*2.7.3 Postoperative*

Following surgery, the patient may get benefit from oral analgesics to manage acute pain. Opioid analgesics may be considered for a short course in appropriate patients. A great concern about the use of opioids in any patient is the potential for OUD. Risk stratification tools exist that can help to determine which patients may be at elevated risk for opioid misuse and abuse [50] (see **Table 1**). Opioid overdose may result in potentially life-threatening respiratory depression; naloxone is a rapid-acting rescue drug. Patients taking opioids following CIED implantation may benefit from a prescription for naloxone and the family or caregivers should be trained in how to administer it in an emergency.

In a single-center retrospective study from Croatia (*n* = 372), 31% of patients being implanted with an ICD received pain medication following surgery; the highest intensity pain recorded in this study was 8 on a 0 to 10 scale [4]. The most frequently prescribed medications in this study were fixed-dose combination oral tramadol and acetaminophen 37.5/325 mg (29%), diazepam 5 mg (17%), tramadol 5 mg monotherapy (16%), and acetaminophen monotherapy


#### **Table 1.**

*While there is no consensus as to the best opioid-screening tool, a variety of validated instruments exist [51–53]. In place of an assessment tool, a clinical interview with the patient may be conducted to assess past drug experiences, familial history of substance use disorders, and attitudes about pain control. Note that these tools are often used in the setting of long-term opioid therapy, rather than short-term postoperative use.*

500 mg (12%) [4]. It should be noted that in this study 69% of patients received no postoperative analgesic medications at all [4]. This strongly suggests that many CIED patients have poorly controlled pain after surgery. Of course, postoperative pain control may be inadequate for many types of surgery. In USA survey of surgical inpatients, who had a variety of procedures, about 80% reported they suffered pain following surgery with 86% of them ranking this pain as "moderate" to "severe" [42]. Perhaps most important is that pain was reported to occur more frequently after discharge than before [42]. Patients may not always know what to expect and some may accept moderate to severe postoperative pain following surgery, not knowing that postoperative pain can often be safely and effectively managed.

An important analgesic strategy involves a combination of multimodal analgesia. Multimodal analgesia is based on the use of two or more analgesics with different mechanisms of action to offer a synergistic benefit to patients. Some fixed-dose combination products offer oral acetaminophen plus, a small amount of opioid, such as oxycodone, in a single oral dose. Adjuvant agents may also be helpful such as gabapentin or pregabalin to help with a neuropathic component to postsurgical pain.

A challenge in pain management following implant is the fact that most device patients do not spend prolonged periods of time in the hospital. Most CIED patients are discharged home shortly after surgery, whether they are outpatients or spend the night in the hospital. Thus, most device patients must manage the longest duration of their postsurgical pain at home. For this reason, patients and their families or caregivers must be educated about the pain medications they are to take, the appropriate doses and timing, and the risks as well as the benefits of these medications. Following transvenous device implant, patients should be educated about arm movements to prevent capsulitis ("frozen shoulder") [54].
