Practical issues in postoperative pain management: pain assessment and personalized choice of analgesics (review)

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INTRODUCTION

Postoperative pain management remains a critical component of surgical care. More than 75% of surgical patients experience moderate to severe pain, yet fewer than 50% receive adequate analgesia [1–3]. In trauma and orthopedic units, the importance of effective postoperative analgesia is particularly pronounced due to the intense pain associated with surgical interventions involving the musculoskeletal system [4]. Adequate pain control in the postoperative period improves clinical outcomes, facilitates early mobilization, reduces the risk of chronic pain development, and enhances patient satisfaction with treatment [5–7]. An essential aspect of postoperative pain management is ensuring the safe use of analgesics and minimizing adverse drug reactions, especially in patients receiving opioid therapy. Approximately 79% of patients treated with opioids experience adverse effects such as nausea, respiratory depression, constipation, and drowsiness [8]. Given the suboptimal efficacy of current analgesic approaches and the high risk of side effects, there is a growing need to develop optimal strategies for postoperative pain control. These strategies should consider the patient’s pharmacologic response to analgesics, the nature and extent of the surgical procedure, and adopt a personalized approach that accounts for genetic factors and comorbidities.

This review addresses key practical considerations for postoperative analgesia that are critical when developing a local pain management protocol in surgical inpatient settings.

SEARCH METHODOLOGY

For a comprehensive analysis of postoperative pain management issues, a systematic search of scientific sources was conducted in leading international databases and electronic libraries of scientific publications, including PubMed, MEDLINE, ScienceDirect, Cochrane Library, and eLIBRARY.RU. The search strategy employed key terms and phrases such as “postoperative analgesia,” “postoperative pain management,” “pain management orthopedics,” and “(analgesia OR (pain management)) AND personalized.” Equivalent terms in Russian were used for searches within Russian-language databases. Search results were refined using filters for publication date and study type. Eligible sources included meta-analyses, randomized clinical trials, and other clinical studies, including retrospective designs. Priority was given to studies published within the last 10 years. To ensure a comprehensive review, current secondary sources—particularly clinical guidelines related to analgesia in trauma and orthopedic care—were also examined.

DISCUSSION

Principles of Rational Pain Management in the Postoperative Period

Standardization of Pain Assessment

Standard Pain Scales

According to the revised 2020 definition by the International Association for the Study of Pain, pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage [9]. This definition emphasizes the inherently subjective nature of pain, which can only be reliably assessed by the patient.

Effective and safe pain management requires regular and standardized assessment, enabling timely initiation, adjustment, or discontinuation of analgesic therapy. Several validated pain scales are used to assess pain intensity [10–13]. In adult clinical research, the Visual Analog Scale (VAS) is among the most frequently used tools. This scale consists of a 100-mm horizontal line with endpoints labeled “no pain” and “worst imaginable pain” [14]. Patients are asked to mark their perceived pain level along this line. Clinicians then measure the distance in millimeters from the left end to the patient’s mark, documenting the result to guide analgesic decision-making. VAS scores of ≥ 70 mm indicate severe pain, 45–69 mm moderate pain, 5–44 mm mild pain, and 0–4 mm no pain [15, 16]. A major advantage of the VAS is its analog format, allowing for nuanced self-reporting without reliance on numerical labels. However, its use in routine practice is limited by the need for manual measurement with a ruler [10].

From a practical perspective, the assessment of pain syndrome using Numerical Rating Scales (NRS) appears more convenient, as they do not require additional measurements [10]. The 11-point NRS (ranging from 0 to 10) is commonly used and can be administered verbally. Verbal NRS is preferred in clinical settings due to its simplicity, absence of additional materials, and strong correlation with VAS results [10, 17].

Pain assessment in children, especially those younger than 6 years, presents challenges when using self-report scales. In preschool-aged children, behavioral pain scales and nonverbal pain cues are more appropriate [13, 18]. The Wong–Baker FACES Pain Rating Scale is widely used in pediatric care. It consists of six cartoon faces depicting varying pain intensities, from no pain to extreme pain [19]. Each face corresponds to a score from 0 to 10 in increments of 2, which aligns with standard 11-point scales. In older children, results obtained with the FACES scale correlate well with verbal NRS assessments [20]. Pain assessment methods in pediatric patients should consider both age and individual cognitive development.

The standard approach to assessing pain syndrome using validated scales enables dynamic evaluation of pain, determination of the need for analgesic therapy, and decisions regarding its modification or discontinuation [3].

Target Pain Scores and Thresholds for Analgesic Intervention

Postoperative pain should be evaluated both at rest and during movement, as movement-evoked pain can hinder rehabilitation and functional recovery.

The target pain score is ≤ 3 on the 0–10 NRS [21, 22]. Moderate to severe pain requires active analgesic management in the postoperative period [23]. Scores exceeding the target threshold warrant additional analgesic intervention, which should be initiated within 30 minutes of assessment [24, 25].

Frequency of Pain Reassessment

There is no universally established optimal interval for postoperative pain reassessment. Timing should be individualized by the attending physician, based on the surgical procedure, comorbidities, side effects, and the dynamics of pain relief. Reassessment should align with the expected peak effect of analgesics, typically 15 to 30 minutes for parenteral agents and 1 to 2 hours for oral medications [3]. In the early postoperative phase, more frequent pain evaluations are warranted to ensure adequate pain control.

Perioperative Multimodal Analgesia

Multimodal Approach to Postoperative Pain Management

A key trend in modern postoperative analgesia is the shift from unimodal to multimodal (multicomponent) strategies. Multimodal analgesia involves the concurrent use of multiple analgesic agents with distinct mechanisms of action and routes of administration, sometimes supplemented by nonpharmacologic methods [26]. This approach may include non-opioid systemic analgesics, opioids, regional anesthesia techniques, and adjunctive nonpharmacologic interventions [3, 27–29]. Combining analgesics with different mechanisms of action allows the use of minimal effective doses of each drug. The goal of this approach is to achieve an additive or synergistic analgesic effect while minimizing the adverse effects associated with high doses of a single analgesic in monotherapy [30]. Medications most commonly used in multimodal analgesia for adults and children are presented in Tables 1 and 2. These lists are not exhaustive, and when using other medications, one should refer to the medical prescribing information.

 

Table 1. Drugs for postoperative pain management in adults.

Drug	Single dose	Dosing regimen	Max daily dose	Max treatment duration
Non-Narcotic Analgesic
Acetaminophen (Paracetamol)	Solution for infusion
	Body weight > 50 kg: 1 g (100 mL)	Administer IV over 15 minutes, up to 4 times daily. Minimum interval between infusions: 4 h	4 g	Not specified
	Body weight 33 to 50 kg inclusive: 15 mg/kg (1.5 mL/kg)	Administer IV over 15 minutes, up to 4 times daily. Minimum interval between infusions: 4 h	≤ 60 mg/kg (not exceeding 3 g)
	Tablets
	500 mg–1 g	Oral, at least 4 hours apart	4 g	Not specified
Nonsteroidal Anti-Inflammatory Drugs
Diclofenac	Solution for intramuscular injection
	75 mg	IM, once daily	150 mg	2 days
	Tablets
	100–150 mg	Oral, once daily	150 mg	Not specified
Ketorolac	Solution for parenteral administration
	Age 16–64 years, body weight > 50 kg: 30 mg	IM or IV, every 6 h	90 mg	2 days
	Body weight < 50 kg or age > 65 years: 15 mg	IM or IV, every 6 h	60 mg	2 days
	Film-coated tablets
	10 mg	Oral, up to 4 times daily	40 mg	5 days
Ketoprofen	Solution for parenteral administration
	100 mg	IV or IM, 1–2 times daily, 12 h apart	200 mg	2 days
	Tablets
	100 mg	Oral, 1 tablet twice daily, every 12 h	200 mg	Not specified
Dexketoprofen	Solution for parenteral administration
	50 mg	IM (deep, slow) or IV (slow, over at least 15 sec), every 8–12 h	150 mg	2 days
	Tablets
	Patients < 65 years: 25 mg	Oral, every 8 h	75 mg	5 days
	Patients ≥ 65 years: 25 mg	Oral, every 12 h	50 mg
Lornoxicam	Solution for parenteral administration
	8 mg	IV or IM, every 12 h	16 mg	Not specified
	Tablets
	8 mg	Oral, every 12 h	16 mg	Not specified
Meloxicam	Tablets
	7.5–15 mg	Oral, once daily	15 mg	Not specified
	Solution for parenteral administration
	7.5–15 mg	IM, once daily	15 mg	Not specified
Opioid and Opioid-Like Analgesics
Tramadol	Solution for parenteral administration
	50–100 mg	IV, IM, or SC; if satisfactory analgesia is not achieved within 30–60 minutes, an additional 50 mg may be administered	400 mg	Not specified
	Tablets
	50–100 mg	Oral; if satisfactory analgesia is not achieved within 30–60 minutes, an additional 50 mg may be administered	400 mg	Not specified
Trimeperidine	Solution for parenteral administration
	10–40 mg	IM, IV, or SC	160 mg	Not specified
	Tablets
	25–50 mg	Oral	200 mg	Not specified
Fentanyl	Solution for Parenteral Administration
	25–100 µg	IV or IM	Not specified	Not specified
Morphine	Solution for parenteral administration
	10 mg	SC, maximum single dose: 20 mg	50 mg	Not specified
	Tablets/Capsules
	30 mg	Oral, 12 h apart	60 mg	Not specified
Gabapentinoids
Pregabalin	Tablets
	150 mg	Oral, 1–2 times daily. If needed, increase to 300 mg/day after 3–7 days	600 mg/day	Not specified
Gabapentin	Tablets
	300 mg	Oral, 3 times daily, at least 8 h apart	First week: 1800 mg/day; with further single-dose escalation: 3600 mg/day	Up to 5 months

 

Table 2. Drugs for postoperative pain management in children.

Drug	Single dose	Dosing regimen	Max daily dose	Max treatment duration
Non-Narcotic Analgesic
Acetaminophen (Paracetamol)	Rectal suppositories
	3–6 months (6–8 kg): 50 mg	Rectal, at least 4–6 h apart	100 mg/day	Not specified
	7–12 months (8–11 kg): 100 mg		200 mg/day
	1–4 years (12–16 kg): 100 mg		400 mg/day
	5–9 years (17–30 kg): 250 mg		1000 mg/day
	10–14 years: 500 mg		2000 mg/day
	≥ 15 years: 500 mg		4000 mg/day
	IV Infusion
	≤ 10 kg: 7.5 mg/kg (0.75 mL/kg)	Up to 4 times daily, with at least 4 h between infusions	≤ 30 mg/kg/day	Not specified
	10–33 kg: 15 mg/kg (1.5 mL/kg)		≤ 60 mg/kg/day, not exceeding 2 g
	33–50 kg: 15 mg/kg (1.5 mL/kg)		≤ 60 mg/kg/day, not exceeding 3 g
	> 50 kg: 1 g (100 mL)		≤ 4 g/day
	Tablets
	6–8 years: 200 mg	Every 4–6 h	60 mg/kg, not exceeding 1 g
	9–11 years: 500 mg		60 mg/kg, not exceeding 2 g
	≥ 12 years: 500–1000 mg		≤ 4 g/day
Nonsteroidal Anti-Inflammatory Drugs
Diclofenac	Powder for oral solution
	14–18 years: 50–100 mg	Oral, 0.5–2 mg/kg/day, divided into 2–3 doses	150 mg	7 days
	Tablets
	6–14 years: 25 mg	Oral, 0.5–2 mg/kg/day, divided into 2–3 doses	150 mg	7 days
	14–18 years: 25–50 mg
Ibuprofen	Suspension (100 mg/5 mL)
	3–6 months (5–7.6 kg): 2.5 mL (50 mg)	Oral, up to 3 times daily, every 6–8 h	7.5 mL (150 mg)	Not specified
	6–12 months (7.7–9 kg): 2.5 mL (50 mg)	Oral, 3–4 times daily, every 6–8 h	10 mL (200 mg)
	1–3 years (10–16 kg): 5 mL	Oral, up to 3 times daily, every 6–8 h	15 mL (300 mg)
	4–6 years (17–20 kg): 7.5 mL		22.5 mL (450 mg)
	7–9 years (21–30 kg): 10 mL		30 mL (600 mg)
	10–12 years (31–40 kg): 15 mL		45 mL (900 mg)
	Suspension (200 mg/5 mL)
	1–3 years (10–16 kg): 2.5 mL (100 mg)	Oral, up to 3 times daily, every 6–8 h	7.5 mL (300 mg)	Not specified
	4–6 years (17–20 kg): 3.75 mL (150 mg)		11.25 mL (450 mg)
	7–9 years (21–30 kg): 5 mL (200 mg)		15 mL (600 mg)
	10–12 years (31–40 kg): 7.5 mL (300 mg)		22.5 mL (900 mg)
	> 12 years (> 40 kg): 7.5–10 mL (300–400 mg)		30 mL (1200 mg)
	Tablets
	6–12 years (body weight > 20 kg): 200 mg	Oral, up to 4 times daily, with at least 6 h between doses	800 mg	Not specified
	> 12 years: 200 mg	Oral, 3–4 times daily, with at least 6 h between doses
	Rectal suppositories (for children)
	3–9 months (6.0–8.0 kg): 1 suppository (60 mg)	Up to 3 times in 24 hours, not exceeding 180 mg/day	30 mg/kg, every 6–8 h	Not exceeding 3 days
	9 months–2 years (8.0–12.0 kg): 1 suppository (60 mg)	Up to 4 times in 24 hours, not exceeding 240 mg/day
Ketorolac	Tablets
	> 16 years: 10 mg	Oral, up to 4 times daily	40 mg	5 days
	Solution for parenteral administration
	> 16 years: 10–30 mg	IV or IM, at least 6 h apart	90 mg	2 days
Opioid and Opioid-Like Analgesics
Morphine	Oral solution/Tablets
	3–7 years: 5 mg	Oral, every 6 h	20 mg	Not specified
	7–17 years, body weight < 70 kg: 5 mg	Oral, every 4 h	30 mg
	7–17 years, body weight ≥ 70 kg: 10 mg		60 mg
	≥ 17 years: 5–10 mg		Not specified
	Solution for parenteral administration
	Birth to 2 years: 100–200 µg/kg (0.1–0.2 mg/kg)	SC, as needed, every 4–6 h	15 mg	Not specified
	> 2 years: 100–200 µg/kg (0.1–0.2 mg/kg)	SC, as needed, every 4–6 h	1.5 mg/kg/day
Tramadol	Solution for parenteral administration
	1–12 years: 1–2 mg/kg	IV, IM, or SC	8 mg/kg/day or ≤ 400 mg/day
	≥ 12 years: 50–100 mg	IV, IM, or SC; if satisfactory analgesia is not achieved within 30–60 minutes, an additional 50 mg may be administered	400 mg/day	Not specified
	Tablets
	> 14 years: 50–100 mg	Oral; if satisfactory analgesia is not achieved within 30–60 minutes, an additional 50 mg may be administered	400 mg/day	Not specified
Trimeperidine	Solution for parenteral administration
	≥ 2 years: 3–10 mg	IV, IM, or SC	Not specified	Not specified
Fentanyl	Solution for parenteral administration
	≥ 1 year, spontaneous breathing: Initial dose 3–5 µg/kg, additional 1 µg/kg	IV	Not specified	Not specified
	≥ 1 year, mechanical ventilation: Initial dose 15 µg/kg, additional 1–3 µg/kg	IV	Not specified	Not specified

 

Opioid-Sparing Strategy in Pain Management

Postoperative opioid use is associated with a high risk of adverse effects, including nausea, vomiting, urinary retention, respiratory depression, and sleep disturbances. Risk factors for opioid-related complications include older age, comorbid conditions, high opioid doses, and concurrent use of benzodiazepines or gabapentinoids [31].

To improve safety, an opioid-sparing strategy is recommended. This involves minimizing opioid use without compromising analgesic efficacy [32]. This principle should guide the development of individualized perioperative multimodal analgesia plans.

Preemptive Analgesia

Preemptive analgesia is an essential component of multimodal pain management. Administered prior to skin incision, it aims to attenuate intraoperative nociceptive input, reduce postoperative pain intensity, and decrease opioid requirements [2, 26, 33–35]. Common agents include acetaminophen, celecoxib, and gabapentin, typically given orally 1–2 hours before surgery [36–39]. While there is no universal standard for preemptive analgesia, expert recommendations—such as those from American pain societies—support the use of gabapentinoids before major surgeries and procedures associated with significant pain [3]. Gabapentinoids are also beneficial for patients with opioid tolerance.

Evidence for the efficacy and safety of preemptive analgesia in pediatric patients is limited. A retrospective study of children with scoliosis (n = 116) undergoing posterior spinal fusion compared standard pain management (n = 52) with a preemptive three-drug oral analgesic regimen started 48 hours preoperatively and continued until discharge (n = 64) [40]. The regimen included acetaminophen (15 mg/kg, four times daily), celecoxib (3.5 mg/kg, twice daily), and gabapentin (7.5 mg/kg, twice daily), dosed according to actual body weight and rounded down to the nearest available strength. The preemptive group showed significantly shorter hospital stays and lower maximum pain scores on postoperative days 1, 3, and 4. However, total opioid consumption in morphine equivalents did not differ significantly between groups.

A notable barrier to preemptive analgesia is the regulatory status of off-label drug use. Most prescribing information does not list preoperative analgesia as an indication. Therefore, such use must be considered off-label and properly documented in medical records.

Stepwise Analgesic Therapy

The wide range of available analgesics can complicate the selection of appropriate multimodal combinations. Clinical guidelines provide suggested regimens tailored to specific surgical procedures, outlining pre-, intra-, and postoperative analgesic strategies [26].

Postoperative analgesia must be adapted based on the patient’s individual response. The World Health Organization (WHO) introduced the concept of the “analgesic ladder,” a stepwise approach in which treatment is escalated when pain control is inadequate [41]. Applying this model within the context of multimodal, opioid-sparing analgesia supports a tiered strategy based on pain intensity (see Fig. 1). The selection of specific medications for postoperative pain management depends on the anticipated pain associated with the type of surgical intervention, the patient’s age, comorbidities, individual tolerability, and genetic factors influencing the efficacy and safety of the therapy. For most orthopedic procedures, open abdominal surgeries, and thoracotomies, a high-intensity pain syndrome is expected, necessitating the inclusion of regional analgesia methods in combination with non-opioid analgesics and non-pharmacological pain relief measures in the multimodal analgesia regimen.

 

Fig. 1. Stepwise multimodal analgesia in the postoperative period.

Note: *Medications included in the list of essential and critical drugs. †Gabapentinoids should be considered for procedures with a high risk of neuropathic pain (e.g., arthroplasty, spinal surgery, limb amputation, etc.). NSAID: nonsteroidal anti-inflammatory drug.

 

Personalized Selection of Analgesic Agents

Specific Considerations for Postoperative Pain Management in Children

When choosing analgesic therapy for children, clinicians must consider several factors that shape pain management strategies. Oral or rectal administration of analgesics is generally preferred over intramuscular or intravenous routes [42]. Dosing should be appropriate for the child’s age and body weight (see Table 2). For children under 12 requiring opioids, morphine is the preferred choice, as tramadol carries a higher risk of adverse effects [43, 44]. When selecting nonsteroidal anti-inflammatory drugs, caution is warranted due to the risk of Reye’s syndrome—a rare but serious condition involving encephalopathy and acute fatty liver degeneration leading to liver failure—particularly with salicylates like aspirin [45]. For drugs with high renal clearance, kidney function in children should be evaluated using the bedside Schwartz equation [46, 47].

Impact of Genetic Factors on the Selection of Analgesic Agents

The impact of individual genetic factors—related to metabolism rates, drug transport, or target sites—on the efficacy and safety of medications has been extensively studied, with evidence supporting such associations for certain nonsteroidal anti-inflammatory drugs (NSAIDs) and tramadol. Patients with genetically determined low activity of the hepatic enzyme CYP2C9 face a higher risk of complications from NSAIDs compared to those without such variants [48]. This is because these patients metabolize active NSAIDs into inactive metabolites more slowly, leading to drug accumulation and elevated plasma concentrations. While this may enhance the analgesic effect, it also increases the risk of severe adverse reactions. Accumulated data have enabled the development of algorithms for selecting an NSAID and its dosage when patients undergo prior genetic testing [49] (Table 3). For tramadol (and codeine), genetic variants have been identified that either cause excessive production of the active metabolite, significantly increasing the risk of toxicity, or result in insufficient metabolite formation, leading to a lack of analgesic effect. When these genetic variants are detected, alternative medications are recommended instead of tramadol or codeine [50].

 

Table 3. Personalized therapy with nonsteroidal anti-inflammatory drugs and tramadol based on patient genetic factors.

Genetically determined CYP2C9 activity	Genetically determined CYP2D6 activity	Recommendations for drug and dose selection for postoperative pain management
Normal (Genotypes: CYP2C9*1/*1, CYP2C9*1/*2)	Normal (Genotypes: CYP2D6*1/*1, CYP2D6*1/*2, CYP2D6*1/*4, CYP2D6*1/*10, CYP2D6*10/*41, CYP2D6*4/*10, etc.)	Use the standard initial dose of NSAIDs and tramadol as recommended in prescribing information.
Reduced (Genotypes: CYP2C9*1/*3, CYP2C9*2/*2, CYP2C9*2/*3, CYP2C9*3/*3)	Normal (Genotypes: CYP2D6*1/*1, CYP2D6*1/*2, CYP2D6*1/*4, CYP2D6*1/*10, CYP2D6*10/*41, CYP2D6*4/*10, etc.)	Consider reducing the initial dose of celecoxib, ibuprofen, flurbiprofen, lornoxicam, meloxicam, piroxicam, or tenoxicam, or use an alternative NSAID (e.g., ketorolac, naproxen, etoricoxib, diclofenac)
Normal (Genotypes: CYP2C9*1/*1, CYP2C9*1/*2)	High or reduced (Genotypes: CYP2D6*1/*1x2, CYP2D6*1/*2x2, CYP2D6*4/*4, CYP2D6*4/*6, CYP2D6*6/*41, etc.)	Avoid tramadol and codeine for pain management. Consider using alternative opioid analgesics, such as trimeperidine
Reduced (Genotypes: CYP2C9*1/*3, CYP2C9*2/*2, CYP2C9*2/*3, CYP2C9*3/*3)	High or reduced (Genotypes: CYP2D6*1/*1x2, CYP2D6*1/*2x2, CYP2D6*4/*4, CYP2D6*4/*6, CYP2D6*6/*41, etc.)	Avoid tramadol and codeine for pain management. Consider reducing the initial dose of celecoxib, ibuprofen, flurbiprofen, lornoxicam, meloxicam, piroxicam, or tenoxicam, or use an alternative NSAID (e.g., ketorolac, naproxen, etoricoxib, diclofenac)

Note. NSAID, nonsteroidal anti-inflammatory drug.

 

Impact of Comorbidities on Analgesic Selection

Before prescribing NSAIDs, clinicians should assess the patient’s risk factors for gastrointestinal, cardiovascular, and renal adverse events.

Patients with a high NSAID-associated gastrointestinal risk include those with a history of complicated stomach or duodenal ulcers (e.g., bleeding or perforation) or those with more than two of the following risk factors: age over 65 years; high-dose NSAID use; a history of uncomplicated ulcers; or concurrent use of acetylsalicylic acid (including low-dose aspirin), anticoagulants, glucocorticoids, or selective serotonin reuptake inhibitors [51, 52]. Patients with one or two of these factors are considered at moderate gastrointestinal risk.

The risk of cardiovascular complications from NSAIDs is calculated using the SCORE/SCORE-2 scale in the absence of cardiovascular disease or corresponds to the established risk level in patients with known cardiovascular pathology [53].

The risk of gastrointestinal and cardiovascular adverse events varies significantly depending on the specific NSAID used.

Celecoxib is the safest option for patients at high risk of gastrointestinal complications, including gastrointestinal hemorrhage [53, 54]. Co-administration of proton pump inhibitors with NSAIDs has proven effective in preventing complications in the upper (but not lower) gastrointestinal tract [54]. For patients with moderate to high cardiovascular risk, naproxen or ibuprofen (the latter at a daily dose not exceeding 1200 mg) should be preferred [53]. Patients at very high cardiovascular risk should avoid NSAIDs altogether and use alternative analgesics, such as acetaminophen, tramadol, or opioid analgesics, for pain relief [55]. Naproxen and celecoxib have been shown to have the least impact on blood pressure and destabilization of hypertension [56].

In cases of combined high gastrointestinal and cardiovascular risk, low-dose celecoxib (200 mg daily) or naproxen with a proton pump inhibitor may be considered [54, 57].

NSAIDs should not be prescribed to patients with a glomerular filtration rate (GFR) below 30 mL/min/1.73 m², or with a GFR of 30–60 mL/min/1.73 m² if they are concurrently taking angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, or diuretics. No NSAID has demonstrated a clear advantage in patients with renal impairment [56].

CONCLUSION

Rational postoperative pain management is a key component of comprehensive care in surgical settings. Implementing routine pain assessments using validated scales enables timely initiation and adjustment of analgesic therapy based on the patient’s individual pharmacologic response. A multimodal analgesic approach—incorporating acetaminophen, NSAIDs, opioids, and regional anesthesia—provides effective pain control while minimizing adverse effects. Personalized selection of analgesic agents is essential, taking into account the anticipated intensity of postoperative pain based on the type of surgery, as well as patient-specific factors such as age, comorbidities, tolerability, and genetic predispositions.

ADDITIONAL INFO

Author contribution. V.A. Otdelenov — collected and analyzed literature, developed the review concept, drafted and edited the manuscript, wrote the manuscript with input from all authors; N.P. Denisenko — collected and analyzed literature, drafted and edited the manuscript; N.I. Sobur — collected and analyzed literature, drafted the manuscript; E.B. Kleymenova — defined the research problem, critically reviewed the manuscript content and approved the final version for publication; I.M. Gairabekov — collected and analyzed literature; A.G. Nazarenko, K.B. Mirzaev, D.A. Sychev — final approval of the version to be published. All authors have approved the final version before publication and have also agreed to be responsible for all aspects of the work, ensuring that issues relating to the accuracy and integrity of any part of it are properly addressed and resolved.

Funding source. This study was carried out with the financial support of the Russian Science Foundation, project No. 23-75-01137 (https://rscf.ru/en/project/23-75-01137).

Disclosure of interests. The authors declare that they have no competing interests.

Provenance and peer-review. This paper was submitted to the journal on an initiative basis and reviewed according to the usual procedure. Two external reviewers, a member of the editorial board and the scientific editor of the publication participated in the review.

About the authors

Vitaly A. Otdelenov

Priorov National Medical Research Center of Traumatology and Orthopedics; Russian Medical Academy of Continuing Professional Education

Author for correspondence.
Email: vitotd@yandex.ru
ORCID iD: 0000-0003-0623-7263
SPIN-code: 8357-5770

MD, Сand. Sci. (Medicine)

Russian Federation, 10 Priorova str., 127299 Moscow; Moscow

Natalia P. Denisenko

Russian Medical Academy of Continuing Professional Education

Email: natalypilipenko3990@gmail.com
ORCID iD: 0000-0003-3278-5941
SPIN-code: 5883-6249

MD, Сand. Sci. (Medicine)

Russian Federation, Moscow

Natalia I. Sobur

Russian Medical Academy of Continuing Professional Education

Email: nisoburm.d@gmail.com
ORCID iD: 0009-0007-8100-4079

MD, resident

Russian Federation, Moscow

Elena B. Kleimenova

Priorov National Medical Research Center of Traumatology and Orthopedics; Russian Medical Academy of Continuing Professional Education

Email: kleymenovaeb@cito-priorov.ru
ORCID iD: 0000-0002-8745-6195
SPIN-code: 2037-7164

MD, Dr. Sci. (Medicine), professor

Russian Federation, 10 Priorova str., 127299 Moscow; Moscow

Anton G. Nazarenko

Priorov National Medical Research Center of Traumatology and Orthopedics

Email: nazarenkoag@cito-priorov.ru
ORCID iD: 0000-0003-1314-2887
SPIN-code: 1402-5186

MD, Dr. Sci. (Medicine), professor of RAS

Russian Federation, 10 Priorova str., 127299 Moscow

Israil M. Gairabekov

Priorov National Medical Research Center of Traumatology and Orthopedics

Email: israil951998@gmail.com
ORCID iD: 0009-0006-6298-7084
Russian Federation, 10 Priorova str., 127299 Moscow

Karin B. Mirzaev

Russian Medical Academy of Continuing Professional Education

Email: karin05doc@yandex.ru
ORCID iD: 0000-0002-9307-4994
SPIN-code: 8308-7599

MD, Dr. Sci. (Medicine), professor

Russian Federation, Moscow

Dmitry A. Sychev

Russian Medical Academy of Continuing Professional Education

Email: dmitriy.alex.sychev@gmail.com
ORCID iD: 0000-0002-4496-3680
SPIN-code: 4525-7556

MD, Dr. Sci. (Medicine), professor; academician of the RAS

Russian Federation, Moscow

References

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