Craniotomy Pain Management Best Practices — SolvingPain — A Project By Ontario's Anesthesiologists

Craniotomy

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.

Preoperative	Intraoperative	Postoperative (Inpatient)	Discharge Strategies
•Acetaminophen •Selective NSAIDs (discuss with surgeon)	•Pre-incisional local anesthesia infiltration •Consider dexamethasone •Consider dexmedetomidine infusion if infratentorial approach •Consider IV lidocaine depending on surgical approach	•Depending on surgical approach, PO/SC opioids vs. PCA opioids •Continue acetaminophen, selective NSAIDs •Consider IV lidocaine depending on surgical approach	MANAGEMENT OF PAIN W/O MEDICATION: •Relaxation techniques (breathing, meditation, mindfulness, etc.) CO-ANALGESICS: •Acetaminophen •Selective NSAIDs (consider a prescription for increased compliance) OPIOID PRESCRIPTION: Recommend: 20 tablets Maximum: 20 tablets; 0-7 days For higher numbers, consider a.part-fill.prescription

*All tabs for discharge are 5mg oral morphine. To convert this dosage, please visit this page. We encourage prescribers to consider discharge prescriptions of short-acting opioids at the lowest effective dose, with the lowest potency, for the shortest duration. Please note that current guidelines give a range of tabs. While we suggest prescribing the lowest effective dose possible, where clinical judgment indicates prescribing toward the higher range, we recommend using a part-fill prescription.

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.

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References

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


•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, meperidine •Postoperative: Reduce dose of acetaminophen •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine

Hepatic dysfunction/Excessive alcohol intakeRenal 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


In general: To minimize risks of postoperative delirium, ketamine should only be used in sub-anesthetic doses; additionally, gapapentiods should be avoided in this population due to the potential for falls •Preoperative: Due to the frequency of multiple comorbidities in advanced age, consider preoperative anesthesia consult as needed to optimize. Also, manage anticoagulants where indicated; avoid long delays in hip fracture patients and consider preoperative regional anesthesia while waiting for OR •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated •Postoperative: Scheduled acetaminophen; oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities


•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


•Consider regional anesthetic techniques, if feasible for specific surgical procedure

Advanced ageChronic pain and/or long-term opiate use History of difficulty with postop pain managementUncontrolled 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


•Avoid neuraxial techniques if any abnormal coagulation; consider following ASRA guidelines

CoagulopathyObstructive 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

References for Treatment Altering Factors

Patient Resources

Best Practices

Craniotomy

Treatment Altering Factors

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