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ⓘ This audio and summary are simplified educational interpretations and are not a substitute for the original text.
Key Takeaways
- Opioid-induced hyperalgesia represents a paradoxical increase in pain sensitivity that develops with chronic opioid use and cannot be reversed through dose escalation alone.
- Ketamine and systemic lidocaine infusions provide opioid-sparing benefits and are particularly valuable in managing opioid-tolerant patients and preventing postoperative complications.
- Buprenorphine should generally continue perioperatively as a partial mu-receptor agonist requiring augmented multimodal and regional anesthesia rather than abrupt discontinuation.
- Specific chronic pain syndromes including phantom limb pain, fibromyalgia, and complex regional pain syndrome each require distinct anesthetic approaches and regional techniques.
- Implantable devices such as intrathecal pumps and spinal cord stimulators necessitate preoperative interrogation and specific reprogramming protocols before surgical anesthesia induction.
- Severely obese and pregnant chronic opioid patients represent special populations requiring tailored perioperative strategies to minimize respiratory and neonatal risks.
Chapter SummaryWhat this audio overview covers
Chronic pain management in the perioperative setting requires a nuanced understanding of pharmacologic strategies, patient-specific considerations, and the complex interplay between analgesic tolerance and heightened pain sensitivity. Elevated postoperative pain contributes to delirium, chronic pain syndrome development, prolonged hospitalization, and escalating opioid consumption, making individualized anesthetic planning essential. Ketamine infusions function as N-methyl-d-aspartate receptor antagonists and benefit opioid-tolerant patients, those at risk for sleep apnea complications, and individuals prone to opioid-induced hyperalgesia, a paradoxical phenomenon where increased pain sensitivity develops despite chronic opioid exposure and cannot be reversed through dose escalation alone. Systemic lidocaine infusions provide significant opioid-sparing effects while reducing postoperative nausea, pain intensity, and ileus duration, particularly in abdominal and thoracic procedures. Management of chronic opioid users demands special attention to opioid-induced hyperalgesia prevention through NMDA antagonists, magnesium supplementation, and opioid rotation strategies. Buprenorphine, a partial mu-receptor agonist with high affinity and extended half-life, should generally continue through surgery with augmented multimodal and regional anesthesia rather than perioperative discontinuation. Specific chronic pain syndromes present distinct perioperative challenges: phantom limb pain affects 50 to 80 percent of amputees and responds to neuraxial techniques and peripheral nerve catheters; cancer pain patients require assessment for opioid tolerance, chemotherapy-related sequelae, and metastatic disease before neuraxial procedures; fibromyalgia mandates gabapentinoid-based multimodal approaches since opioid efficacy diminishes in this population; and complex regional pain syndrome benefits from minimally invasive surgical approaches, reduced tourniquet time, and aggressive regional catheter analgesia. Special populations including severely obese patients, where regional techniques are strongly preferred to minimize opioid-related respiratory depression, and pregnant patients on chronic opioid therapy, where supervised withdrawal risks outweigh continuation risks, require tailored strategies. Implantable devices including intrathecal drug delivery systems and spinal cord stimulators demand specific perioperative protocols: IDDS pumps require interrogation surrounding magnetic resonance imaging, while neuromodulation devices must be deactivated and reprogrammed before anesthesia induction, with monopolar electrosurgery avoided when possible.