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xxii Contents
Closing Remarks
The Future of Perioperative Pain Management ....................... 703
Elizabeth Scholzen and Kristopher Schroeder
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 704
2 Future ........................................................ 704
3 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 710
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 710
Index ............................................................. 715
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Introduction
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Perioperative Pain Management-
Introduction
David L. Snyder, Girgis Girgis, and Alaa Abd-Elsayed
Abstract A greater understanding of acute and chronic pain is vital to creating a safe
and effective perioperative pain management plan for surgical patients. Expedited
recovery after surgery (ERAS) protocols aimed at improving perioperatively pain
control help facilitate early postoperative ambulation and rehabilitation for patients.
This is of great interest to patients who experience less postoperative complica-
tions and to hospitals who seek high patient satisfaction scores and shorter length of
stay times. The perioperative team has many techniques at their disposal to provide
patients with these benefits: medications which target various pain receptors, mini-
mally invasive procedures which utilize image-guidance to maximize effectiveness
and reduce risk, and tailored care to address the biopsychosocial profile of the
individual patients.
Keywords Perioperative pain
· Analgesia · Anesthesiology · Pain management ·
Regional anesthesia · Opioids · Multimodal pain control · Biopsychosocial pain
model
Perioperative pain management is an important aspect of surgical care for healthcare
professionals and patients alike. Understanding the pathophysiology, psychosoci-
ology and pharmacology of pain is essential to devising an appropriate plan for pain
prevention and/or treatment of pain in the perioperative setting. This book aims to
comprehensively outline and evaluatethe current understanding of perioperative pain
and the various tools which the medical community has available to address it.
But first we must examine why effective perioperative pain control matters. Poor
perioperative pain control can obviously lead to acute patient suffering but has other
important short and long term physiologic and psychological consequences [1]. The
D. L. Snyder · G. Girgis
Pain Management, Cleveland Clinic, Cleveland, OH, USA
e-mail: GirgisG@ccf.org
A. Abd-Elsayed (
B
)
Anesthesiology, University of Wisconsin, Madison, WI, USA
e-mail: alaaawny@hotmail.com
© 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_1
3
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4 D. L. Snyder et al.
postoperative period carries the highest risk of complications as patients recover
from surgery. The role that pain plays in increasing that risk and exacerbating those
potential problems is becoming better defined. One example of this is the clear
benefit seen in patients recovering from joint replacement surgery where anesthetic
techniques focused on improved pain management help facilitate early postoperative
ambulation and rehabilitation which leads to decreased postoperative complications
and shorter length of stay [2].
The clearest example of this is seen with the increased utilization of regional
anesthetic techniques. Peripheral nerve, epidural, and spinal blocks are the mainstays
of regional anesthesia. Their use can provide better pain control than intravenous
narcotics, promote early recovery of bowel function and easier breathing from less
splinting due to pain, require less need for systemic pain medications (including
opioids) and therefore less systemic adverse effects, and allow for easier and earlier
participation in physical therapy [3]. While regional anesthesia techniques come
with their own risks, in general they can be implemented safely and effectively in the
perioperative arena at hospitals and ambulatory surgery centers, in the emergency
department and the intensive care unit. This book will discuss the vast role that
regional anesthesia can play in perioperative pain control.
An undeniable fact of medicine is that so many of the driving forces behind what
we do are determined by financial feasibility, and perioperative pain management is
no exception. Shorter length of stay times are not only important to healthcare facil-
ities but also to patients who are eager to be home with their loved ones to continue
their recovery and rehabilitation. Effective perioperative pain management is one
of the major facilitators of this and lies at the core of their shared goal of hospi-
tals and patients. Enhanced recovery after surgery (ERAS) protocols have helped
to improve perioperative pain management through advanced planning and imple-
menting multimodal analgesia (MMA) leading to shorter length of stay and overall
direct and indirect reduction of healthcare cost to the patient and general population
[4]. Proper and effective perioperative pain control adds tremendous value to the
overall health system.
One cannot talk about pain, especially in the United States, without mentioning
opioids and the opioid epidemic. According to the Center for Disease Control (CDC),
the deaths related to opioid overdose in the United States was the highest in history
in 2021, with more than 80,000 deaths attributed [5]. Our role in in this cannot be
ignored; when we dive deeper into the statistics, we find that prescription opioid-
involved death rates continue to rise (increased 17% from 2019 to 2020) [6]. Even
though care is shifting away from indiscriminate opioid prescribing for postoperative
pain as part of a larger movement towards more restrictive opioid distribution, this
book will delve into various opioids and their safe utility in the perioperative setting
[7]. Furthermore, this book will elucidate various perioperative pain control tech-
niques that can help decrease opioid consumption as part of a movement towards more
responsible opioid stewardship in anesthesiology and the larger medical community
[8].
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Perioperative Pain Management- Introduction 5
Patient satisfaction after surgery is largely determined by the effectiveness of their
pain management. A review of studies looking at patient satisfaction ubiquitously
site pain as a significant factor in a patient’s interpretation of the quality of care they
receive [9]. Furthermore, the perception of showing concern for patient’s pain by
physicians and nurses was associated with greater patient satisfaction [10]. At the
heart of managing emotional and physical symptoms in the perioperative setting is
acknowledging and addressing pain effectively. We will discuss how to best manage
pain in the perioperative setting to maximize effectiveness and therefore patient
satisfaction.
The following chapters will examine the various mechanisms of pain including
the transition from acute to chronic pain, as well as the various influences on pain
including genetics and patient history. As mentioned above, we delve into the contro-
versial topic of opioids and the role they play in perioperative setting with specific
attention to pharmacology and clinical application of specific opioids. We also aim to
highlight non-opioid, systemic pain medications as well as more advanced, interven-
tional techniques and technologies such as regional anesthesia, catheters, stimulators,
and ablations. As a result of the above, we wish to dissect the role of the inpa-
tient pain service as leaders on the perioperative team in the clinic, post-anesthesia
care unit, and wards. This book will also look at the various populations and their
distinct pain considerations including LGBTQIA, prisoners, children, patients with
sickle cell disease, non-English speakers, critical care patients in the intensive care
unit, patients with significant psychiatric disease, patients with history of substance
abuse, and patients who are terminally ill and/or are on the palliative care service.
We will also give attention to specific surgical subspecialties because patients who
undergo spine, cardiac, breast, or obstetric and gynecologic surgeries have distinct
needs. Finally, we will look ahead in perioperative pain to give our analysis on what
perioperative pain management may look like in the near future.
References
1. Peters ML, Sommer M, van Kleef M, Marcus MA. Predictors of physical and emotional
recovery 6 and 12 months after surgery. Br J Surg. 2010;97(10):1518–27. https://doi.org/10.
1002/bjs.7152. PMID: 20737463.
2. Zhu S, Qian W, Jiang C, Ye C, Chen X. Enhanced recovery after surgery for hip and knee
arthroplasty: a systematic review and meta-analysis. Postgrad Med J. 2017;93(1106):736–42.
https://doi.org/10.1136/postgradmedj-2017-134991.
3. American Society of Regional Anesthesia (ASRA)—Risks and benefits of regional
anesthesia. https://www.asra.com/patient-information/regional-anesthesia/risks-and-benefits.
Accessed 15 April 2023.
4. Dong Y, Zhang Y, Jin C. Comprehensive economic evaluation of enhanced recovery after
surgery in hepatectomy. Int J Equity Health. 2021;20(1):245. https://doi.org/10.1186/s12939-
021-01583-3.
5. CDC—National Center for Health Statistics, U.S. Overdose Deaths In 2021 Increased Half as
Much as in 2020 – But Are Still Up 15%. https://www.cdc.gov/nchs/pressroom/nchs_press_r
eleases/2022/202205.htm. Accessed 20 March 2023.
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6 D. L. Snyder et al.
6. CDC—Injury prevention and control, understanding the opioid overdose epidemic. https://
www.cdc.gov/opioids/basics/epidemic.html. Accessed 20 March 2023.
7. Klueh MP, Sloss KR, Dossett LA, Englesbe MJ, Waljee JF, Brummett CM, Lagisetty PA, Lee
JS. Postoperative opioid prescribing is not my job: A qualitative analysis of care transitions.
Surgery. 2019;166(5):744–751. https://doi.org/10.1016/j.surg.2019.05.033. Epub 2019 Jul 11.
PMID: 31303324; PMCID: PMC7068723.
8. Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK.
Perioperative pain management and opioid stewardship: a practical guide. Healthcare (Basel).
2021;9(3):333. https://doi.org/10.3390/healthcare9030333.
9. Trinh LN, Fortier MA, Kain ZN. Primer on adult patient satisfaction in perioperative settings.
Perioper Med (Lond). 2019;8:11. https://doi.org/10.1186/s13741-019-0122-2.
10. Jamison RN, Ross MJ, Hoopman P, Griffin F, Levy J, Daly M, Schaffer JL. Assessment of
postoperative pain management: patient satisfaction and perceived helpfulness. Clin J Pain.
1997;13(3):229–36. https://doi.org/10.1097/00002508-199709000-00008.
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Foundations
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General Principles of Perioperative Pain
Management
Tyler Speaks, Margeaux Epner, Sandra Chavez-Carmona, James Kim,
and Anthony T. Machi
Abstract Perioperative pain management is founded on the science and under-
standing of acute pain. The analgesic process begins with a preoperative evaluation
that focuses on screening and making strategic assessments to individualize pain
therapy. This information is inserted into a multimodal analgesia framework, with or
without the aid of standardized protocols, such as Enhanced Recovery Protocols, and
used as a basis to inform and educate patients on planned therapeutics and expected
analgesic outcomes. The framework is then utilized to craft a pain management
strategy that is patient and pain mechanism-specific and employs pharmacologic
therapies, nonpharmacologic therapies, and interventional therapies that mitigate
pain and the physiologic stresses of surgery. Frequent assessment and reassessment
are used to fine-tune therapy and assist the patient in mitigating pain and helping
them progress along their goals for functional recovery.
Keywords Perioperative pain management
· Pain pathway · Pain assessment ·
Multimodal analgesia · Enhanced Recovery after Surgery (ERAS) · Interventional
acute pain management
· Regional analgesia
T. Speaks · M. Epner · S. Chavez-Carmona · J. Kim · A. T. Machi (
B
)
Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, TX, USA
e-mail: anthony.machi@utsouthwestern.edu
T. Speaks
e-mail: tyler.speaks@utsouthwestern.edu
M. Epner
e-mail: margeaux.epner@utsouthwestern.edu
S. Chavez-Carmona
e-mail: sandra.chavez-carmona@utsouthwestern.edu
J. Kim
e-mail: james.kim2@utsouthwestern.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_2
9
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10 T. Speaks et al.
1 Introduction
Descriptions of perioperative pain management can be traced as far back as ancient
Egyptian civilizations [1]. The ancient Greeks advanced the theories of periopera-
tive pain management with basic ideas of the nervous system, sensory experience
and perception of pain. Over the ensuing millennia, modest, incremental advances
were made with the discovery of analgesic medications, such as opium, therapeutic
modalities, such as heat and cold applications, and even electricity via the electro-
genic torpedo fish. Nonetheless, perioperative analgesia remained rudimentary until
the Scientific Revolution of the eighteenth and nineteenth centuries heralded new
theories, techniques, tools, and medications that modernized the practice of pain
management into a field recognizable as today’s practices. A key step was the devel-
opment of the specificity theory proposed by Descartes and refined by Schiff in
1858, which postulated a basic concept of pain pathways [1]. Further work by Bliz,
Goldschieder and von Frey in the late nineteenth century distinguished fundamental
aspects of the nervous system including separate receptors for pain, touch, warmth
and cold. This may be viewed as the nascent basis for the development of multimodal
analgesia.
The nineteenth century witnessed two key areas for development of perioper-
ative analgesia: the discovery of applications and techniques for local anesthetics
and harnessing the powers of opioids. The next 100 years would see perioperative
pain management focus largely on those two aspects. The many great wars of the
nineteenth and twentieth centuries, and in particular World War I and II, provided
stimulus for further developments due to the magnitude of traumas, ensuing surg-
eries, and exigencies of war. For the use of local anesthetics, development of three
key features were necessary for clinical use: the syringe, the needle, and a local
anesthetic drug. The oldest of these three is the local anesthetic drug, the first being
cocaine. Derived from the plant Erythroxylum coca, which was known to the peoples
of Central and South America for thousands of years, it was first recognized for its
pain relieving properties by a Westerner and Jesuit priest, Bernabé Cobo in 1653 [2].
Its medicinal application was limited until the mid-nineteenth century when incre-
mental improvements were made toward creating a hollow bore needle, connecting
that needle to a syringe for medicinal application, and isolating the cocaine alkaloid
from the coca plant [3]. However, it was not until the Viennese ophthalmologist,
Karl Koller, discovered the utility of cocaine as a topical local anesthetic in 1884 that
Western medicine found a substrate to utilize for regional anesthesia. Soon thereafter,
various physicians broadened the application of local anesthesia to local infiltration,
neuraxial blockade, and peripheral nerve blockade. The various toxicities and limi-
tations of cocaine were also recognized, and chemists embarked on identifying and
creating novel chemicals to serve as local anesthetics that would be safer and have
more desirable characteristics of faster onset, longer duration, and specificity of
neuronal blockade.
In parallel to the development of local anesthetics, the history of opioids dates to
ancient civilizations with some of the earliest reference to medicinal properties of
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General Principles of Perioperative Pain Management 11
opioids associated with ancient Sumeria at the end of the third millennia BCE [4]. In
the ensuing centuries, opium spread across civilizations and throughout the world.
It was used as an analgesic, particularly in Arabic, Indian and Chinese medicinal
traditions, and it was also used as a drug of abuse, notably in China in the seventeenth
and eighteenth centuries. However, specific reference to perioperative application
remained sparse. In 1806, morphine was isolated by Sertürner, and codeine was
identified a few years later [4]. Like local anesthetics, medicinal use remained limited
by the ability to deliver it until the mid-nineteenth century with the invention of the
hollow bore needle and glass syringe. From there, perioperative usage developed, and
investigators sought to develop opioids with greater potency and safety profiles. In
the process, thebaine and the semi-synthetic opioids hydrocodone, hydromorphone,
oxycodone, and diacetylmorphine (heroin) were identified. The constraint of opium
supply due to World War II spurred on the development of synthetic opioids, such
as meperidine and methadone [5, 6].
Despite the developments of new medications and refined methods of delivery,
the strategy of perioperative analgesia centering around local anesthetic administra-
tion and opioids remained unchanged until the second half of the twentieth century.
During this time, many investigations were conducted regarding the mechanisms of
analgesia related to local anesthetics, opioids, other medications, and techniques. A
seminal event in pain management history occurred in 1965 when Melzack and
Wall developed and published the gate control theory which related the impact
of ascending and descending modulation systems on neural impulse propagation,
providing a marked impact on the understanding of pain mechanisms. While initially
most impactful in the realm of chronic pain management in the immediate decades,
the concept began to find new application in the perioperative setting in the twenty-
first century. Also in the second half of the twentieth century, the investigations in
the mechanisms of pain and pain pathways led to the conceptual framework of multi-
modal analgesia by the Danish surgeon Henrik Kehlet [7]. This approach refers to the
use of more than one analgesic medicine or technique to leverage additive or syner-
gistic analgesic effects while minimizing adverse effects. It is with this background
that we apply a current theory for perioperative pain management.
2 Contemporary Principles of Perioperative Pain
Management
The analgesic process begins with a preoperative evaluation that defines the indi-
vidual’s pain experience and conducts a strategic assessment while considering the
following questions:
1. How much pain is anticipated from the surgery? What is the expected duration
of pain? What is the location of pain?
2. What are the specific post-operative functional goals to facilitate?
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