Postsurgical Pain Management Toolkit

• Reduce acute post-operative pain to a tolerable level (not necessarily eliminate all pain)
• Tailor pain control strategies to individual patient needs and surgery type

• Support early mobilization and physical therapy
• Facilitate participation in activities of daily living (e.g., walking, breathing exercises)
• Shorten hospital stays and reduce readmissions

• Reduce risk of complications such as pneumonia, deep vein thrombosis (DVT), or chronic post-surgical pain
• Support respiratory function by enabling deep breathing and coughing

• Use the lowest effective dose for the shortest duration
• Prioritize non-opioid and multimodal analgesia to reduce dependence and risk of misuse

• Address pain proactively and set realistic expectations
• Educate patients about pain control plans, side effects, and when to seek help

• Help patients resume normal physical activity, self-care, and social roles
• Enable participation in rehabilitation programs or home-based care

• Use multimodal analgesia (e.g., NSAIDs, acetaminophen, regional blocks, local anesthetics)
• Tailor treatment to individual risk factors, surgical procedure, and comorbidities
• Monitor for efficacy and adverse effects throughout recovery

Multimodal analgesia is the utilization of multiple pain management modalities for more effective pain control, which can lead to enhanced clinical and economic benefits, including:

Decreases In:

• Opioid use
• Postsurgical complications
• Risk of developing chronic pain
• Acute postsurgical pain
• Length of hospital stay
• Cost per patient

Improvements In:

• Efficiency of hospital resources
• Patient satisfaction

• Acetaminophen
• NSAIDs
• Gabapentinoids
• Transcutaneous Electrical Stimulation (TENS)
• Cryotherapy
• NMDA antagonists (ketamine at low doses)
• Alpha-2 agonists (e.g., clonidine or dexmedetomidine)
• Regional blocks (e.g., TAP block, femoral nerve block)
• Local anesthetics (e.g., bupivacaine or liposomal bupivacaine)
• And more

• Combine non-opioid medications (e.g., acetaminophen, NSAIDs) with local/regional anesthesia when possible.
• Use opioids only when necessary, at the lowest effective dose for the shortest duration.
• Include non-pharmacologic strategies (e.g., ice, elevation, breathing exercises, cognitive-behavioral techniques).

• Tailor strategies to patient factors (e.g., age, comorbidities, prior opioid use, substance use history).
• Engage in shared decision-making with the patient to align treatment with their goals and concerns.
• Consider surgical procedure type and expected pain intensity.

• Use nerve blocks or long-acting local anesthetics (e.g., bupivacaine liposome [Exparel]) when appropriate.
• Consider catheter-based infusion systems for prolonged regional analgesia.

• Use scheduled non-opioid agents first (acetaminophen, NSAIDs).
• Reserve opioids for breakthrough or severe pain.
• Avoid long-acting opioids postoperatively unless already part of a chronic pain regimen.
• Prescribe limited quantities at discharge with follow-up guidance.

• Use validated pain assessment tools
• Monitor response to medications and adjust accordingly.
• Watch for opioid-related adverse effects, including respiratory depression, sedation, and constipation.

• Set realistic expectations: pain will improve, but may not be eliminated.
• Provide written instructions on medication schedules, side effects, and when to seek help.
• Educate about the risks of opioids, safe use, and disposal.

• Provide a clear pain management plan for home.
• Coordinate with primary care or pain specialists if prolonged pain or opioid use is anticipated.
• Ensure patient follow-up if pain persists or worsens after discharge.

• Examination of current postsurgical pain management standards of care reveals that there are alarming gaps in knowledge and practice in how postsurgical pain is managed across the US healthcare continuum. This presents an opportunity for a panel of multidisciplinary key opinion leaders in perioperative pain management to present their expert consensus recommendations and best practices for postoperative pain management.
• The Surgical Pain Consortium provides procedure-specific multimodal pain management recommendations, while considering recently optimized multimodal pain management approaches.
• These recommendations should be utilized as a foundational resource for perioperative pain management. They are not intended to supersede clinical judgment or individual patient choices or values. Ultimately, clinical decision-making must always be customized to the individual situation. The attending physician should make appropriate modifications based on their expertise on a patient-to-patient basis.

• Acetaminophen 1 gm, PO ~2 hours, preoperatively
• Celecoxib 400 mg, PO ~2 hours, preoperatively (OPTIONAL)
• Gabapentin 300-600 mg, PO OR pregabalin 50-75 mg, PO ~ 2 hours, preoperatively
• Consider oxycodone CR 10mg, PO OR Tramadol ER 200 mg, PO, ~ 2 hours, preoperatively in opioid naïve patients who are <65 years old, if no contraindications
  • Patients who are on chronic opioid medications may take their daily dose on the day of surgery, although the exact dosing strategy remains controversial
• Regional analgesia options (for open procedures only)
  • Epidural analgesia
  • Erector spinae plane block

• Minimize intraoperative opioid dose
  • Fentanyl 25-50 mcg boluses as necessary, preferably a total of less than ~1 mcg/kg [IBW]/h
    • Preferably, no long-acting opioid until end of surgery
    • Laparoscopy may be associated with hyperdynamic response, and not necessarily due to pain, thus treating this hemodynamic response with opioids is inappropriate. If necessary, use vasoactive drugs (e.g., esmolol, metoprolol, OR labetalol).
    • Use of intraoperative infusions of ketamine, lidocaine, dexmedetomidine remains controversial and thus their routine use is not recommended.
• Dexamethasone 8 mg IV after induction of anesthesia
• Acetaminophen 1 g IV, if not given preoperatively. May be repeated after 4 h, if necessary.
• Ketorolac 15-30 mg, IV at the end of surgery, if no contraindication AND celecoxib not given preoperatively
• Hydromorphone 5-10 mcg/kg, IBW OR Morphine 0.05-0.1mg/kg, IBW, approximately 20-30 minutes prior to expected time of extubation (i.e., at the start of surgical wound closure)
• Regional analgesia
  • Open procedures: if no preoperative blocks - TAP blocks ± Surgical site infiltration
    • At the end of surgery, surgeon performs local anesthetic infiltration with ropivacaine 300 mg + saline OR liposomal bupivacaine (20 mL) + 0.25% bupivacaine (30 mL) + saline. Total volume: 60-120 mL (based upon the size of the surgical incision). Meticulous injections 1-1.5 mL every 1-1.5 cm into fascial and subdermal tissues.
  • Laparoscopic procedures: Port site infiltration

• Recovery room: Hydromorphone 0.2 – 0.4 mg, IV bolus, until comfortable
• Epidural analgesia: discontinue as soon as patient can tolerate oral analgesics
  • If no epidural analgesia: IV-PCA opioid until oral tolerate oral
• Acetaminophen 1 gm PO q 8 hours, scheduled (If unable to take PO, give IV)
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Gabapentin 300 mg PO q 8 hours OR Pregabalin 50-75 mg PO q 12 hours until discharge
  • Doses should be modified according to creatinine clearance
• IV bolus opioids OR oral opioids for breakthrough (rescue) pain relief
  • Hydromorphone 0.2-0.4 mg, IV bolus, q 4 hours, PRN
  • Oxycodone IR 5-10 mg, PO, q 6 hours, PRN

• Acetaminophen 650 mg – 1 gm, PO q 6-8 hours
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Oxycodone IR 5-10 mg, PO, q 8 hours, PRN OR Tramadol 50-100 mg, PO, q 6 hours, PRN
  • Caution acetaminophen dose should not exceed 4 gm/day

• Acetaminophen 1.5 gm, PO ~2 hours, prior to surgery
• Celecoxib 400 mg, PO ~2 hours, prior to surgery, if available

• Acetaminophen 1 gm, IV, if not given preoperatively
• Dexamethasone 8 mg, IV after induction of anesthesia, if no contraindications
• Ketorolac 30 mg, IV at the end of surgery, if no contraindications, AND celecoxib not given preoperatively
• Port site infiltration
• Intraperitoneal instillation of bupivacaine or ropivacaine may be considered, if basic analgesic technique (acetaminophen + NSAIDs + surgical site infiltration) is not possible OR
• Field blocks performed by the surgeon using high volume of local anesthetic solution, if basic analgesic technique (acetaminophen + NSAIDs + surgical site infiltration) is not possible

• Mini-port (≤ 5 mm). Costs and complications, need to be considered
• Low intra-abdominal pressure (<12 mmHg)
• Saline lavage under the diaphragm followed by suction at the end of surgery
• Deliberate aspiration of pneumoperitoneum under direct vision
  • Open the port and press the abdomen.
  • Could use the suction irrigator placed under the diaphragm.
  • If suction is attached to the trocar, it could suck omentum or bowel into the trocar

• Acetaminophen 650 mg – 1 gm, PO q 6-8 hours
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Oxycodone IR 5-10 mg, PO, q 8 hours, PRN OR Tramadol 50-100 mg, PO, q 6 hours, PRN
  • Caution acetaminophen dose should not exceed 4 gm/day

• Acetaminophen 1 gm, PO ~2 hours, preoperatively
• Celecoxib 400 mg, PO ~2 hours, preoperatively (OPTIONAL)
• Gabapentin 300-600 mg, PO OR pregabalin 50-75 mg, PO ~ 2 hours, preoperatively
• Patients who are on chronic opioid medications should take their daily dose on the day of surgery, although the exact dosing strategy remains controversial
• Local/Regional Analgesia Technique Options
  • Paravertebral analgesia – continuous local anesthetic infusion
  • Erector spinae plane block
  • PECS 1 and 2 blocks

• Minimize intraoperative opioid dose
  • Fentanyl 50 mcg boluses as necessary, preferably, a total of less than ~1 mcg/kg [IBW]/h
    • Preferably, no long-acting opioid until end of surgery
    • If necessary, control hyperdynamic response with vasoactive drugs (e.g., esmolol, metoprolol, OR labetalol)
• Dexamethasone 8 mg IV after induction of anesthesia
• Acetaminophen 1 g IV, if not given preoperatively. May be repeated after 4 h, if necessary
• Ketorolac 15-30 mg, IV at the end of surgery, if no contraindication AND celecoxib not given preoperatively
• Local/Regional Analgesia Technique
  • PECS 1 and 2 blocks by the surgeon or surgical site infiltration prior to closure, if no block was performed preoperatively
• If patient is opioid tolerant: ketamine infusion (0.25 mg/kg bolus followed by infusion 0.1-0.2 mg/kg/h discontinued approximately an hour before end of surgery)

• Recovery room: Hydromorphone 0.2 – 0.4 mg, IV bolus, until comfortable
• Acetaminophen 1 gm PO q 8 hours (If unable to take PO, give IV)
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Gabapentin 300 mg PO q 8 hours OR Pregabalin 50-75 mg PO q 12 hours until discharge
  • Doses should be modified according to creatinine clearance
• IV bolus opioids OR oral opioids for breakthrough (rescue) pain relief
  • Hydromorphone 0.2-0.4 mg, IV bolus, q 3 hours, PRN
  • Oxycodone CR 10 mg, PO, q 12 hours OR Oxycodone IR 5-10 mg, PO, q 6 hours, PRN

• Acetaminophen 650 mg – 1 gm, PO q 6-8 hours
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Oxycodone IR 5-10 mg, PO, q 8 hours, PRN OR Tramadol 50-100 mg, PO, q 6 hours, PRN
  • Caution acetaminophen dose should not exceed 4 gm/day

Preoperative

• Acetaminophen 1 gm, PO ~2 hours, preoperatively
• Patients who are on chronic opioid medications should take their daily dose on the day of surgery, although the exact dosing strategy remains controversial

Intraoperative: After the baby is delivered

• Dexamethasone 8 mg IV
• Ketorolac 30 mg, IV, if no contraindications
• Acetaminophen 1 g IV, if not given preoperatively
• Regional analgesia
  • Tansversus abdominis plane (TAP) blocks ± surgical site infiltration
    • Surgeon performs local anesthetic infiltration with ropivacaine 300 mg + saline OR liposomal bupivacaine (20 mL) + 0.25% bupivacaine (30 mL) + saline. Total volume: 60-120 mL (based upon the size of the surgical incision). Meticulous injections 1-1.5 mL every 1-1.5 cm into fascial and subdermal tissues.
  • TAP blocks performed after the surgery

Postoperative Day 0 – Until Discharge

• Recovery room: Hydromorphone 0.2 – 0.4 mg, IV bolus, until comfortable
• Acetaminophen 1 gm PO q 8 hours, scheduled
• Conventional non-steroidal anti-inflammatory drug, scheduled (e.g., ibuprofen 600 mg PO, q 6-8 h)
• IV bolus opioids OR oral opioids for breakthrough (rescue) pain relief
  • Hydromorphone 0.2-0.4 mg, IV bolus, q 4 hours, PRN
  • Oxycodone IR 5-10 mg, PO, q 6 hours, PRN

Preoperative

• Acetaminophen 1 gm, PO ~2 hours, preoperatively
• Celecoxib 400 mg, PO ~2 hours, preoperatively (OPTIONAL)
• Gabapentin 300-600 mg, PO OR pregabalin 50-75 mg, PO ~ 2 hours, preoperatively
• Patients on chronic opioid medications may take their daily dose on the day of surgery, although the exact dosing strategy remains controversial

Intraoperative

• Minimize intraoperative opioid dose
  • Fentanyl 50 mcg boluses as necessary, preferably a total of less than ~1 mcg/kg [IBW]/h
    • Preferably, no long-acting opioid until end of surgery
    • Laparoscopy may be associated with hyperdynamic response, and not necessarily due to pain, thus treating this hemodynamic response with opioids is inappropriate. If necessary, use vasoactive drugs (e.g., esmolol, metoprolol, OR labetalol).
    • Use of intraoperative infusions of ketamine, lidocaine, dexmedetomidine remains controversial and thus their routine use is not recommended.
• Dexamethasone 8 mg IV after induction of anesthesia
• Acetaminophen 1 g IV, if not given preoperatively. May be repeated after 4 h, if necessary.
• Ketorolac 15-30 mg, IV at the end of surgery, if no contraindication AND celecoxib not given preoperatively
• Hydromorphone 5-10 mcg/kg OR Morphine 0.05-0.1mg/kg, IBW, approximately 20-30 minutes prior to expected time of extubation (i.e., at the start of surgical wound closure)
• Regional analgesia
  • Open procedures: TAP blocks ± Surgical site infiltration
    • At the end of surgery, surgeon performs local anesthetic infiltration with ropivacaine 300 mg + saline OR liposomal bupivacaine (20 mL) + 0.25% bupivacaine (30 mL) + saline. Total volume: 60-120 mL (based upon the size of the surgical incision). Meticulous injections 1-1.5 mL every 1-1.5 cm into fascial and subdermal tissues.
  • Laparoscopic procedures: Port site infiltration

Postoperative Day 0 – Until Discharge

• Recovery room: Hydromorphone 0.2 – 0.4 mg, IV bolus, until comfortable
• Acetaminophen 1 gm PO q 8 hours (If unable to take PO, give IV)
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Gabapentin 300 mg PO q 8 hours OR Pregabalin 50-75 mg PO q 12 hours until discharge
  • Doses should be modified according to creatinine clearance
• IV bolus opioids OR oral opioids for breakthrough (rescue) pain relief
  • Hydromorphone 0.2-0.4 mg, IV bolus, q 4 hours, PRN
  • Oxycodone IR 5-10 mg, PO, q 6 hours, PRN

Post-Discharge

• Acetaminophen 650 mg – 1 gm, PO q 6-8 hours
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Oxycodone IR 5-10 mg, PO, q 8 hours, PRN OR Tramadol 50-100 mg, PO, q 6 hours, PRN
  • Caution acetaminophen dose should not exceed 4 gm/day

Preoperative

• Acetaminophen 1 gm, PO ~2 hours, preoperatively
• Celecoxib 400 mg, PO ~2 hours, preoperatively (OPTIONAL)
• Gabapentin 300-600 mg, PO OR pregabalin 50-75 mg, PO ~ 2 hours, preoperatively
• Patients who are on chronic opioid medications should take their daily dose on the day of surgery, although the exact dosing strategy remains controversial
• Regional analgesia options (for open procedures only)
  • Epidural analgesia
  • Erector spinae plane block

Intraoperative

• Minimize intraoperative opioid dose
  • Fentanyl 50 mcg boluses as necessary, preferably a total of less than ~1 mcg/kg [IBW]/h
    • Preferably, no long-acting opioid until end of surgery
    • Laparoscopy may be associated with hyperdynamic response, and not necessarily due to pain, thus treating this hemodynamic response with opioids is inappropriate. If necessary, use vasoactive drugs (e.g., esmolol, metoprolol, OR labetalol).
    • Use of intraoperative infusions of ketamine, lidocaine, dexmedetomidine remains controversial and thus their routine use is not recommended.
• Dexamethasone 8 mg IV after induction of anesthesia
• Acetaminophen 1 g IV, if not given preoperatively. May be repeated after 4 h, if necessary.
• If patient is opioid tolerant: ketamine (0.25 mg/kg bolus followed by infusion 0.1-0.2 mg/kg/h discontinue approximately an hour before end of surgery)
• Lidocaine infusion as an alternative to regional analgesia (bolus 1.5 mg/kg followed by infusion 1.5 mg/kg/h until the end of surgery or until discharge from the recovery room)
• Ketorolac 15-30 mg, IV at the end of surgery, if no contraindication AND celecoxib not given preoperatively
• Hydromorphone 5-10 mcg/kg OR Morphine 0.05-0.1mg/kg, IBW, approximately 20-30 minutes prior to expected time of extubation (i.e., at the start of surgical wound closure)
• Regional analgesia
  • Open procedures:
    • If no preoperative blocks AND upper and lower umbilical incisions four quadrant TAP blocks OR Surgical site infiltration
    • If no preoperative blocks AND lower umbilical incisions TAP blocks ± surgical site infiltration
    • At the end of surgery, surgeon performs local anesthetic infiltration with ropivacaine 300 mg + saline OR liposomal bupivacaine (20 mL) + 0.25% bupivacaine (30 mL) + saline. Total volume: 60-120 mL (based upon the size of the surgical incision). Meticulous injections 1-1.5 mL every 1-1.5 cm into fascial and subdermal tissues.
  • Laparoscopic procedures: Port site infiltration

Postoperative Day 0 – Until Discharge

• Recovery room: Hydromorphone 0.2 – 0.4 mg, IV bolus, until comfortable
• Epidural analgesia: discontinue as soon as patient can tolerate oral analgesics
  • If no epidural analgesia: IV-PCA opioid until oral tolerate oral
• Acetaminophen 1 gm PO q 8 hours, scheduled (If unable to take PO, give IV)
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Gabapentin 300 mg PO q 8 hours OR Pregabalin 50-75 mg PO q 12 hours until discharge
  • Doses should be modified according to creatinine clearance
• IV bolus opioids OR oral opioids for breakthrough (rescue) pain relief
  • Hydromorphone 0.2-0.4 mg, IV bolus, q 4 hours, PRN
  • Oxycodone IR 5-10 mg, PO, q 6 hours, PRN

• Acetaminophen 1 gm, PO ~2 hours, preoperatively
• Celecoxib 400 mg, PO ~2 hours, preoperatively (OPTIONAL)
• Gabapentin 300-600 mg, PO OR pregabalin 50-75 mg, PO ~ 2 hours, preoperatively
• Patients who are on chronic opioid medications should take their daily dose on the day of surgery, although the exact dosing strategy remains controversial
• Prior to discontinuing conventional non-steroidal anti-inflammatory drugs, patients should receive another non-opioid analgesic such as acetaminophen and/or cyclo-oxygenase (COX)-2 specific inhibitor

• Minimize intraoperative opioid dose
  • Fentanyl 50 mcg boluses as necessary, preferably, a total of less than ~1 mcg/kg [IBW]/h
    • Preferably, no long-acting opioid until end of surgery
    • If necessary, control hyperdynamic response with vasoactive drugs (e.g., esmolol, metoprolol, OR labetalol)
• Dexamethasone 8 mg IV after induction of anesthesia
• Acetaminophen 1 g IV, if not given preoperatively. May be repeated after 4 h, if necessary
• Ketorolac 15-30 mg, IV at the end of surgery, if no contraindication AND celecoxib not given preoperatively
• Regional analgesia
  • Open procedures: if no preoperative blocks - TAP blocks ± Surgical site infiltration
    • At the end of surgery, surgeon performs local anesthetic infiltration with ropivacaine 300 mg + saline OR liposomal bupivacaine (20 mL) + 0.25% bupivacaine (30 mL) + saline. Total volume: 60-120 mL (based upon the size of the surgical incision). Meticulous injections 1-1.5 mL every 1-1.5 cm into all layers of the surgical incision (fascial and subdermal tissues).
  • Laparoscopic procedures: Port site infiltration

• Recovery room: Hydromorphone 0.2 – 0.4 mg, IV bolus, until comfortable
• Acetaminophen 1 gm PO q 8 hours (If unable to take PO, give IV)
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Gabapentin 300 mg PO q 8 hours OR Pregabalin 50-75 mg PO q 12 hours until discharge
  • Doses should be modified according to creatinine clearance
• IV bolus opioids OR oral opioids for breakthrough (rescue) pain relief
  • Hydromorphone 0.2-0.4 mg, IV bolus, q 3 hours, PRN
  • Oxycodone CR 10 mg, PO, q 12 hours OR Oxycodone IR 5-10 mg, PO, q 6 hours, PRN

• Acetaminophen 650 mg – 1 gm, PO q 6-8 hours
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Oxycodone IR 5-10 mg, PO, q 8 hours, PRN OR Tramadol 50-100 mg, PO, q 6 hours, PRN
  • Caution acetaminophen dose should not exceed 4 gm/day

Preoperative

• Acetaminophen 1.5 gm, PO ~2 hours, prior to surgery
• Celecoxib 400 mg, PO ~2 hours, prior to surgery (OPTIONAL)

Intraoperative

• Acetaminophen 1 gm, IV, if not given preoperatively
• Dexamethasone 8 mg, IV after induction of anesthesia, if no contraindications
• Ketorolac 30 mg, IV at the end of surgery, if no contraindications, AND celecoxib not given preoperatively
• Port site infiltration
• Intraperitoneal instillation of bupivacaine or ropivacaine may be considered, if basic analgesic technique (acetaminophen + NSAIDs + surgical site infiltration) is not possible

Surgical Technique

• Mini-port (≤ 5 mm). Costs and complications, need to be considered
• Low intra-abdominal pressure (<12 mmHg)
• Saline lavage under the diaphragm followed by suction at the end of surgery
• Deliberate aspiration of pneumoperitoneum under direct vision
  • Open the port and press the abdomen.
  • Could use the suction irrigator placed under the diaphragm.
  • If suction is attached to the trocar, it could suck omentum or bowel into the trocar

Postoperative

• Acetaminophen 650 mg – 1 gm, PO q 6-8 hours
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Oxycodone IR 5-10 mg, PO, q 8 hours, PRN OR Tramadol 50-100 mg, PO, q 6 hours, PRN
  • Caution acetaminophen dose should not exceed 4 gm/day

• Acetaminophen 1 gm, PO ~2 hours, preoperatively
• Celecoxib 400 mg, PO ~2 hours, preoperatively (OPTIONAL)
• Regional anesthesia: Brachial plexus block through the Interscalene approach

• Minimize intraoperative opioid dose
  • Fentanyl 50 mcg boluses as necessary, preferably, a total of less than ~1 mcg/kg [IBW]/h
    • Preferably, no long-acting opioid until end of surgery
    • If necessary, control hyperdynamic response with vasoactive drugs (e.g., esmolol, metoprolol, OR labetalol)
• Dexamethasone 8 mg IV after induction of anesthesia
• Acetaminophen 1 g IV, if not given preoperatively. May be repeated after 4 h, if necessary
• Ketorolac 15-30 mg, IV at the end of surgery, if no contraindication AND celecoxib not given preoperatively
• At the end of surgery, surgeon performs periarticular local anesthetic infiltration, if the patient has not received brachial plexus block
  • Solution: Ropivacaine 300 mg + saline OR liposomal bupivacaine (20 mL) + 0.25% bupivacaine (30 mL) + saline. Total volume: 40-60 mL (based upon the size of the surgical incision).
  • Technique of Injection: Infiltration should be meticulous and extensive, using direct visualization using a 20 mL syringe with a 1.5-inch 22G needle. Inject as the needle is withdrawn. Deep injections (humeral insertion), Mid layer injections (muscles) and Superficial injections (subdermal tissues and around the drain)

• Recovery room: Hydromorphone 0.2 – 0.4 mg, IV bolus, until comfortable
• Acetaminophen 1 gm PO q 8 hours
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Opioids for breakthrough (rescue) pain relief
  • Oxycodone IR 5-10 mg, PO, q 6 hours, PRN OR Tramadol 50-100 mg, PO, q 6 hours, PRN

• Acetaminophen 650 mg – 1 gm, PO q 6-8 hours
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Oxycodone IR 5-10 mg, PO, q 8 hours, PRN OR Tramadol 50-100 mg, PO, q 6 hours, PRN
  • Caution acetaminophen dose should not exceed 4 gm/day

• Acetaminophen 1 gm, PO ~2 hours, preoperatively
• Celecoxib 400 mg, PO ~2 hours, preoperatively (OPTIONAL)
• Gabapentin 300-600 mg, PO OR pregabalin 50-75 mg, PO ~ 2 hours, preoperatively
• Consider oxycodone CR 10mg, PO OR Tramadol ER 200 mg, PO ~ 2 hours, preoperatively in opioid naïve patients who are <65 years old, if no contraindications
  • Patients who are on chronic opioid medications should take their daily dose on the day of surgery, although the exact dosing strategy remains controversial

• Minimize intraoperative opioid dose
  • Fentanyl 50 mcg boluses as necessary, preferably, a total of less than ~1 mcg/kg [IBW]/h OR remifentanil infusion 0.05 - 0.1 mcg/kg/min
    • Preferably, no long-acting opioid until end of surgery
    • If necessary, control hyperdynamic response with vasoactive drugs (e.g., esmolol, metoprolol, labetalol, OR nicardipine)
    • Use of intraoperative infusions of ketamine, lidocaine, dexmedetomidine remains controversial and thus their routine use is not recommended
• Dexamethasone 8 mg IV after induction of anesthesia
• Acetaminophen 1 g IV, if not given preoperatively. May be repeated after 4 h, if necessary
• Methocarbamol 1000 mg, IV, over 3-5 min, 20-30 min before the end of surgery
• At the end of surgery, surgeon performs local anesthetic infiltration with ropivacaine 300 mg + saline OR liposomal bupivacaine (20 mL) + 0.25% bupivacaine (30 mL) + saline. Total volume: 60-120 mL (based upon the size of the surgical incision). Meticulous injections 1-1.5 mL every 1-1.5 cm into fascial and subdermal tissues. Also, consider muscular injections to reduce muscle spasm

• Recovery room: Hydromorphone 0.2 – 0.4 mg, IV bolus, until comfortable
• Acetaminophen 1 gm PO q 8 hours (If unable to take PO, give IV)
• Celecoxib 200 mg, PO q 12 hours (OPTIONAL)
• Gabapentin 300 mg PO q 8 hours OR Pregabalin 50-75 mg PO q 12 hours until discharge
  • Doses should be modified according to creatinine clearance
• IV bolus opioids OR oral opioids for breakthrough (rescue) pain relief
  • Hydromorphone 0.2-0.4 mg, IV bolus, q 3 hours, PRN
  • Oxycodone CR 10 mg, PO, q 12 hours OR Oxycodone IR 5-10 mg, PO, q 6 hours, PRN
• Methocarbamol 500 mg, PO q 6-8 hours, PRN

• Acetaminophen 650 mg – 1 gm, PO q 6-8 hours, scheduled
• Celecoxib 200 mg, PO q 12 hours (OPTIONAL)
• Oxycodone IR 5-10 mg, PO, q 8 hours, PRN OR Tramadol 50-100 mg, PO, q 6 hours, PRN
  • Caution acetaminophen dose should not exceed 4 gm/day
• Methocarbamol 500 mg, PO q 6-8 hours, PRN

Preoperative

• Acetaminophen 1 gm, PO ~2 hours, preoperatively
• Celecoxib 400 mg, PO ~2 hours, preoperatively (OPTIONAL)
• Gabapentin 300-600 mg, PO OR pregabalin 50-75 mg, PO ~ 2 hours, preoperatively
  • Avoid in patients > 65 years old, morbidly obese with obstructive sleep apnea
  • Doses should be modified according to creatinine clearance
• Patients who are on chronic opioid medications should take their daily dose on the day of surgery, although the exact dosing strategy remains controversial
• Regional analgesia options (for open procedures only)
  • Paravertebral blocks
  • Erector spinae plane blocks

Intraoperative

• Minimize intraoperative opioid dose
  • Fentanyl 50 mcg boluses as necessary, preferably a total of less than ~1 mcg/kg [IBW]/h
    • Preferably, no long-acting opioid until end of surgery
    • Routine use of intraoperative infusions of ketamine, lidocaine, dexmedetomidine remains controversial and thus not recommended.
    • If patient is opioid tolerant: ketamine (0.25 mg/kg bolus followed by infusion 0.1-0.2 mg/kg/h discontinue approximately an hour before end of surgery)
• Dexamethasone 8 mg IV after induction of anesthesia
• Acetaminophen 1 g IV, if not given preoperatively. May be repeated after 4 h, if necessary.
• Ketorolac 15-30 mg, IV at the end of surgery, if no contraindication AND celecoxib not given preoperatively
• If no regional analgesia is administered: hydromorphone 5-10 mcg/kg OR Morphine 0.05-0.1mg/kg, IBW, approximately 20-30 minutes prior to expected time of extubation (i.e., at the start of surgical wound closure)
• Regional analgesia
  • Open procedures:
    • If no preoperative blocks: at the end of surgery, surgeon performs thoracic cavity field blocks with ropivacaine 300 mg + saline OR liposomal bupivacaine (20 mL) + 0.25% bupivacaine (30 – 60 mL) without epinephrine + saline. Total volume: 60-300 mL (based upon the size of the surgical incision).
    • Alternatively, surgeon can place a catheter into the paravertebral or extrapleural space and exteriorize the catheter.
  • Thoracoscopic procedures: Thoracic cavity field block and port site infiltration
  • Chest tube site infiltration with diluted mixture.

Postoperative Day 0 – Until Discharge

• Recovery room: Hydromorphone 0.2 – 0.4 mg, IV bolus, until comfortable, but try to avoid IV Narcs
• Acetaminophen 1 gm PO q 8 hours, scheduled (If unable to take PO, give IV)
• Conventional non-steroidal anti-inflammatory drug (e.g., meloxicam 15 mg, PO q 24 h) OR Celecoxib 200 mg, PO q 12 hours, scheduled or ketoralac 15 – 30 mg IV q 6
• Gabapentin 300 mg PO q 8 hours OR Pregabalin 50-75 mg PO q 12 hours until discharge
  • Doses should be modified according to creatinine clearance
  • Methocarbamol (Robaxin) 500mg – 1000mg IV or PO q 8
• Regional analgesia
  • Continuous local anesthetic infusion through the paraveterbral catheter or intercostal catheter, if available
• Opioids (IV bolus OR oral opioids) for breakthrough (rescue) pain relief
  • Hydromorphone 0.2-0.4 mg, IV bolus, q 4 hours, PRN
  • Oxycodone IR 5-10 mg, PO, q 6 hours, PRN
  • Tramadol 50 mg, PO, q 6 h, PRN

Preoperative

• Acetaminophen 1 gm, PO ~2 hours, preoperatively
• Celecoxib 400 mg, PO ~2 hours, preoperatively (OPTIONAL)
• Gabapentin 300-600 mg, PO OR pregabalin 50-75 mg, PO ~ 2 hours, preoperatively
• Consider oxycodone CR 10mg, PO OR Tramadol ER 200 mg, PO ~ 2 hours, preoperatively in opioid naïve patients who are <65 years old, if no contraindications
  • Patients who are on chronic opioid medications may take their daily dose on the day of surgery, although the exact dosing strategy remains controversial
• Prior to discontinuing conventional non-steroidal anti-inflammatory drugs, patients should receive another non-opioid analgesic such as acetaminophen and/or cyclo-oxygenase (COX)-2 specific inhibitor

Intraoperative

• Minimize intraoperative opioid dose
  • Fentanyl 50 mcg boluses as necessary, preferably, a total of less than ~1 mcg/kg [IBW]/h
    • Preferably, no long-acting opioid until end of surgery
    • If necessary, control hyperdynamic response with vasoactive drugs (e.g., esmolol, metoprolol, OR labetalol)
• Dexamethasone 8 mg IV after induction of anesthesia
• Acetaminophen 1 g IV, if not given preoperatively. May be repeated after 4 h, if necessary
• Ketorolac 15-30 mg, IV at the end of surgery, if no contraindication AND celecoxib not given preoperatively
• At the end of surgery, surgeon performs periarticular local anesthetic infiltration: Infiltration should be meticulous and extensive, using direct visualization using a 20 mL syringe with a 1.5-inch 22G needle. Inject as the needle is withdrawn.
  • Solution: Ropivacaine 300 mg + saline OR liposomal bupivacaine (20 mL) + 0.25% bupivacaine (30 mL) + saline. Total volume: 60-120 mL (based upon the size of the surgical incision).
  • Technique of Injection: Deep injections (posterior capsule and posterior soft tissues): 20-30 mL, mid layer injections: 20-30 mL, and superficial injections (subdermal tissues and around the drain): 20-30 mL

Postoperative Day 0 – Until Discharge

• Recovery room: Hydromorphone 0.2 – 0.4 mg, IV bolus, until comfortable
• Acetaminophen 1 gm PO q 8 hours (If unable to take PO, give IV)
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Gabapentin 300 mg PO q 8 hours OR Pregabalin 50-75 mg PO q 12 hours until discharge
  • Doses should be modified according to creatinine clearance
• IV bolus opioids OR oral opioids for breakthrough (rescue) pain relief
  • Hydromorphone 0.2-0.4 mg, IV bolus, q 4 hours, PRN
  • Oxycodone CR 10 mg, PO, q 12 hours OR Oxycodone IR 5-10 mg, PO, q 6 hours, PRN

Post-Discharge

• Acetaminophen 650 mg – 1 gm, PO q 6-8 hours
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Oxycodone IR 5-10 mg, PO, q 8 hours, PRN OR Tramadol 50-100 mg, PO, q 6 hours, PRN
  • Caution acetaminophen dose should not exceed 4 gm/day

Preoperative

• Acetaminophen 1 gm, PO ~2 hours, preoperatively
• Celecoxib 400 mg, PO ~2 hours, preoperatively (OPTIONAL)
• Gabapentin 300-600 mg, PO OR pregabalin 50-75 mg, PO ~ 2 hours, preoperatively
• Consider oxycodone CR 10mg, PO OR Tramadol ER 200 mg, PO ~ 2 hours, preoperatively in opioid naïve patients who are <65 years old, if no contraindications
  • Patients who are on chronic opioid medications may take their daily dose on the day of surgery, although the exact dosing strategy remains controversial
• Adductor canal block, as an adjunct to periarticular local anesthetic infiltration
• Prior to discontinuing conventional non-steroidal anti-inflammatory drugs, patients should receive another non-opioid analgesic such as acetaminophen and/or cyclo-oxygenase (COX)-2 specific inhibitor

Intraoperative

• Minimize intraoperative opioid dose
  • Fentanyl 50 mcg boluses as necessary, preferably, a total of less than ~1 mcg/kg [IBW]/h
    • Preferably, no long-acting opioid until end of surgery
    • If necessary, control hyperdynamic response with vasoactive drugs (e.g., esmolol, metoprolol, OR labetalol)
• Dexamethasone 8 mg IV after induction of anesthesia
• Acetaminophen 1 g IV, if not given preoperatively. May be repeated after 4 h, if necessary
• Ketorolac 15-30 mg, IV at the end of surgery, if no contraindication AND celecoxib not given preoperatively
• At the end of surgery, surgeon performs periarticular local anesthetic infiltration performs periarticular local anesthetic infiltration: Infiltration should be meticulous and extensive, using direct visualization using a 20 mL syringe with a 1.5-inch 22G needle. Inject as the needle is withdrawn
  • Solution: Ropivacaine 300 mg + saline OR liposomal bupivacaine (20 mL) + 0.25% bupivacaine (30 mL) + saline. Total volume: 60-120 mL (based upon the surgical incision)
  • Technique of Injection:
    • Deep injections: 10 mL into the posterior capsule, the superficial and deep fibers of the medial and lateral collateral ligaments, the iliotibial band and its insertion on Gerdy’s tubercle, the popliteus, the periosteum around the cut surfaces of the medial femur and tibia, the peri-articular synovial reflections, the supra-patellar pouch and the soft-tissue envelope. Inject 10 mL into the quadriceps tendon and muscles and peri-patellar soft tissue.
    • Mid layer injections: 20-30 mL solution into the deep tissue planes including muscle, targeting the femoral, saphenous and posterior tibial nerve distributions
    • Superficial injections: 20-30 mL in the subdermal tissues and around the drain

Postoperative Day 0 – Until Discharge

• Recovery room: Hydromorphone 0.2 – 0.4 mg, IV bolus, until comfortable
• Acetaminophen 1 gm PO q 8 hours (If unable to take PO, give IV)
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Gabapentin 300 mg PO q 8 hours OR Pregabalin 50-75 mg PO q 12 hours until discharge
  • Doses should be modified according to creatinine clearance
• IV bolus opioids OR oral opioids for breakthrough (rescue) pain relief
  • Hydromorphone 0.2-0.4 mg, IV bolus, q 4 hours, PRN
  • Oxycodone CR 10 mg, PO, q 12 hours OR Oxycodone IR 5-10 mg, PO, q 6 hours, PRN

Post-Discharge

• Acetaminophen 650 mg – 1 gm, PO q 6-8 hours
• Conventional non-steroidal anti-inflammatory drug OR Celecoxib 200 mg, PO q 12 hours
• Oxycodone IR 5-10 mg, PO, q 8 hours, PRN OR Tramadol 50-100 mg, PO, q 6 hours, PRN
  • Caution acetaminophen dose should not exceed 4 gm/day

• Expand patient and provider access to FDA approved non-opioid pain management approaches in all outpatient surgical settings beginning in 2025.
• Require a report to Congress on limitations, gaps, barriers to access, or deficits in Medicare coverage or reimbursement for therapeutic services.
• Mandates that Medicare provide ASP+6% reimbursement for FDA-approved qualifying non-opioid options for the management of postsurgical pain
• Provides reimbursement across HOPD and ASC settings

• ENSURE: billing and coding teams thoroughly understand the key tenets of the NOPAIN Act, specifically focusing on additional reimbursement for non-opioid pain management options. Medicare allows you to update claims within 1 year of the date of service, in case your system has not operationalized the NOPAIN Act reimbursement by January 1, 2025.


• CAPTURE: the current utilization of qualifying non-opioid options in postsurgical settings and explore service lines with high outpatient volume or potential for outpatient transition to better understand coding needs. Identifying the need for additional documentation based on service line expansion may help facilitate accurate and timely reimbursement.


• INTEGRATE: HCPCS code J0666 to capture the additional Medicare reimbursement across all outpatient settings for dates of service on or after January 1, 2025. Now that the code is available, perform tests to confirm that the HCPCS codes and workflows are correctly integrated and functioning.


• INFORM: financial, clinical, and operational stakeholders to ensure system-wide readiness. Educate stakeholders on the importance of accurate documentation to support billing and coding. Relevant stakeholders include: revenue cycle management, billing/coding, clinical pharmacists, administrative & organizational leadership, and more (orthopedic surgeons, general surgeons, anesthesiologists).


• TRACK: claims submissions and key outcomes to monitor reimbursement and impact of implementation. Gathering data can aid in leadership discussions and help address P&T Committee queries.

• Reevaluate the utilization of qualifying non-opioids within your health system
• Identifying the need for additional documentation based on service line expansion may help facilitate accurate and timely reimbursement
• Perform tests to confirm that the codes and workflows are correctly integrated and functioning
• Educate relevant stakeholders on the importance of accurate documentation to support billing and coding
• Medicare allows you to update claims within 1 year of the date of service, in case your system has not operationalized NOPAIN Act reimbursement by January 1, 2025
• Once you've implemented NOPAIN Act reimbursement for your Medicare patients, consider leveraging this new ASP+6% CMS reimbursement in the HOPD when negotiating contracts with commercial payers

• Personalize the pain management plan
• Improve patient understanding and expectations
• Minimize opioid exposure when appropriate
• Support functional recovery and satisfaction
• Prevent under-treatment or over-treatment of pain

• What are your biggest concerns about pain after surgery?
• Have you had challenges with pain medications in the past?
• Do you have a history of substance use, addiction, or chronic pain?

• Pain is expected after surgery, but our goal is to keep it at a manageable level—not to eliminate all pain.
• You should be able to breathe, move, and sleep with tolerable discomfort.
• We’ll work together to balance comfort, safety, and recovery.

• Explan the benefits and potential limitations of each option

• Opioids can cause drowsiness, constipation, nausea, and in rare cases, lead to misuse or addiction.
• Not treating pain well can delay recovery and cause complications (e.g., pneumonia, DVT).

• Combine medications and strategies for best effect (multimodal pain management)
• Adjust based on patient pain level, procedure type, and preferences
• Identify who to contact if pain worsens or side effects occur

• Include names and schedules of medications
• Clear signs of when to call for help
• Safe opioid use and storage guidelines, if applicable

• <!--StartFragment -->Postsurgical pain should be discussed as soon as possible when planning for surgery. Some medications are given during surgery, so it is important to discuss your pain management plan with your doctor well before your procedure.<!--EndFragment -->

• Postoperative pain is often managed using a multimodal approach to pain control, which may include:
  • Non-opioid medications (e.g., acetaminophen, NSAIDs, and similar)
  • Local anesthetics (e.g., nerve blocks or long-acting injections, such as Exparel)
  • Other strategies like ice, elevation, or physical therapy
  • Opioids, if needed, but only for short-term use
  • Other methods like ice, movement, and positioning strategies

• Yes - postsurgical pain can be effectively managed without the use of opioids! Even in individuals without a history of addiction, using non-opioid medications for postoperative pain management can reduce the possible side effects associated with opioids, while also alleviating any addiction concerns.

• Follow your medication schedule
• Use cold packs or elevation if instructed
• Keep moving (as directed) to prevent stiffness and complications
• Let us know if pain is worse than expected or not improving

• It is important to educate patients that some pain and discomfort after surgery is normal and may be different for everyone. Let your provider or care team know if your pain increases or becomes severe or not tolerable.