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.
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.
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.
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).
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Cite this: Management of Postop Pain in Nontraumatic Emergency Surgery Clinical Practice Guidelines (WSES/GAIS/SIAARTI/AAST, 2022) - Medscape - Sep 29, 2022.