Procedure-specific pain management: the road to improve postsurgical pain management?

780 April 2013 T benefits of optimal pain management are well recognized. Nevertheless, treatment of postoperative pain continues to be a major challenge and inadequate postoperative pain relief remains disturbingly high.1,2 This is also demonstrated in a large, comprehensive, prospective cohort study from Germany by Gerbershagen et al.3 published in this issue of ANEstHEsioloGy. one of the reasons for suboptimal pain management may be related to inadequate or improper application of available analgesic therapies, probably due to the significant amount of new and conflicting information that is increasingly available, and continuing traditional use of opioids instead of multimodal opioidsparing analgesia.2,3 several studies have reported an increased incidence of opioidrelated adverse events,4,5 since the Joint Commission declared pain as the “fifth vital sign” and emphasized that a specific pain score be achieved for all patients (e.g., pain score of less than 4/10),‡ probably because lower pain scores are being achieved with opioids alone.6 Fortunately, in a recent sentinel event alert, the Joint Commission has now recognized that not all pain could be eliminated and a goal-related therapy may be appropriate.§ one of the important steps toward developing optimal pain management treatments is to understand the degree of pain generated by various surgical procedures, particularly in relationship with the analgesic technique used. Gerbershagen et al.3 assessed the intensity of pain after a wide variety of surgical procedures. surprisingly, the authors found that several “minor” surgical procedures, which are commonly performed in an outpatient or short-stay setting (e.g., laparoscopic appendectomy, laparoscopic cholecystectomy, tonsillectomy, and hemorrhoidectomy), were associated with high pain intensities, whereas patients undergoing some of the “major” surgical procedures had lower pain scores. The authors provide us with a ranking of surgical procedures based on the severity of pain observed in the first 24 h, postoperatively. However, it is imperative that this ranking is not taken “literally” to suggest the degree of pain intensity generated by a certain surgical procedure. in fact, the pain intensities observed are a function of the analgesic technique used in various surgical procedures. Thus, the most likely reason for the observations of this study is that patients undergoing the surgical procedures that have the reputation of being less painful received inadequate pain relief. in contrast, patients undergoing highly painful surgical procedures received more aggressive analgesic therapy. As stated by the authors “After many laparoscopic surgeries patients often reported severe pain, but did not receive any opioids at all or only in low doses...” in addition, the data from this study support the belief that patient responses are variable and there is not a direct correlation between noxious stimuli and perceived pain. Therefore, healthcare professionals responsible for postoperative pain management should titrate appropriate pain therapy to the complaints of pain Procedure-specific Pain Management