possible
adverse events of regional anesthesia include nerve damage, hematoma, infection,
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Perioperative Pain Management: Miscellaneous (Monitoring, Risk … 97
and intravascular injection of local anesthetic [12]. In addition, the presence of local
anesthetic systemic toxicity (LAST) from injection into vasculature presents with
immediate seizures, which is more likely to occur in elderly patients likely due to
decreased circulating plasma proteins and diminished hepatic function [12, 13].
2 Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) is another medical diagnosis that should be consid-
ered in patients in the perioperative period. There are approximately 1 billion people
affected globally by OSA making this an incredibly common diagnosis. Frequently,
patients may present without a diagnosis of OSA and a thorough preoperative discus-
sion may unveil a constellation of findings suggestive of the diagnosis [14]. The
STOP-Bang questionnaire is an effective screening tool for OSA which includes
asking patients about their snoring, tiredness, observed apnea, blood pressure, body
mass index, age, neck size, and gender [15]. Providing adequate analgesia for patients
with OSA may be difficult as opioids can be associated with a decrease in hypoxic
and hypercapnic ventilatory drive that can further exacerbate nocturnal desatura-
tion events [16]. In patients with OSA, the utilization of multimodal analgesia,
including NSAIDs, acetaminophen, tramadol, ketamine, pregabalin, regional blocks
or catheters may be helpful in decreasing the need for opioids [17]. Regional anes-
thesia approaches should consider the impact of diminished diaphragmatic function
and potentially preferentially select approaches that avoid impacting the pulmonary
system. Oral opioids should be the preferred route of administration following
surgery, as patients with OSA are more likely to have oxygen desaturations with
intravenous opioids [17]. Although there are no evidence-based guidelines, it would
be appropriate to monitor these patients more closely in the postoperative period for
any oxygen desaturations [18]. In certain patients (i.e. those with severe OSA or in
whom large doses of postoperative opioid administration are anticipated), it may be
prudent to error on the side of inpatient monitoring until patients can be more safely
discharged.
3 Opioid Use Disorder
Opioid use disorder (OUD) is a chronic disease characterized by tolerance, craving,
inability to control the use, and continued use despite adverse consequences [19].
Patients with OUD have a significant impairment and disability in daily activities at
home and work [20]. This subset of patients can pose a challenge in terms of finding
the right balance of adequate acute pain control without compromising the patient’s
road to recovery. Patients oftentimes encounter unfair treatment and are misjudged
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98 E. Amirianfar et al.
by providers because of the stigma associated with their condition. Inadequate pain
relief, withdrawal symptoms and an increased relapse rate are common concerns in
the perioperative setting [21].
It is imperative that a multidisciplinary team approach is utilized to successfully
manage the analgesic needs of these patients. A referral to an acute pain service,
substance use disorder team, psychologist and obtaining a thorough pain management
history from the provider managing OUD is crucial. A urine toxicology screen testing
for substances being used to treat OUD such as methadone, buprenorphine, opioids
and illicit substances are helpful to gather objective information. The online prescrip-
tion drug monitoring program databases should also be reviewed for confirmation of
prescribed analgesics [22].
Patients who are at higher risk for opioid misuse and concomitant high anxiety
levels and catastrophizing may benefit from further evaluation and categorization
through use of the Pain Catastrophizing Scale. It has been shown that negative
thinking can affect anxiety levels and may also trigger drug craving [23]. The
utilization of the opioid risk tool can help guide postoperative pain management by
screening patients with chronic pain who may be at high risk for relapse if opioid
analgesics are prescribed.
Patients with OUD also have a higher tolerance to opioid medications and this
must be taken into consideration when developing an appropriate pain regimen. For
patients receiving opioid agonist therapy (OAT) with methadone or buprenorphine,
their home dosage should be confirmed and continued in the perioperative period
[17]. It is thought that patients on buprenorphine may require higher doses of opioids
to displace buprenorphine from the mu opioid receptors in order to achieve adequate
pain control [24]. Therefore, providers may need to administer higher starting doses
of opioid medications in this population as compared to the opioid naïve popula-
tion. Patients on OAT therapy should also receive oral and/or IV opioids with the
use of patient-controlled anesthesia (PCA) [25]. However, patients with low doses
of buprenorphine (considered 2 to 8 mg per day) may benefit from more frequent
buprenorphine dosing (i.e. every 6 to 8 h) which will allow the drug to provide
enhanced analgesic effects. The American Society of Regional Anesthesia recom-
mends against the discontinuation of buprenorphine in the perioperative period for
patients with OUD as this practice may be associated with an increased risk of relapse
and overdose.
On the day of surgery, patients consuming chronic opioid analgesics should take
their usual dose of oral opioid the morning of their surgery and should receive their
daily maintenance dose preoperatively before the induction of general, spinal or
regional anesthesia [26]. If a patient is unable to receive oral intake (i.e. preopera-
tive fasting), the oral opioid dose should be converted to the IV dose of morphine
[26]. Intraoperatively, further opioid administration should be guided by vital signs,
specifically heart rate and blood pressure, and pupil dilation [26]. The Analgesia
Nociception Index may also be used for guidance of opioid medication dosing, but
the utility of this may be limited in patients who have severe arrhythmias, atrial fibril-
lation, implanted pacemakers, cardiopulmonary bypass, and those on antimuscarinic
drugs [27].
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Perioperative Pain Management: Miscellaneous (Monitoring, Risk … 99
A multimodal approach to pain management should be strongly considered in
this patient population where the utility of escalating opioid doses is frequently
limited. For example, the use of non-steroidal anti-inflammatory drugs (NSAIDs),
acetaminophen, and regional anesthesia techniques should be strongly considered.
The use of NSAIDs in the perioperative period may be associated with adverse effects
that limit the applicability of these agents, including an increased risk of bleeding
and kidney injury, which increases with higher dosage, concomitant anticoagulant
use and higher COX-1 selectivity [28].
Post-operative pain management should always be individualized. The patient
and the provider should be partners when determining which medication should be
used while weighing a patient’s history of analgesic management with the risks and
benefits of proposed treatment options. Regardless of the type of surgical interven-
tion, analgesic management plans should include pharmacologic non-opioid medica-
tions, regional anesthesia when appropriate and non-pharmacological interventions.
In choosing which medication to use, i.e. methadone, buprenorphine and naltrexone,
the providers should consider the patient’s preference, drug interactions, and existing
cardiac conduction problems such as prolonged QT interval. If the use of opioids is
inevitable, patients should be made aware of the risk and benefits associated with
opioid administration and the patients’ addictionologist should be included as a
decision-making collaborator.
It is necessary to educate patients and family members of opioid safe practices
including safe medication use, storage and disposal, follow-up appointments, moni-
toring for signs and symptoms of cravings, withdrawals and anxiety. It is necessary
for these patients to have close monitoring and encouragement for them to continue
their OUD treatment and be provided with support as necessary [22].
4 Cannabis Use
“Cannabis” refers to products derived from the plant Cannabis sativa and includes
marijuana, which contains significant amounts of tetrahydrocannabinol (THC) [29].
Marijuana is the most commonly used federally illegal drug in the United States and
it is estimated that 30% of marijuana users have cannabis use disorder (CUD), which
is defined as problematic cannabis use leading to impairment or distress that includes
impaired control, continued use despite social/medical problems, craving, tolerance
and withdrawal [30, 31]. The American Society of Regional Anesthesia and Pain
Medicine have created guidelines as a response to the increased use of cannabis. One
study showed that patients who were cannabis users experienced more postoperative
pain and higher opioid consumption [32]. These guidelines recommend screening
all patients for cannabis use, type of cannabis used, amount, frequency, and time and
route of last consumption [33].
The various patient populations discussed may pose difficulties in managing pain.
Specific tools to monitor and assess treatment should be implemented to assist
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100 E. Amirianfar et al.
providers in addressing pain. Although these are mostly subjective, they can give
the provider an idea of whether or not the interventions are providing any benefit.
Monitoring
As analgesia with opioid medications is frequently required following surgery,
healthcare professionals must be aware of the potential side effects that they can
cause, the most serious of which remains sedation and respiratory depression [34].
Respiratory depression occurs through activation of µ-opioid receptors at specific
sites in the central nervous system, including the respiratory rhythm generating area
in the pons [35].
The PRediction of Opioid-induced respiratory Depression IN patients monitored
by capnoGraphY (PRODIGY) trial created a risk prediction tool that accurately
predicts respiratory depression in patients receiving parenteral opioids [36]. The
PRODIGY Risk Prediction Tool consists of five different domains: age, sex, previous
opioid use, presence of sleep disordered breathing, and presence of chronic heart
failure (CHF). Each domain is designated a score and the sum of each domain is
totaled. If the total score is less than 8 points, then the patient is considered low
risk for respiratory depression. If the total score is 8 to 14, the patient is considered
intermediate risk for respiratory depression. High risk of respiratory depression is
considered 15 points or higher. See the table below that describes the PRODIGY
Risk Prediction Tool (Table 1).
Table 1 PRODIGY risk score tool
Risk factors Scoring criteria Points Score
Patient age (years) Age < 60
Age 60–69
Age 70–79
Age ≥ 80
= 0 points
= 8 points
= 12 points
= 16 points
Sex Male
Female
= 8 points
= 0 points
Previous opioid use Opioid naïve
Previous opioid use
= 3 points
= 0 points
Sleep disordered breathing (SDB) Known SDB or high STOP-BANG
score
= 5 points
= 0 points
Chronic heart failure (CHF) Coexisting CHF
No known CHF
= 7 points
= 0 points
Total PRODIGY risk score
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Perioperative Pain Management: Miscellaneous (Monitoring, Risk … 101
5 Assessment
Pain assessment plays an important role for practitioners when they are prescribing
pain medication. One study showed that poor pain assessment was the single most
important barrier to adequate pain management [37]. Many different tools are used
for pain assessment in patients perioperatively, including the Visual Analog Scale
(VAS), Oswestry Disability Index, and the Functional assessment.
6VAS
The VAS was the most frequently used scale in one study comparing different pain
assessment tools (Fig. 1)[38]. The VAS is known to be a simple tool that is easy to
understand for those that are cognitively intact and its ease of use is convenient in the
clinical setting [39, 40]. The VAS is a line that is 100 mm in length that is labeled from
0 to 100 mm, corresponding to “no pain” and “worst possible pain,” respectively,
as seen in Fig. 2. As this is on a millimeter scale, patients are asked to mark where
their pain intensity is on the VAS, with 101 possible levels of pain intensity [41].
Studies have shown that ranges on the VAS from 0 to 4 mm can be considered
no pain, 5 to 44 mm as mild pain, 45 to 74 mm as moderate pain, and 75 mm to
100 mm as severe pain [42]. Assessing responses to analgesics should correlate with
the mode of administration of the medication and expected time to maximal effect,
where intravenous administration of opioids are typically assessed 15 to 30 min
after administration and oral medications are reassessed at 45–60 min following
administration [43]. The minimal clinically important difference is a change of 10 mm
on the VAS, with acceptable pain control after surgery being less than 33 mm [44].
Fig. 1 Visual analog scale
No pain Worst pain
imaginable
Fig. 2 Numeric rating scale
010
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102 E. Amirianfar et al.
7 Numerical Rating Scale (NRS)
The Numerical Rating Scale (NRS) evaluates patients’ pain from a scale, usually 0 to
10, See Fig. 2 [45]. Compared to the VAS, this scale has a certain amount of options
(i.e. in a 0 to 10 point scale there are 11 possible options) whereas the VAS can
have unlimited answers options. The NRS has been validated as a pain assessment
measuring tool that has similar validity to other pain s cales and strongly correlated
with VAS [46].
8 Oswestry Disability Index
Introduced in 1980, the Oswestry Disability Index (ODI) is the most commonly used
outcome-measure questionnaire for low back pain in the hospital setting and consists
of ten sections, scored from 0 to 5 for each answer for a total possible score of 50 [47,
48]. The statements are scored on a scale from 0 to 5 with 0 representing no disability
and 5 representing most severe disability. This score is then multiplied by 2 and is
then converted into a percentage. An ODI of 0–20% represents minimal disability,
21–40% represents moderate disability, 41–60% represents severe disability, 61–
80% represents severely crippled, 81–100% represents patients are bed bound [49].
Studies have shown that patients with LBP but no disability have an average ODI of
11.88, while those who have LBP with disability have an average ODI of 22.07 [50].
Studies have shown that the ODI is reliable and easy to use in clinical practice for
patients with low back pain [51]. In the year 2000, modifications were made to the
ODI with changes in wording of statements in multiple sections, now called version
2.0, and is now preferred over the original version [52].
9 Functional Pain Scale
Another way to assess pain is in terms of its relation to a patient’s functional status
and their ability to attend to their daily duties/activities. The Functional Pain Scale
(FPS) evaluates a patient’s pain and its effect on their daily activities on a scale of 0
(indicating no pain) to 10 (indicating immobilizing pain) [53]. Table 2 describes the
different levels of pain with their appropriate descriptors. Pain is considered “mild” if
from 1 to 3, “moderate” if from 4 to 6, and “severe” if 7 or higher [53]. These numbers
will correlate to different activities of daily living, sleep habits and communicability
with others and has the potential to give the clinician a more objective assessmentof
a patient’s pain and their response to medications. The FPS does have its limitations
though, including its use in those with lower education, as the FPS has some words
that require a level of reading comprehension/understanding that may exceed the
ability of some patients [53].
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Perioperative Pain Management: Miscellaneous (Monitoring, Risk … 103
Table 2 Functional pain scale description and definition
Description Definition
No pain (0) No pain
Minimal (1) Hardly noticeable/no impact on ADL’s/ sleep not affected and able to use
passive distraction for comfort
Mild (2) Noticeable when not distracted/no impact on ADL’s/sleep only slightly
affected and able to use both passive and active distraction for comfort
Uncomfortable
(3)
Pain is present but can complete all ADL’s/ sleep is slightly affected and
passive distraction only give marginal relief
Moderate (4) Constantly aware of pain but can complete ADLs with modification/sleep
marginally affected at times/ passive distraction is of no use, but active
distraction gives some relief
Distracting (5) Aware of pain/ able to complete some ADL’s but limited by pain/sleep is
affected and active distraction are only slightly useful
Distressing (6) Pain is present/unable to complete most ADLs limited by pain/ sleep is
difficult and active distraction is only marginal
Unmanageable
(7)
Pain interfere with normal ADL’s/nothing seems to help/ sleep is very
difficult/active distractions are very difficult to concentrate on
Intense (8) Cannot complete any ADLs without much assistance/ cannot concentrate/
conversation is difficult/ unable to sleep and unable to use distraction
Severe (9) Cannot do any ADL’s even with assistance can barely talk/ unable to sleep
and unable to use distraction
Immobilizing
(10)
Unable to move or talk due to intensity of pain/unable to sleep and unable to
use distraction
10 Conclusion
Pain management in the perioperative period may pose a challenge to many practi-
tioners and a detailed history is imperative in customizing a pain regimen to create
an individualized plan for each patient. One must consider whether or not a patient is
high risk and should take this into account when creating a treatment plan. Assessing
pain response to different interventions may also be difficult as most of the tools used
are subjective and include the VAS, NRS, and ODI. The FPS can help provide the
practitioner more of an objective view of how the patient’s current pain status is and
help further guide treatment.
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104 E. Amirianfar et al.
11 Key Takeaway Points
1. Each patient must have their pain regimens customized including those who are
considered high risk.
2. Utilizing the various pain scales can help providers assess patients’ response to
pain.
3. Using a multimodal approach to analgesia can help patients achieve pain relief,
while also mitigating side effects.
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