Management of postoperative pain in non traumatic emergency surgery: WSES guidelines

The clinical guidelines, published in the World Journal of Emergency Surgery, were released jointly by the Global Alliance for Infection in Surgery (GAIS), World Society of Emergency Surgery (WSES), Analgesia Intensive Care (SIAARTI), Italian Society of Anesthesia, and American Association for the Surgery of Trauma (AAST).

Nonopioid and Opioid Drugs

• The use of opiates should be reduced as much as possible. Multimodal analgesia should always be considered; a step-up approach that includes significant opiates when necessary should be adopted.
• In the absence of contraindications, 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, unresponsive to other drugs, and in which regional anesthesia is not indicated.
• In opioid-naïve patients, initial opioid infusion via intravenous (IV) patient-controlled analgesia (PCA) should be avoided. If indicated, opiate infusion via IV PCA should be preferred to spinal PCA whenever the IV route is viable.

Route of drugs administration

• Whenever feasible, oral administration should be preferred over IV administration. The intramuscular (IM) route should be avoided. Epidural and regional anesthesia is recommended in general emergency surgery whenever 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

• In both adults and children, regional anesthesia is adequate. Abdominal-wall block can be considered to have an opioid-sparing effect. The transversus abdominis plane (TAP) block is safe and effective in laparoscopic abdominal surgery; the 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 non-communicative 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 unsuitable for further interventions. For (2), a combination of systemic multimodal analgesia with regional analgesia is suggested. For both (1) and (2), palliation should be considered to achieve control of related symptoms (e.g., nausea, vomiting, dyspnea, agitation, delirium).

The researchers wrote in their conclusion, "dealing with postop pain in the settings of emergency abdominal surgery is complex, needs special attention, and should be multidisciplinary. Various tools are available, and their combination is necessary whenever possible."

"Analgesic approach to several situations and conditions should be patient based and tailored per the pathology, procedure, response, age, and available expertise," they added. "It is necessary to better understand the pathomechanisms of postoperative pain for short- and long-term outcomes to improve prophylactic and treatment strategies."

Reference:

Coccolini F, Corradi F, Sartelli M, Coimbra R, Kryvoruchko IA, Leppaniemi A, Doklestic K, Bignami E, Biancofiore G, Bala M, Marco C, Damaskos D, Biffl WL, Fugazzola P, Santonastaso D, Agnoletti V, Sbarbaro C, Nacoti M, Hardcastle TC, Mariani D, De Simone B, Tolonen M, Ball C, Podda M, Di Carlo I, Di Saverio S, Navsaria P, Bonavina L, Abu-Zidan F, Soreide K, Fraga GP, Carvalho VH, Batista SF, Hecker A, Cucchetti A, Ercolani G, Tartaglia D, Galante JM, Wani I, Kurihara H, Tan E, Litvin A, Melotti RM, Sganga G, Zoro T, Isirdi A, De'Angelis N, Weber DG, Hodonou AM, tenBroek R, Parini D, Khan J, Sbrana G, Coniglio C, Giarratano A, Gratarola A, Zaghi C, Romeo O, Kelly M, Forfori F, Chiarugi M, Moore EE, Catena F, Malbrain MLNG. Postoperative pain management in non-traumatic emergency general surgery: WSES-GAIS-SIAARTI-AAST guidelines. World J Emerg Surg. 2022 Sep 21;17(1):50. doi: 10.1186/s13017-022-00455-7. PMID: 36131311; PMCID: PMC9494880.