Best Practices
Hysterectomy
All best practices are subject to change and may require modifications depending on a patient’s history and status. Healthcare practitioners should always defer to their clinical judgement and, whenever appropriate, consult with additional resources for further guidance.
Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy — Laparoscopic
| Preoperative | Intraoperative | Postoperative (Inpatient) | Discharge Strategies |
|---|---|---|---|
| •Acetaminophen •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) | •IV NSAIDs if not given preop •Infiltration of local anesthesia at surgical site •Consider IV lidocaine bolus (1-1.5mg/kg) plus infusion at 0.5-1.5mg/kg/hr | •Acetaminophen •NSAIDs •Oral opioids x 24hrs | MANAGEMENT OF PAIN W/O MEDICATION: Suggestions to be submitted by testers CO-ANALGESICS: •Acetaminophen •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) OPIOID PRESCRIPTION*: 0-10 |
Vaginal Hysterectomy with Bilateral Salpingo-Oophorectomy — +/- Laparoscopic Assisted
| Preoperative | Intraoperative | Postoperative (Inpatient) | Discharge Strategies |
|---|---|---|---|
| •Acetaminophen •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) | •IV NSAIDs if not given preop •Consider IV ketamine •Consider IV lidocaine bolus (1-1.5mg/kg) plus infusion at 0.5-1.5mg/kg/hr | •Acetaminophen •NSAIDs •Oral opioids x 24hrs | MANAGEMENT OF PAIN W/O MEDICATION: Suggestions to be submitted by testers CO-ANALGESICS: •Acetaminophen •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) OPIOID PRESCRIPTION*: 0-12 |
Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy — Open Benign with Low Transverse Abdominal Incision
| Preoperative | Intraoperative | Postoperative (Inpatient) | Discharge Strategies |
|---|---|---|---|
| •Acetaminophen •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) •Consider low dose gabapentinoids •Consider thoracic epidural anesthesia if significant patient risk factors | •IV NSAIDs if not given preop •Consider IV ketamine •Consider IV lidocaine bolus (1-1.5mg/kg) plus infusion at 0.5-1.5mg/kg/hr | •Acetaminophen •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) • +/- IV PCA, transition to PO in 24-48 hrs •Consider continue IV lidocaine x 24-48hrs •Consider transversus abdominis plane blocks if discontinuing IV lidocaine •Consider low-dose gabapentinoids | MANAGEMENT OF PAIN W/O MEDICATION: Suggestions to be submitted by testers CO-ANALGESICS: •Acetaminophen •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) OPIOID PRESCRIPTION*: 0-10 tabs |
Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectomy — Open Oncologic with/without Staging or Debulking
| Preoperative | Intraoperative | Postoperative (Inpatient) | Discharge Strategies |
|---|---|---|---|
| •Acetaminophen •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) •Consider low-dose gabapentinoids •Consider regional anesthesia ...oPC thoracic epidural analgesia with local anesthesia and low-dose opioids solution | •IV NSAIDs if not given preop •Consider IV ketamine •Consider IV lidocaine bolus (1-1.5mg/kg) plus infusion at 0.5-1.5mg/kg/hr if no thoracic epidural anesthesia | •Acetaminophen •NSAIDs •Continue thoracic epidural analgesia or IV lidocaine x 24-48hrs •Consider transversus abdominis plane blocks if no thoracic epidural anesthesia and discontinuing IV lidocaine •+/- IV PCA, transition to PO in 24-72hrs •Consider low-dose gabapentinoids | MANAGEMENT OF PAIN W/O MEDICATION: Suggestions to be submitted by testers CO-ANALGESICS: •Acetaminophen •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) OPIOID PRESCRIPTION*: 20-25 tabs |
*All tabs for discharge are oxycodone, 5mg. To convert this dosage, please visit this page. For conversions involving oxycodone, please note that it is 50% more potent than morphine. We encourage prescribers to consider discharge prescriptions of short-acting opioids at the lowest effective dose, with the lowest potency, for the shortest duration.
Before surgery, and at the surgical safety checklist time, the surgical and anesthesia team should work together to develop a multimodal pain management plan with active strategies to optimize perioperative pain management.
Healthcare practitioners are also encouraged to help patients set realistic expectations around pain management, including the use of prescription medications. Additional useful information to enhance recovery after surgery can be found at Enhanced Recovery Canada.
See our full disclaimer here.
References
Clarke HA. Manoo V. Pearsall EA. Goel A. Feinberg A. Weinrib A. et al. Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery. Canadian Journal of Pain. 2020;4(1):67–85.
El Bayoumy R. Guirgis R. Guyer Cl. Trans-Abdominal Plane (TAP) Block Analgesia For Day-Case Laparoscopic Gynaecological Procedures: A Prospective Study: 14AP5-2. Eur. J. Anaesthesiol. 2011 June;28:20.1
Felix MMDS, Ferreira MBG, da Cruz LF, Barbosa MH. Relaxation Therapy with Guided Imagery for Postoperative Pain Management: An Integrative Review. Pain Manag Nurs. 2019 02;20(1):3-9.
Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, et al. Guidelines for Postoperative Care in Gynecologic/Oncology Surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part II. Gynecol Oncol. 2016 Feb;140(2):323-32.
Seagle BL, Miller ES, Strohl AE, Hoekstra A, Shahabi S. Transversus Abdominis Plane Block With Liposomal Bupivacaine Compared To Oral Opioids Alone For Acute Postoperative Pain After Laparoscopic Hysterectomy For Early Endometrial Cancer: A Cost-Effectiveness Analysis. Gynecol Oncol Res Pract. 2017;4:12.
Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHaffie JG, et al. Mindfulness Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced Analgesia. J Neurosci. 2015 Nov 18;35(46):15307-25.
Zeidan F, Martucci KT, Kraft RA, Gordon NS, McHaffie JG, Coghill RC. Brain Mechanisms Supporting the Modulation of Pain by Mindfulness Meditation. J Neurosci. 2011 Apr 6;31(14):5540-8.
Treatment Altering Factors
Below are a few of the more common and/or impactful health factors that may result in deviation from the above best practices. Please note that the following list is not exhaustive and that the remarks for each factor are not surgery-specific. Healthcare practitioners should always defer to their clinical judgement and, if appropriate, consult with additional resources for further guidance. See our full disclaimer here.
Organ Dysfunction
Hepatic dysfunction/Excessive alcohol intake
| •In general: Limit or avoid acetaminophen altogether, depending on degree of hepatic dysfunction •Preoperative: Avoid or reduce dose of acetaminophen •Intraoperative: Decrease dose of opioids, benzodiazepines, meperdine •Postoperative: Reduce dose of acetaminophen •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Renal dysfunction
| •In general: Limit or avoid NSAIDs altogether, depending on degree of renal dysfunction •Preoperative: Avoid NSAIDs and use gabapentinoids cautiously •Intraoperative: Avoid morphine and meperidine •Postoperative: Avoid NSAIDs and use lower dose of gabapentin •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Patient Specific Factors
Advanced age
| •Preoperative: Due to the frequency of multiple comorbidities in advanced age, anesthesia preoperative consult as needed to preoptimize. Also, manage anticoagulants where indicated; avoid long delays in hip fracture patients and practice preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated •Postoperative: Regular dose acetaminophen; oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities |
Chronic pain and/or long-term opiate use
| •In general: May attempt to wean chronic opioids if surgery is to treat issues contributing to the chronic pain but otherwise continue chronic pain medication perioperatively if patient uses it •Preoperative: Anesthesia consult where indicated; continue preop opioids on day of surgery and give preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated; use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance •Postoperative: Use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance; regular dose acetaminophen and oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities and avoid opioid dose escalation from preop, if possible |
History of difficulty with postop pain management
| •Consider regional anesthetic techniques, if feasible for specific surgical procedure |
Uncontrolled anxiety/depressive symptoms
| •Preoperative: Consider anxiolytics prior to administration of anesthetic •Discharge: While reviewing expected duration of opioid use, as well as opioid safety strategies including the appropriate storage and disposal of unused pills, should be standard practice, it is of paticular importance with patients who have uncontrolled anxiety/depressive symptoms Special note for paediatric surgeries: Given the risk of opioid misuse in youth with depressive symptoms, consider heightened opioid safety factors including reviewing with caregivers at discharge |
System Disorders
Coagulopathy
| •Avoid neuraxial techniques if any abnormal coagulation; consider following ASRA guidelines |
Obstructive sleep apnea
| •Preoperative: Use multi-modal analgesia; reduce or avoid use of gabapentinoids •Intraoperative: Reduce or avoid benzodiazepines; reduce doses of opioid medications •Postoperative: Use multi-modal analgesia; reduce use of opioids and gabapentinoids •Discharge: Reduce opioid dosing |