Perioperative Analgesia
A useful pain plan enables breathing, sleep and mobilization while limiting adverse effects. Combine appropriate nonopioid drugs, local/regional techniques and nonpharmacological measures, with opioids when needed. The combination should fit the patient and operation; adding every available drug is not the goal of multimodal care.[1]
This is the clinical workflow. Agent dosing, renal/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/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]
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.
Buprenorphine for opioid-use disorder should not routinely be stopped or tapered perioperatively. 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; use weight- and liver-appropriate limits rather than a universal adult maximum |
| 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; it is not a mandatory 8–10 mg dose for every surgical patient. See PONV and Steroids |
Gabapentinoids
Routine new perioperative gabapentin/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/acute-pain protocol with trained staff and respiratory/hemodynamic monitoring. Review cardiovascular instability, active psychosis, pregnancy and hepatic disease. “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. Its risk–benefit balance varies by procedure; it is not simply a fallback whenever NSAIDs cannot be used. 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/fascial-plane block or port-site infiltration and starting IV lidocaine, and four hours after stopping IV lidocaine before a new block or wound/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/compatibility instructions.[8]
GU-Specific Regional Analgesia
The 2026 ASA guideline supports fascial plane blocks for adult open abdominal, retroperitoneal and pelvic surgery, and for minimally invasive abdominal surgery, to reduce pain and/or opioid requirements during the first 24 hours. Choice remains procedure- and patient-specific; it does not establish an ESP/QL/TAP hierarchy. 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 |
| 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/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]
Use an individualized immediate-release opioid when additional acute-pain relief is needed, generally through the oral route once feasible. PCA may be appropriate when pain is severe or oral dosing is impractical. 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.
Position changes, reassurance, relaxation and procedure-appropriate cooling or elevation 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 which agents continue, their stop/taper plan and the clinician responsible for follow-up. Reconcile acetaminophen in combination tablets, provide a bowel plan when needed, and explain symptoms that require prompt review.
Newer Evidence and Agents
Suzetrigine (Journavx)
Suzetrigine is FDA-approved for moderate-to-severe acute pain, including postoperative pain, in adults. Two pivotal randomized trials enrolled 1,118 abdominoplasty and 1,073 bunionectomy patients and demonstrated improvement versus placebo over 48 hours. They did not establish superiority to hydrocodone/acetaminophen. These operations do not establish effectiveness for every major GU reconstruction.[9]
Review CYP3A interactions, hepatic impairment and hormonal contraception before prescribing. The July 2026 label advises the shortest suitable duration and states that acute-pain use beyond 14 days has not been studied. A peripheral nonopioid mechanism is not evidence of zero adverse-event risk; see the analgesic drug hub.[9]
Comparing Multimodal Combinations
Graham et al. (2025) analyzed 23,238 procedures in six Veterans Health Administration hospitals using an instrumental-variable observational design. NSAID/dexamethasone and NSAID/regional combinations had favorable opioid-use estimates. This was not randomized allocation to each combination and does not justify withholding otherwise suitable acetaminophen or prescribing NSAIDs despite contraindications.[10]
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.” 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. Primary guideline.
8. EXPAREL. Current US prescribing information. DailyMed label.
9. JOURNAVX (suzetrigine). US prescribing information, revised July 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. 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.