Perioperative Analgesia
A useful pain plan enables breathing, sleep and mobilization while limiting adverse effects. Combine appropriate nonopioid drugs, local and regional techniques and nonpharmacological measures, with opioids when needed.[1]
This is the clinical workflow. Agent dosing, renal and hepatic adjustments and label restrictions are maintained in NSAIDs & Analgesics, Local Anesthetics, Gabapentinoids and Liposomal Bupivacaine. See Nerve Blocks for regional technique selection.
Preoperative Interventions
Risk Screening and Planning
Document baseline pain and function, previous difficult recoveries, current analgesics and actual daily opioid exposure. Assess kidney and liver function, sleep apnea, respiratory disease, frailty and concurrent sedatives. Discuss expected pain, functional goals, rescue treatment and the plan after discharge. Assess distress and substance-use history without assuming that either makes reported pain unreliable.[1]
Patient Education
The 2016 APS-led postoperative-pain guideline strongly recommends individually tailored preoperative education and documented postoperative pain goals, based on low-quality evidence; clinical benefit was not clearly shown for patients without more intensive needs.[1] Cover the expected severity and time course of pain, the scheduled drugs and when to use rescue medication, non-drug coping (positioning, relaxation, early walking), side effects that need a call, and the plan for stopping opioids. Tell patients that the aim is tolerable pain that allows walking, coughing and sleep, not zero pain.
For a patient taking long-term opioids, distinguish baseline treatment from the additional requirement for surgical pain. An automatic “opioids only as rescue” pathway can leave baseline dependence untreated. Coordinate changes with the usual prescriber and acute-pain team.
For opioid-use disorder, the 2021 multisociety panel recommends continuing buprenorphine without routine tapering (Grade B, moderate certainty). The 2021 multisociety expert panel emphasizes recurrence risk, multimodal analgesia and coordinated follow-up. Additional analgesia can be provided while buprenorphine continues; complex dose changes require an individualized plan.[2]
Nonopioid Foundation
Acetaminophen and/or an NSAID can form a scheduled foundation when appropriate. Prefer oral treatment when it is feasible; IV administration is not inherently more effective. Reassess suitability as bleeding, perfusion, oral intake and kidney function change.[1]
| Decision | Practical check |
|---|---|
| Acetaminophen | Count all combination products; set limits by weight and liver function |
| NSAID/COX-2 inhibitor | Review kidney injury, hypovolemia, GI bleeding/ulcer risk, cardiovascular risk and concurrent antithrombotics; avoid duplicate NSAIDs |
| Bowel anastomosis | Discuss procedure- and agent-specific concerns with the surgeon; see Bowel Anastomosis |
| Ketorolac | Verify the age-, weight- and renal-function-specific dosing limits and the combined oral/parenteral duration limit in the drug hub |
| Dexamethasone | Select for the overall antiemetic/analgesic plan. For adult PONV prophylaxis, the consensus lists 4–8 mg IV at induction.[22] See PONV and Steroids |
Scheduled Dosing Reference
The postoperative-pain guideline suggests around-the-clock nonopioids as part of multimodal analgesia when appropriate; use the dosing ceilings below and reassess scheduled treatment as pain changes.[1] Agent-level contraindications and comparative data are in the NSAIDs & Analgesics hub.
| Agent | Labeled adult dosing boundary | Points that change the plan |
|---|---|---|
| Acetaminophen (IV) | ≥50 kg: 1,000 mg every 6 h or 650 mg every 4 h, maximum 4 g/24 h from all routes; <50 kg: 15 mg/kg every 6 h or 12.5 mg/kg every 4 h, maximum 75 mg/kg/day | Count combination opioid tablets; severe hepatic disease is a contraindication; lower ceilings for malnutrition, alcohol use or hepatic risk[12] |
| Ketorolac (IV/IM) | Single IV dose: 30 mg if <65 years, or 15 mg if ≥65, renally impaired or <50 kg. Single IM dose: 60 mg or 30 mg, respectively. For repeated IV/IM dosing, use 30 mg or 15 mg every 6 hours, with respective daily maxima of 120 mg or 60 mg. Total IV/IM plus oral course no longer than 5 days | Contraindicated with active or prior peptic ulcer disease or GI bleeding, aspirin/NSAID hypersensitivity, advanced renal impairment or renal-failure risk from volume depletion, hemorrhagic diathesis or incomplete hemostasis, and concurrent aspirin or other NSAIDs; contraindicated as prophylactic analgesia before major surgery. Correct hypovolemia and confirm hemostasis before postoperative dosing.[13] |
| Oral ibuprofen, celecoxib, meloxicam | Use the product label for the patient's age, weight and renal function | Same kidney, GI, cardiovascular and antithrombotic screen; do not stack NSAIDs |
Gabapentinoids
Routine new perioperative gabapentin or pregabalin is not supported by the 2020 synthesis of 281 trials and 24,682 participants, which found no clinically important overall analgesic benefit and more adverse effects. FDA highlights respiratory risk with opioids or other CNS depressants, respiratory disease and older age.[3][4]
Existing therapy requires medication reconciliation, renal adjustment and assessment of sedation, indication and withdrawal risk. Neither automatic full-dose continuation during organ dysfunction nor abrupt cessation of established treatment is a sound universal rule.
Intraoperative Interventions
Ketamine
Subanesthetic ketamine can be considered for painful surgery, including selected opioid-tolerant patients. Bolus treatment and infusions both have evidence; it is incorrect to restrict all benefit to an infusion or all use to opioid-tolerant patients. The ASRA/AAPM/ASA acute-pain guidance finds an opioid-sparing role, while emphasizing variable regimens and limited evidence in important comorbid populations.[5]
Use an anesthesia or acute-pain protocol with trained staff and respiratory and hemodynamic monitoring. The 2018 ASRA/AAPM/ASA consensus advises avoiding ketamine with poorly controlled cardiovascular disease (grade C, moderate certainty), pregnancy or active psychosis (grade B, moderate certainty). Avoid infusions in severe hepatic disease; in moderate hepatic dysfunction, check liver tests before and during infusion (grade C, low certainty).[5] “Subanesthetic” dosing does not guarantee preserved airway safety or freedom from psychomimetic effects.[5]
Intravenous Lidocaine
IV lidocaine for analgesia is an off-label, high-risk intervention, selected under a monitored protocol. The 2021 consensus uses ideal-body-weight dosing and generally limits an infusion to 24 hours, with specialist reassessment for any extension.[6]
The consensus advises avoiding concurrent IV lidocaine and other local-anesthetic techniques during their period of action. It specifies at least four hours between a nerve or fascial-plane block or port-site infiltration and starting IV lidocaine, and four hours after stopping IV lidocaine before a new block or wound or epidural bolus. These intervals do not override longer formulation-specific restrictions, including EXPAREL. Consult the complete protocol for catheter-infusion and small-dose spinal exceptions.[6][8]
Surgical Site Infiltration
Agree on one cumulative local-anesthetic plan before injections begin. Count both sides of a block, wound infiltration, topical use and planned rescue injections. A concentration and volume are not a complete prescription without the resulting milligram dose, formulation and patient factors.
EXPAREL is not interchangeable milligram-for-milligram with plain bupivacaine. Its label supports local infiltration and specified peripheral blocks; pudendal, penile, spermatic-cord and TAP blocks are not among its established regional indications. Do not promise 72-hour analgesia at every GU site or copy a bilateral pudendal dose from an unrelated block. The label advises avoiding additional local anesthetic within 96 hours, subject to its specific administration and compatibility instructions.[8]
GU-Specific Regional Analgesia
The 2026 ASA guideline strongly recommends fascial plane blocks for adult open abdominal, retroperitoneal and pelvic surgery and for adult minimally invasive cholecystectomy, appendectomy, bariatric surgery, gastrectomy and liver resection, to reduce pain and/or opioid requirements during the first 24 hours; both recommendations are based on moderate-strength evidence. ESP, QL and TAP block selection depends on the procedure and patient. See Nerve Blocks.[11]
Select a block by the actual incision and pain generators, not the operation's name alone. Regional anesthesia can reduce somatic pain without treating all visceral discomfort or catheter symptoms. Technique details and supporting evidence belong in Nerve Blocks.
| Technique | Potential role and limitation |
|---|---|
| Pudendal nerve block | Selected perineal/vaginal procedures; coverage does not extend to all pelvic visceral pain. In two randomized vaginal-reconstruction trials, adding a block did not significantly reduce opioid use; one trial found less pain on postoperative day 1, but the 13.3-mm difference was below its prespecified 20-mm threshold for clinical importance.[18][19] |
| Dorsal penile/ring block | Penile surgery; additional surgical sites may require separate analgesia |
| TAP/rectus sheath | Incisional abdominal-wall pain; coverage depends on approach and incision |
| Ilioinguinal/iliohypogastric | Selected inguinal or lower abdominal incisions; not complete testicular/visceral coverage |
| QL/ESP | Selected abdominal/flank operations; spread and clinical benefit vary, without a universal superiority ranking |
Intrathecal (Spinal) Morphine
Intrathecal morphine can provide prolonged analgesia but can also cause delayed respiratory depression, pruritus, nausea and urinary retention. Choose the dose and postoperative location with anesthesia before administration.
For single-injection neuraxial hydrophilic opioids such as conventional morphine, ASA/ASRA recommends monitoring for at least 24 hours: at least hourly for the first 12 hours, then at least every two hours for the next 12. Assess ventilation, oxygenation and consciousness; pulse oximetry alone is not the full monitoring plan. Higher-risk patients or concurrent sedatives or systemic opioids may require more intensive monitoring. Different formulations and catheter regimens have different schedules.[7]
Postoperative Assessment and Rescue
Reassess pain during activity as well as at rest, along with sedation, respiration, nausea, bowel function and urinary drainage. New or disproportionate pain may indicate a complication: examine the patient before simply escalating medication.[1]
After gynecologic laparoscopy, shoulder-tip pain is referred pain from diaphragmatic phrenic-nerve irritation; residual intraperitoneal gas and peritoneal stretching are proposed contributors.[14] It occurs in up to 80% of women after gynecologic laparoscopy and is typically noted when the patient sits up.[14] A 2019 Cochrane review found that selected intraoperative gas-release, fluid-instillation, drain and peritoneal (not subdiaphragmatic) local-anesthetic techniques may reduce the incidence or severity of postoperative shoulder pain, with variable certainty.[14] A 2026 review of 11 randomized trials (n = 1,143) in benign gynecologic laparoscopy found less shoulder-tip pain after intraperitoneal crystalloid overall, but no detected reduction in the subgroup of studies using routine postoperative NSAIDs.[20] In a separate randomized gynecologic laparoscopy trial (n = 166), active aspiration through a drain showed no detected advantage over manual evacuation when both groups received pulmonary recruitment; at 24 hours, shoulder/subcostal pain of NRS ≥3 occurred in 8/70 assessed patients in each arm.[21] A small randomized trial of preoperative gabapentin before laparoscopic ovarian cystectomy (n=40) lowered pain scores at 2 and 12 hours postoperatively, though the reduction in overall occurrence (45% versus 75%) did not reach significance.[15] New or severe shoulder or chest pain still needs evaluation for more serious causes, including myocardial infarction, pulmonary embolism and pneumothorax, before it is attributed to referred diaphragmatic irritation.
Use an individualized immediate-release opioid when additional acute-pain relief is needed, generally through the oral route once feasible. IV PCA may be appropriate when severe pain requires parenteral dosing or oral medication is impractical. The 2016 postoperative-pain guideline strongly recommends avoiding routine basal opioid infusion with IV patient-controlled analgesia in opioid-naive adults (moderate-quality evidence).[1] Account for baseline tolerance, organ function and all sedatives. A fixed oxycodone dose is not appropriate for every older, opioid-naive or renally impaired patient.
Non-drug measures add comfort at low risk. Early mobilization limits sensitization and deconditioning, relaxation and breathing techniques reduce distress, and TENS or other cognitive modalities can be offered as adjuncts.[1] Position changes and procedure-appropriate cooling or elevation of genital and perineal swelling may help. Protect skin and grafts from direct ice, pressure and unapproved compression. Rescue regional treatment requires a fresh review of antithrombotics, infection, prior local-anesthetic exposure and the cause of pain.
At discharge, specify the agents, opioid quantity and expected duration, stop or taper plan, and clinician responsible for follow-up. A 2025 review of nine randomized discharge-duration trials (6,739 surgical patients, mainly gynecologic/obstetric or orthopedic) found no detected pain difference between longer and shorter opioid courses at measured follow-up (low to moderate certainty).[24] Reconcile acetaminophen in combination tablets, provide a bowel plan when needed, and explain symptoms that require prompt review.
Pathway Summary
| Phase | Core elements | Adjust or omit when |
|---|---|---|
| Preoperative | Risk screen, education, baseline opioid and buprenorphine plan, acetaminophen and/or NSAID, regional plan | Renal, GI, cardiovascular or bleeding contraindication to NSAIDs; severe hepatic disease[12][13] |
| Intraoperative | Incision-matched fascial plane, pudendal or penile block and/or wound infiltration; opioid-sparing or selected opioid-free anesthesia when regional analgesia provides adequate coverage[23]; selected ketamine or IV lidocaine under protocol | Anticoagulation or infection at the block site; unresolved cumulative local-anesthetic dose |
| Postoperative | Scheduled nonopioids, non-drug measures, activity-based reassessment, individualized immediate-release opioid for breakthrough pain | New or disproportionate pain, which needs examination before escalation |
| Discharge | Named agents, stop or taper dates, bowel plan, acetaminophen total, who follows up | Long-term opioid or buprenorphine patients need the prescriber named |
Newer Evidence and Agents
Suzetrigine (Journavx)
Suzetrigine, a selective peripheral Nav1.8 sodium-channel blocker, is FDA-approved (January 2025) for moderate-to-severe acute pain, including postoperative pain, in adults. Two randomized trials enrolled 1,118 abdominoplasty patients (447 on suzetrigine) and 1,073 bunionectomy patients (426 on suzetrigine) and demonstrated improvement versus placebo over 48 hours. The 48-hour pain-intensity composite (SPID48) did not differ significantly from hydrocodone/acetaminophen after abdominoplasty (least-squares mean difference 6.6, 95% CI −5.4 to 18.7), but favored hydrocodone/acetaminophen after bunionectomy (difference −20.2, 95% CI −32.7 to −7.7).[9]
Concomitant strong CYP3A inhibitors are contraindicated; avoid suzetrigine with strong or moderate CYP3A inducers or grapefruit, in severe hepatic impairment (Child-Pugh C), and when eGFR is <15 mL/min. Reduce the dose with moderate CYP3A inhibitors or moderate hepatic impairment (Child-Pugh B), and assess sensitive CYP3A substrates for loss of effect. Patients using hormonal contraceptives with progestins other than levonorgestrel or norethindrone need an additional nonhormonal method or alternative contraception during treatment and for 28 days afterward. The label states that acute-pain use beyond 14 days has not been studied.[9] See the analgesic drug hub.
Comparing Multimodal Combinations
Graham et al. (2025) analyzed 23,238 procedures in six Veterans Health Administration hospitals using an instrumental-variable observational design. Any multimodal analgesia was associated with 6.8 fewer oral morphine equivalents in inpatients (95% CI −10.2 to −3.4) and a 1.0-point lower pain score in outpatients. NSAID plus dexamethasone and NSAID plus regional anesthesia gave the largest reductions in opioid use (about 29.5 and 28.4 oral morphine equivalents), and acetaminophen contributed less than the NSAID and dexamethasone components.[10] This was not randomized allocation to each combination.[10]
Penile implant surgery. Two retrospective comparisons found lower opioid use with a multimodal regimen (acetaminophen, an NSAID or COX-2 inhibitor, gabapentin and intraoperative local or regional blocks) than with an opioid-based regimen. Tong et al. compared 19 multimodal patients with 38 opioid-based patients: mean VAS pain scores were lower in the PACU, on POD0 and POD1, patients were discharged with a mean of 12.7 versus 51.3 opioid tablets, and 11% versus 49% requested a refill.[16] Lucas et al. reported a multi-institutional matched-cohort comparison of 103 multimodal and 100 opioid-based patients: median pain scores were lower at every timepoint, patients were discharged with a median of 20 versus 30 tablets, and 10.7% versus 28.0% requested a refill.[17] Both retrospective, matched-cohort comparisons support an opioid-sparing multimodal plan after IPP; neither isolates a drug or block or establishes long-term functional benefit.[16][17]
References
1. Chou R, Gordon DB, de Leon-Casasola OA, et al. “Management of Postoperative Pain: A Clinical Practice Guideline.” J Pain. 2016;17:131–157. doi:10.1016/j.jpain.2015.12.008.
2. Kohan L, Potru S, Barreveld AM, et al. “Buprenorphine Management in the Perioperative Period: Educational Review and Recommendations from a Multisociety Expert Panel.” Reg Anesth Pain Med. 2021;46:840–859. doi:10.1136/rapm-2021-103007.
3. Verret M, Lauzier F, Zarychanski R, et al. “Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis.” Anesthesiology. 2020;133:265–279. doi:10.1097/ALN.0000000000003428.
4. US Food and Drug Administration. “Gabapentin and Pregabalin: Serious Breathing Problems.” 2019. FDA safety communication.
5. Schwenk ES, Viscusi ER, Buvanendran A, et al. “Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists.” Reg Anesth Pain Med. 2018;43:456–466. doi:10.1097/AAP.0000000000000806.
6. Foo I, Macfarlane AJR, Srivastava D, et al. “The Use of Intravenous Lidocaine for Postoperative Pain and Recovery: International Consensus Statement on Efficacy and Safety.” Anaesthesia. 2021;76:238–250. doi:10.1111/anae.15270.
7. ASA Task Force on Neuraxial Opioids and ASRA. “Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration.” Anesthesiology. 2016;124:535–552. doi:10.1097/ALN.0000000000000975. Primary guideline.
8. EXPAREL. US prescribing information, label effective December 2025. DailyMed label.
9. JOURNAVX (suzetrigine). Vertex Pharmaceuticals. US prescribing information, revised 1/2026. DailyMed label.
10. Graham LA, Illarmo S, Wren SM, Mudumbai SC, Odden MC. “Optimal Multimodal Analgesia Combinations to Reduce Pain and Opioid Use Following Non-cardiac Surgery: An Instrumental Variable Analysis.” Reg Anesth Pain Med. Published online July 17, 2025. doi:10.1136/rapm-2025-106720.
11. Joshi GP, Mariano E, Elkassabany NM, et al. "2026 American Society of Anesthesiologists Practice Guideline on Perioperative Pain Management Using Local and Regional Analgesia for Cardiothoracic Surgeries, Mastectomy, and Abdominal Surgeries." Anesthesiology. 2026;144:19–43. doi:10.1097/ALN.0000000000005790.
12. Acetaminophen injection: US prescribing information. DailyMed. Primary source. Accessed September 25, 2026.
13. Ketorolac tromethamine injection: US prescribing information. DailyMed. Primary source. Accessed September 25, 2026.
14. Kaloo P, Armstrong S, Kaloo C, Jordan V. “Interventions to Reduce Shoulder Pain Following Gynaecological Laparoscopic Procedures.” Cochrane Database Syst Rev. 2019;1:CD011101. doi:10.1002/14651858.CD011101.pub2.
15. Valadan M, Banifatemi S, Yousefshahi F. “Preoperative Gabapentin to Prevent Postoperative Shoulder Pain After Laparoscopic Ovarian Cystectomy: A Randomized Clinical Trial.” Anesth Pain Med. 2015;5(6):e31524. doi:10.5812/aapm.31524.
16. Tong CMC, Lucas J, Shah A, Foote C, Simhan J. “Novel Multi-Modal Analgesia Protocol Significantly Decreases Opioid Requirements in Inflatable Penile Prosthesis Patients.” J Sex Med. 2018;15(8):1187–1194. doi:10.1016/j.jsxm.2018.05.017.
17. Lucas J, Gross M, Yafi F, et al. “A Multi-institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Reduction in Pain Scores and Narcotic Usage.” J Sex Med. 2020;17(3):518–525. doi:10.1016/j.jsxm.2019.11.267.
18. Slopnick EA, Sears SB, Chapman GC, et al. "Pudendal Nerve Block Analgesia at the Time of Vaginal Surgery: A Randomized, Double-Blinded, Sham-Controlled Trial." Urogynecology (Phila). 2023;29(10):827-835. doi:10.1097/SPV.0000000000001351
19. Torosis M, Fullerton M, Kaefer D, Nitti V, Ackerman AL, Grisales T. "Pudendal Block at the Time of Transvaginal Prolapse Repair: A Randomized Controlled Trial." Urogynecology (Phila). 2024;30(8):706-713. doi:10.1097/SPV.0000000000001448
20. Lemos MJ, Curi-Pesantes B, da Silva DBP, Queiroz LF, Carugno J. "Intraperitoneal Crystalloid Instillation to Reduce Shoulder-Tip Pain After Benign Gynecologic Laparoscopy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials." J Minim Invasive Gynecol. 2026;33(6):715-724. doi:10.1016/j.jmig.2026.01.046
21. Navarro AS, Wallet J, Le Deley MC, et al. "Post-operative pain after laparoscopy in gynecologic surgery: randomized trial on peritoneal gas drainage." Int J Gynecol Cancer. 2026;36(2):102864. doi:10.1016/j.ijgc.2025.102864
22. Gan TJ, Belani KG, Bergese S, et al. "Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting." Anesth Analg. 2020;131(2):411–448. doi:10.1213/ANE.0000000000004833.
23. de Carvalho CC, El-Boghdadly K, Guedes IHL, et al. "Opioid-free vs. opioid-inclusive anaesthesia with or without regional anaesthesia for postoperative pain: a systematic review with network meta-analysis of randomised controlled trials." Anaesthesia. 2026;81(5):702–712. doi:10.1111/anae.70121
24. Jamshidi M, Jones CMP, Langford AV, et al. "Comparative Effectiveness of Different Opioid Regimens, in Daily Dose or Treatment Duration, Prescribed at Surgical Discharge: a Systematic Review and Meta-Analysis." CNS Drugs. 2025;39(4):345–360. doi:10.1007/s40263-025-01165-9