Expert Consensus
Copyright ©The Author(s) 2021.
World J Clin Cases. Mar 26, 2021; 9(9): 2090-2099
Published online Mar 26, 2021. doi: 10.12998/wjcc.v9.i9.2090
Table 1 Risk factors for chronic postsurgical pain[7-14]
Risk factors for CPSP[7-14]
Preoperative factorsPreoperative chronic pain; psychological factors (depression, anxiety, pain catastrophizing and fear of surgery); smoking; younger age; female gender; genetic susceptibility
Surgical factors Type and site of surgery (amputation, breast cancer, thoracotomy, hysterectomy, inguinal hernia repair, cesarean section); surgical technique (open surgery > laparoscopy and thoracoscopy, traditional hernia repair > tension-free hernia repair); extensive use of electric knife; long operation time; infection on incision site; nerve damage or compression
Postoperative factorsSevere acute postoperative pain; opioid use (high doses of opioids can cause hyperalgesia and may be related to NMDA receptor activation); neuropathic pain (early postoperative neuropathic pain is prone to chronic); complication (cardiovascular, respiratory, renal/gastrointestinal, wound, thrombotic or neural)
Table 2 Algorithm for pharmacotherapy of chronic post-surgical pain
Algorithm for pharmacotherapy of CPSP
First-line therapyGabapentin; pregabalin; duloxetine; venlafaxine; tricyclic antidepressants
Second-line therapyCapsaicin cream/patch; lidocaine cream/patch; tramadol; paracetamol dihydrocodeine
Third-line therapyStrong opioids; botulinum toxin type A
Table 3 Oxford Centre for Evidence-Based Medicine levels of evidence
Level
Therapy/prevention, etiology/harm
1aSystematic review of RCTs
1bRCT
1c“All-or-none”
2aSystematic review of cohort studies
2bCohort study or poor RCT
2c“Outcomes” research; ecological studies
3aSystematic review of case-control studies
3bIndividual case-control study
4Case series
5Expert opinion without critical appraisal, or based on physiology, bench research or “first principles”
Table 4 Division and cooperation between surgeons, anesthesiologists and pain physicians
Division and cooperation between surgeons, anesthesiologists and pain physicians
Surgeon(1) Optimize surgical methods based on the principle of minimizing tissue trauma; (2) Communicate with the anesthesiologist before surgery to negotiate the best anesthesia plan; and (3) Provide preventive medication and necessary psychological intervention for patients at high risk of CPSP
Anesthesiologist(1) Carefully evaluate the patient’s medical history, including chronic pain, opioid use, drug abuse and mental illness. Screen for patients at high risk of CPSP; (2) Educate patients and their families. Inform them about the possible challenges of perioperative analgesia and the risks of CPSP; (3) Communicate with the surgeon before the operation to understand the surgical method and discuss the best anesthesia plan; (4) Establish perioperative pain management files; (5) Based on a comprehensive assessment of the patient’s condition, an individualized multimodal analgesic plan is formulated; (6) Carefully evaluate and record the analgesic effect on the patient; (7) If the patient does not have good postoperative analgesia and uses high-dose opioids, the pain management file should be transferred to the pain physician 1 wk after the operation; and (8) Based on the follow-up results and the latest progress on research, continue to summarize and optimize the analgesia schemes for different surgical operations
Pain physician(1) Review the perioperative pain management files after taking over the patient; (2) Carefully analyze the nature and source of pain and develop a corresponding treatment plan; (3) Establish a follow-up mechanism; (4) If CPSP occurs, provide pain management in time; and (5) Regularly discuss difficult cases of CPSP with surgeons and anesthesiologists. Summarize risk factors and feedback treatment effect. Discuss further optimization of perioperative analgesia plan and preventive measures