Postoperative pain management following ambulatory anesthesia: challenges and solutions

Abstract

Worldwide, there is an increasing trend toward performing more and more complex surgery in an ambulatory setting, partially driven by economic considerations. Provision of appropriate pain relief is still often inadequate in this setting; poor pain control and adverse effects of opioids provided for pain control are common reasons for readmission, with human and economic consequences. Therefore, improved analgesia after ambulatory surgery is an important goal; appropriate strategies include identification of at-risk patients, provision of multimodal analgesia, and early use of rescue strategies. Multimodal analgesia is based on the combined use of multiple medications or techniques for pain control, which have different mechanisms of action or act on different sites at the pain pathways. Thereby, such an approach improves analgesia, reduces opioid requirements, and reduces adverse effects of opioids. Important components of multimodal analgesia are nonopioids (acetaminophen and anti-inflammatory drugs), corticosteroids, and alpha-2-delta modulators (gabapentin, pregabalin), but most importantly the use of local and regional anesthesia techniques. Here, the use of adjuvants is one way to increase the duration of pain relief, but, increasingly, continuous peripheral nerve blocks via catheters are used in ambulatory patients, too. Finally, the planning of discharge medications needs a balancing act between the requirements for provision of good analgesia and the risk of opioids going out into the community.

Consensus statement on anaesthesia for day care surgeries

“…In addition, type of surgery is important as now there are data that certain surgical procedures including breast surgery and hernia repair surgery can be associated with increased risk of chronic post-surgical pain. [ 31 32 ]…”

“…Combinations of different medications with different mechanisms of action and/or working at different sites along the pain pathway are used to obtain additive (or even synergistic) pain relief, while leading to an opioid-sparing effect and thereby minimising adverse effects [ Figure 3 ]. [ 31 ]…”

“…It can not only be used on its own as an analgesic in day surgeries but also combined with NSAIDs for superior analgesia. [ 31 ]…”

“…[ 34 ] It is necessary to emphasise that planning of discharge medications needs a balancing act between the requirements for provision of good analgesia and the risk of opioids going out into the community. [ 31 ] The recently published guidelines on the management of post-operative pain by the American Pain Society recommend the use of peripheral regional anaesthesia techniques for post-operative pain management. [ 35 ] In our survey, 97% reported the preferential usage of multimodal analgesia for post-operative pain management.…”

Interdisziplinäres Positionspapier „Perioperatives Schmerzmanagement“

“…Diese sollten routinemäßig im Rahmen der präoperativen Anästhesieaufklärung eingesetzt werden. Patientinnen und Patienten mit einem hohen Chronifizierungsrisiko benötigen eine besonders engmaschige schmerzmedizinische Betreuung [138,140].…”