current issues in postoperative pain management

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Eur J Anaesthesiol 2016; 33:160–171

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REVIEW

Current issues in postoperat
ive pain management
Narinder Rawal

Postoperative pain has been poorly managed for decades.Recent surveys from USA and Europe do not show any majorimprovement. Persistent postoperative pain is common aftermost surgical procedures, and after thoracotomy and mas-tectomy, about 50% of patients may experience it. Opioidsremain the mainstay of postoperative pain treatment in spiteof strong evidence of their drawbacks. Multimodal analgesictechniques are widely used but new evidence is disappoint-ing. Regional anaesthetic techniques are the most effectivemethods to treat postoperative pain. Current evidencesuggests that epidural analgesia can no longer be con-sidered the ‘gold standard’. Perineural techniques are goodalternatives for major orthopaedic surgery but remain under-used. Infiltrative techniques with or without catheters areuseful for almost all types of surgery. Simple surgeon-deliv-ered local anaesthetic techniques such as wound infiltration,preperitoneal/intraperitoneal administration, transversusabdominis plane block and local infiltration analgesia can

ht © European Society of Anaesthesiology. Un

m the Department of Anaesthesiology and Intensive Care, University Hospital, Ore

rrespondence to Narinder Rawal, Professor, Department of Anaesthesiology and Il: +46 70 6305567; e-mail: [email protected]

65-0215 Copyright � 2016 European Society of Anaesthesiology. All rights reser

play a significant role in improvement of postoperative care,and the last of these has changed orthopaedic practice inmany institutions. Current postoperative pain managementguidelines are generally ‘one size fits all’. It is well known thatpain characteristics such as type, location, intensity andduration vary considerably after different surgical pro-cedures. Procedure-specific postoperative pain manage-ment recommendations are evidence based, and also takeinto consideration the role of anaesthetic and surgical tech-niques, clinical routines and risk–benefit aspects. The role ofacute pain services to improve pain management and out-come is well accepted but implementation seems challen-ging. The need for upgrading the role of surgical ward nursesand collaboration with surgeons to implement enhancedrecovery after surgery protocols with regular audits toimprove postoperative outcome cannot be overstated.

Published online 27 October 2015

Introduction
Pain relief after surgery continues to be a major medical
challenge. Poorly managed postoperative pain may delay

discharge and recovery, and result in the patient’s inability

to participate in rehabilitation programmes, leading to poor

outcomes. Recent advances include better understanding

of pain mechanisms, physiology and pharmacology, pub-

lication of guidelines, establishment of acute pain services

(APSs), initiatives such as ‘pain as the fifth vital sign’ and

availability of new drugs and devices. However, these

advances have not led to any major improvements, and

undertreatment of postoperative pain continues as a con-

siderable problem worldwide.1,2

Prevalence of postoperative pain – stillappalling numbersA leading group of postoperative pain researchers has

commented on the current ‘. . . appalling high rates of

significant postoperative pain’.3 A 2011 report from the

US National Institutes of Health states that more than

80% of patients suffer postoperative pain, with fewer than

50% receiving adequate pain relief.4 US surveys from

1993, 2003 and 2012 have shown that postoperative pain

is common and remains undertreated, and that distri-

bution and quality of perceived pain have remained

largely unchanged.5

A European survey which included 746 hospitals con-

cluded that the management of postoperative pain was

suboptimal. Among the problems identified in this 2008

report were absence of pain assessment in 34% of institu-

tions, absence of documentation in 56% of institutions

and no written protocols in 75% of institutions.6 A simi-

larly disappointing picture emerged from a recent US

survey of 301 hospitals (101 teaching hospitals). There

were no written protocols in 45% of hospitals, and intra-

venous patient-controlled analgesia (PCA) was the most

common method to treat pain. Interestingly, this was

managed by surgeons in 75% of hospitals; nurses were not

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bro, Sweden

ntensive Care, University Hospital, 70132 Orebro, Sweden

ved. DOI:10.1097/EJA.0000000000000366

mailto:[email protected]

http://dx.doi.org/10.1097/EJA.0000000000000366

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Postoperative pain management 161

allowed to adjust PCA in 38% of hospitals, epidurals in

57% of hospitals and perineural catheters in 79% of

hospitals.7

Certain categories of patients are at a greater risk of being

undertreated including the pregnant, the paediatric, the

elderly, the opioid tolerant and the patient undergoing

ambulatory surgery.

Persistent postoperative painPersistent postoperative pain (PPP) is common, causes

disability, lowers quality of life and has economic

implications; it is a major cause of chronic pain and

therefore an important public health problem.8 Severe

PPP affects 2 to 10% of adults undergoing surgery.9

Worldwide, about 235 million patients undergo surgery

annually, and this means that millions of patients suffer

from the consequences of PPP. The reported incidence

of PPP is variable; after some common operations such as

thoracotomy, mastectomy, coronary artery bypass and

hernia repair, the incidence can be 30 to 50%. After limb

amputation, the risk is even higher.10 Over 20 surgical,

psychosocial and patient-related genetic and environ-

mental risk factors have been identified. These include

preoperative factors such as anxiety, depression, impaired

pain modulation, genetic factors, sleep disorders and

catastrophising. In the intraoperative and postoperative

healing phase, the factors to consider are surgical tech-

nique, nerve injury and tissue ischaemia. In the later

postoperative period, the important factors are post-

operative pain hyperalgesia, chemotherapy or radiother-

apy, repeat surgery and a variety of psychosocial

factors.1,8,10,11 No single factor seems to play a dominant

role.

Given the multiplicity of neurotransmitters and pain

pathways involved in the transition from acute to chronic

pain, it is not surprising that there are no definitive

pharmacological interventions to prevent or treat PPP.

It would seem logical that a combination of mechanisms

needs to be targeted by different approaches to inhibit

central sensitisation. Gabapentinoids are considered an

interesting class of drugs because of their analgesic

effects in neuropathic pain as well as their anxiolytic

effects. However, the literature is conflicting. A systema-

tic review of 11 randomised controlled trials (RCTs)

showed that gabapentin decreased the incidence of

PPP,12 whereas a more recent Cochrane review13 and a

meta-analysis 14 dispute this. Of the 11 different analge-

sics evaluated, only intravenous ketamine had a modest

effect.13 A meta-analysis showed that the number needed

to treat for intravenous ketamine versus placebo was 12.

This meta-analysis also reported that reduction of acute

pain intensity may not be linked directly to reduced

prevalence of development of PPP.15 Intravenous keta-

mine may be appropriate in patients undergoing painful

operations, particularly those who are expected to require

large doses of opioids.

yright © European Society of Anaesthesiology. U

Surgeons can play an important role in reducing PPP by

using minimally invasive and nerve-sparing techniques

such as sentinel node biopsy for mastectomy, thereby

avoiding axillary dissection and intercostal nerve damage.

Thoracoscopic techniques spare intercostal nerves and

avoid the use of rib retractors. Intracostal sutures (versus

pericostal sutures) have been shown to be associated with

lower pain scores up to 3 months after thoracotomy.16

At present, one of the most promising strategies to reduce

PPP seems to be the use of regional techniques. A recent

Cochrane review of 23 RCTs showed that epidural

anaesthesia and paravertebral block, may prevent PPP

after thoracotomy and breast cancer surgery in about one

out of every four to five patients treated. The data

consistently favoured regional anaesthesia, and three

studies favoured wound infiltration for hernia repair, iliac

crest harvesting and vasectomy.17

In conclusion, more than 20 years after the first reports of

development of a chronic pain state lasting months or

years after surgery,1 there is no definitive evidence for the

role of any intervention to prevent or treat this complex

entity. Intravenous ketamine may have a modest role.

Regional anaesthesia techniques show some promise, and

should be used more frequently because they also reduce

the need for opioids. An APS may have a role in identify-

ing at-risk patients and in follow-up after they are dis-

charged home.8 Given the very high prevalence, it is time

to include the risk of PPP in preoperative information

routines, particularly for patients at high risk.

Pharmacological management – no majorbreakthroughsOpioid therapyIn spite of the growing awareness of the value of multi-

modal pain management plans, opioid monotherapy

remains the foundation of postsurgical pain therapy. A

recent retrospective review based on more than 300 000

patients across 380 US hospitals showed that about 95%

of surgical patients were treated with opioids.18 Opioids

are widely used because they are highly effective for

relieving moderate-to-severe postoperative pain, do not

have a ceiling effect and are available in a wide variety of

formulations. There is also a long tradition of decades of

opioid use, familiarity with the technique and accumu-

lated experience. However, opioids have many dose-

limiting side-effects that range from bothersome to

life-threatening, including nausea, vomiting, consti-

pation, oversedation, somnolence and respiratory depres-

sion.1,18 Elderly or sleep apnoeic patients, the obese and

smokers are all at increased risk of oversedation and

respiratory depression. Patients may self-limit their

opioid use to reduce opioid side-effects, but this can lead

to inadequate analgesia. Opioid-related adverse events

have been associated with an increase in overall cost,

length of stay and even decreased survival during in-

hospital resuscitation.19 However, these developments

nauthorized reproduction of this article is prohibited.Eur J Anaesthesiol 2016; 33:160–171

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162 Rawal

have not resulted in reduced use of opioids. Indeed, the

use of opioids has increased in recent years, both for

inpatients1 and outpatients.20

The introduction of new analgesic drugs has been incred-

ibly slow and hardly any new drugs have come to the

market in the last 50 years.21 Postoperative pain manage-

ment is still based on the use of traditional opioids,

paracetamol, NSAIDs and local anaesthetics. The main

innovations have been in the use of older drugs in new

delivery systems and routes of administration such as

transdermal (fentanyl, buprenorphine), intranasal (fenta-

nyl, sufentanil, diamorphine, ketamine), oral transmuco-

sal (fentanyl) and sublingual (buprenorphine, sufentanil).

The other innovations have been in the development of

extended-release local anaesthetics and epidural mor-

phine (now withdrawn from the market). A transdermal

system using iontophoresis to allow rapid transfer of

fentanyl to the circulation allowed the patient to self-

administer 40 mg of fentanyl with a 10-min lockout time.

This transdermal PCA system was shown to provide

comparable analgesia to that seen with intravenous mor-

phine PCA.22,23 This ‘needle-free PCA system’ was

approved by the US and European regulatory agencies

but was voluntarily withdrawn because of technical pro-

blems. The impressive device is undergoing further

development and might re-emerge.

Multimodal analgesia – much rhetoric, disappointingevidenceThe concurrent use of more than one class of analgesic

drug or technique to target different mechanisms of

analgesia has been advocated to improve analgesia

through additive or synergistic effects while reducing

opioid-induced side-effects.1,24 In general, the main

aim is to reduce or eliminate the use of strong opioids

which are recognised to have many disadvantages and

unacceptable side-effects. A large number of nonopioids

are available including paracetamol, NSAIDs, local

anaesthetics, gabapentinoids, ketamine and glucocorti-

coids. Although the concept of multimodal analgesia is

widely accepted, the literature on the possible harmful

effects of combining analgesics is poorly studied. There is

also surprisingly little evidence to show that using an

arsenal of different analgesics is better than more simple

regimens.25 Meta-analyses have shown beneficial analge-

sic effects when opioids are combined with nonopioid

drugs such as paracetamol, NSAIDs, a2-delta modulators

(gabapentin, pregabalin), a2-agonists (clonidine, dexme-

detomidine), ketamine and magnesium. However, with

the exception of a combination of paracetamol and

NSAIDs, there is no meta-analysis of combinations of

different nonopioids. There is hardly any literature on a

combination of three or more analgesics, which is a

common clinical practice.26 In general, research into

multimodal analgesia has not shown a consistent level

of success because of a large number of variables in

ight © European Society of Anaesthesiology. UnEur J Anaesthesiol 2016; 33:160–171

available studies. These include a variety of analgesics

or analgesic modalities and different doses and drug

combinations, making it difficult to draw relevant con-

clusions.

A recent review of systematic reviews and meta-analyses

showed that the 24-h morphine-sparing effects of non-

opioids as monotherapy are rather modest.27 A systematic

review of adverse effects of nonopioids found that para-

cetamol was associated with trivial adverse effects but the

use of NSAIDs was associated with anastomotic leakage.

Gabapentinoids, especially pregabalin, were associated

with an increased risk of sedation, dizziness and visual

disturbances.14,27,28 There is also increasing concern

regarding substance misuse and abuse of gabapentin29

and pregabalin.30

The concept of multimodal analgesia for managing post-

operative pain was introduced by Kehlet and Dahl in

1993.24 Over the years, they have repeatedly promoted it

in multiple publications.31 However, the implementation

of such techniques in routine clinical practice is appar-

ently challenging.32 A 2012 report from 12 surgical

departments from their own institution showed surpris-

ingly disappointing results. Their data indicated that 75%

of patients were treated with opioids as first choice during

the first three postoperative days and that doses of non-

opioids were inadequate. The quality of pain manage-

ment was unclear because pain scores were not recorded

in most patients. The authors concluded that ‘. . . the use

of multimodal opioid-sparing pain treatment was subop-

timal’.32 In 2006, a group of US experts reviewed the

literature and concluded that there was little evidence of

any benefits of multimodal analgesia, except for the

combination of paracetamol and NSAIDs.33 Eight years

later, a review by one of the two originators of the concept

not only came to a similar disappointing conclusion but

also noted that many patients receiving combination

analgesia may be at increased risk of adverse events.34

So we seem to be back to square one after 20 years of

multimodal analgesia. This does not mean that we should

stop combining nonopioids because the goal of avoiding

strong opioids, though daunting, is still valid. It is time to

shift our focus to evaluate the role of simple, local

anaesthetic-based infiltrative techniques as a primary

component of multimodal analgesia.

The two safest nonopioids available to us are paracetamol

and local anaesthetics. The latter seem to be underused

as an important component of multimodal regimens.

Based on our standard protocol since 1991, every surgical

patient at our hospital receives a combination of para-

cetamol and wound infiltration with bupivacaine (by the

surgeon at the end of surgery).35 Other regional tech-

niques, NSAIDs, opioids or intravenous morphine PCA

are added as necessary. Nearly 25 years of this multi-

modal regimen, in tens of thousands of patients, and

results of repeated audits testify to the remarkable safety


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of this regimen (see ‘Acute Pain Services’ below). Wound

infiltration techniques are now recommended as part of

multimodal regimens by several national and inter-

national societies such as the American Society of

Anesthesiologists36 and the Australian and New Zealand

College of Anaesthetists.37

In conclusion, in spite of major drawbacks with the use of

opioids, we have been unable to replace them as the

mainstay of treatment of moderate to severe postopera-

tive pain. In spite of much rhetoric, current evidence

suggests that the advantages of combining paracetamol

and NSAIDs are rather modest, the benefits of combining

other nonopioids overrated, the side-effects generally

ignored and the role of combining more than two non-

opioids largely unknown. Future studies need to address

the role of surgeon-delivered local anaesthetic-based

infiltrative techniques as a first-line component of

multimodal analgesia.

Regional anaesthesia techniquesIn recent years, there has been an increase in the use of

regional techniques for surgery and perioperative pain

management, particularly in patients undergoing obste-

tric, orthopaedic or paediatric surgery.38 By stopping pain

transmission, regional techniques with local anaesthetics

can provide excellent pain control. Multiple routes of

local anaesthetic administration are available. The fol-

lowing is a brief summary of the current status of regional

techniques for postoperative pain.

Epidural techniques – ‘gold standard’ no more!Epidural analgesia is a widely used technique to provide

excellent postoperative pain after major surgery. Several

earlier meta-analyses have shown that the use of the

technique is also associated with other benefits such as

reduced cardiovascular, pulmonary and gastrointestinal

morbidity. Some studies have also shown reduced

mortality. For decades, epidural techniques have been

considered the ‘gold standard’ for pain management after

major surgery. However, more rigorous evaluation of

previous data and newer meta-analyses show less optim-

istic results. Several meta-analyses and data from more

robust trials in patients undergoing major surgery such as

aortic, colonic or gastric procedures failed to show any

reduction in mortality with perioperative epidural analge-

sia compared with general anaesthesia and systemic

opioids.39 The authors of a meta-analysis of 28 RCTs

with more than 2700 cardiac surgery patients did not

recommend epidural analgesia because of its poor risk–

benefit ratio.40 The protective effect of epidural analgesia

against pneumonia after abdominal or thoracic surgery

has decreased over the last 35 years because of an overall

reduction in baseline risk because of changes in surgical

routines including early postoperative mobilisation and

active physiotherapy.41 Furthermore, the debate about

the pulmonary benefits of epidural analgesia is becoming

less relevant with increasing use of endoscopic surgical


procedures instead of open ones. A review has questioned

the use of epidural analgesia in abdominal surgery.42

There are several meta-analyses showing that the far less

invasive intravenous lidocaine infusion is associated with

many benefits in abdominal surgery such as reduced

duration of ileus, decreased pain scores, lower risk of

postoperative nausea and vomiting (PONV) and shorter

hospital stay.43 There are three meta-analyses showing

that an even simpler and safer evidence-based method to

prevent or ameliorate postoperative ileus is the use of the

humble chewing gum.39,44 Chewing gum therapy is part

of enhanced recovery after surgery (ERAS) protocols in

many institutions.

Epidural analgesia has been promoted as an essential

component of ERAS protocols for colorectal surgery.

Perioperative clinical pathways facilitate postoperative

rehabilitation by optimising analgesia, early oral intake

and ambulation and avoidance of fluid overload.45 ERAS

programmes with a coordinated team approach in imple-

menting the various elements of such protocols have

been shown to reduce morbidity and hospitalisation

times.45,46 Such pathways have been promoted for many

surgical procedures, but those for colorectal surgery are

the most widely studied. However, it remains difficult to

demonstrate supporting evidence for individual com-

ponents.39,45,47 On account of the mediocre to poor

quality of studies, the authors of a Cochrane review

did not recommend ‘fast-track’ (ERAS) as a standard

of care.48 At present, there is no evidence that epidural

analgesia is an essential component of ERAS proto-

cols.39,45 Thus, it appears that the success of ERAS

programmes for colorectal surgery is primarily a result

of a structured, protocol-based approach and a modified

attitude towards postoperative rehabilitation goals. Pain

relief is important, but its role seems to be secondary,

particularly in the increasingly common laparoscopic

procedures. There is no convincing evidence that an

epidural technique is essential or any better than simple

local anaesthetic-based infiltrative techniques.39 The

procedure-specific postoperative pain management

(PROSPECT) group does not recommend epidural

analgesia for the increasingly more common laparoscopic

colonic surgery. Neither is epidural analgesia recom-

mended as the first choice for most other abdominal

procedures including laparoscopic cholecystectomy, hys-

terectomy, prostatectomy and caesarean section.49

The controversy about the role of epidural analgesia in

influencing postoperative morbidity and mortality has

resurfaced with the publication of four new reports50–53

with meta-analyses reporting both reduced50 and

increased51,52 morbidity. A literature review concluded

that epidural analgesia can no longer be considered as a

standard of care after routine surgery.53

Several studies (almost all retrospective) and editorials

have reported that the risks of severe neurological


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Table 1 Reasons for the diminishing role of epidural analgesia inpostoperative pain management

Re-evaluation of previous data and newer metaanalyses show less impressiveoutcome results regarding postoperative mortality and morbidity

Widespread adoption of prophylactic anticoagulant techniques by surgeons haseliminated the DVT-reducing benefits of EA while creating practical obstaclesfor EA catheter management

EA increasingly unnecessary because of change from open to minimally invasiveand endoscopic surgical techniques – also, many previous inpatientoperations are now day-case or overnight stay procedures

Benefits of EA versus systemic opioids for postoperative pulmonarycomplications have decreased over the years because of overallimprovements in postoperative rehabilitation and physiotherapy routines

EA failure rates can be very high (30 to 47%). Most anaesthesiologists unawareof their failure rates (day 1, day 2, day 3) because audits are not performed inthe vast majority of institutions

Risk of side-effects such as hypotension and urinary retention is relatively high,hindering postoperative mobilisation

Monitoring requirements are labour intensive (at many institutions patientsnursed in high-dependency units or ICU because of shortage of trainedpersonnel)

Availability of several equally effective and far less invasive regional anaesthesiatechniques (see text)

Risks of serious complications (including death) greater than previously believedNo convincing cost-effectiveness data in spite of years of EA useLitigation concerns because of risks of severe neurological complications

DVT, deep vein thrombosis; EA, epidural analgesia.

complications of epidural analgesia are higher than pre-

viously believed.39,54,55 A recent closed claims analysis

from Finland reported six deaths over a period of 9 years.

The risk of neuraxial haematoma was far greater with

epidural analgesia (1 : 26 400) than spinal anaesthesia

(1 : 775 000).56 A much higher risk was noted in a recent

audit report of over 35 000 patients from the USA: cardiac

arrest 1 : 5000, epidural abscess 1:27 000 and epidural

haematoma 1 : 5400.57

In making the decision to use epidural analgesia, the

failure rate has to be taken into consideration. This can

vary from 32% to about 50%.39,53 To be considered

successful, epidurals need to facilitate the early post-

operative mobilisation (‘walking epidural’) that is

required for ERAS protocols and function effectively

for the entire duration of treatment (typically 48 to

72 h). This has to be balanced against the costs of

labour-intensive monitoring requirements; in many hos-

pitals, such patients are still nursed in high-dependency

units or ICUs. Only institutional audits can guide the

clinicians as to whether their epidural analgesia risk–

benefit ratios are acceptable.

Based on current evidence, the main indications for

epidural analgesia could be high-risk patients scheduled

for open major surgery; extensive surgery involving large

areas of the body; centres wherein peripheral regional

techniques have not been introduced and possible future

new indications such as anticancer benefits and preven-

tion of chronic postoperative pain. For labour analgesia,

epidural analgesia remains the ‘gold standard’.

In conclusion, the advantages of epidural analgesia are

not as impressive as formerly believed and the risks are

greater than estimated in the past. Epidural analgesia

may have a role in high-risk patients undergoing open

major vascular or cardiac surgery. In general, the role of

epidural techniques has been decreasing in recent years

for reasons shown in Table 1. Regional anaesthesia

techniques provide the most effective postoperative pain

relief. The risk–benefit equation has shifted away from

epidural analgesia and in favour of less invasive but

equally effective and safer regional anaesthesia tech-

niques (Fig. 1). Epidural analgesia can no longer be

considered the ‘gold standard’ as a routine method for

the management of postoperative pain. The continued

use of epidural analgesia at any institution can only be

justified by results from its own audits. Very few institu-

tions perform regular audits. Consequently, the success

rates of epidural analgesia in each institution remain

largely unknown.

Perineural techniques – effective but underusedIt is well established that perineural techniques are

highly effective and are superior to intravenous opioid

techniques.58 A large number of nerve block techniques

have been reported for almost every part of the body. A


limitation of the single-injection peripheral nerve block is

the relatively short duration of analgesia. Catheter tech-

niques allow prolonged analgesia. Regardless of the

location of the catheter, continuous perineural tech-

niques are opioid sparing and associated with a reduced

risk of opioid-related side-effects such as PONV and

sedation.58 As these techniques may be as effective as

epidural analgesia but are less invasive with a better

adverse effect profile, they are recommended as the first

choice for major orthopaedic surgical procedures such as

hip or knee replacement surgery.49,59 Several meta-

analyses conclude that peripheral blocks such as femoral

and sciatic are superior to epidural analgesia for knee

replacement.59,60 Systematic reviews have shown that

paravertebral blocks may be as effective as epidural

analgesia after thoracotomy but with a lower risk of

adverse effects such as hypotension, urinary retention,

PONV and pulmonary complications.49,61 Correct identi-

fication of nerves is technically challenging, with an

average failure rate of about 20%.62 Ultrasound-guided

blocks have improved the success rates but have not

eliminated the problem. In some technically challenging

blocks such as 3-in-1 block, catheters may be in an

incorrect position in 60 to 77% of patients.62,63 In

addition, peripheral blocks may be associated with com-

plications such as nerve injury, catheter migration into

blood vessels resulting in local anaesthetic toxicity, pneu-

mothorax despite ultrasound guidance and unintentional

spread of block epidurally or intrathecally. These risks

depend on the site of the block, and fortunately they are

not common. There is an ongoing debate about the risk of

falls due to quadriceps weakness after femoral nerve

block for pain management after total knee replacement.

In recent years, adductor canal block (ACB) performed at


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Fig. 1

Before 1980s - GA + i.m. opioids - i.v. opioid PCA after 1990s

1980s - Neuraxial blocks - epidural - spinal opioids - CSE

1990s - Peripheral n. blocks - femoral - femoral-sciatic - lumbar plexus

Currently* - LIA

- Femoral - ACB - Ultra long-acting LA?

*Within multimodal analgesia strategies and ERAS pathways

An example of how postoperative analgesic techniques for knee surgery have evolved over time. Total knee replacement is a common surgicalprocedure and generally considered very painful. ACB, adductor canal block; CSE, combined spinal and epidural; ERAS, enhanced recovery aftersurgery; LA, local anaesthetic; LIA, local infiltration analgesia.

the level of the mid-thigh has been increasingly advo-

cated64 to eliminate the problem (Fig. 1).

Nevertheless, most anaesthesiologists have not been able

to introduce these techniques into their clinical routines.

Studies have shown that the use of perineural techniques

to treat postoperative pain is very low in the USA, Europe

and elsewhere.62,65,66 Data from the US National Center

for Health Statistics showed that regional anaesthesia was

used in only 8% of ambulatory cases.66 A French survey

showed that less than 5% of inpatients received post-

operative analgesia by peripheral nerve blocks and a

surprisingly low 1.5% received epidural analgesia.65 A

recent USA database report from over 400 acute care

hospitals with 191 570 patients undergoing total knee

arthroplasty (TKA) showed that only 12.1% of patients

received postoperative analgesia with a peripheral nerve

block.67

In conclusion, there is convincing evidence about the

efficacy and feasibility of peripheral nerve blocks to

manage pain. Catheter techniques can prolong the

duration of analgesia for an unlimited time. Ultra-

sound-guided blocks have reduced failure rates and

encouraged more anaesthesiologists to use such tech-

niques. However, routine use of these techniques still

remains restricted to a relatively small percentage of

institutions. In ambulatory surgery patients, perineural


catheter techniques for pain management will most likely

be restricted to an even smaller number of institutions

because of safety concerns in the medically unsupervised

patient at home.

Infiltrative techniques – growing andevolving, the way forwardEpidural and perineural catheter techniques are very

effective in controlling postoperative pain, but these

techniques require the expertise of an anaesthesiologist,

are associated with technical failures and catheter man-

agement can be labour intensive. In recent years, several

infiltrative techniques have received increasing attention

as simple and less invasive local anaesthesia-based altern-

atives either alone or as part of multimodal regimens to

treat postoperative pain. These techniques can be single

dose or catheter techniques and are usually surgeon

administered.

The ease of use and safety of local anaesthetics has been

well recognised for decades. Collectively, they serve as

one of the most important classes of drugs in periopera-

tive pain management. The main advantage of local

anaesthetics is that they directly act on the tissue to

which they are applied and do not have the adverse

effects of opioids. Consequently, they should be evalu-

ated further as component of multimodal techniques.


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166 Rawal

Simple surgeon-delivered techniques such as wound

infiltration, preperitoneal/intraperitoneal administration,

transversus abdominis plane (TAP) block and local infil-

tration analgesia (LIA) as single administration or with

catheters placed under direct vision and in collaboration

with anaesthesiologists and the APS can play a significant

role in improvement of postoperative care. A meta-

analysis concluded that even a simple instillation of local

anaesthetic in the peritoneal cavity can provide effective

analgesia, albeit for only about 6 h postoperatively after

gynaecological laparoscopy.68 As some of these tech-

niques are relatively new and others still evolving, there

is a need for further studies to address the many

unanswered questions.

Wound infiltration and catheter infusion techniques –surprisingly effectiveDirect application of local anaesthetics to the surgical site

is a rational approach to block pain transmission from

afferent nociceptive barrage. Local anaesthetics also

inhibit the inflammatory response to injury and may,

therefore, reduce the risk of hyperalgesia. The technique

is simple and inexpensive, and has a good safety profile

with few side-effects. It can be used alone or as part of

multimodal regimens depending on the severity of post-

operative pain. Surgeon-administered wound infiltration

at the end of surgery is a simple and effective technique,

and is used routinely in many hospitals.35,69

Wound catheter infusions (WCIs) should preferably be

called surgical-site catheter infusions because the

catheters are not always strictly in the surgical wound.

The technique involves catheters placed in a number of

sites including subcutaneous, subfascial, preperitoneal,

intraperitoneal, subacromial, intraosseous, intra-articular

and others.62 A systematic review of 44 RCTs showed

that WCI techniques provided effective pain relief at rest

and movement, and reduced opioid use and increased

patient satisfaction, with some limited evidence for

shorter hospital stay. No major adverse effects were

reported, and the rates of wound infection were very

low (0.7%) and similar to those in the control group. WCI

was effective across a variety of surgical procedures

(abdominal, cardiothoracic, orthopaedic and others).70

A more recent meta-analysis of 14 RCTs (756 patients)

focused on ropivacaine for WCI, the authors noting

consistent evidence of effective analgesia and opioid

sparing in a wide range of surgical procedures such as

total knee or hip replacement, and major abdominal and

cardiac surgery.71 Similarly, a meta-analysis of infiltrative

techniques (WCI, TAP, intraperitoneal) versus placebo

for routine analgesia for colorectal surgery concluded that

the infiltrative techniques were associated with lower

pain scores, reduction of opioid requirements, shorter

length of stay and no increase in complications.72

It must be emphasised that all studies with wound

infiltration are not positive. A Cochrane review concluded


that the beneficial effects of wound infiltration were

modest in patients undergoing laparoscopic cholecystect-

omy.73 Meta-analysis has also shown modest benefits of

wound infiltration in patients undergoing mastectomy

and those undergoing spinal surgery.74

Local infiltration analgesia – game changer inorthopaedic practiceThe LIA technique was introduced by Kerr and Kohan

mainly for controlling pain after total hip arthroplasty

(THA) and TKA.75 In spite of its name, the original LIA

technique is not just infiltration of local anaesthetic but a

multicomponent optimisation package. In addition to

infiltration with a mixture of ropivacaine, adrenaline

and ketolorac into all tissues subject to surgical trauma,

it includes extensive preoperative patient education,

minimally invasive surgery, accelerated postoperative

rehabilitation and structured follow-up care. This is

combined with an intra-articular catheter for analgesic

top-ups, allowing the blockade to last as long as 36 h. Ice

packs and compression bandages are also a part of the

technique. Surgery is performed under spinal anaesthe-

sia. Thrombosis prophylaxis consists of aspirin only.

Postoperative analgesia is provided by paracetamol and

ibuprofen with morphine as a rescue analgesic. Post-

operative mobilisation is started about 4 h after surgery.

In a case series of 325 patients, more than half of those

undergoing surgery could be discharged on the first post-

operative day and most of the remainder were discharged

on the following day. Postoperative pain scores were low

and there were very few thromboembolic complications.

The details of the infiltration technique and the other

components of LIA technique are described elsewhere.75

The LIA technique has achieved widespread acceptance

by orthopaedic surgeons, especially in the Scandinavian

countries, UK, Australia and some other countries.47

Much of the literature is from Denmark, Sweden, Nor-

way, UK, USA and Australia, although none of these

studies has been able to replicate the 1 to 3 days discharge

times reported by Kerr and Kohan. In general, the dis-

charge times are in the range of 3 to 5 days, which is still

much shorter than the pre-LIA hospitalisation times of 6

to 10 days.47 The 2014 report of the Swedish Knee

Arthroplasty Register showed that almost every patient

(97.3%) received LIA for TKA in 2013. However, the

intra-articular catheter was used in only 25.6% of

patients.76

The LIA technique has shown favourable results when

compared with traditional methods of pain relief such as

epidural analgesia77–79 and intrathecal morphine80–82 for

both THA and TKA, and also with femoral nerve block

for TKA.83,84 In comparison with epidural for TKA, LIA

was not only more effective but was also associated with

superior knee function, lower cumulative morphine dose,

faster mobilisation and shorter hospital stay.78,79 LIA with

a catheter for TKA was not only associated with similar


Cop


pain scores as with epidural, but also the opioid con-

sumption was reduced and hospital stay was 2 days

shorter in the LIA group.79

A literature review concluded that LIA may be useful for

TKA but not for THA if nonopioid multimodal analgesia

is used.85 However, no evidence was provided to support

this claim. Furthermore, another systematic review of

LIA for THA disagreed and concluded that the tech-

nique was an effective method for THA.86 Two editorials

concluded that LIA for TKA is promising but that further

studies are necessary.69,87

Analgesia for TKA is a good example of how regional

techniques have evolved in recent years. As shown in

Fig. 1, the femoral block was shown first to be an effective

alternative to epidural analgesia49,59 and now there is

increasing evidence that ACB with LIA may be an

effective alternative to femoral block within the frame-

work of ERAS programmes for TKA.64,88,89 LIA was

associated with effective analgesia, improved ambulation

and ability to climb stairs. Combining ACB with LIA was

associated with further increases in ambulation and more

rapid discharge home.88

In conclusion, LIA is a major recent development in

lower extremity joint replacement surgery. In some

institutions, it has been a game changer. In Sweden,

almost every TKA is performed in association with a

LIA technique. Although controlled trials are necessary

to address the many unanswered questions such as the

role of intra-articular catheters and the most appropriate

drug combinations, the technique is here to stay. The

results of ongoing studies with ultra long-acting local

anaesthetics are eagerly awaited.

Intraperitoneal local anaesthetics for abdominal surgery– site of catheter placement may be keyIn a meta-analysis of 30 RCTs, intraperitoneal use of local

anaesthetic in laparoscopic cholecystectomy was shown

to reduce pain, opioid use and the need for rescue

analgesia.90 Literature is now appearing in which WCI

has been compared with other regional techniques. A

meta-analysis of nine RCTs compared WCI with epidural

analgesia in abdominal surgery including liver resection,

colorectal and aortic aneurysm repair concluded that WCI

was associated with comparable pain scores both at rest

and during movement up to 48 h, and with less urinary

retention.91 With increasing published literature, certain

aspects of WCI are becoming clearer. For example, the

importance of catheter positioning was demonstrated in

two studies in patients undergoing open colorectal

surgery. Ropivacaine infusion through a preperitoneally

placed catheter provided effective analgesia, less PONV

and accelerated postoperative recovery.92–94 The tech-

nique has been demonstrated to be superior to epidural

analgesia in terms of analgesia and reduction of hospital

stay.93,94 For caesarean section, the most appropriate


position is subfascial rather than subcutaneous and in

this position, WCI was as effective as epidural analgesia95

or better.96 This catheter placement is recommended by

the PROSPECT group.49

Transversus abdominis plane blocks – increasingevidence of efficacyOwing to the ease of administration and efficacy, TAP

infiltration has been used successfully in bowel surgery,

appendicectomy, hernia repair, umbilical surgery and

gynaecological surgery.97 There is a substantial quantity

of safety and efficacy data which has allowed several

meta-analyses98–100 and a Cochrane review.101 Another

meta-analysis has shown TAP block to be effective for

pain after caesarean section,102 and it is also recom-

mended by the PROSPECT group.49

Current management guidelines are ‘one sizefits all’ – need for procedure-specificrecommendationsAll pain management guidelines advocate generalised

‘one size fits all’ recommendations for the use of analgesic

drugs and techniques. Such guidelines are derived from

different surgical procedures with varying pain charac-

teristics such as type (visceral versus somatic), location,

intensity and duration. The efficacy of an analgesic can

vary depending on a surgical procedure.103 Also, even

similar high pain intensities may be associated with

widely different postoperative morbidity, for example

dental extraction pain versus open thoracotomy or upper

abdominal surgery, the latter procedures are associated

with considerable pulmonary dysfunction.26 In clinical

practice, it is well recognised that there are clear differ-

ences in perception of pain intensity and its con-

sequences across different surgical procedures, for

example thoracotomy versus hysterectomy, or knee

replacement versus hip replacement. Furthermore, the

consequences of surgical technique (open versus endo-

scopic surgery) on postoperative pain and morbidity will

influence the choice of analgesic technique and its risk–

benefit ratio. For example, although epidural analgesia is

very effective for analgesia, it may not have risk–benefit

advantages in thoracoscopic versus thoracotomy and

laparoscopic versus laparotomy procedures. Thus, there

is a need for surgical procedure-specific recommen-

dations.

PROSPECT guidelines are such a source of evidence-

based, procedure-specific recommendations from an

international group of anaesthesiologists and surgeons.

The PROSPECT recommendations are based on sys-

tematic reviews of the literature for a particular surgical

procedure and include randomised studies that evaluate

the role of analgesic drugs and techniques and also the

role of anaesthetic and surgical techniques on postopera-

tive pain. The recommendations also take into consider-

ation clinical routines and risk–benefit aspects. For


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168 Rawal

Table 2 RequirementsM for establishing an organised Acute PainService (APS) team

Designated personnel responsible for 24-h serviceRegular pain assessment at rest and movement and maintaining scores below

predetermined thresholdDocumentation of pain scores before and after interventionDocumentation of side-effectsActive cooperation with surgeons to implement analgesic protocols as part of

ERAS programmes to achieve preset goals for postoperative rehabilitationOngoing teaching programmes for ward nurses (drugs and modalities used,

‘standard orders’, PCA pump programming, regional anaesthesia cathetertechniques, recognition and management of adverse effects, monitoringroutines)

Patient education regarding their right to good analgesia and treatment optionsOngoing prospective data collection system for regular audits of risk–benefit of

analgesic techniques and patient-related quality of life outcomesPolicies and procedures for continuous quality improvement

ERAS, enhanced recovery after surgery; PCA, patient-controlled analgesia.M Irrespective of the APS model selected, these are considered to be the essentialrequirements (see text for details).

example, the PROSPECT group does not recommend

epidural analgesia as first-line treatment for a number of

surgical procedures (laparoscopic cholecystectomy, hys-

terectomy, laparoscopic colorectal surgery, THA, TKA,

caesarean section) in spite of its documented analgesic

efficacy in all these procedures.49 Readers are presented

with algorithms and different alternatives to help with

clinical decision making. Implementation of procedure-

specific protocols has been shown to be associated with

significant improvement in pain management.104

PROSPECT recommendations are freely available

online (www.postoppain.org). At present, the following

procedures are online: cholecystectomy; hip replace-

ment; knee replacement; thoracotomy; hysterectomy;

prostatectomy; inguinal hernia surgery; haemorrhoidect-

omy; and mastectomy. The latest procedure to go online

is caesarean section. Among the evidence-based (Level

of Evidence 1, Grade of Recommendation A) recommen-

dations are preoperative gabapentin, Joel-Cohen and

similar transverse incisions (superior to the commonly

used Pfannenstiel incision), nonclosure of peritoneum,

infiltrative techniques such as wound infiltration includ-

ing WCI, iliohypogastric and ilioinguinal blocks, and

TAP block. This again illustrates that the PROSPECT

group also evaluates the role of surgical techniques in

improving postoperative pain. It is proposed that 15 to 20

of the most common surgical procedures will be included.

The recommendations are updated regularly. At present,

PROSPECT is funded and administered by a grant from

the European Society of Regional Anaesthesia and

Pain Therapy.

Acute pain services still ‘work in progress’25 years onThe establishment of an Acute Pain Service has been

accepted as an important tool in the improvement of

postoperative pain management on surgical wards and in

providing safe analgesia with the use of more advanced

techniques such as intravenous opioid PCA, epidural

analgesia and other regional techniques. APS with a

multidisciplinary team approach has received widespread

formal acceptance from national and international organ-

isations.105

It is generally accepted that the problem of undertreated

postoperative pain is best addressed by having an appro-

priate APS organisation. Worldwide, the number of hos-

pitals with an APS seems to be increasing.106 However, a

prevalence of APSs does not mean much in the absence of

established standards for structure and function of an

APS.107 There is evidence that many APSs provide only

a token service because of financial constraints and low

priority.106 A literature review concluded that most APSs

worldwide did not meet basic quality criteria, defined as

regular recording of pain scores at least once a day, written

protocols, dedicated personnel and policies for pain man-

agement during nights and weekends (Table 2).107 In


Norway and Denmark, the APS numbers have decreased

in recent years, apparently because of increasing imple-

mentation of ERAS programmes. An editorial made a

connection between this reduction in APSs with increased

deaths because of opioid overdose on Norwegian surgical

wards and concluded that APSs and ERAS programmes are

not mutually exclusive and that ERAS programmes should

complement, not replace, APSs.108

Various APS models, with significant differences in struc-

ture and function, have been reported.2 The main

examples include the model described above with 24-h

cover by an anaesthesiologist,2,107 and a ‘low-cost’

specialist nurse-based APS supervised by anaesthesiolo-

gists.35,109 A literature review showed that physician-

based APSs were more common than the nurse-based

APSs.2 Whichever the model selected, an APS should

have a collaborative interdisciplinary approach to mana-

ging postoperative pain. Table 2 shows the requirements

that are generally accepted for a good APS.2,107,110 It is

beyond the scope of this review to debate the pros and

cons of the APS models and how to implement APSs;

these have been addressed elsewhere.109 In any model of

an APS, the role of ward nurses needs to be upgraded if

postoperative pain management is to improve on surgical

wards. Even today, in most institutions and countries,

ward nurses are not allowed to administer opioids through

intravenous lines or local anaesthetics through epidural or

perineural catheters. A 2012 US survey of APSs in 301

hospitals showed that PCA was the most common

method to treat pain and was managed by surgeons in

75% of hospitals. Notably, ward nurses were not allowed

to adjust PCA in 38% of hospitals, epidural analgesia in

57% of hospitals and perineural techniques in 79% of

hospitals.7 Similar disappointing results were reported

from European surveys.6 There is very little information

from low-resource countries, and it is probably even more

disappointing. In physician-based APSs, surgical ward

nurses are required to call the APS anaesthesiologist


http://www.postoppain.org/

Cop


every time the patient needs dose adjustments for PCA or

epidural. The patient remains in pain until the physician

arrives, and it is not uncommon that this physician is

relatively inexperienced.110 This system seems time-

consuming, cost-ineffective and inhumane.

Specialist nurse-based, anaesthesiologist-supervised APS

models which cover all patients undergoing surgery (not

just those requiring hi-tech services) address the above

issues by allowing ward nurses to administer intravenous

opioids on demand, programme PCA pumps and adjust

PCA, epidural and perineural techniques as necessary.

Details of this model, including the responsibilities of the

APS anaesthesiologist, APS nurses, ‘section anaesthesiol-

ogist’, surgeon, ward nurse and ‘pain representative’

nurse and surgeon on each ward are described else-

where.108–110 Since the implementation of this model

at our hospital in 1991 and based on audit results, many

changes have taken place over the years. Some of the key

changes have been the change from intramuscular or

subcutaneous to titrated doses of intravenous morphine

administered by ward nurses on every surgical ward;

patient information brochures in 16 languages and video;

regular pain assessment at rest and on movement (every

3 h in awake patients) and documentation of pain scores;

pain assessment tool changed to numerical rating scale

from visual analogue scale; increase from one to three

APS nurses (two of these part time) although the total

number of operations decreased gradually from 20 000 to

about 15 000 per year; annual audit feedback to surgeons

and ward nurses; epidural PCA mode instead of continu-

ous infusion to allow better mobilisation with ‘walking

epidural’; modified analgesic routines to adapt to surgical

ERAS protocols; increased use of perineural techniques

on surgical wards; electronic recording of pain scores; and

the use of hand-held computers by APS nurses to pro-

spectively collect audit data and joining the PAIN OUT

international database for benchmarking of our APS.111

The general principles of this APS model have been

recommended for Swedish hospitals by the Swedish

Medical Association (Svenska Lakaresallskapet) in

2001112 and have also been implemented in several other

countries.2,109,113

This ‘office hours only’ APS nurse-based model does

not provide direct hands-on patient care, nor does it

provide out of hours cover. This model is a resource for

education and training and promotion of good clinical

practice. It relies on the on-call anaesthesiologist being

consulted during nights and weekends. The number of

times these anaesthesiologists are consulted has

decreased over the years; at present, this only happens

occasionally.

In conclusion, it is increasingly clear that the decades-old

problem of undertreated postoperative pain is not

because of lack of effective drugs or techniques but to

a lack of an organised, multidisciplinary approach (APS)


which uses existing treatments. Irrespective of the APS

model, teaching programmes to upgrade the role of ward

nurses, standardised protocols and regular audits are

necessary to address the problem. The role of the last

of these to improve outcomes cannot be overstated.

Acknowledgements relating to this articleAssistance with the review: none.

Financial support and sponsorship: none.

Conflicts of interest: none.

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http://www.anzca.edu.au/resources/college-publications/pdfs/Acute%20Pain%20Management/books-and-publications/acutepain.pdf

http://www.anzca.edu.au/resources/college-publications/pdfs/Acute%20Pain%20Management/books-and-publications/acutepain.pdf

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