managing-postoperative-pain

# Managing Postoperative Pain

Structures multimodal pain management with ERAS protocols and opioid stewardship documentation.

## Why This Skill Exists

Postoperative pain is the most common patient concern after surgery, and its management directly affects recovery, length of stay, patient satisfaction (HCAHPS scores), and long-term outcomes. The 2016 CDC Guideline for Prescribing Opioids and subsequent ACS/ERAS Society recommendations have shifted the paradigm from opioid-centric protocols to multimodal analgesia strategies that reduce opioid consumption while maintaining adequate pain control. Institutions that adopt multimodal protocols see 30-40% reductions in opioid use, faster return of bowel function, earlier ambulation, and shorter hospital stays.

Inadequate pain management delays ambulation (increasing VTE and pneumonia risk), impairs pulmonary function (atelectasis, pneumonia), and drives patient dissatisfaction. Conversely, excessive opioid prescribing causes respiratory depression (the leading cause of opioid-related death in hospitalized patients), ileus, urinary retention, and contributes to the opioid epidemic through new persistent use. This skill structures a balanced, evidence-based approach to postoperative pain that prioritizes function and safety.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What procedure was performed and what is the expected pain severity? **Default: [VERIFY — obtain from operative report]**
2. Does the patient have chronic pain or current opioid use? **Default: no opioid use**
3. What is the patient's renal function (GFR) and hepatic function? **Default: normal**
4. Does the patient have a history of substance use disorder? **Default: no**
5. Were any regional anesthetic techniques used (nerve block, epidural, TAP block, local infiltration)? **Default: none**
6. Does the patient have allergies or intolerances to specific analgesics? **Default: NKDA**
7. Is the patient enrolled in an ERAS pathway? **Default: no**
8. What is the patient's weight (for dose calculations)? **Default: [VERIFY]**

### Documents to Request

- Operative report (procedure details, EBL, regional anesthesia used)
- Anesthesia record (intraoperative opioid doses, regional techniques)
- Preoperative pain assessment and opioid use history
- State PDMP (Prescription Drug Monitoring Program) report
- Allergy list
- Pharmacy medication reconciliation
- Institutional opioid stewardship protocol

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## Step 1: Pain Assessment Framework

Perform structured pain assessments at standardized intervals:

**Assessment tools:**

| Tool | Population | Scale |
|---|---|---|
| Numeric Rating Scale (NRS) | Adults, verbal | 0-10 (0 = none, 10 = worst) |
| Visual Analog Scale (VAS) | Adults, verbal | 0-100 mm line |
| Wong-Baker FACES | Pediatric, non-verbal | 6 faces |
| CPOT (Critical-Care Pain Observation Tool) | Intubated/sedated ICU patients | 0-8 |
| BPS (Behavioral Pain Scale) | Intubated/sedated | 3-12 |

**Assessment frequency:**
- PACU: Every 15 minutes until discharge criteria met
- Floor (POD 0-1): Every 4 hours and 30 minutes after each intervention
- Floor (POD 2+): Every 8 hours with each nursing assessment

**Functional pain goals** (document these, not just a NRS number):
- Can the patient take a deep breath and use incentive spirometry? (NRS ≤4 target)
- Can the patient get out of bed and ambulate? (NRS ≤4 target)
- Can the patient sleep without being awakened by pain? (NRS ≤3 target)

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## Step 2: Multimodal Analgesia Protocol

Layer non-opioid analgesics as the foundation, adding opioids only for breakthrough pain:

### Tier 1 — Scheduled Non-Opioid Foundation

| Medication | Dose | Route | Frequency | Contraindications |
|---|---|---|---|---|
| Acetaminophen | 1000 mg | PO/IV | Q6h scheduled | Liver disease (reduce to 2g/day), hepatic impairment |
| Celecoxib | 200 mg | PO | Q12h (2-3 day course) | Sulfa allergy, CKD (GFR <30), active GI bleed, post-CABG |
| Ketorolac | 15-30 mg | IV | Q6h x 48h max | CKD, GI bleed history, EBL >500 mL, platelet dysfunction |
| Ibuprofen | 400-600 mg | PO | Q6h (transition from ketorolac) | Same as ketorolac |

### Tier 2 — Adjunctive Agents

| Medication | Dose | Route | Frequency | Notes |
|---|---|---|---|---|
| Gabapentin | 300 mg | PO | Q8h | Reduce for renal impairment; caution if age >65, sedation risk |
| Pregabalin | 75 mg | PO | Q12h | Alternative to gabapentin; same precautions |
| Lidocaine IV infusion | 1-2 mg/kg/h | IV | Continuous intraop → 24h postop | Cardiac monitoring required; useful in abdominal surgery |
| Ketamine (sub-anesthetic) | 0.1-0.3 mg/kg/h | IV | Continuous 24-48h | For opioid-tolerant patients; avoid in psychosis, elevated ICP |
| Lidocaine patch 5% | 1-3 patches | Topical | 12h on / 12h off | Low risk; apply adjacent to incision |

### Tier 3 — Regional Anesthesia Techniques

| Technique | Indication | Duration | Management |
|---|---|---|---|
| Thoracic epidural | Open thoracic or upper abdominal surgery | 48-72h | Acute Pain Service manages; monitor sensory level, hypotension |
| TAP block (single shot) | Abdominal surgery (laparoscopic or open) | 12-24h | Anesthesia performs; provides somatic wall analgesia |
| TAP block (catheter) | Major abdominal surgery | 48-72h | Continuous local anesthetic infusion |
| Paravertebral block | Thoracic surgery, breast surgery | 12-24h (single shot) | Unilateral; fewer hemodynamic effects than epidural |
| Adductor canal block | Knee surgery | 12-24h | Preserves quadriceps strength (vs. femoral block) |
| Wound infiltration (liposomal bupivacaine) | Various | Up to 72h | Injected at incision closure |

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## Step 3: Opioid Prescribing with Stewardship

When opioids are required for breakthrough pain (NRS ≥4 despite multimodal regimen):

**Inpatient opioid orders:**

| Setting | Medication | Dose | Route | Frequency |
|---|---|---|---|---|
| PACU (immediate) | Fentanyl | 25-50 mcg | IV | Q5min PRN (nurse-titrated) |
| Floor — mild/moderate | Oxycodone | 5 mg | PO | Q4h PRN (NRS 4-6) |
| Floor — moderate/severe | Hydromorphone | 0.2-0.4 mg | IV | Q3h PRN (NRS 7-10) |
| PCA (when indicated) | Hydromorphone | 0.2 mg demand, 8 min lockout, 1.2 mg/4h limit | IV | No basal rate |

**Opioid stewardship documentation requirements:**
- Calculate daily oral morphine equivalents (OME) and document in the chart
- Target: de-escalate to PO-only opioids by POD 2
- Target: reduce OME by ≥25% daily from peak consumption
- If OME >90 mg/day for >48h, trigger pharmacy and pain service review
- Document PDMP check prior to discharge opioid prescriptions

**Opioid-tolerant patients** (defined as ≥60 mg OME/day for ≥1 week):
- Continue baseline opioid regimen (do not withdraw)
- Add non-opioid multimodal agents aggressively
- Consider ketamine infusion for opioid-sparing effect
- Consult Acute Pain Service
- Set realistic functional goals (may not achieve NRS 0)

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## Step 4: Monitoring and Safety

**Opioid-related adverse effect monitoring:**

| Parameter | Frequency | Action Threshold |
|---|---|---|
| Respiratory rate | Q1h x 12h after IV opioid, then Q2h | <10 breaths/min → hold opioid, assess, consider naloxone |
| Sedation level (POSS or Ramsay) | With every opioid administration | POSS ≥3 → hold opioid, supplemental O2, escalate |
| Oxygen saturation | Continuous (POD 0-1); spot-check thereafter | SpO2 <92% on RA → assess, supplemental O2 |
| Capnography | Recommended for PCA and high-risk patients | ETCO2 >50 or <30 → assess airway |
| Bowel function | Daily | If no BM by POD 3 → initiate bowel regimen, consider reducing opioids |
| Urinary retention | After Foley removal | >400 mL on bladder scan → straight cath, assess opioid contribution |

**Naloxone (Narcan) protocol:**
- For respiratory depression (RR <8 or unresponsive): Naloxone 0.04-0.4 mg IV, repeat Q2-3 min
- For over-sedation without respiratory failure: Start with 0.04 mg IV (low dose to avoid precipitating withdrawal in opioid-tolerant patients)
- Have naloxone available at the bedside for all PCA patients

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## Step 5: Discharge Pain Management and Opioid Prescribing

**Discharge prescribing framework:**

| Procedure Category | Typical Opioid at Discharge | Quantity Limit |
|---|---|---|
| Minor (laparoscopic cholecystectomy, hernia repair) | Oxycodone 5 mg Q6h PRN | 10-15 tablets |
| Moderate (colectomy, hysterectomy) | Oxycodone 5 mg Q4-6h PRN | 15-20 tablets |
| Major (Whipple, open aortic repair) | Oxycodone 5-10 mg Q4-6h PRN | 20-30 tablets |

**Mandatory discharge documentation:**
- Non-opioid medications to continue (acetaminophen, ibuprofen scheduled)
- Opioid prescribed: name, dose, quantity, refill policy (no refills for acute surgical pain)
- PDMP checked and documented
- Patient education: opioid storage, disposal (drug take-back), overdose signs
- Expected pain trajectory: "Pain should improve daily; if worsening after POD 3-5, contact our office"
- Follow-up appointment with timeline for reassessment

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the multimodal regimen documented with scheduled non-opioid foundation before any opioid orders?
2. Are opioids ordered as PRN only (no scheduled opioids unless chronic pre-existing use)?
3. Is the daily OME being tracked and a de-escalation target set?
4. Are monitoring parameters (respiratory rate, sedation scale, SpO2) ordered with action thresholds?
5. Is the discharge opioid prescription within the institutional quantity limit with PDMP documentation?

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## Quality Audit

- [ ] Pain assessment tool documented (NRS, CPOT, BPS)
- [ ] Functional pain goals documented (spirometry, ambulation, sleep)
- [ ] Multimodal non-opioid regimen ordered as scheduled (not PRN)
- [ ] Regional anesthesia technique documented (if used)
- [ ] Opioid orders include dose, route, frequency, and indication (NRS threshold)
- [ ] Daily OME calculated and documented
- [ ] OME de-escalation trajectory documented
- [ ] Opioid-tolerant status identified and baseline regimen continued
- [ ] Respiratory monitoring ordered with specific RR and sedation thresholds
- [ ] Naloxone availability verified for PCA patients
- [ ] PDMP checked before discharge opioid prescribing
- [ ] Discharge opioid quantity within institutional guidelines
- [ ] Patient education on opioid safety, storage, and disposal documented
- [ ] Follow-up plan includes pain reassessment timeline

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## Guidelines

1. Non-opioid multimodal agents are the FOUNDATION, not the adjunct — start acetaminophen and NSAIDs scheduled before the patient awakens, and add opioids only for breakthrough.
2. Never order a basal rate on a PCA for opioid-naive patients — this is the leading modifiable risk factor for PCA-related respiratory depression.
3. Track and document daily OME — this is the single most important metric for opioid stewardship and identifies patients at risk for persistent opioid use.
4. Check the state PDMP before every discharge opioid prescription. Document the check.
5. For patients with substance use disorder, involve the Acute Pain Service and addiction medicine (if available) early — do not withhold appropriate analgesia, but implement enhanced monitoring and a structured taper.
6. Gabapentin/pregabalin are effective adjuncts for surgical pain but carry sedation risk, especially combined with opioids in elderly patients — start at the lowest dose and titrate.
7. Set functional pain goals (spirometry, ambulation, sleep) rather than targeting a specific NRS number — an NRS of 4 with full functional recovery is better than an NRS of 0 with oversedation.
8. Educate patients that postoperative pain is expected to improve daily; worsening pain after POD 3-5 should prompt clinical reassessment for complications, not just escalating analgesics.