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Management of acute perioperative pain

Edward R Mariano, MD, MAS
Section Editor
Scott Fishman, MD
Deputy Editor
Marianna Crowley, MD


The goals of perioperative pain management are to relieve suffering, achieve early mobilization after surgery, reduce length of hospital stay, and achieve patient satisfaction. Pain control regimens must take into account medical, psychological, and physical condition; age; level of fear or anxiety; surgical procedure; personal preference; and response to agents given. The optimal strategy for perioperative pain control consists of multimodal therapy to minimize the need for opioids. The overprescribing of opioids has reached a critical level worldwide [1], and surgery may be the trigger for long-term opioid use in many patients [2,3].

This topic will discuss the rationale and therapeutic options for a multimodal approach to control and prevent acute perioperative pain. The management of chronic pain is discussed separately. (See "Evaluation of chronic pain in adults" and "Overview of the treatment of chronic non-cancer pain".)


Perioperative pain results from inflammation caused by tissue trauma (ie, surgical incision, dissection, burns) or direct nerve injury (ie, nerve transection, stretching, or compression) (figure 1) [4]. The patient senses pain through the afferent pain pathway (figure 2), which is the target of various pharmacologic agents.

Tissue trauma releases local inflammatory mediators that can produce augmented sensitivity to stimuli in the area surrounding an injury (hyperalgesia) or misperception of pain to non-noxious stimuli (allodynia) (figure 3). Other mechanisms contributing to hyperalgesia and allodynia include sensitization of the peripheral pain receptors (primary hyperalgesia) and increased excitability of central nervous system neurons (secondary hyperalgesia) [4-6].

Traditionally, acute perioperative pain management has relied solely on opioid medications to target central mechanisms involved in the perception of pain (figure 4). A better approach uses several agents, each acting at different sites of the pain pathway, and is known as multimodal analgesia. This approach reduces the dependence on a single medication and mechanism, and importantly, may reduce or eliminate the need for opioids. Synergy between opioid and nonopioid medications reduces both the overall opioid dose and unwanted opioid-related side effects.


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