Postoperative pain management - NYSORA

Explore NYSORA knowledge base for free:

Postoperative pain management

Learning objectives

  • Describe the importance of postoperative pain management
  • Assess postoperative pain
  • Manage postoperative pain


  • Adequate postoperative pain management is essential to enable a quick return to normal function
  • Uncontrolled pain increases sympathetic activity and the stress response, leading to multisystem consequences (e.g., hyperglycemia, immunosuppression, increased risk of myocardial ischemia)
  • Pain after abdominal or thoracic surgery can lead to splinting of the diaphragm and chest wall, resulting in  decreased lung volumes, atelectasis, poor cough, sputum retention, infection, and hypoxia
  • Pain can reduce mobility and increase the risk of thromboembolism
  • Psychological effects: anxiety, feeling of helplessness
  • Untreated or inadequately treated postoperative pain can lead to chronic pain
  • Traditionally, opioids were the standard treatment for postoperative pain
  • Today, multimodal approaches for pain management are the treatment of choice

Pain assessment

  • Perform pain assessment at regular, frequent intervals and after every intervention
  • The severity of pain and the effectiveness of analgesia determine the frequency
  • Record pain as the fifth vital sign
  • Assessment includes:
    • Site, circumstances associated with onset
    • Character
    • Intensity (at rest and on movement)
    • Associated symptoms (e.g., nausea)
    • Effect on activity and sleep
    • Relevant medical history
    • Other factors influencing the patient’s treatment
    • Current and previous medications and analgesic strategies
  • Severity scales:
    • Unidimensional
      • Numeric (numeric rating scales, visual analog scale)
      • Categorical (verbal descriptor scale)
    • Multidimensional (less useful in acute postoperative pain)
      • McGill Pain Questionnaire
      • Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) can be used to identify those at risk of developing chronic neuropathic pain
    • Pictorial and behavioral scales may be needed for children or cognitively impaired patients
      • FLACC scale
      • Abbey pain scale

Pain management strategy

postoperative pain management, opioid, educate, analgesia, paracetamol, non-steroidal anti-inflammatory drugs, nsaids, nausea, vomiting, sedation, pruritus, respiratory depression, constipation, urinary retention, gabapentinoids, n-methyl-d-aspartate receptor antagonists, alpha-2 adrenergic agonists, multimodal, clonidine, dexmedetomidine, ketamine, dexamethasone, regional anesthesia, local infiltration, peripheral nerve blocks, neuraxial, epidural, spinal WHO pain ladder

Pain in special circumstances

  • Opioid-dependent patients (long-term opioids for chronic pain, opioids for cancer pain, recreational use)
    • Manage patient expectations
    • Provide adequate analgesia
    • Prevent or manage withdrawal symptoms
  • Acute neuropathic pain after surgery
    • Incidence depends on type of surgery (e.g., 85% following limb amputation)
    • Pre-emptive analgesia (regional techniques, ketamine, administration before start of surgery) may be helpful
    • Maintain a high index of suspicion for patients at high risk
    • Treatment is extrapolated from chronic neuropathic pain treatment: Tricyclic antidepressants, ketamine, anticonvulsants, lidocaine, and tramadol may have a role

Suggested reading

  • Horn R, Kramer J. Postoperative Pain Control. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
  • Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
  • Tharakan L, Faber P. Pain management in day-case surgery. BJA Education. 2015;15(4):180-3.

We would love to hear from you. If you should detect any errors, email us