How to write a Literature Review and Critical Appraisal on pain management

How to write a Literature Review and Critical Appraisal on pain management

Literature Review

Proper pain management, particularly postoperative pain, is a key concern for nurses, clinicians, and patients undergoing surgery. Effective pain management improves recovery, minimizes complications, and has a huge influence on patient satisfaction (Levy et al., 2019). This discussion focuses on the review of literature regarding the challenge of pain management after surgery,multimodal approaches to pain management, and how they compare to pain management using the three-step ladder model.

Key terms

Pain, Post-operative pain, Multimodal pain management, WHO analgesic ladder, Enhanced recovery, Opioid analgesics

Summary Of Research

Postoperative pain is not just annoying but it can cause serious problems or turn to be chronic if not treated correctly. Effective pain management is among the interventions that improve recovery after surgery while reduces host stress response (Levy et al., 2019). Various studies have analyzed the importance of pain assessment, management, and the use of different medications to pain control postoperatively. When left untreated, postoperative pain drives the stress response along with the surgical injury itself, with the potential to cause a variety of complications (Nimmo et al., 2017). For instance, poorly managed pain can lead to the development of postoperative cognitive dysfunction and may cause the development of chronic pain for susceptible individuals. There is also sufficient evidence that demonstrates the use of different pain management approaches postoperatively. Nimmo et al (2017) discuss how the use of analgesics like opioids, non-steroidal anti-inflammatory agents (NSAIDs), and local anesthetics can help reduce postoperative pain. While different agents are available, this research recommends the use of multimodal approaches rather than a single agent.

Critical appraisal

This article discusses the effects of postoperative pain and the different approaches that can be used to manage the pain. One strength of this evidence is that it comprehensively discusses various pain management strategies for postoperative patient care. The study also analyzes newer innovations like the use of liposomal bupivacaine that might turn out to be effective in the future. The gap identified in this study focuses on pain assessment before the prescription of analgesics postoperatively. The use of acute pain teams should be implemented to allow pain assessment that can guide the choice of analgesia for patients (Nimmo et al., 2017). One disadvantage of the study is that it is just an opinion from experts. The study uses already published articles and practice guidelines to sum its conclusions.

Optimal pain management is an essential component of enhanced recovery after surgery (ERAS). In recent years, researchers have found a correlation between the type of medication used and the quality of enhanced recovery achieved after surgery.         Opioids remain the mainstay of perioperative and postoperative pain management despite the adverse effects involved (Barker et al., 2020). The shift in focus to pain management using multimodal approaches is observed to yield positive results than the use of opioids alone. Multimodal analgesia regimens utilize varying combinations of local and/or regional analgesic techniques and non-opioid analgesics alongside adjuncts like dexamethasone (Barker et al., 2020). This study also indicates that it is crucial to balance the efficacy of the analgesic technique and the adverse effects. In conclusion, the researchers recommend that multimodal analgesia should be incorporated in every single procedure with opioids only recommended for breakthrough pain (Barker et al., 2020). Additionally, this intervention best works when implemented across 3-time points in the preoperative, intraoperative, and postoperative settings.

Critical appraisal. This article highlights the importance of using multimodal analgesia for postoperative pain management. The strength of this evidence is that it analyzes each approach to pain management and gives recommendations according to evidence from research. The researchers observe that protocols that rely on opioid-only pain therapy are outdated and discouraged (Barker et al., 2020). The disadvantage of this article is that it primarily focuses on pain management after plastic surgery. Based on the complexity of this procedure, some practitioners may find their recommendations inappropriate to other patient groups.

Opioids are routinely prescribed for postoperative pain management for most patients. This approach mainly uses the World Health Organization (WHO) 3-step analgesic ladder to determine the extent of medication use and the need for a shift from one opioid to another (Mark et al., 2018). However, with concerns growing regarding the use of opioids, a shift to other pain management strategies seems like the best alternative. A case-controlled study was conducted to evaluate whether, after hospital discharge, post-surgical acute pain can be effectively managed with a markedly reduced number of opioid doses. During the intervention, patients who underwent simple surgical procedures were given alternative analgesics unless they required 5 or more doses of oral opioids. For complicated procedures, opioid medication use was restricted to three days with intermittent tapering of doses. This study found out that many patients achieved pain relief with the use of unrestricted opioid prescription (Mark et al., 2018). The use of opioids should be restricted due to the observed effects of dependence and adverse events like sedation, constipation, and respiratory depression.

Critical appraisal. This article discusses the use of opioid analgesics for pain control and how dependence on these drugs can be reduced using alternative therapies. The strengths of the study include the use of a large control group (606 controls) with similar patient characteristics and the need to demonstrate change in healthcare professionals’ practice patterns. The gap identified in this research is the lack of healthcare professionals’ awareness of better patient outcomes that can be achieved without reliance on opioid analgesics (Mark et al., 2018). One limitation observed was that the researchers recruited only women to participate in the study.

Pain management presents a particular challenge to the elderly population because of their sensitivity to the effects of the medications. Opioids used for pain control among the elderly pose a challenge due to the central nervous system effects that may cause impairment to this population (Brooks et al., 2017). The use of multimodal approaches postoperatively has been advocated to have an opioid-sparing effect while still achieving adequate pain control. To test this hypothesis, an observational study was conducted for elderly patients undergoing elective arthroplasty. Upon observation, the researchers noted a minimal difference in pain control using multimodal approaches compared to the traditional method (Brooks et al., 2017). It was established that some populations, like the elderly, may fail to respond well to pain control due to the number of drugs used in multimodal approaches. While this strategy can work well in other populations, it is crucial to consider special populations that might have various challenges.

Critical appraisal. This research positively informs healthcare professionals of the need to reconsider multimodal approaches to pain management for special populations like the elderly. Another strength of the study was the use of comprehensive patient assessment using the CAM and MMSE methods to ascertain relativity (Brooks et al., 2017). The study identified the gap of multimodal pain management for the elderly and other special populations that may be used for future research. One limitation of the study was the use of small sample size (150 patients).


Barker, J. C., Joshi, G. P., & Janis, J. E. (2020). Basics and best practices of multimodal pain management for the plastic surgeon. Plastic and Reconstructive Surgery. Global open8(5), e2833.

Brooks, E., Freter, S. H., Bowles, S. K., & Amirault, D. (2017). Multimodal pain management in older elective arthroplasty patients. Geriatric Orthopedic Surgery & Rehabilitation8(3), 151-154.

Levy, N., Mills, P., & Rockett, M. (2019). Post-surgical pain management: Time for a paradigm shift. British Journal of Anaesthesia123(2), e182–e186.

Mark, J., Argentieri, D. M., Gutierrez, C. A., Morrell, K., Eng, K., Hutson, A. D., Mayor, P., Szender, J. B., Starbuck, K., Lynam, S., Blum, B., Akers, S., Lele, S., Paragh, G., Odunsi, K., de Leon-Casasola, O., Frederick, P. J., & Zsiros, E. (2018). Ultrarestrictive opioid prescription protocol for pain management after gynecologic and abdominal surgery. JAMA Network Open1(8), e185452.

Nimmo, S. M., Foo, I., & Paterson, H. M. (2017). Enhanced recovery after surgery: Pain management. Journal of Surgical Oncology116(5), 583–591.

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