Acute Pain Service

Article 1 :

Methodology


A. Definition of Acute Pain Management in the Perioperative Setting  , acute pain is defined as pain that is

present in a surgical patient after a procedure. Such pain may be the result of trauma from the procedure or

procedure related  complications. Pain management in the perioperative setting refers to actions before,

during, and after a procedure that are intended to reduce or eliminate postoperative pain


before discharge.
  APS (Acute Pain Service ) Guideline Purpose: 

(1) facilitate the safety and effectiveness of acute pain management in the perioperative setting;

(2) reduce the risk of adverse outcomes;

(3) maintain the patient’s functional abilities, as well as physical and psychologic

well-being; and

(4) enhance the quality of life for patients with acute pain during the perioperative period. Adverse outcomes

that may result from the undertreatment of perioperative pain  include (but are not limited to)

thromboembolic and pulmonary complications, additional time spent in an intensive care

unit or hospital, hospital readmission for further pain management, needless suffering, impairment of health-

related quality of life, and development of chronic pain. Adverse outcomes associated with the management

of perioperative pain include  (but are not limited to) respiratory depression, brain or other  neurologic

injury, sedation, circulatory depression, nausea, vomiting, pruritus, urinary retention, impairment of bowel 

function, and sleep disruption. Health-related quality of life  includes (but is not limited to) physical,

emotional, social, and  spiritual well-being.


*Patients with severe or concurrent medical illness such as


sickle cell crisis, pancreatitis, or acute pain related to cancer

or cancer treatment may also benefit from aggressive pain

control. Labor pain is another condition of interest to anesthesiologists.

However, the complex interactions of concurrent

medical therapies and physiologic alterations make it

impractical to address pain management for these populations

within the context of this document.    

Recommendations for Preoperative Preparation of the Patient.

Patient preparation for perioperative pain management should include appropriate adjustments or

continuation of medications to avert an abstinence syndrome, treatment of preexistent pain, or preoperative

initiation of  therapy for postoperative pain management.

Anesthesiologists offering perioperative analgesia service should provide, in collaboration with others as

appropriate,patient and family education regarding their important roles in achieving comfort, reporting pain,

and in proper use of the recommended analgesic methods. Common misconceptions  that overestimate the

risk of adverse effects and addiction  should be dispelled. Patient education for optimal use of

patient-controlled analgesia (PCA) and other sophisticated  methods, such as patient-controlled epidural

analgesia  might include discussion of these analgesic methods at the  time of the preanesthetic evaluation,

brochures and videotapes  to educate patients about therapeutic options, and discussion  at the bedside

during postoperative visits. Such education  may also include instruction in behavioral modalities

for control of pain and anxiety.

IV. Perioperative Techniques for Pain Management

Perioperative techniques for postoperative pain management

include but are not limited to the following single modalities:

(1) central regional (i.e., neuraxial) opioid analgesia;

(2) PCAwith systemic opioids; and

(3) peripheral regional analgesic techniques, including but not limited to intercostal blocks,

plexus blocks, and local anesthetic infiltration of incisions.

Central regional opioid analgesia: Randomized controlled trials report improved pain relief when use of

preincisional  epidural or intrathecal morphine is compared with  preincisional oral, intravenous, or

intramuscular morphine

(Category A2 evidence).36–39 RCTs comparing preoperative

or preincisional intrathecal morphine or epidural sufentanil

with saline placebo report inconsistent findings regarding

pain relief 
(Category C2 evidence).40–43 RCTs comparing

preoperative or preincisional epidural morphine or

fentanyl with postoperative epidural morphine or fentanyl

are equivocal regarding postoperative pain scores

(Category C2 evidence).44,45

Meta-analyses of RCTs46–54 report improved pain relief

and increased frequency of pruritus in comparisons of

postincisional epidural morphine and saline placebo

(Category A1 evidence); findings for the frequency of nausea or

vomiting were equivocal

(Category C1 evidence). Meta-analyses of RCTs comparing postincisional epidural morphine

with intramuscular morphine report improved pain relief

and an increased frequency of pruritus

(Category A1 evidence). 49,55–59

One RCT reports improved pain scores and

less analgesic use when postincisional intrathecal fentanyl is

compared with no postincisional spinal treatment

(CategoryA3 evidence).60

One RCT reports improved pain scores when postoperative

epidural morphine is compared with postoperative epidural

saline

(Category A3 evidence).61
Meta-analyses of RCTs62–70 report

improved pain scores and a higher frequency of pruritus

and urinary retention when postoperative epidural morphine is

compared with intramuscular morphine

(Category A3 evidence);

findings for nausea and vomiting are equivocal

(Category C2 evidence).

Findings from RCTs are equivocal

regarding the analgesic efficacy of postoperative epidural

fentanyl compared with postoperative IV fentanyl

(Category C2 evidence)71–74;

meta-analytic findings are equivocal

for nausea and vomiting and pruritus

(Category C1 evidence).72–76

PCA with systemic opioids: Randomized controlled trials

report equivocal findings regarding the analgesic efficacy of

IV PCA techniques compared with nurse or staff-administered

intravenous analgesia  (Category C2 evidence).77–80   
 V. Multimodal Techniques for Pain Management

Multimodal techniques for pain management include the

administration of two or more drugs that act by different

mechanisms for providing analgesia. These drugs may be

administered via the same route or by different routes.   SEE EXAMPLES OF CASE :   http://www.penncancer.org/pdf/NETs%20and%20Surgery_Karakousis.pdf     Appendix 1: Summary of

Recommendations

I. Institutional Policies and Procedures for Providing

Perioperative Pain Management

• Anesthesiologists offering perioperative analgesia services should

provide, in collaboration with other healthcare professionals as

appropriate, ongoing education and training to ensure that hospital

personnel are knowledgeable and skilled with regard to the

effective and safe use of the available treatment options within the

institution.

Educational content should range from basic bedside pain

assessment to sophisticated pain management techniques (e.g., epidural analgesia, PCA, and various regional anesthesia techniques)

and nonpharmacologic techniques (e.g., relaxation,

imagery, hypnotic methods).

For optimal pain management, ongoing education and training

are essential for new personnel, to maintain skills, and

whenever therapeutic approaches are modified.

• Anesthesiologists and other healthcare providers should use standardized,

validated instruments to facilitate the regular evaluation

and documentation of pain intensity, the effects of pain therapy,

and side effects caused by the therapy.

• Anesthesiologists responsible for perioperative analgesia should

be available at all times to consult with ward nurses, surgeons, or

other involved physicians.

They should assist in evaluating patients who are experiencing

problems with any aspect of perioperative pain relief.

• Anesthesiologists providing perioperative analgesia services

should do so within the framework of an Acute Pain Service.

They should participate in developing standardized institutional

policies and procedures.II. Preoperative Evaluation of the Patient

• A directed pain history, a directed physical examination, and a

pain control plan should be included in the anesthetic preoperative

evaluation.

III. Preoperative Preparation of the Patient

• Patient preparation for perioperative pain management should

include appropriate adjustments or continuation of medications to

avert an abstinence syndrome, treatment of preexistent pain, or preoperative

initiation of therapy for postoperative pain management.

• Anesthesiologists offering perioperative analgesia services should

provide, in collaboration with others as appropriate, patient and

family education regarding their important roles in achieving

comfort, reporting pain, and in proper use of the recommended

analgesic methods.

Common misconceptions that overestimate the risk of adverse

effects and addiction should be dispelled.

Patient education for optimal use of PCA and other sophisticated

methods, such as patient-controlled epidural analgesia,

might include discussion of these analgesic methods at the

time of the preanesthetic evaluation, brochures and videotapes

to educate patients about therapeutic options, and discussion

at the bedside during postoperative visits.

Such education may also include instruction in behavioral

modalities for control of pain and anxiety.

IV. Perioperative Techniques for Pain Management

• Anesthesiologists who manage perioperative pain should use

therapeutic options such as epidural or intrathecal opioids, systemic

opioid PCA, and regional techniques after thoughtfully

considering the risks and benefits for the individual patient.

These modalities should be used in preference to intramuscular

opioids ordered “as needed.”

• The therapy selected should reflect the individual anesthesiologist’s

expertise, as well as the capacity for safe application of the

modality in each practice setting.

This capacity includes the ability to recognize and treat adverse

effects that emerge after initiation of therapy.

• Special caution should be taken when continuous infusion

modalities are used because drug accumulation may contribute

to adverse events.   V. Multimodal Techniques for Pain Management

• Whenever possible, anesthesiologists should use multimodal pain

management therapy.

Unless contraindicated, patients should receive an aroundthe-

clock regimen of NSAIDs, COXIBs, or acetaminophen.

Regional blockade with local anesthetics should be considered.

• Dosing regimens should be administered to optimize efficacy

while minimizing the risk of adverse events.

• The choice of medication, dose, route, and duration of therapy

should be individualized VI. Patient Subpopulations

• Pediatric patients

Aggressive and proactive pain management is necessary to

overcome the historic undertreatment of pain in children.

Perioperative care for children undergoing painful procedures

or surgery requires developmentally appropriate pain assessment

and therapy.

Analgesic therapy should depend upon age, weight, and comorbidity,

and unless contraindicated should involve a multimodal

approach.

Behavioral techniques, especially important in addressing the

emotional component of pain, should be applied whenever

feasible.

Sedative, analgesic, and local anesthetics are all important components

of appropriate analgesic regimens for painful procedures.

Because many analgesic medications are synergistic with sedating

agents, it is imperative that appropriate monitoring be used during

the procedure and recovery.

• Geriatric patients

Pain assessment and therapy should be integrated into the

perioperative care of geriatric patients.

Pain assessment tools appropriate to a patient’s cognitive abilities

should be used. Extensive and proactive evaluation and

questioning may be necessary to overcome barriers that hinder

communication regarding unrelieved pain.

Anesthesiologists should recognize that geriatric patients may

respond differently than younger patients to pain and analgesic

medications, often because of comorbidity.

Vigilant dose titration is necessary to ensure adequate treatment

while avoiding adverse effects such as somnolence in this

vulnerable group, who are often taking other medications (including

alternative and complementary agents). • Other subpopulations

Anesthesiologists should recognize that patients who are critically

ill, cognitively impaired, or have communication difficulties

may require additional interventions to ensure optimal

perioperative pain management.

Anesthesiologists should consider a therapeutic trial of an analgesic

in patients with increased blood pressure and heart rate or

agitated behavior when causes other than pain have been excluded.

Appendix 2: Methods and Analyses

A. State of the Literature

For these updated Guidelines, a review of studies used in the

development of the original Guidelines was combined with studies

published subsequent to approval of the original Guidelines

in 2003.* The scientific assessment of these Guidelines was

based on evidence linkages or statements regarding potential relationships between clinical interventions and outcomes. The

interventions listed below were examined to assess their relationship

to a variety of outcomes related to the management of acute

pain in the perioperative setting.

Institutional Policies and Procedures for Providing Perioperative Pain

Management

Education and training of healthcare providers

Monitoring of patient outcomes

Documentation of monitoring activities

Monitoring of outcomes at an institutional level

24-h availability of anesthesiologists providing perioperative

pain management

Acute pain service

Preoperative Evaluation of the Patient

A directed pain history (e.g., medical record review and patient

interview to include current medications, adverse effects, preexisting

pain conditions, medical conditions that would influence a

pain therapy, nonpharmacologic pain therapies, alternative and

complementary therapies)

A directed physical examination

Consultations with other healthcare providers (e.g., nurses, surgeons,

pharmacists) Preoperative Preparation of the Patient

Preoperative adjustment or continuation of medications whose sudden

cessation may provoke an abstinence syndrome

Preoperative treatment(s) to reduce preexisting pain and anxiety

Premedication(s) before surgery as part of a multimodal analgesic

pain management program

Patient and family education

Perioperative Techniques for Pain Management

Epidural or intrathecal analgesia with opioids (vs. epidural placebo,

epidural local anesthetics, or IV, intramuscular, or oral opioids)

Patient-controlled analgesia with opioids:

IV PCA versus nurse-controlled or continuous IV

IV PCA versus intramuscular

Epidural PCA versus epidural bolus or infusion

Epidural PCA versus IV PCA

IV PCA with background infusion of opioids versus no background

infusion

Regional analgesia with local anesthetics or opioids

Intercostal or interpleural blocks

Plexus and other blocks

Intraarticular opioids, local anesthetics or combinations

Infiltration of incisions

Multimodal Techniques (Epidural, IV, or Regional Techniques) Two or more analgesic agents, one route versus a single agent, one route

Epidural or intrathecal analgesia with opioids combined with:

Local anesthetics versus epidural opioids

Local anesthetics versus epidural local anesthetics

Clonidine versus epidural opioids

IV opioids combined with:

Clonidine versus IV opioids

Ketorolac versus IV opioids

Ketamine versus IV opioids

Oral opioids combined with NSAIDs, COXIBs, or acetaminophen

versus oral opioids Two or more drug delivery routes versus a single route

Epidural or intrathecal analgesia with opioids combined with IV,

intramuscular, oral, transdermal, or subcutaneous analgesics versus

epidural opioids

IV opioids combined with oral NSAIDs, COXIBs, or acetaminophen

versus IV opioids

Nonpharmacologic, alternative, or complementary pain management

combined with pharmacologic pain management versus

pharmacologic pain management

Special Patient Populations

Pain management techniques for pediatric patients

Pain assessment techniques

Dose level adjustments

Avoidance of repetitive diagnostic evaluation (heel sticks) for neonates

Pain management techniques for geriatric patients

Pain assessment techniques

Dose level adjustments

Painmanagementtechniques for other special populations (e.g., cognitively

impaired, critically ill, patients with difficulty communicating)

Pain assessment methods specific to special populations

Pain management techniques specific to special populations