Pain Management

Significant acute postoperative pain is common, even among those on an established pain management protocol (1). Pain after surgery is associated with increased risk of postoperative readmission to hospital, emergency department visits, myocardial injury, delirium, and chronic pain (2-7). Postoperative pain control may be improved by addressing modifiable patient risk factors such as sleep, BMI, depression, anxiety, and preoperative pain (8).

Screening Tools

The Perioperative Opioid Quality Improvement (POQI) score is an algorithm being developed at St. Paul's Hospital. It aims to identify patients at increased risk of significant postoperative pain and long-term opioid use, so that their care plans may be tailored with the intent of helping reduce initial opioid consumption. (9) It incorporates several variables associated with increased risk for developing postoperative pain and uses consumption of > 90 morphine milligram equivalents per day while inpatient after surgery as a surrogate marker for assessing performance (9). While the POQI score is not validated, it was selected to support postoperative pain risk stratification based on local BC experience with the tool. A POQI score >= 7 is considered to be ‘increased risk.’

Perioperative Opioid Quality Improvement (POQI) Assessment

Prehabilitation and Optimization Algorithm

Prehabilitation and Optimization Recommendations

Patient Education
  • Set patient expectations for postoperative pain management
  • "Given your risk factors, managing post-surgery pain might be challenging. There are many ways we can work together before and after surgery to decrease this.”
Self-Referral Options
  • Refer to online patient resources including access to the following:
    • Managing Pain Before and After Surgery (PainBC): A free self-paced online program for people having surgery and their families to better manage pain after surgery and decrease complications.
    • Coaching for Health (PainBC): A free one-on-one telephone coaching program designed to help people living with chronic pain learn self-management skills, regain function, and improve well-being
Referral for Anesthesia Consult
  • To develop effective pain management strategies and explore options for anesthesia and postoperative pain control, especially in moderate to severely invasive surgery
Physician-Referral Options
  • Mind-space.ca - Mindfulness teaching virtually
  • Referral to Transitional Pain Clinic
    • Transitional pain clinics are short-term outpatient services that manage pain before and after surgery to prevent acute pain from becoming chronic. Currently available at Vancouver Coastal Health and Providence Health sites.
  • Referral to Chronic Pain Clinic

References

1. Sommer, M., de Rijke, J. M., van Kleef, M., Kessels, A. G., Peters, M. L., Geurts, J. W., Gramke, H. F., & Marcus, M. A. (2008). The prevalence of postoperative pain in a sample of 1490 surgical inpatients. European journal of anaesthesiology, 25(4), 267–274. https://doi.org/10.1017/S0265021507003031

2. Katz, J., Jackson, M., Kavanagh, B. P., & Sandler, A. N. (1996). Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. The Clinical journal of pain, 12(1), 50–55. https://doi.org/10.1097/00002508-199603000-00009

3. Hernandez-Boussard, T., Graham, L. A., Desai, K., Wahl, T. S., Aucoin, E., Richman, J. S., Morris, M. S., Itani, K. M., Telford, G. L., & Hawn, M. T. (2017). The fifth vital sign: Postoperative pain predicts 30-day readmissions and subsequent emergency department visits. Annals of Surgery, 266(3), 516–524. https://doi.org/10.1097/SLA.0000000000002372

4. Dubljanin Raspopović, E., Meissner, W., Zaslansky, R., Kadija, M., Tomanović Vujadinović, S., & Tulić, G. (2021). Associations between early postoperative pain outcome measures and late functional outcomes in patients after knee arthroplasty. PLOS ONE, 16(7), e0253147. https://doi.org/10.1371/journal.pone.0253147

5. Buvanendran, A., Della Valle, C. J., Kroin, J. S., Shah, M., Moric, M., Tuman, K. J., & McCarthy, R. J. (2019). Acute postoperative pain is an independent predictor of chronic postsurgical pain following total knee arthroplasty at 6 months: A prospective cohort study. Regional Anesthesia & Pain Medicine, 44(3), e100036. https://doi.org/10.1136/rapm-2018-100036

6. Turan, A., Leung, S., Bajracharya, G. R., Babazade, R., Barnes, T., Schacham, Y. N., Mao, G., Zimmerman, N., Ruetzler, K., Maheshwari, K., Esa, W. A. S., & Sessler, D. I. (2020). Acute Postoperative Pain Is Associated With Myocardial Injury After Noncardiac Surgery. Anesthesia & Analgesia, 131(3), 822–829. https://doi.org/10.1213/ANE.0000000000005033

7. Khaled, M., Sabac, D., Fuda, M., Koubaesh, C., Gallab, J., Qu, M., Lo Bianco, G., Shanthanna, H., Paul, J., Thabane, L., & Marcucci, M. (2024). Postoperative pain and neurocognitive outcomes after noncardiac surgery: a systematic review and dose-response meta-analysis. British journal of anaesthesia, S0007-0912(24)00550-6. Advance online publication. https://doi.org/10.1016/j.bja.2024.08.032

8. Yang, M. M. H., Hartley, R. L., Leung, A. A., Ronksley, P. E., Jetté, N., Casha, S., & Riva-Cambrin, J. (2019). Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis. BMJ open,9(4), e025091. https://doi.org/10.1136/bmjopen-2018-025091

9. Görges, M., Sujan, J., West, N. C., Sreepada, R. S., Wood, M. D., Payne, B. A., Shetty, S., Gelinas, J. P., & Sutherland, A. M. (2024). Postsurgical Pain Risk Stratification to Enhance Pain Management Workflow in Adult Patients: Design, Implementation, and Pilot Evaluation. JMIR perioperative medicine, 7, e54926. https://doi.org/10.2196/54926