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12 T. Speaks et al.
3. How is the pain anticipated to affect the patient, and what physiologic challenges
may arise directly or indirectly because of it?
4. Will the patient be ambulatory or hospitalized following surgery?
5. Can regional anesthesia be utilized?
6. Does the patient have specific baseline pain modifying considerations, such as:
a. Advanced age
b. Mental health disorder: anxiety, depression, substance use, PTSD
c. History of pain: chronic, neuropathic, nociplastic
d. Opioid tolerance or central sensitization
e. Pain catastrophizing
7. Are there any contraindications to any specific treatments or techniques? [8–10].
Following the initial evaluation, education should be provided to the patient and
caregivers r egarding goals of care, treatment options and coordination made with the
anesthesia professional or team, surgeon, and any consultants, if necessary. Anal-
gesic elements then begin prior to surgery with multimodal analgesia delivered via
oral medication and regional analgesia, continued intraoperatively with intravenous
medications and the application of local anesthetics via local infiltration, peripheral
blockade or neuraxial blockade and continued in the postoperative period with multi-
modal analgesia by all suitable means to provide the most comfort while incurring
the least side effects and permitting the patient to engage in rehabilitation as soon as
possible. Newer long-lasting analgesic modalities, such as cryoneurolysis or percu-
taneous peripheral nerve stimulation, may play important roles for longer duration
perioperative pain management in the future. Throughout the treatment period, vali-
dated tools for assessment should be utilized and documented to track responses
to treatment and guide when adjustment of the regimen is necessary in relation to
adequacy of relief.
The cornerstones of this approach are t he rational selection of pharmacolog-
ical agents and the strategic use of peripheral and central neural blockade. Because
perioperative pain results from a variety of mechanisms, including nociception,
inflammation, nerve injury, peripheral and central sensitization, transcriptional and
post-transcriptional dysregulation, augmented facilitation, structural organization
and disinhibition, multimodal analgesia provides an approach capable of addressing
these distinct analgesic requirements of the perioperative patient [11, 12]. Specific
medications and techniques that are recommended will be reviewed.
3 Types of Pain
The current International Association for the Study of Pain (IASP) definition of pain is
“an unpleasant sensory and emotional experience associated with, or resembling that
associated with, actual or potential tissue damage” [13]. According to the American
Society of Anesthesiologists, acute pain in the perioperative setting is defined as pain
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General Principles of Perioperative Pain Management 13
that is “present in a surgical patient after a procedure” and is “the result of trauma
from the procedure or procedure related complications” [14]. Acute pain occurs
when an insult to tissue causes nociceptive neuronal firing in peripheral nerves that
is transmitted to the dorsal horn of the spinal cord and up to the brain. The trauma leads
to a local inflammatory response and release of immune cell mediators. Recurrent
release of these mediators typically resolves within days to weeks. Pain, especially in
the perioperative period, is coupled with a stress response. The stress response to pain,
when combined with the stress response from surgery itself, can further promote the
proinflammatory state, decrease the immune response, and predispose the patient
to a higher risk of chronic pain after surgery. Several patient and surgical factors
increase the risk of developing chronic pain, and it is imperative that perioperative
pain be treated adequately to minimize this evolution.
Chronic pain has been described as pain that persists beyond the normal expected
time of healing [15]. According to the American Society of Anesthesiologists,
“Chronic pain is defined as pain of any etiology not directly related to neoplastic
involvement, associated with a chronic medical condition or extending in duration
beyond the expected temporal boundary of tissue injury and normal healing, and
adversely affecting the function or well-being of the individual” [14]. In the periop-
erative period, acute post-operative pain may persist, and it is described as chronic
postsurgical pain (CPSP) if it is specifically a pain that has developed or increased in
intensity after a surgical procedure or tissue injury and persists beyond the healing
process beyond 3 months from the time of surgery [16]. The incidence of CPSP
varies greatly depending on the type of surgery (5–85%) with many studies indi-
cating 10–20% of all patients who undergo surgery will have persistent chronic pain
that limits functionality after surgery [17].
Chronic postsurgical pain is frequently associated with effects on mood and sleep,
often causing disruption to quality of life. Mood disorders (i.e., anxiety, depression,
and PTSD) and poor social support, which are frequently associated with chronic
pain, predispose individuals to developing chronic pain. Several predictive factors
of developing chronic pain can be used to identify higher risk individuals to prevent
CPSP. These risk factors include younger adults, high BMI, l ower educational level,
smokers, more medical comorbidities, prior disability, longer surgery time, more
surgical complications, depression, and anxiety [18]. Additionally, specific surgeries
are more frequently associated with post-operative chronic pain, and these include
amputation, thoracotomy, and mastectomy [17].
Several animal models have been used to hypothesize the mechanisms by which
chronic pain changes our central nervous system. Acute injury and chronic inflam-
mation are thought to cause changes in gene expression in the spinal cord and cere-
bral cortex. This tissue damage and inflammation can form pathological changes
to the peripheral and central nervous system, resulting in nociceptive hypersensi-
tivity [19]. Neuronal changes and remodeling can lead to sensitization, which can
progress to hyperalgesia and allodynia [20]. In time, gene expression plays a role in
spinal and supraspinal areas which are distant from the initial inciting lesion [19].
Beyond changes in primary DNA sequencing, there is evidence of the roles of DNA
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14 T. Speaks et al.
methylation, histone modification, and expression of mRNAs in the continuation of
pain.
In contrast to postsurgical pain, neuropathic pain is that which stems from
pathology of the nervous system itself [21]. Neuropathic pain is one of the leading
causes of chronic pain across the world and is only becoming increasingly preva-
lent. Approximately 15–25% of chronic pain is neuropathic [22]. Diabetes (diabetic
neuropathy), infection (herpes zoster), nerve compression, nerve trauma, and autoim-
mune disease (multiple sclerosis) are some examples of different types of neuropathic
pain. Compared with nociceptive pain, neuropathic pain is typically associated with
more numbness, allodynia, and neurological findings. Neuropathic pain is often
described as shooting and tingling, whereas nociceptive pain is more commonly
described as aching, stabbing, and throbbing. In the perioperative period, neuro-
pathic pain is important to consider for pain management. Preoperative neuropathic
pain can lead to worse pain in the post-operative period through central sensitization
[23–25]. CPSP commonly manifests from neuropathic pain either worsened by or
originating from the surgery. Intraoperative nerve damage or impaired pain modu-
lation may lead to chronic neuropathic pain. Management and prevention of CPSP
involves perioperative prophylactic strategies and the adequate treatment of chronic
neuropathic pain [26].
4 Neurophysiology of Pain
In order to manage perioperative pain, a basic understanding of the pain system is
necessary. Pain has four major elements of signal processing: transduction, transmis-
sion, modulation, and perception [27]. The pathway starts at the peripheral nocicep-
tive receptors located throughout the body and terminates at the cerebral somatosen-
sory cortex. Each element provides an avenue to intervene on the pain signal, and
therefore, an opportunity to modify the pain experience.
5 Transduction
Transduction refers to the activation of primary afferent nociceptive receptors by
mechanical (e.g., pressure, stretching), chemical (e.g., prostaglandins, histamine), or
thermal stimuli [27]. When activated by a noxious stimulus, nociceptors generate
electrical impulses that travel via the peripheral nerves to the spinal cord and then
ascend to the brain. Nociceptors are found throughout the body, including the skin,
muscles, joints, and internal organs. There are no nociceptors found in the CNS
[28, 29].
Nociceptors are comprised of two major classes of afferent free nerve endings: Aδ
fibers and c-fibers [30]. Aδ fibers are medium diameter, thinly myelinated afferents
that transmit acute, well-localized, fast pain signals. Aδ fibers play an important role
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General Principles of Perioperative Pain Management 15
in alerting the body of impending tissue damage and in initiating protective reflexes,
such as withdrawal from noxious stimuli. In contrast to Aδ fibers, c-fibers are smaller
diameter, unmyelinated afferents that are responsible for dull, poorly localized, slow
pain signals. A common example of these nociceptors is displayed by a stubbed toe
which leads to an initial, sharp pain transmitted by Aδ fibers, followed by a dull,
throbbing pain elicited by c-fiber nerve endings.
By targeting the first step of pain processing—activation of mechanical, thermal,
and chemical stimuli—pain can be inhibited or modified. For example, there
are several factors released from damaged tissues that activate nociceptors and
initiate the pain signaling process. Extreme temperature, force and tissue destruc-
tion activate nociceptors directly and indirectly via inflammatory chemicals such
as prostaglandins, histamine, bradykinin, and substance-P [30]. NSAID’s, such as
ibuprofen or naproxen, block the production of prostaglandins, thereby providing a
means to inhibit transduction and reduce pain.
6 Transmission
Once nociceptors are activated by noxious stimuli and an action potential is gener-
ated, the impulse is transmitted from the periphery to the central nervous system
through first, second and third-order neurons [27]. The first-order neuron starts with
transduction at nociceptors and ends with a synapse at the dorsal horn of the spinal
cord. The second-order neuron begins at the dorsal horn and ends at the thalamus.
Finally,the third-order neuron travels from the thalamus to the somatosensory cortex.
This process involves interplay between the nervous system, neurotransmitters and
other signaling molecules.
The ability to generate action potentials underlies the pain signal pathway.
Noxious stimuli activate nociceptors causing voltage-gated sodium channels to open
which lead to an influx of sodium that is then propagated along the nerve [31]. Local
anesthetics block nerve impulse transmission by blocking voltage-gated sodium
channels. Regional blocks are an invaluable tool to manage perioperative pain in
the setting of a wide variety of surgeries.
7 Modulation
Modulation involves the alteration of afferent pain propagation along the neural
pathway [27, 31]. The dorsal horn of the spinal cord is the site where many receptors,
such as NMDA and neurokinin, affect action potential propagation. Many inhibitory
neurotransmitters, including endorphins, glycine, and GABA, work at these sites
[11]. In contrast, augmentation of pain can also result via neurotransmitters like gluta-
mate, substance-P, calcitonin gene-related peptide, and aspartate [31]. Additionally,
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16 T. Speaks et al.
the modulation process can lead to neuroplasticity resulting in hyperalgesia, making
subsequent pain more difficult to manage.
8 Perception
The culmination of the pain propagation system is the integration of signals from the
somatosensory and limbic cortices to produce pain perception [32].This is how the
brain interprets and responds to signals indicating tissue injury or potential harm.
Pain is both a sensory and emotional experience. Emotional factors, such as previous
experiences, anxiety, and fear, all play a role in the perception of pain.
There are many ways to target the perception of pain in the perioperative setting,
and pain is a result of intricate peripheral and central processes. By understanding
how pain signals are transmitted and processed, clinicians may select from among
the available tools to administer effective perioperative pain management.
9 Pain Assessment
Reliable assessments of pain are essential for perioperative pain management. Pain
is a multi-dimensional subjective experience dictated by the character and intensity
of the pain, the patient’s emotional state, and many other variables. These factors
make it difficult to measure pain objectively. Patient self-report using their own
pain vocabulary, when cognitively and physically able, is the best way to measure
changes in pain character and intensity over time [33]. Self-reporting scales are useful
in simplifying and standardizing pain data. The Numerical Rating Scale (NRS) and
Visual Analog Scale (VAS) are viewed as the gold standard methods for assessing
pain; however, there are other pain assessment scales that incorporate non-verbal
cues when a patient is unable to self-report [34]. These include the Adult Non-
Verbal Pain Scale (NVPS), Behavioral Pain Scale (BPS), and Pain Assessment in
Advanced Dementia Scale (PAINAD), among others. Overall, these tools are best for
measuring changes in acute pain and are less helpful for measuring pain in absolute
terms or in comparing the pain for two different individuals’ experiences.
The NRS and VAS scales focus on pain intensity, as intensity is typically the
distinguishing dimension of acute pain for acute treatment. In the NRS assessment,
patients are asked to choose a number between 0 (no pain) and 10 (worst possible
pain) [35]. It is a simple and quick tool that can easily be administered verbally, over
the phone or through surveys. The VAS is similar but consists of a straight line upon
which a scale is constructed ranging from 0 to 100 and which can be marked anywhere
along its continuous spectrum. In one study, NRS, VAS, and Brief Pain Inventory
(BPI-PS) were compared, and the results did not show a significant difference in
validity or effectiveness among the three scales [36]. Similarly, another study showed
that there was no significant difference between the reliability of the VAS and NRS
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General Principles of Perioperative Pain Management 17
[37]. Overall, these self-reporting scales are reliable and interchangeable; however,
they lack objectivity and are still poor measurements of pain.
Two of the most widely used pain scales for patients who are unable to self-
report pain are the Adult Non-Verbal Pain Scale (NVPS) and the Behavioral Pain
Scale (BPS). These tools, along with all the other non-verbal pain assessment tools,
are useful for patients with dementia, who are non-verbal, or who have intellectual
impairment. The BPS assesses critically-ill patients who are sedated and intubated.
Patients are given a score which is comprised of the sum of 3 categories: Facial
Expressions, Movements of Upper Limbs, and Compliance with Mechanical Venti-
lation. The NVPS consists of five categories scored 0–2: Facial expression, Activity
level, Guarding, Physiology (vital signs), and Respiratory status [38]. Unfortunately,
none of these non-verbal pain assessment scales are particularly reliable. It can be
nearly impossible to distinguish between pain and emotional distress or determine a
patient’s pain intensity. The inability for us to objectively measure pain, especially
in those who are unable to self-report, can often lead to undertreatment of pain.
10 Treatment of Perioperative Pain
An individual’s experience of pain is a complex and subjective issue, which has
physical, emotional, and existential implications. A physician’s understanding of
pain must incorporate an understanding of the physiological origin of the sensation,
and a method of assessing and anticipating an individual’s need for pain treatment.
The final common pathway,however, lies in the treatment of pain. Improper treatment
of perioperative pain can lead to poor patient satisfaction and chronic pain, as well
as numerous objective complications such as delayed mobility and cardiopulmonary
morbidity [39–41]. The aim of this section is to briefly introduce several common,
contemporary methods for the treatment of perioperative pain, and how their use can
assist the physician and patient as part of a broader pain control toolbox that can be
adjusted for an individual and procedure-specific clinical situation.
11 Local Anesthetics
Local anesthetics are a class of drugs that reversibly block voltage-gated sodium
ion channels in nerves, reducing the transmission of an action potential [42]. Local
anesthetics have a long and diverse history in anesthesia and pain management, and
the permutations of their application regarding site, injection technique, drug choice,
dose and use of adjuncts are vast. Depending on the nerves blocked by the local
anesthetic, the effect may be the elimination of painful sensation, temperature, touch,
or motor blockade. These drugs are often administered directly at the surgical site,
surrounding peripheral nerves or nerve plexuses of the upper and lower extremities,
in fascial planes where nerves travel, or the epidural and intrathecal spaces. The
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18 T. Speaks et al.
utility of local anesthesia is that it provides safe, exquisite pain control, and can
serve as a sole anesthetic, adjunct to general anesthesia, or be used for post-operative
pain control.
Intravenous (IV) administration of lidocaine in the perioperative period is the
only common non-regional analgesia use of a local anesthetic to reduce surgical
pain [43]. Evidence from meta-analysis suggests it yields a small reduction in pain
scores in the immediate postoperative period, and its use may be more beneficial
as an intraoperative adjunct in large abdominal and spine surgeries, particularly in
patients who are not candidates for neuraxial anesthesia [44, 45].
Local and regional analgesia involve injection of local anesthetic at the surgical
site, or along the afferent pathway of pain transmission, which can involve a single
peripheral nerve, fascial planes containing peripheral nerves, a nerve plexus, or near
nerve roots exiting the spinal cord. Injection can be performed as a single injection
or placement of an indwelling catheter. Regional analgesia has become a mainstay
of multimodal and opioid-sparing perioperative pain control [8, 46, 47]. The diverse
individual applications are beyond the scope of this section, but a large body of
evidence suggests safety and efficacy behind techniques used for pain management
in orthopedic, thoracic, and large abdominal surgeries [48, 49]. In addition to supe-
rior pain control compared to IV pharmacotherapy alone, regional blocks lead to
a reduction in postoperative opioid use, reduced pulmonary complications, earlier
discharge, and may decrease the risk of postoperative cognitive decline. Thus, in
addition to their role as an adjunct to multimodal pain management, they may serve
as a useful option for providing anesthesia in patients too fragile to undergo general
anesthesia [50–53]. Local anesthetic is also commonly deposited into the epidural
and/or intrathecal space for perioperative pain control. Epidural analgesia is a corner-
stone technique for analgesia in major open surgeries of the chest, abdomen and
pelvis associated with severe pain, with evidence showing epidurals are associated
with superior pain control over systemic opioid administration alone [49, 54–56].
Aside from reduced opioid use, benefits include reduced cardiac and pulmonary
complications and decreased ileus.
12 Non-opioid Pharmacologic Therapies
Multiple physiologic mechanisms and receptors are responsible for the production
and processing of surgical pain phenomena. Thus, it makes sense that targeting
multiple receptors with different analgesics will be more effective than monotherapy.
This is the basis for multimodal analgesia, wherein more than one pharmacologic
class of analgesic targets different receptors in order to improve analgesia and
reduce class-specific side effects [7]. Several common drugs and their role in the
perioperative pain regimen are introduced below.
Acetaminophen is a common and effective first-line analgesic. It is safe, afford-
able, widely available, and often used to treat mild to moderate pain and fever [8, 57,
58]. Acetaminophen in the perioperative setting is commonly used preoperatively
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General Principles of Perioperative Pain Management 19
in the oral form, as well as intravenously in patients not tolerating oral medication.
Acetaminophen is most useful as a scheduled analgesic, in combination with other
drugs such as nonsteroidal anti-inflammatory drugs, where it has a synergistic and
opioid sparing effect [59, 60].
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a diverse group of medi-
cations that exert analgesic and anti-inflammatory effects through inhibition of the
COX-1 and COX-2 enzymes. Like acetaminophen, these drugs are affordable, and
available in multiple formulations. Their role in perioperative pain treatment has been
widely studied. They are effective for treating pain, reducing pain with movement
and are most effective when scheduled [61–63]. Providers must be aware of potential
side effects such as platelet inhibition, renal impairment and additional risks when
used for prolonged periods of time.
Glucocorticoids are another widely used class of drugs that decrease inflammation.
They are frequently used in the perioperative setting to decrease nausea and vomiting,
but there is also evidence that suggests a marked reduction in pain by decreasing the
inflammatory response to surgery [64, 65]. Single dose intravenous dexamethasone
is an effective component of an analgesic regimen, but providers must always be
aware of the potential side effects of increased blood glucose levels, fluid retention,
mood changes and other side effects if given more frequently [66].
Ketamine is a NMDA receptor antagonist with actions at numerous additional
sites involved in transmission and processing of painful stimuli. Depending on
the dose, ketamine is used as a dissociative anesthetic, an anesthetic adjunct, or
in anti-nociceptive pain therapy [67]. Research suggests improved analgesia and
decreased opioid consumption with perioperative ketamine administration in certain
patient populations. Ketamine is particularly useful in opioid-tolerant patients to
reduce hyperalgesia by decreasing neuronal excitability and the transmission of pain
impulses [68].
Gabapentin and pregabalin are structurally related to the neurotransmitter γ-
aminobutyric acid and are commonly used anticonvulsants that modulate voltage-
gated calcium channels in the central nervous system [69]. Gabapentinoids are often
used for treatment of neuropathic pain, and much recent work has been devoted to
understanding their role in acute perioperative pain. Studies suggest a modest reduc-
tion in pain scores and opioid-sparing effects in specific populations, though use must
be balanced against common side effects of dizziness, sedation and potentiation of
respiratory depression [70]. Due to these side effects, perioperative use should be
limited to patients and scenarios at risk for the effects of neuropathic pain [71].
Dexmedetomidine is a selective α
2
receptor agonist that is used in the perioperative
and intensive care setting for sedation, and as an anesthetic adjunct. Some evidence
supports dexmedetomidine as a modest analgesic adjunct that reduces pain scores
and has opioid-sparing effects [72, 73]. Despite a lack of respiratory depression, it
must be administered with caution due to the sedating effects, as well as hypotension
and bradycardia.
Magnesium is a common intracellular ion that also acts as a NMDA antagonist.
A meta-analysis suggested a modest pain-reduction and opioid-sparing effect from
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20 T. Speaks et al.
magnesium administration, though further research is needed to determine optimal
timing and dosage for its use in the perioperative setting [74].
13 Opioid and Opiate Therapies
Opioids and their synthetic derivatives have a long and well-studied history in
the treatment of pain. Long-considered the standard for pain management due to
their effectiveness in relieving acute pain, their central role is now under increasing
scrutiny due to the numerous harmful side-effects and the ineffectiveness of a unilat-
eral approach [75, 76]. Opioid receptors are g-protein coupled receptors that are
diffusely present throughout the nervous system and body, thus the effects from
these drugs are widespread [77]. The most dangerous is respiratory depression, but
the most common are nausea, pruritis and constipation [78]. In addition to physi-
ologic side effects, opioids rapidly produce tolerance and can lead to dependence,
which is a growing international concern [79, 80].
Opioids are administered in a variety of ways, but the most common periopera-
tive routes are oral, intravenous, and neuraxial, with short, intermediate, and long-
acting variations available [81]. Fentanyl, morphine and hydromorphone are admin-
istered IV in the operating and recovery rooms, with transition to longer acting
oral medication when appropriate. Patient controlled analgesia (PCA) allows the
conscious patient to self-bolus medication, resulting in improved patient satisfaction
and decreased nursing demand, but with no reduction in total opioid use or hospital
length of stay [82]. Despite their powerful role in suppressing acute pain, it is recog-
nized that opioids should be used at the minimum effective dose for the shortest
duration possible [83].
14 Non-pharmacologic Therapies
Pharmacologic agents and regional anesthetic techniques are the backbone of peri-
operative pain management, but the practitioner should be aware of the physical and
behavioral interventions that may also be helpful. These techniques can assist with
specific scenarios, though evidence is generally weak and still emerging [8]. Tran-
scutaneous electrical nerve stimulation (TENS) involves generation of non-painful
electrical current across the skin that activates a neural inhibitory network, causing
analgesia [84, 85]. The use of acupuncture for pain management is on the rise, but
requires a highly experienced practitioner [86–88]. Modulation of central processing
and the subjective nature of pain is the goal of behavioral and psychological interven-
tions. Cognitive-behavioral therapy and biofeedback may adjust the central percep-
tion of pain, increase a patient’s ability to deal with pain, and improve patient coping
[89, 90].
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General Principles of Perioperative Pain Management 21
15 Treatment Summary
The most effective management of perioperative pain involves patient and surgery
specific targeting of the diverse mechanisms and receptors involved in producing
painful stimulations. The above therapies are most beneficial as part of a large toolbox
used by the perioperative physician to improve patient comfort while minimizing
pharmacologic side effects [12]. Further sections will address these and additional
treatment modalities and their supporting evidence in greater detail.
16 Role of Pain Management in ERAS
The primary goals of an enhanced recovery protocol are to achieve the highest
quality results and fastest recovery for patients after surgery to lead them to optimal
health outcomes. Optimal perioperative pain management is a fundamental feature
of enhanced recovery protocols. The idea for Enhanced Recovery After Surgery®
was developed by a group of academic surgeons in Europe in 2001 who aimed to
shift the focus of recovery from a singular goal of speed popularized by “fast-track
surgery” in the 1990s to quality of recovery [91]. The enhanced recovery concepts
leveraged multi-disciplinary teamwork, evidence-based guidelines and continuous
cycles of audit and refinement [92–94]. From the outset the group aimed to modify
the endocrine and metabolic response by addressing nutrition, inflammation, protein
metabolism and analgesia, while also revealing to the surgical community how
complete perioperative care rather than surgical technique alone determined post-
surgical outcomes [95]. The group formed the ERAS Society in 2010, and they
published the first protocols addressing colorectal surgery and pancreaticoduodenec-
tomy in 2012. Their ideas spread to many other types of surgery and led to the
creation of protocols both by society members and by other professionals [96–100].
As the groups developed comprehensive protocols to achieve these goals, optimizing
analgesia featured prominently.
While published protocols such as those developed by the ERAS Society are
a good starting point, forming a pathway involves many components beyond the
concerns of pain management [101, 102]. The first step is forming a multidisciplinary
team that includes surgeons, anesthesiologists, nurses, and may include other stake-
holders, such as physical therapists, occupational therapists and care coordinators.
This team will then set goals and priorities, review existing evidence-based guidelines
and literature, identify concerns for design and implementation and identify existing
resources. The next step is creating a pathway that is service and institution specific
that meets the core tenets of enhanced recovery protocols, including comprehensive
analgesia, the return to homeostasis, early mobilization, restoration of postoperative
alimentation and early discharge from the hospital. Following this, support must be
garnered from leadership and additional stakeholders and users must be educated.
The protocol and corresponding pathway may then be implemented for patient care
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