Perioperative analgesia in high-risk patients, what clinicians and searchers must know? A narrative review.

Background: Severe postoperative pain remains a significant clinical challenge, particularly in high-risk patients. While risk factors for acute and chronic postoperative pain have been well characterized, effective prevention and management strategies remain suboptimal. A multidimensional understanding of pain-including biological, psychological, and social factors-is essential for improving patient outcomes.

Objective: This narrative review aims to provide an updated overview of perioperative analgesia in high-risk patients, highlighting key considerations, illustrated by concrete examples, for clinicians and researchers.

Methods: Evidence was selected from the literature, summarising the current understanding of risk factors, pathophysiology, outcome measures, and management strategies related to perioperative pain in high-risk patients. Special attention was given to patient-specific and procedure-specific approaches, multimodal analgesia, and gaps in research methodologies.

Findings: High-risk patients-such as those with preoperative pain, opioid dependence, psychological distress, or complex surgical procedures-exhibit increased vulnerability to severe postoperative pain and persistent opioid use. Pain mechanisms involve nociceptive sensitization, neuroinflammation, and opioid-induced hyperalgesia, requiring tailored multimodal analgesic approaches. Standardized, multidimensional outcome measures, including patient-reported outcomes, functional recovery, and pain trajectories, are essential for evaluating analgesic efficacy. Despite advances in pain classification (e.g., ICD-11) and study designs, research remains fragmented, with high-risk patients often excluded from clinical trials.

Conclusion: Optimizing perioperative pain management in high-risk patients necessitates a personalized, evidence-based approach. Improved risk stratification, multimodal treatment strategies, and innovative research designs are critical for addressing the complexities of postoperative pain. Future studies should focus on identifying effective interventions for high pain responders and integrating long-term patient-centered outcomes into perioperative pain management protocols.