LBJ Ventral Hernia Protocol: Postoperative Pain Management

Note: The regimen below is the maximum standard regimen and does not need to be ordered for all patients. See the postop protocol for the patient’s surgery (e.g., eTEP versus open component separation) for recommendations for which agents to order.

• Possible postoperative pain orders:
  • Acetaminophen 1000 mg PO Q6H scheduled
    • Consider IV route if extensive lysis or pain uncontrolled
  • Ketorolac 15-30 mg IV Q8H scheduled
    • Scheduled x3 days, then switch to naproxen 500mg Q12H x 7 days
    • Discontinue if AKI develops
    • Start scheduled PPI with NSAIDs
  • Methocarbamol 500 mg PO Q6H scheduled
    • Consider IV route if extensive lysis or pain uncontrolled
    • Caution if age > 65, as it can cause delirium
  • Oxycodone 5 mg PO Q6H PRN
    • Do not schedule
    • Start with 2.5 mg dose in small patients
    • Caution if age > 65, consider 2.5 mg dose
  • Gabapentin 300 mg PO TID
    • Start at 100 mg PO TID if pre-existing CKD
    • Caution if age > 65, as it can cause delirium and urinary retention
    • Do not order if patient has a history of depression
  • Possible adjunctive medications – for uncontrolled pain
    • Ketamine 0.1 mg/kg/hr – Not titrated, requires IMU or ICU admission
    • Dronabinol 5mg PO q6h – titrate to effect
      • Consider starting empirically in patients with history of chronic marijuana use
    • Methadone 5mg PO BID
    • Lidocaine patch – if no epidural or pain catheters
    • For IV lidocaine, regional blocking, or other advanced techniques, consult APMS
  • Escalation/de-escalation of pain regimen:
    • Pain meds should be escalated and de-escalated in a step-wise fashion
    • Opioids and other adjunctive medications should be discontinued first, followed by methocarbamol and/or gabapentin, then NSAIDs