Perioperative care refers to the comprehensive medical care provided to a patient before, during, and after surgery. It encompasses all of the interventions aimed at ensuring patients are in the optimal health condition needed for surgery in order to minimize surgical risk, improve patient experience, and encourage a smooth recovery. When planning perioperative care, one of the key factors is the timing of analgesics, or pain-relieving medications.1 Anesthetic agents have different physiological effects, onsets and durations of action, and interactions with other drugs. Determining the optimal timing of perioperative analgesics is important for patient care, as well as reducing the use of opioid medications.

Perioperative analgesics are the pain-relieving medications given before, during, and/or after surgery to manage surgical pain effectively. The most common categories of perioperative analgesics include opioids (e.g., morphine, fentanyl), non-opioid analgesics (e.g., acetaminophen and NSAIDs like ibuprofen or ketorolac), local anesthetics (e.g., lidocaine), adjunctive agents (e.g., gabapentin, dexmedetomidine), and regional anesthesia techniques. Proper timing of these components can enhance patient outcomes by reducing side effects and decreasing reliance on opioids. The three phases of perioperative care are the preoperative phase (before), intraoperative phase (during), and postoperative phase (after), each necessitating different considerations for analgesic strategy.

The administration of pain-relieving medications before the initial surgical incision is called preemptive analgesia. It reduces central and peripheral sensitization, which contributes to postoperative pain. Several drugs, such as non-opioid analgesics (acetaminophen, NSAIDs) and adjuncts (gabapentinoids), are often administered preoperatively. For example, administering acetaminophen 1-2 hours before orthopedic surgery is common practice, as significant postoperative pain is expected. Advantages of preemptive analgesia include reducing postoperative pain intensity, decreasing the need for high doses of postoperative opioids, and limiting the development of chronic pain by minimizing pain sensitivity.

Intraoperative pain control plays a dual role: maintaining patient comfort and upholding optimal surgical conditions by minimizing the physiologic stress response to surgery. These analgesics could be delivered systemically or regionally. Options include short-acting opioids (e.g., fentanyl), nerve blocks, and adjunct agents (ketamine, dexmedetomidine, or lidocaine infusions).2 For example, lidocaine infusions are often used at the beginning of surgery to blunt the sympathetic response and allow for easier intubation.

After surgery, pain management aims to enhance recovery, promote early mobilization, and prevent complications like chronic pain. The safest and most efficacious strategy is a multimodal approach to pain control, which includes a combination of medications that target different pain pathways.3 In the current opioid crisis, minimizing postoperative opioid

use is a priority which is also achieved through a multimodal strategy. Additionally, regional blocks (e.g., continuous epidurals) can provide extended relief into the postoperative period. For example, after major abdominal surgery, a patient may receive acetaminophen, an NSAID like ketorolac, and a low-dose opioid, all of which would be supplemented by an intraoperative regional nerve block for optimal pain relief.

There are many factors to consider when planning perioperative analgesia, such as type of surgery, patient age or comorbidities (e.g., kidney disease), and preexisting chronic pain conditions, all of which may influence drug selection, dosing, and timing. By tailoring the type and dose of analgesia across three different phases (pre-, intra-, and postoperative), clinicians can decrease opioid-related effects, reduce pain, and improve patient outcomes regarding recovery and satisfaction.

References

1. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council [published correction appears in J Pain. 2016 Apr;17(4):508-10. doi: 10.1016/j.jpain.2016.02.002. Dosage error in article text]. J Pain. 2016;17(2):131-157. doi:10.1016/j.jpain.2015.12.008

2. Weber M, Chao M, Kaur S, Tran B, Dizdarevic A. A Look Forward and a Look Back: The Growing Role of ERAS Protocols in Orthopedic Surgery. Anesthesiol Clin. 2024;42(2):345-356. doi:10.1016/j.anclin.2023.11.014

3. Hinther A, Nakoneshny SC, Chandarana SP, et al. Efficacy of Multimodal Analgesia for Postoperative Pain Management in Head and Neck Cancer Patients. Cancers (Basel). 2021;13(6):1266. Published 2021 Mar 12. doi:10.3390/cancers13061266