Management of Postop Pain in Nontraumatic Emergency Surgery Clinical Practice Guidelines (WSES/GAIS/SIAARTI/AAST, 2022)

World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST)

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

September 29, 2022

Guidelines for management of postoperative pain in nontraumatic emergency general surgery were published in September 2022 by the World Society of Emergency Surgery (WSES), the Global Alliance for Infection in Surgery (GAIS), the Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and the American Association for the Surgery of Trauma (AAST) in World Journal of Emergency Surgery.[1]

Nonopioid and Opioid Drugs

Opiate usage should be reduced as much as possible. Multimodal analgesia should always be considered; a step-up approach that includes major opiates when necessary should be adopted.

When contraindications are absent, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentinoids are recommended in multimodal analgesia. Acetaminophen given at the start of postoperative analgesia may be superior. Coxibs may be considered if there are no contraindications.

Major opiates are indicated for moderate-to-severe pain that is unresponsive to other drugs and in which regional anesthesia is not indicated.

Initial opioid infusion via intravenous (IV) patient-controlled analgesia (PCA) should be avoided in opioid-naïve patients. If indicated, opiate infusion via IV PCA should be preferred to spinal PCA whenever the IV route is viable.

Route of Drug Administration

Oral administration should be preferred to IV administration whenever feasible. The intramuscular (IM) route should be avoided. Epidural and regional anesthesia is recommended in emergency general surgery whenever it is feasible and does not delay emergency procedures.

Neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine should be avoided.

Perioperative Nerve Block and Local Infiltration

Regional anesthesia is effective in both adults and children. Abdominal-wall block can be considered to have an opioid-sparing effect. Transversus abdominis plane (TAP) block is safe and effective in laparoscopic abdominal surgery; rectus sheath block is a viable alternative.

Local wound infusion is suggested as a component of multimodal analgesia.

Pain Assessment

Periodic assessment of pain with validated systems is mandatory. Observational pain scales are less reliable than patient-reported metrics but should still be applied in noncommunicative patients.

Drug Therapy

Multimodal analgesia is suggested to treat moderate-to-severe pain in (1) patients not amenable to surgical intervention and (2) patients already operated on but not suitable for further interventions. For (2), combination of systemic multimodal analgesia with regional analgesia is suggested. For both (1) and (2), palliation should be considered in order to achieve control of related symptoms (eg, nausea, vomiting, dyspnea, agitation, delirium).

For more information, please go to Local and Regional Anesthesia and Transversus Abdominis Plane Block.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.