Eduovisual
Perioperative & Surgical Care
Postoperative pain management and multimodal analgesia
— Postoperative pain = nociceptive (incisional, visceral) ± neuropathic (nerve injury, retractor stretch) ± inflammatory component, peaking 24–72h after surgery
— Multimodal analgesia (MMA) = combining agents with different mechanisms (opioid, acetaminophen, NSAID/COX-2, gabapentinoid selectively, regional/local anesthetic, ketamine, α2-agonist) to maximize analgesia while minimizing opioid dose and adverse effects
— Endorsed by ASA, ASRA, ERAS, and the Joint Commission as the standard of care for nearly all surgical procedures
— Patient-reported numeric rating scale (NRS) ≥4/10 at rest or ≥6/10 with movement, despite scheduled analgesics
— Functional surrogates: inability to cough, ambulate, perform incentive spirometry, or tolerate PT
— Autonomic signs: tachycardia, hypertension, diaphoresis, restlessness (but always rule out hypoxia, hemorrhage, withdrawal first)
— Sleep disruption, anxiety, delirium especially in elderly
— Uncontrolled pain → atelectasis/pneumonia, ileus, DVT (immobility), poor wound healing, persistent post-surgical pain (PPSP) syndromes, opioid escalation
— Overtreatment → respiratory depression, oversedation, opioid-induced constipation, urinary retention, post-discharge opioid use disorder, diversion
— Step 3 stems test the balance: opioid-sparing strategies that still deliver adequate analgesia
— Preoperative chronic pain or chronic opioid use, anxiety/catastrophizing, younger age, female sex, thoracotomy/upper abdominal/orthopedic procedures, opioid tolerance
Board pearl: The exam-correct framework is scheduled non-opioid baseline (acetaminophen + NSAID) + regional anesthesia when feasible + opioids only as rescue — never opioid monotherapy as first-line postop analgesia in an opioid-naïve adult.
Key distinction: Acute postop pain becomes persistent post-surgical pain when it lasts >3 months beyond expected healing — a distinct chronic pain diagnosis requiring multimodal long-term management.
— Onset: expected pain peaks within 24h; sudden new severe pain after improvement suggests complication (hematoma, anastomotic leak, compartment syndrome, ischemia) — not analgesic failure
— Quality: sharp/incisional = somatic nociceptive; cramping/colicky = visceral; burning/shooting/electric = neuropathic (intercostobrachial nerve after mastectomy, ilioinguinal after hernia repair)
— Radiation: shoulder tip after laparoscopy = referred diaphragmatic irritation from CO₂, not pathology
— Severity: NRS at rest AND with movement/cough — movement scores drive functional recovery
— Timing: breakthrough between scheduled doses suggests need to shorten interval or add long-acting agent, not just escalate dose
— Preoperative opioid use (MME/day), benzodiazepine use, alcohol/substance use — predicts tolerance and withdrawal risk
— History of OSA, COPD, obesity hypoventilation → ↑ risk of opioid-induced respiratory depression
— Renal function (limits NSAIDs, morphine, codeine), hepatic function (limits acetaminophen dose), GI bleed/PUD history (limits NSAIDs)
— Allergies and prior adverse reactions (e.g., codeine → CYP2D6 ultrarapid metabolizer concerns)
— Pregnancy/lactation status
— Current medications: SSRIs/SNRIs + tramadol = serotonin syndrome risk; MAOI + meperidine contraindicated
— Sleep, appetite, mood, ability to participate in PT
— Catastrophizing or high anxiety predicts higher opioid requirement → consider preop CBT, gabapentin selectively, or psych consult
— Discharge environment: who will manage medications, lockbox availability, naloxone access
Step 3 management: On admission for any elective surgery, document a preoperative pain plan including baseline MME, expected postop regimen, and an opioid taper/stop date — this is now a measured quality metric and an exam-favored answer for "next best step in preop optimization."
Board pearl: Sudden severity escalation that breaks through a previously adequate regimen = workup for surgical complication first, dose escalation second.
— Tachycardia, hypertension, tachypnea from pain — but these are nonspecific; always exclude hypovolemia, hypoxia, sepsis, MI, withdrawal before attributing to pain
— Hypotension + bradycardia after neuraxial opioid or epidural = sympathetic blockade or high block
— RR <10 or SpO₂ <92% on room air, sedation score (Pasero Opioid-Induced Sedation Scale ≥3) = opioid toxicity until proven otherwise — hold opioid, consider naloxone
— Inspect for hematoma, expanding ecchymosis, wound dehiscence, erythema, drainage — any of these reframes "pain" as a complication
— Palpate for crepitus (necrotizing infection), fluctuance (abscess), tense compartments (compartment syndrome — pain out of proportion, pain on passive stretch is the earliest sign)
— Abdominal exam: rigidity, rebound, absent bowel sounds → peritonitis or ileus; distention with tympany after laparotomy = postop ileus vs. obstruction
— Sensory level after epidural/spinal — unexpected ascending block = epidural hematoma/abscess concern, especially with anticoagulation
— Motor weakness persisting >4h after expected local anesthetic resolution = emergency MRI to rule out epidural hematoma
— Peripheral nerve block: document dermatomal coverage; new motor or sensory deficit after block resolution may indicate nerve injury
— Ability to deep breathe, cough, ambulate, perform ADLs
— Incentive spirometry volumes trending down → suspect splinting from inadequate analgesia (especially thoracic/upper abdominal surgery)
— Pain interference with sleep, oral intake, PT participation drives regimen adjustment, not just NRS number
Key distinction: Pain out of proportion to exam + pain on passive stretch + tense compartment = compartment syndrome — do not mask with escalating opioids; obtain compartment pressures and call surgery immediately. Epidural analgesia can dangerously obscure this presentation in lower extremity orthopedic cases.
Board pearl: Any new neurologic deficit in a patient with an indwelling epidural catheter, especially if on prophylactic anticoagulation, requires immediate MRI of the spine to rule out epidural hematoma — a time-critical surgical emergency (decompression within 6–8h preserves function).
— Numeric Rating Scale (NRS) 0–10: standard for adults who can self-report; assess at rest and with movement
— Visual Analog Scale (VAS): research and clinical, similar performance
— Wong-Baker FACES: pediatric (≥3 yr) and cognitively impaired adults
— FLACC (Face, Legs, Activity, Cry, Consolability): nonverbal children, infants
— CPOT or Behavioral Pain Scale (BPS): intubated/sedated ICU patients
— PAINAD: advanced dementia
— Self-report is the gold standard when obtainable; observational scales when not
— Pasero Opioid-Induced Sedation Scale (POSS) or Richmond Agitation-Sedation Scale (RASS) with every opioid dose
— Continuous pulse oximetry and capnography (EtCO₂) for high-risk patients: OSA, obesity, elderly, concurrent sedatives, basal-rate PCA
— Respiratory rate alone is insensitive — sedation precedes respiratory depression
— CBC: drop in Hgb suggests bleeding/hematoma as pain source
— BMP: AKI contraindicates NSAIDs and alters opioid (morphine, codeine, tramadol) dosing
— LFTs: hepatic dysfunction caps acetaminophen at ≤2 g/day and alters opioid metabolism
— Lactate, WBC, CRP if infection/ischemia suspected
— Urine drug screen if diversion, withdrawal, or undisclosed use suspected — with patient notification
— New severe pain, peritoneal signs, expanding hematoma, suspected leak, ischemia → CT with contrast (or US for hematoma/abscess at bedside)
— Suspected epidural complication → MRI spine without and with contrast, emergently
Step 3 management: Reassess pain 15–30 min after IV opioid, 60 min after PO opioid, and document response. Failure to reassess is a common quality/safety stem distractor — the correct "next step" is reassessment, not automatic dose escalation.
CCS pearl: Order "pain score q4h and PRN, sedation score with each opioid dose, continuous SpO₂" as standing postop orders — these appear on CCS rubrics for any surgical case.
— Nociceptive somatic (incision, bone): responds to NSAIDs, acetaminophen, opioids, local infiltration
— Nociceptive visceral (bowel manipulation, bladder): opioids, antispasmodics, regional (TAP, epidural)
— Neuropathic (nerve injury, e.g., post-thoracotomy, post-mastectomy, post-amputation): gabapentinoids, TCAs, SNRIs, lidocaine — opioids less effective
— Inflammatory: NSAIDs, ice, elevation
— Mixed: most postop pain — hence multimodal approach
— DN4 or LANSS questionnaires; burning, electric shock, allodynia, hyperalgesia
— Persistent pain >2 weeks with neuropathic features = early intervention prevents PPSP
— Disproportionate pain → r/o compartment syndrome (pressures), ischemia (CTA/lactate), abscess (CT/US), DVT (Doppler)
— Persistent ileus with pain → CT abdomen for obstruction/leak; check electrolytes (K, Mg)
— Urinary retention from opioids/anticholinergics → bladder scan, straight cath
— Constipation/OIBD → abdominal exam, KUB if obstipated
— New chest pain → ECG, troponin, CXR, D-dimer/CTPA per pretest probability (postop PE risk)
— Epidural not working: check catheter position (depth, dislodgement), test dose, infusion rate, sensory level; consider catheter replacement vs. transition to IV PCA
— Peripheral block resolved early: confirm with US-guided needle re-localization vs. transition to systemic regimen
Key distinction: A patient with rising opioid requirement has three possibilities — (1) inadequate dosing/regimen, (2) tolerance, or (3) new surgical complication. The exam-favored next step before dose escalation is focused exam + workup for complication.
Board pearl: Persistent neuropathic features at 2 weeks postop = start gabapentin or duloxetine and refer to a pain specialist; early treatment reduces progression to PPSP, which affects 10–50% after thoracotomy, mastectomy, amputation, and inguinal hernia repair.
— Foundation (scheduled, around-the-clock): acetaminophen 1 g q6h (max 3–4 g/day, ≤2 g if hepatic disease/elderly/EtOH) + NSAID (ibuprofen 400–600 mg q6h or ketorolac 15 mg IV q6h ≤5 days) unless contraindicated
— Regional/local: surgical site infiltration with liposomal bupivacaine, peripheral nerve blocks, neuraxial (epidural/spinal), continuous catheter infusions — use whenever feasible
— Adjuncts: gabapentin/pregabalin (selectively — see below), low-dose ketamine infusion, IV lidocaine infusion (abdominal surgery), dexmedetomidine, dexamethasone (single intraop dose)
— Opioids: shortest duration, lowest effective dose, oral preferred over IV when tolerating PO; rescue only, not scheduled in opioid-naïve
— High-risk: age >65, OSA, BMI >35, CKD, hepatic disease, concurrent benzo/gabapentinoid/sedative, history of OUD, sleep-disordered breathing
— These patients need lower starting doses, continuous monitoring (SpO₂ ± EtCO₂), and aggressive non-opioid optimization
— Thoracotomy/VATS: thoracic epidural or paravertebral/erector spinae block + acetaminophen + NSAID; consider gabapentin
— Open abdominal: thoracic epidural OR TAP block + IV lidocaine + acetaminophen + NSAID
— TKA/THA: adductor canal block (TKA) or PENG/fascia iliaca (THA) + periarticular infiltration + acetaminophen + NSAID
— C-section: spinal morphine + scheduled acetaminophen + NSAID + TAP block as rescue
— Outpatient general surgery: local infiltration + acetaminophen + NSAID ± short opioid course
Step 3 management: The exam answer for "opioid-naïve patient s/p open cholecystectomy, what is the optimal regimen?" = scheduled acetaminophen + ibuprofen/ketorolac + TAP block or wound infiltration + oxycodone 5 mg PO q4h PRN for breakthrough — not a basal PCA.
Board pearl: Gabapentinoids are no longer routinely recommended for all surgeries (2022+ ASRA/ERAS) due to sedation, dizziness, falls, and respiratory depression risk when combined with opioids; reserve for high-risk neuropathic procedures (spine, amputation, mastectomy).
— First-line scheduled agent for nearly every surgery; central + peripheral mechanism
— Dose: 1 g PO/IV q6h, max 4 g/day (3 g if elderly, malnourished, chronic EtOH; 2 g if cirrhosis)
— IV form offers no analgesic advantage over PO when PO tolerated; reserve IV for NPO/ileus — cost is a stewardship point
— Hepatotoxicity at supratherapeutic doses; check all combination products (Percocet, Norco) to avoid stacking
— Ketorolac 15 mg IV q6h (use 15 mg if >65 or <50 kg or CrCl <30 — actually avoid if CrCl <30) for ≤5 days
— Ibuprofen 400–600 mg PO q6h; naproxen 250–500 mg BID; celecoxib 200 mg BID (COX-2 selective — preferred when bleeding/GI risk concern but caution with CV disease)
— Contraindications: AKI/CKD (eGFR <30), active GI bleed, history of NSAID-induced ulcer, severe HF, allergy, last trimester pregnancy
— Cautions: post-bariatric surgery (anastomotic ulcer risk — often avoided), some orthopedic surgeons restrict in spinal fusion (controversial bone healing data — current evidence supports short-course safety)
— CV risk: all NSAIDs ↑ MI/stroke risk; naproxen has the most favorable CV profile
— Gabapentin 100–300 mg TID or pregabalin 75 mg BID — taper off by 1–2 weeks postop
— Renally dosed; sedating, especially with opioids → falls in elderly
— Indication: neuropathic-prone surgeries, chronic pain patients, opioid tolerance
— 0.1–0.5 mg/kg/h infusion in opioid-tolerant or opioid-intolerant patients
— NMDA antagonist; prevents central sensitization; opioid-sparing
— Side effects: dysphoria, hallucinations, hypertension, tachycardia — co-administer low-dose benzo if needed
— 1–2 mg/kg bolus then 1–2 mg/kg/h, for open abdominal/laparoscopic surgery
— Reduces ileus, opioid use; monitor for toxicity (perioral numbness, tinnitus, arrhythmia)
— Single intraop 4–8 mg IV: analgesic + antiemetic
— Caveat: transient hyperglycemia in diabetics
Board pearl: Scheduled acetaminophen + NSAID reduces opioid requirements by 30–50% versus opioid alone — this combination is the highest-yield exam answer for "best initial postop analgesia plan."
Key distinction: Tramadol is not a clean opioid-sparing agent — it has SNRI activity (serotonin syndrome with SSRIs), seizure risk, variable CYP2D6 metabolism, and is now a Schedule IV controlled substance. Avoid in elderly and in patients on serotonergic drugs.
— Oxycodone 5–10 mg PO q4h PRN — preferred PO breakthrough; predictable absorption
— Hydromorphone 0.2–0.5 mg IV q3h PRN — preferred IV in renal impairment (no active metabolites)
— Morphine 2–4 mg IV q3h PRN — avoid in CKD (M6G accumulation → respiratory depression)
— Fentanyl 25–50 mcg IV — short-acting, useful in renal failure, hemodynamic instability
— Avoid: meperidine (normeperidine seizures), codeine (CYP2D6 variability — death in ultrarapid metabolizers, especially children post-tonsillectomy — FDA black box)
— Demand-only mode standard; avoid basal infusions in opioid-naïve (↑ respiratory depression without analgesic benefit)
— Typical hydromorphone PCA: 0.2 mg demand, 8-min lockout
— Family/proxy-controlled administration is contraindicated (PCA by proxy is a sentinel event)
— Continuous SpO₂ ± EtCO₂ for OSA/high-risk patients
— Morphine 10 mg IV ≈ morphine 30 mg PO ≈ oxycodone 20 mg PO ≈ hydromorphone 1.5 mg IV ≈ 7.5 mg PO ≈ hydrocodone 30 mg PO
— When rotating opioids, reduce by 25–50% for incomplete cross-tolerance
— Neuraxial: epidural (continuous local + opioid, e.g., bupivacaine 0.1% + fentanyl 2 mcg/mL) — gold standard for open thoracic/abdominal; spinal morphine for C-section (24h analgesia, monitor for delayed respiratory depression at 6–12h)
— Peripheral nerve blocks: interscalene (shoulder), supraclavicular (arm), femoral/adductor canal (knee), popliteal sciatic (foot/ankle), TAP (abdominal wall), erector spinae (thoracic/abdominal), PEC blocks (breast)
— Continuous catheters extend analgesia 2–5 days
— Prophylactic LMWH: 12h before/after catheter manipulation; therapeutic: 24h
— DOACs: 72h hold before neuraxial; resume 6h after
— Aspirin/NSAIDs alone: not a contraindication
— Clopidogrel: hold 5–7 days
Step 3 management: For a patient on prophylactic enoxaparin postop with an epidural in place, the next dose is delayed until ≥4h after catheter removal, and the catheter is removed ≥12h after the last LMWH dose — violating this is the classic stem for epidural hematoma.
Board pearl: Naloxone 0.04–0.1 mg IV titrated (not the full 0.4 mg ampule) for opioid-induced respiratory depression in a hospitalized postop patient — full doses precipitate severe pain, withdrawal, hypertension, and pulmonary edema.
— Start low, go slow: reduce opioid starting doses by 25–50%; longer dosing intervals
— Increased sensitivity to CNS effects: delirium, falls, oversedation
— Beers Criteria — avoid: meperidine, pentazocine, long-acting benzos, skeletal muscle relaxants (cyclobenzaprine, methocarbamol), tertiary TCAs
— Acetaminophen max 3 g/day; preferred first-line
— NSAIDs: use cautiously, short courses, with PPI; avoid if CKD, HF, anticoagulation
— Regional anesthesia is preferred when feasible — reduces opioid exposure, delirium, pulmonary complications
— Screen for delirium (CAM) daily; treat pain adequately because untreated pain itself causes delirium
— Avoid: morphine (M3G/M6G accumulation), meperidine (normeperidine — seizures), codeine, tramadol (lower dose, longer interval)
— Preferred: hydromorphone, fentanyl, methadone, buprenorphine (no active metabolites or minimal renal clearance)
— NSAIDs: avoid if eGFR <30; caution at eGFR 30–60; can precipitate AKI especially with ACEi/ARB/diuretic ("triple whammy")
— Gabapentin/pregabalin: renally dosed — gabapentin 100 mg daily at CrCl 15–30
— Acetaminophen: safe at standard doses
— Acetaminophen: cap at 2 g/day in cirrhosis (still preferred over NSAIDs which precipitate hepatorenal syndrome and GI bleeding)
— NSAIDs: avoid in cirrhosis (variceal bleed, hepatorenal)
— Opioids: reduce dose and frequency; fentanyl and hydromorphone preferred; avoid morphine and tramadol; avoid methadone in severe hepatic dysfunction
— Sedation risk ↑↑ due to altered metabolism and ↑ encephalopathy risk
— Review every med for sedation contribution
— Pharmacist consultation for high-risk patients
Step 3 management: For an 82-year-old s/p hip ORIF with CKD stage 4, optimal regimen = scheduled acetaminophen 650 mg q6h + fascia iliaca block + hydromorphone 0.2 mg IV q4h PRN — no NSAIDs, no morphine, no gabapentin without renal adjustment, no muscle relaxants.
Board pearl: Undertreated pain in the elderly causes delirium just as readily as opioid overtreatment — the goal is adequate analgesia via opioid-sparing regional + acetaminophen, not opioid avoidance per se.
— Acetaminophen: first-line in all trimesters
— NSAIDs: avoid after 20 weeks (oligohydramnios, fetal renal injury — FDA 2020 warning) and absolutely after 30 weeks (premature ductus arteriosus closure); safe in early pregnancy short courses
— Opioids: short courses acceptable for acute postop pain (e.g., post-C-section); avoid chronic use — neonatal abstinence syndrome
— Post-C-section gold standard: spinal/epidural morphine + scheduled acetaminophen + NSAID (postpartum) + TAP block PRN; oxycodone for breakthrough
— Lactation: most opioids enter breast milk minimally; avoid codeine and tramadol (CYP2D6 ultrarapid metabolizer infant deaths — FDA contraindication in breastfeeding)
— Aspirin avoided in lactation (Reye risk)
— Use weight-based dosing and validated tools (FLACC, FACES, NRS by age)
— Acetaminophen 10–15 mg/kg q4–6h (max 75 mg/kg/day, ≤4 g)
— Ibuprofen 10 mg/kg q6h (>6 months)
— Opioids: oxycodone 0.05–0.1 mg/kg q4h; morphine 0.05 mg/kg IV
— Avoid codeine and tramadol in <12 yr and in <18 yr post-tonsillectomy/adenoidectomy (FDA black box — ultrarapid metabolizer deaths)
— Caudal blocks for lower abdominal/urologic surgery; regional widely used
— Continue baseline opioid (or methadone/buprenorphine maintenance) — never abruptly stop
— Buprenorphine: current consensus is to continue through the perioperative period rather than stop (older practice); supplement with full agonists as needed for breakthrough
— Methadone maintenance: continue daily dose; add short-acting opioid for acute pain on top
— Multimodal aggressive: regional, ketamine infusion, lidocaine infusion, gabapentinoids, acetaminophen, NSAIDs
— Involve addiction medicine; coordinate with OUD prescriber; check PDMP; provide naloxone at discharge
Key distinction: "Patient on buprenorphine for OUD undergoing surgery" — current ASRA/AAAP recommendation is to continue buprenorphine and use multimodal + full agonist breakthrough rather than stop it preop. Stopping triggers withdrawal and worsens pain control.
Board pearl: Codeine and tramadol are contraindicated in children <12, post-tonsillectomy patients <18, and breastfeeding mothers — CYP2D6 ultrarapid metabolizer phenotype has caused fatal respiratory depression.
— Respiratory depression: sedation precedes hypopnea; risk ↑ with OSA, obesity, elderly, basal PCA, concurrent benzo/gabapentinoid — monitor SpO₂ ± EtCO₂; treat with naloxone titration, hold opioid, reassess regimen
— Oversedation/delirium: especially elderly; manage with dose reduction, opioid rotation, regional rescue
— Opioid-induced constipation/ileus: prophylactic bowel regimen (senna ± docusate ± PEG) with every opioid order; PAMORAs (methylnaltrexone, naloxegol) for refractory
— Urinary retention: especially with neuraxial opioids; bladder scan, straight cath
— Pruritus: neuraxial morphine — low-dose naloxone infusion, nalbuphine, antihistamines
— Nausea/vomiting (PONV): ondansetron, dexamethasone, scopolamine, dropéridol; address with multimodal antiemetic prophylaxis
— Hyperalgesia and tolerance: paradoxical pain worsening with escalating opioid — treat with opioid rotation, ketamine, regional
— AKI (especially with ACEi/ARB/diuretic triple whammy), GI bleed/ulcer, platelet inhibition (bleeding), CV events, HF exacerbation, hyperkalemia
— Limit to 3–5 days at therapeutic dose postop
— Epidural hematoma: anticoagulation timing violations — new motor/sensory deficit → emergent MRI + neurosurg, decompression within 6–8h
— Epidural abscess: fever, back pain, neurologic deficit — MRI, antibiotics, drainage
— Local anesthetic systemic toxicity (LAST): perioral numbness, tinnitus, seizures, arrhythmia, cardiac arrest → 20% lipid emulsion 1.5 mL/kg bolus then infusion, stop block, ACLS modifications (avoid lidocaine, vasopressin, calcium channel blockers)
— Nerve injury (transient or permanent), pneumothorax (supraclavicular, paravertebral), high spinal, post-dural puncture headache (epidural blood patch if persistent)
— Risk: thoracotomy, mastectomy, amputation, hernia repair, sternotomy, joint replacement
— Prevent with aggressive multimodal acute control + regional anesthesia + early neuropathic agent if features emerge
CCS pearl: For LAST during a nerve block, the immediate orders are "stop local anesthetic, ABCs, 20% lipid emulsion bolus 1.5 mL/kg over 1 min, then 0.25 mL/kg/min infusion, call for help, ACLS with reduced-dose epinephrine (<1 mcg/kg)."
Board pearl: Combining an opioid with a benzodiazepine or gabapentinoid carries an FDA black box warning for respiratory depression and death — high-yield exam association.
— Sustained RR <8, SpO₂ <90% despite supplemental O₂, naloxone-requiring respiratory depression
— Hemodynamic instability from neuraxial block (high spinal) requiring vasopressor support
— LAST with cardiovascular compromise
— Suspected epidural hematoma or abscess pending decompression
— Severe withdrawal (opioid, alcohol, benzo) with autonomic instability
— Refractory pain requiring ketamine or lidocaine infusion that exceeds floor capacity (institution-dependent)
— Opioid-tolerant patients, OUD, methadone/buprenorphine maintenance
— Failed conventional regimen, escalating opioid requirement
— Need for regional catheter management, ketamine/lidocaine infusion
— Complex postop (multitrauma, burn, transplant, oncologic)
— Chronic pain patients on high baseline MME
— Addiction medicine: OUD, AUD, polysubstance use, MAT initiation/continuation
— Psychiatry: severe anxiety, catastrophizing, delirium not responsive to standard measures
— Palliative care: cancer-related surgery, refractory symptoms, complex goals of care
— Surgery (primary team): any concern for surgical complication driving pain escalation
— Anesthesia/regional: malfunctioning epidural, new neurologic deficit, regional reinsertion
— PT/OT: early mobilization is itself analgesic and reduces complications
— Sedation score ≥3 with RR <10, SpO₂ <90%
— Acute mental status change
— New chest pain, dyspnea, hypotension postop
Step 3 management: Patient with PCA on the floor develops RASS −4 and RR 6 — immediate orders: stop PCA, naloxone 0.04 mg IV titrate q1min, bag-mask if needed, continuous SpO₂/EtCO₂, ABG, rapid response, transfer to step-down/ICU, then reformulate analgesia plan with regional/non-opioid emphasis.
CCS pearl: Don't forget "consult Acute Pain Service" as an order for any opioid-tolerant patient or those with failed first-line regimen — it appears in CCS scoring rubrics for complex surgical cases.
Board pearl: A postop patient on prophylactic LMWH who develops new lower extremity weakness with an indwelling epidural = stop LMWH, MRI spine STAT, neurosurgery consult, prepare for emergent laminectomy — every minute counts (functional recovery drops sharply after 8h).
— Hematoma: expanding mass, ecchymosis, Hgb drop — US/CT, may need evacuation
— Wound infection/abscess: erythema, fluctuance, fever, leukocytosis — incision and drainage, antibiotics
— Anastomotic leak (GI): peritonitis, sepsis, ileus — CT with contrast, return to OR
— Compartment syndrome: pain out of proportion, pain on passive stretch, tense compartment, paresthesia — pressures >30 mmHg or ΔP <30 → emergent fasciotomy
— Mesenteric ischemia: pain out of proportion to exam, lactic acidosis — CTA, vascular surgery
— Bowel obstruction/ileus: distention, vomiting, no flatus — KUB, CT, NG decompression
— PE: pleuritic pain, dyspnea, tachycardia, hypoxia — D-dimer of limited use postop; CTPA
— MI: postop type 2 MI common; ECG, troponin, especially elderly/CAD
— Pneumonia/atelectasis: pleuritic pain, fever, hypoxia — CXR
— DVT: unilateral leg pain/swelling — Doppler US
— Urinary retention: suprapubic pain — bladder scan, straight cath
— Constipation/fecal impaction: abdominal pain, distention — KUB, manual disimpaction, laxatives
— C. difficile: postop antibiotics + abdominal pain + diarrhea — stool PCR
— Post-dural puncture headache (PDPH): positional headache 24–72h after spinal/epidural; conservative (caffeine, hydration), epidural blood patch if persistent
— Transient neurologic symptoms (TNS) after spinal lidocaine
— Failed block: requires alternative analgesia, not opioid escalation alone
Key distinction: Pain out of proportion to exam is the cardinal sign of three time-critical surgical emergencies — compartment syndrome, mesenteric ischemia, and necrotizing fasciitis. The Step 3 stem will reward workup over opioid escalation every time.
Board pearl: Any postop patient with sudden tachycardia, hypoxia, and pleuritic chest pain — PE is the answer until proven otherwise; CTPA is the next step. Don't be distracted by "incisional pain" framing.
— Opioid withdrawal: yawning, lacrimation, rhinorrhea, mydriasis, piloerection, abdominal cramping, diarrhea, anxiety, tachycardia, hypertension — onset 6–24h after last dose; treat with resuming baseline opioid (or methadone/buprenorphine), clonidine, symptomatic care
— Alcohol withdrawal: tremor, tachycardia, hypertension, diaphoresis, hallucinations, seizures, DTs — CIWA-Ar, benzodiazepines (lorazepam in hepatic disease), thiamine before glucose
— Benzodiazepine withdrawal: tremor, anxiety, seizures — taper slowly, do not abruptly stop chronic users
— Nicotine withdrawal: irritability, craving, restlessness — nicotine replacement
— Always check PDMP and home med list preop
— Especially elderly, ICU, hip surgery, cardiac surgery
— Hypoactive delirium often missed
— Causes: inadequate or excessive analgesia, infection, electrolytes, hypoxia, sleep disruption, anticholinergics, benzos
— Treat underlying cause; nonpharm first; haloperidol or quetiapine sparingly
— Anxiety, depression, PTSD, catastrophizing amplify reported pain — co-manage with psych support, not opioid escalation
— Somatic symptom disorder considerations in persistent post-surgical pain
— Shoulder pain after laparoscopy (CO₂ diaphragmatic irritation) — reassurance, NSAIDs, ambulation
— Back pain from positioning, prolonged supine — PT, NSAIDs
— Headache: caffeine withdrawal (common!), PDPH, hypertension, dehydration
— Sore throat from intubation — lozenges, reassurance
— Bisphosphonate-induced bone pain, statin myalgia, fluoroquinolone tendinopathy
— Drug-induced pancreatitis (steroids, valproate)
Step 3 management: A patient on chronic methadone 80 mg admitted for elective surgery — continue methadone at home dose (consider splitting BID for analgesic effect) + multimodal non-opioid + short-acting opioid PRN for breakthrough; do not stop methadone and "start fresh."
Board pearl: Postop tachycardia + hypertension + diaphoresis + anxiety in a smoker/drinker is alcohol withdrawal until proven otherwise — not "anxiety" or "uncontrolled pain." Initiate CIWA protocol and thiamine immediately.
— Match quantity to procedure-specific evidence (typically 5–15 tablets for most ambulatory surgeries; <3 days for many)
— No refills without reassessment
— Avoid co-prescribing benzodiazepines, gabapentinoids, sedating muscle relaxants
— Use short-acting only; no long-acting/ER opioids in opioid-naïve discharge
— Check PDMP before every opioid prescription
— Document indication, expected duration, taper plan
— Prescribe to: patients on ≥50 MME/day, concurrent benzodiazepine, OUD history, OSA, household risk (children, opioid users)
— Educate patient and family on use; many states have standing orders
— Scheduled acetaminophen + NSAID (if no contraindication) for 5–7 days
— Topical agents: lidocaine patch, diclofenac gel for incisional pain
— Ice/heat, elevation, early mobilization
— Bowel regimen as long as on opioids
— Realistic expectations: some pain is normal; goal is function, not zero pain
— How to taper opioids (reduce by 1 dose every 1–2 days as pain improves)
— Safe storage (lockbox), safe disposal (DEA take-back, drug deactivation pouches, mix with coffee grounds)
— Red flags: fever, expanding wound, new neurologic symptoms, severe escalating pain
— Up to 6% of opioid-naïve patients become chronic opioid users after surgery — the leading iatrogenic source of new opioid use
— Even a single perioperative prescription increases 1-year opioid use risk
— CDC 2022 guidelines: lowest effective dose, shortest duration, immediate-release only, taper
— If pain persists beyond expected healing (6 weeks), refer to chronic pain specialist
— Screen for neuropathic features → gabapentin, duloxetine, TCAs
— Multidisciplinary: PT, CBT, interventional pain procedures
Step 3 management: For a healthy adult after laparoscopic cholecystectomy: discharge with acetaminophen 1 g q6h scheduled × 5 days + ibuprofen 600 mg q6h scheduled × 5 days + oxycodone 5 mg q4h PRN, #10 tablets, no refills, with naloxone if risk factors and written taper instructions.
Board pearl: PDMP query before every controlled substance prescription is required in most US states and is a frequently tested patient-safety/legal item.
— Phone or telehealth check at 24–72h: pain control, opioid use, side effects, red flags
— In-person surgical follow-up 1–2 weeks: wound, function, pain trajectory, opioid taper
— At 4–6 weeks: assess return to baseline function; if not, evaluate for complication or PPSP
— At 3 months: any persistent pain = formal PPSP evaluation
— Pain scores (rest and movement), opioid consumption (MME/day trend)
— Function: ADLs, ambulation distance, return to work, sleep quality
— Side effects: constipation, sedation, nausea
— Mood: depression and anxiety screening (PHQ-2, GAD-2) — comorbidity drives chronification
— For NSAIDs: BMP if prolonged use, BP monitoring
— For gabapentinoids: sedation, gait stability, taper progress
— Early mobilization is itself analgesic — bed rest worsens pain, deconditioning, DVT, atelectasis
— Physical therapy for joint procedures, spine, major abdominal
— Occupational therapy for ADL recovery
— Pulmonary rehab and incentive spirometry post-thoracic/upper abdominal
— Cardiac rehab post-CABG
— Pelvic floor PT post-pelvic/gyn surgery
— Sleep hygiene (pain disrupts sleep, sleep loss amplifies pain — bidirectional)
— Smoking cessation (slows healing, ↑ pain, ↑ chronic pain risk)
— Alcohol moderation (interacts with opioids and acetaminophen)
— Nutrition and protein intake for wound healing
— Anxiety/CBT resources
— Postop opioid prescribing volume tracked; new persistent opioid use is a quality measure
— Patient-reported outcomes (PROMs) increasingly tied to reimbursement
— Readmissions for pain are largely preventable with structured discharge planning
Step 3 management: Schedule a structured 72-hour postdischarge phone call for every surgical patient discharged on opioids — high-yield intervention reducing ED visits, readmissions, and opioid escalation; an evidence-based answer to "next best step in transition of care."
Board pearl: Persistent pain at 3 months postop with neuropathic features → start duloxetine 30 mg daily (or gabapentin titrated) and refer to multidisciplinary chronic pain clinic — early treatment of PPSP improves long-term outcomes.
— Regional anesthesia: discuss risks (nerve injury 0.02–0.4%, LAST, hematoma, infection, failure) and alternatives — specifically document
— Opioid risk discussion at discharge: dependence, addiction, overdose, driving impairment — required in many states (e.g., NY I-STOP, CA, MA)
— Patients with cognitive impairment: surrogate decision-maker for regional and complex analgesia decisions
— PDMP query: required by state law before opioid prescriptions in most states
— Suspected diversion: document and address; report per institutional policy
— Pediatric overdose, intentional overdose: report per state child/adult protection statutes
— Impaired driving on opioids: counsel patients; some states mandate physician reporting of impaired drivers
— Discharge medication reconciliation is a Joint Commission National Patient Safety Goal — failure is a leading cause of adverse events
— Common errors: continuing inpatient opioid doses unchanged at home, duplicate acetaminophen across products, missed taper instructions, failure to restart preop chronic meds
— Standardized handoff (e.g., I-PASS), warm handoff to primary care, structured discharge summary including opioid plan with stop date
— Documented disparities: Black and Hispanic patients receive less analgesia for equivalent surgeries; women's pain often undertreated; patients labeled "drug-seeking" face bias
— Use objective tools (validated scales), apply protocols uniformly, examine your own practice patterns
— Trauma-informed care for patients with history of abuse, OUD, incarceration
— OUD patients on buprenorphine: discuss expected need for higher full-agonist doses, plan for breakthrough
— Jehovah's Witness: blood-conservation regional anesthesia, tranexamic acid, multimodal to avoid transfusion triggers
— Pediatric assent + parental consent
— Co-prescribing alerts (opioid + benzo + gabapentinoid)
— Standardized PCA orders with mandatory monitoring
— Sedation scoring with every opioid administration
— Anticoagulation–neuraxial timing checklists
Step 3 management: Before discharging a postop patient with a new opioid prescription, you must: (1) query the PDMP, (2) document an opioid risk/benefit discussion, (3) reconcile against home medications, (4) prescribe lowest effective quantity with stop date, (5) co-prescribe naloxone if indicated, (6) schedule 72h follow-up — missing any of these is a tested safety failure.
Board pearl: Co-prescribing an opioid with a benzodiazepine triggers an FDA black box warning and is a leading sentinel-event risk — the exam-correct action is to deprescribe one (usually the benzo, with appropriate taper) before discharge.
— Meperidine → normeperidine → seizures (especially renal failure)
— Morphine → M6G accumulation → respiratory depression in CKD
— Codeine/tramadol → CYP2D6 ultrarapid metabolizer → pediatric/breastfeeding deaths (FDA black box)
— Tramadol + SSRI/SNRI → serotonin syndrome; tramadol → seizures
— Methadone → QT prolongation, torsades (baseline + follow-up ECG)
— Fentanyl patch → only for opioid-tolerant, never opioid-naïve postop
— Ketorolac >5 days → AKI, GI bleed
— Acetaminophen + chronic EtOH → hepatotoxicity at therapeutic doses
— Gabapentin + opioid → respiratory depression, falls
— Bupivacaine intravascular → LAST → lipid emulsion 20%
— Epidural + LMWH timing violation → epidural hematoma
— Thoracotomy → thoracic epidural or paravertebral/erector spinae
— Open abdominal → thoracic epidural or TAP + IV lidocaine
— TKA → adductor canal + IPACK
— THA → fascia iliaca or PENG block
— Shoulder → interscalene
— Hand/forearm → supraclavicular/infraclavicular
— Foot/ankle → popliteal sciatic + saphenous
— C-section → spinal with intrathecal morphine
— Breast → PEC I/II or erector spinae
— Inguinal hernia → TAP or ilioinguinal/iliohypogastric
— Morphine 10 mg IV = 30 mg PO
— Oxycodone 20 mg PO ≈ morphine 30 mg PO
— Hydromorphone 1.5 mg IV ≈ morphine 10 mg IV
— Hydromorphone 7.5 mg PO ≈ morphine 30 mg PO
— Fentanyl 100 mcg IV ≈ morphine 10 mg IV
— Reduce 25–50% for incomplete cross-tolerance on rotation
— Opioid overdose → naloxone
— LAST → 20% lipid emulsion
— Acetaminophen overdose → N-acetylcysteine
— Benzodiazepine overdose → flumazenil (rarely used postop — seizure risk)
Board pearl: "Postop patient on hydrocodone-acetaminophen 10/325 four tabs/day plus OTC Tylenol 500 mg q6h" → calculate: 1300 + 2000 = 3300 mg/day acetaminophen — already at the elderly/hepatic limit. The tested error is duplicate acetaminophen across combination products.
— Healthy adult, opioid-naïve, post-laparoscopic cholecystectomy or hernia repair
— Answer: scheduled acetaminophen + NSAID + local infiltration/TAP + low-dose oxycodone PRN
— Distractors: IV morphine PCA with basal rate (wrong — basal in naïve), scheduled oxycodone (wrong — PRN only), opioid monotherapy (wrong)
— Elderly, OSA, on PCA with basal infusion, RR 6, sedated
— Answer: stop PCA, titrate naloxone 0.04 mg, reassess regimen, switch to regional/non-opioid emphasis, continuous monitoring
— Distractor: give full 0.4 mg naloxone (wrong — precipitates pain, HTN, pulmonary edema)
— Patient with epidural catheter, prophylactic enoxaparin given 4h ago, new lower extremity weakness
— Answer: emergent MRI spine, neurosurgery consult — epidural hematoma
— Distractor: "wait and see if local anesthetic wearing off" (wrong — emergency)
— Lower extremity fracture s/p ORIF, escalating pain despite high opioid, pain on passive stretch
— Answer: measure compartment pressures, emergent fasciotomy
— Distractor: increase opioid dose
— On methadone 80 mg or buprenorphine 16 mg, undergoing surgery
— Answer: continue baseline opioid/MAT, multimodal aggressive, add full agonist for breakthrough, APS consult
— Distractor: stop buprenorphine 72h before surgery (outdated)
— Child age 8 post-T&A, pain at home
— Answer: scheduled acetaminophen + ibuprofen, oxycodone PRN if severe; avoid codeine and tramadol
— Distractor: codeine syrup
— CKD 4 patient post-surgery
— Answer: acetaminophen + hydromorphone or fentanyl + regional; avoid NSAIDs, morphine, codeine, tramadol
— Patient on chronic benzo, postop pain, what to prescribe
— Answer: minimize opioid, prefer non-opioid; if opioid necessary, co-prescribe naloxone, taper benzo if possible, document risk discussion
— During interscalene block, patient develops perioral numbness, tinnitus, then seizes
— Answer: stop injection, ABCs, 20% lipid emulsion 1.5 mL/kg bolus then infusion
— Post-thoracotomy at 4 months with burning chest wall pain
— Answer: gabapentin or duloxetine, refer to multidisciplinary pain clinic
Board pearl: When the stem says "next best step" for postop pain — first ask: is this a new complication (workup), an inadequate regimen (optimize multimodal), or opioid toxicity (deescalate)? Choosing the right bucket nails the question.
Step 3 management: The single most repeated correct answer flavor on Step 3 postop pain stems is "add scheduled non-opioid analgesics and a regional block" before escalating opioids — when in doubt, opioid-sparing wins.
Optimal postoperative analgesia is multimodal — scheduled acetaminophen plus an NSAID, plus regional or local anesthesia whenever feasible, plus short-acting opioids only as PRN rescue — tailored to the procedure, the patient's organ function, and their opioid history, with continuous reassessment and a structured opioid taper at discharge.
— Foundation: scheduled acetaminophen (≤4 g/day, ≤2 g cirrhosis) + NSAID (avoid if AKI, GI bleed, severe HF) reduces opioid use 30–50%
— Regional anesthesia is the highest-impact opioid-sparing intervention — thoracic epidural for thoracotomy/open abdominal, adductor canal for TKA, fascia iliaca/PENG for THA, interscalene for shoulder, TAP for abdominal, spinal morphine for C-section
— Opioids PRN only in opioid-naïve; never basal-rate PCA in opioid-naïve; rotate by 25–50% dose reduction for incomplete cross-tolerance
— Avoid: meperidine (always), codeine/tramadol in children <12 and breastfeeding (FDA black box), morphine in CKD, NSAIDs if eGFR <30, opioid + benzo co-prescribing (FDA black box)
— Special populations: elderly — start low, prefer regional, max acetaminophen 3 g; OUD — continue methadone/buprenorphine, aggressive multimodal; pregnancy — acetaminophen first-line, avoid NSAIDs after 20 weeks
— Safety bundles: PDMP before every opioid prescription, naloxone co-prescription for high-risk, 72h post-discharge phone call, ASRA anticoagulation–neuraxial timing
— Red flags: pain out of proportion (compartment syndrome, ischemia), new neurologic deficit with epidural + anticoagulation (hematoma — MRI stat), sudden severe pain after improvement (surgical complication — workup before dosing)
— Long term: persistent pain >3 months = PPSP — duloxetine/gabapentin, multidisciplinary referral; 6% of opioid-naïve patients become chronic users after surgery, making stewardship a primary prevention duty
Board pearl: The exam reward goes to the clinician who prevents opioid harm via multimodal design upfront, reassesses before escalating, and transitions care with explicit taper plans, naloxone, PDMP review, and structured follow-up — the entire arc from preop to 3-month outcome is fair game on Step 3.