New Advances in Acute Postoperative Pain Management

Abstract

Over the last decade, Enhanced Recovery after Surgery (ERAS) pathways and protocols are becoming the benchmark standards for enhancing postoperative recovery. Multimodal analgesia (MMA) is an essential component of such care. Further, in the wake of serious and persistent concern on the opioid epidemic in the USA, there has been a recent renewal of interest in non-opioid alternatives or adjuncts in controlling postoperative pain, often in the context of MMA. Intravenous (IV) acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), magnesium, ketamine, dexmedetomidine, liposomal bupivacaine, and newer neuraxial and peripheral regional techniques as well as patient-controlled modalities are gaining importance. Gabapentinoids have become popular but recent meta-analytic reviews have cast doubt on their routine use in perioperative settings. Among opioids, sublingual sufentanil, IV oxycodone, and iontophoretic transdermal fentanyl hold promise. Acupuncture and transcutaneous electrical nerve stimulation may be useful as adjuncts in MMA packages. Genetic testing, derivatives of herbal preparations, and an extended role of acute pain services may emerge as potential areas of importance in the future. There are, however, critical gaps in good quality evidence in many of the practice guideline recommendations. In the era of opioid epidemic, several lines of evidence have emerged to support non-opioid-based drugs and approaches along with a few newer opioid formulations for postoperative pain management, although more research is needed to find the right balance of efficacy and safety.

<p>The Safety and Efficacy of Ultrasound-Guided Serratus Anterior Plane Block (SAPB) Combined with Dexmedetomidine for Patients Undergoing Video-Assisted Thoracic Surgery (VATS): A Randomized Controlled Trial</p>

“…However, opioids remain the cornerstone treatment for acute postoperative pain. 21 Dale et al report that reducing opioid consumption is very important because of their side effects, such as urinary retention, pruritus, oversedation, opioid-induced hyperalgesia, respiratory depression, nausea, and vomiting. 22 Albrecht et al have shown that regional analgesia may be a crucial component of multimodal postoperative pain management to reduce perioperative opioid consumption.…”

<p>An efficient and long-acting local anesthetic: ropivacaine-loaded lipid-polymer hybrid nanoparticles for the control of pain</p>

“…22,23 Briefly, PCL (100 mg) as polymer, PEG-DSPE (100 mg) as lipid, and lecithin (20 mg) as lipophilic surfactant were dissolved in acetone (5 mL) as an organic solvent to form the oil phase (1). RPV (20 mg) was dissolved in sodium dodecyl sulfate (0.5 mL, 5%, w/v) solution to form the internal aqueous phase (2). Next, solution (1) was sonicated (1 minute) in an ice-bathed solution (2) for emulsification.…”

“…Postoperative pain management remains one of the most common challenges which have been largely unmet. 1,2 Local anesthetics are used clinically for the control of pain following operation (including gastrointestinal surgery), or for the management of other acute and chronic pain. [3][4][5] However, the major limitation of local anesthetics is their short duration of action (,8 hours).…”

Designing the ideal perioperative pain management plan starts with multimodal analgesia

“…Ketamine has a clear opioid-sparing effect in the perioperative period [ 20 ] and may even reduce long-term opioid consumption in opioid-tolerant patients [ 21 ] as well as persistent postsurgical pain when used intravenously [ 22 ]. It is increasingly being featured in MMA protocols as an opioid alternative [ 23 ]. Although reviews have not consistently shown an increased incidence of side effects compared to controls [ 20 , 24 ], ketamine has the potential to cause psychomimetic effects and this should be factored into treatment decisions.…”