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Canadian Journal of Anesthesia/Journal canadien d'anesthésie
Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie 8/2022

17-05-2022 | Opioids | Special Article

Elective surgery in ankle and foot disorders—best practices for management of pain: a guideline for clinicians

Authors: Derek Dillane, MD, FCARCSI, Ailar Ramadi, PT, PhD, Stephanie Nathanail, MA, CAT, Bruce D. Dick, PhD, R. Psych, Geoff Bostick, PT, PhD, Kitty Chan, MD, Chris Douglas, BScRN, Gordon Goplen, MD, James Green, MD, Susan Halliday, MD, Braiden Hellec, BScPharm, Saifee Rashiq, MD, Angela Scharfenberger, MD, Guy Woolsey, MD, Lauren A. Beaupre, PT, PhD, M. Elizabeth Pedersen, MD, MSc

Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie | Issue 8/2022

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Abstract

Purpose

Complex elective foot and ankle surgeries are often associated with severe pain pre- and postoperatively. When inadequately managed, chronic postsurgical pain and long-term opioid use can result. As no standards currently exist, we aimed to develop best practice pain management guidelines.

Methods

A local steering committee (n = 16) surveyed 116 North American foot and ankle surgeons to understand the “current state” of practice. A multidisciplinary expert panel (n = 35) was then formed consisting of orthopedic surgeons, anesthesiologists, chronic pain physicians, primary care physicians, pharmacists, registered nurses, physiotherapists, and clinical psychologists. Each expert provided up to three pain management recommendations for each of the presurgery, intraoperative, inpatient postoperative, and postdischarge periods. These preliminary recommendations were reduced, refined, and sent to the expert panel and “current state” survey respondents to create a consensus document using a Delphi process conducted from September to December 2020.

Results

One thousand four hundred and five preliminary statements were summarized into 51 statements. Strong consensus (≥ 80% respondent agreement) was achieved in 53% of statements including the following: postsurgical opioid use risk should be assessed preoperatively; opioid-naïve patients should not start opioids preoperatively unless non-opioid multimodal analgesia fails; and if opioids are prescribed at discharge, patients should receive education regarding importance of tapering opioid use. There was no consensus regarding opioid weaning preoperatively.

Conclusions

Using multidisciplinary experts and a Delphi process, strong consensus was achieved in many areas, showing considerable agreement despite limited evidence for standardized pain management in patients undergoing complex elective foot and ankle surgery. No consensus on important issues related to opioid prescribing and cessation highlights the need for research to determine best practice.
Appendix
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Metadata
Title
Elective surgery in ankle and foot disorders—best practices for management of pain: a guideline for clinicians
Authors
Derek Dillane, MD, FCARCSI
Ailar Ramadi, PT, PhD
Stephanie Nathanail, MA, CAT
Bruce D. Dick, PhD, R. Psych
Geoff Bostick, PT, PhD
Kitty Chan, MD
Chris Douglas, BScRN
Gordon Goplen, MD
James Green, MD
Susan Halliday, MD
Braiden Hellec, BScPharm
Saifee Rashiq, MD
Angela Scharfenberger, MD
Guy Woolsey, MD
Lauren A. Beaupre, PT, PhD
M. Elizabeth Pedersen, MD, MSc
Publication date
17-05-2022
Publisher
Springer International Publishing
Keywords
Opioids
Opioids
Published in
Canadian Journal of Anesthesia/Journal canadien d'anesthésie / Issue 8/2022
Print ISSN: 0832-610X
Electronic ISSN: 1496-8975
DOI
https://doi.org/10.1007/s12630-022-02267-4

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