Pain Management for Ambulatory Surgery: Current Controversies and Concerns

Purpose of Review: Adequate pain control is essential for ensuring optimal outcomes after ambulatory surgery. However, postoperative pain continues to be inadequately treated. This review presents the available evidence regarding strategies for pain management for ambulatory surgery with the aim of developing an optimal procedure-specific multimodal approach. Recent Findings: Optimal analgesic strategy should include preoperative identification of patients at high risk of postoperative pain, patient education, and an opioid-sparing multimodal analgesic technique using non-opioid analgesics such as acetaminophen and non-steroidal anti-inflammatory drugs or cyclooxygenase-2 specific inhibitors combined with dexamethasone and procedure-specific local/regional analgesia techniques. In addition, non-pharmacologic therapies further improve pain relief and reduce opioid requirements. Summary: Pain management after ambulatory surgery poses unique challenges. The goal of pain management in this setting should not only be minimizing pain at rest, but also promoting early mobilization and active participation in physical therapy. Because of significant variations in postoperative pain, the analgesic technique should be individualized, which requires procedure-specific and patient-specific approaches. Unless contraindicated, all patients should receive a combination of acetaminophen and either a non-steroidal anti-inflammatory drug or cycoxygenase-2 specific inhibitor preoperatively or intraoperatively and continued postoperatively. These drugs should be supplemented with intraoperative dexamethasone and procedure-specific regional analgesic technique and/or surgical site local anesthetic infiltration. Opioids should be administered as a rescue. Patients should be closely followed for early identification and management of those with an abnormal pain trajectory and persistent opioid use. Finally, integration of a procedure-specific pain management regimen in a multidisciplinary-enhanced recovery pathway should improve pain control and avoid analgesic gaps.