In the immediate post operative period it should be intravenous infusion by syringe pump. Later it can be shifted to oral/transmucosal preparations

I think the choice depends on several factors e,g type of operation,pain severity, level of post op monitoring, local policy and training. Epidural opioids can be used for certain types of patients.I am not aware strong evidence regarding the choice between IM and IV opioids, however, I prefer to use intravenous opioids if the patient is closely monitored postoperatively preferably by PCA .

I agree with Ghazi it obviously depends on type of surgery, site of surgery i prefer to give opioids by IV route or epidurally if surgery permits. later stage can use fentanyl patch which works excellently with less of side effects and prolonged action & requires less monitoring.

The use of IM opioids post-operatively is an out dated practice that disregards the advances made in pain medicine in the last 30 years. Intervels between IM injections is often much lower than the duration of action of opioid given. There is a wealth of evidance for PCA, putting the patient in control of the amount of analgesia they require and avoiding the peak and trough effect of IM injections. A persons perception of pain is not totally reflected by the type and severity of the surgery. Many other factors influance the persons individual perception of their pain.

One of my students is currently doing a useful review of Patient controlled intravenous opioids versus nurse controlled IV opioids and has found little difference between the two except for the fact that the presence of the nurse is said to be less vital in the former. I agree with the comments above that IM injections are rarely warranted, epidural can give very effective analgesia with limited side effects but all methods require vigilance for side effects, toxic effects and pain assessment. The occurance of 'late' toxic effects with epidural and transdermal fentanyl requires excellent vigilance.

I agree that the least invasive route of pain management post-operatively is advisable. IM injections are no longer used since there are more effective alternatives. With new anesthesia techniques including regional nerve blocks and laparoscopic surgery many patients can begin oral pain medications early on after surgery. Oral pain medications are safer and prepare the patient for discharge on a medication regimen that is effective after discharge.

It is important to appreciate the efficacy of oral analgesia in post-operative pain. If we use numbers needed to treat as a guide we can see that common oral analgesics such as a combination of ibuprofen and paracetamol can have as good an effect as 10mg morphine (IM equivalence). These may be disregarded or mistrusted because of ignorance about NNT data. I accept that NNT data is single use in toothpain usually but it still provides a rough guide for acute pain situations.

Patient control analgesia is the best with proper setup dose and lock out time regarding to opiods which you select

PCA or epidural as per suitability of set up, patient's education level , level of post operative monitoring available . IM injections a total NO. Fentanyl patches can also work in postop if suitably timed and aplied.

The Best way for Treatment of postoperative Pain is i.v. But we do not forget subcutaneous, and other in experimental pase like inhalatory .

Most safer use is epidural route for administration of opioids for post of pain relief

The best practice for administration of opioids in treatment of postoperative pain differ according to situation of incisional acces, type or surgery, intensity of pain, and patient pathlogies or drug interactions...

If Regional pain is possible, Regional anesthesia procedures with opioids and local anesthetics are needed, in this aspect I am agree with Sharon. the ESRA has launched a clinical practice guideline for this objetive.

But other procedures need drugs with strong analgesic potence, by very fast onset and brief action, security margin, minor secondary effects, and adaptable in case of Renal , Hepatic, and organ failure.

The paradigm is Morphine, and the route of administration contrasted is intravenous, by a metod providing plasmatic stable levels, and possibility of amounts for incidental pain (movements, phisiotherapy, etc) with PCA + Continuous iv metod.

However, in strict pharmachologic basis ,the ideal route of administration for opioids could be the most close to mu receptors (intrathecal, Epidural, Perineural?).

The response is: Depends...

BW

Enrique

I agree with you .the best method to administer opoid is intra muscular route.

Patient controlled analgesia-good patient satisfaction,no overdose problems.

Although great work is being carried out in the postoperative pain setting, there is still a long way to go. It is necessary to apply a MULTIMODAL APPROACH to pain that includes the routine use of regional techniques, a combination of analgesics such as paracetamol, non-specific or COX-2 NSAIDs and opioids, making a responsible choice of the type of patient, the surgical setting and the predicted adverse effects. The true role of coadjutant drugs and non-pharmacological therapies is yet to be well defined, and in the future it will be essential to have a practical guide based on clinical evidence for each process, that includes postsurgical rehabilitation.

The PROSPECT GROUP (www.postoppain.org) provides evidence-based clinical recommendations for 10 surgical procedures. Strong opioids are recommended plus Local anesthetics via epidural or inthradural route for major thoraco-abdominal or orthopaedic surgery (grade A or B). When regional analgesia is not possible, or postoperative pain measurement is high (VAS > 6), my personal opinion is that IV-PCA opioids analgesia is the best choice for pain managenment.

We must delve deeply into the pathophysiology of pain, and in the direct application of this knowledge to new drugs and new systems of delivery of drugs that achieve a lower number of postoperative complications, as well as a better overall recovery and general well being of the patients.

The best route for administration of opioid in carrdiac surgical patients to relieve postoperative pain is intravenous though there are few reports on epidural and caudal approach

Intra-venous

As Mr. Enrique has suggested, severety of post operative pain can vary with the type of surgery (caesarean to open chest surgery, amputation or tumour removal. The mechanism of pain varies, the mode should vary and as Mr Borja suggested, multimodal and rotatory schedule with multiple agents suits peri and immediate post op. pain management (to manage inflammation, release of endotheins by tumour cells leading to pain, neuropathic pain etc.). As you suggested, the least invasive mode is intramuscular or oral, which works well with caesarean patients, and good old practice of acupuncture. This case needs a meta analysis on the use of oral or intramuscular route.

I think the best route is i/v, lines are already there and the effect is immediate

The question is TOO GENERAL. Patient's age, gender, comorbidities, extent of the surgery, previous pain experience, culture, NPO status .......(the list goes on) are key factors to determine an answer to this question.