Practice Guidelines for Acute Pain Management in the Perioperative Setting

PRACTICE Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.This document updates the “Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management,” adopted by the ASA in 2003 and published in 2004.*For these Guidelines, 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.The purpose of these Guidelines is to (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.These Guidelines focus on acute pain management in the perioperative setting for adult (including geriatric) and pediatric patients undergoing either inpatient or outpatient surgery. Modalities for perioperative pain management addressed in these Guidelines require a higher level of professional expertise and organizational structure than “as needed” intramuscular or intravenous injections of opioid analgesics. These Guidelines are not intended as an exhaustive compendium of specific techniques.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.Although patients undergoing painful procedures may benefit from the appropriate use of anxiolytics and sedatives in combination with analgesics and local anesthetics when indicated, these Guidelines do not specifically address the use of anxiolysis or sedation during such procedures.These Guidelines are intended for use by anesthesiologists and individuals who deliver care under the supervision of anesthesiologists. The Guidelines may also serve as a resource for other physicians and healthcare professionals who manage perioperative pain. In addition, these Guidelines may be used by policymakers to promote effective and patient-centered care.Anesthesiologists bring an exceptional level of interest and expertise to the area of perioperative pain management. Anesthesiologists are uniquely qualified and positioned to provide leadership in integrating pain management within perioperative care. In this leadership role, anesthesiologists improve quality of care by developing and directing institution-wide, interdisciplinary perioperative analgesia programs.The original Guidelines were developed by an ASA appointed task force of 11 members, consisting of anesthesiologists in private and academic practices from various geographic areas of the United States, and two consulting methodologists from the ASA Committee on Standards and Practice Parameters.The Task Force updated the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence. Second, original published research studies from peer-reviewed journals relevant to acute pain management were reviewed and evaluated. Third, expert consultants were asked to: (1) participate in opinion surveys on the effectiveness of various acute pain management recommendations and (2) review and comment on a draft of the updated Guidelines. Fourth, opinions about the updated Guideline recommendations were solicited from a sample of active members of the ASA. Fifth, opinion-based information obtained during an open forum for the original Guidelines, held at a major national meeting,†was reexamined. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the updated Guidelines. Seventh, all available information was used to build consensus to finalize the updated Guidelines. A summary of recommendations may be found in appendix 1.Preparation of these Guidelines followed a rigorous methodological process. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence.Study findings from published scientific literature were aggregated and are reported in summary form by evidence category, as described below. All literature (e.g. , randomized controlled trials RCTs, observational studies, case reports) relevant to each topic was considered when evaluating the findings. However, for reporting purposes in this document, only the highest level of evidence (i.e. , level 1, 2, or 3 within category A, B, or C, as identified below) is included in the summary.Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.Information from observational studies permits inference of beneficial or harmful relationships among clinical interventions and clinical outcomes.The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions and clinical outcomes.The lack of scientific evidence in the literature is described by the following terms.Inadequate: The available literature cannot be used to assess relationships among clinical interventions and clinical outcomes. The literature either does not meet the criteria for content as defined in the “Focus” of the Guidelines or does not permit a clear interpretation of findings due to methodological concerns (e.g. , confounding in study design or implementation).Silent: No identified studies address the specified relationships among interventions and outcomes.All opinion-based evidence (e.g. , survey data, open-forum testimony, Internet-based comments, letters, editorials) relevant to each topic was considered in the development of these updated Guidelines. However, only the findings obtained from formal surveys are reported.Opinion surveys were developed for this update by the Task Force to address each clinical intervention identified in the document. Identical surveys were distributed to expert consultants and ASA members.Survey responses from Task Force-appointed expert consultants are reported in summary form in the text, with a complete listing of consultant survey responses reported in appendix 2.Survey responses from active ASA members are reported in summary form in the text, with a complete listing of ASA member survey responses reported in appendix 2.Opinion survey responses are recorded using a 5-point scale and summarized based on median values.§Strongly Agree: Median score of 5 (At least 50% of the responses are 5)Agree: Median score of 4 (At least 50% of the responses are 4 or 4 and 5)Equivocal: Median score of 3 (At least 50% of the responses are 3, or no other response category or combination of similar categories contain at least 50% of the responses)Disagree: Median score of 2 (At least 50% of responses are 2 or 1 and 2)Strongly Disagree: Median score of 1 (At least 50% of responses are 1)Open-forum testimony from the previous update, Internet-based comments, letters, and editorials are all informally evaluated and discussed during the development of Guideline recommendations. When warranted, the Task Force may add educational information or cautionary notes based on this information.Institutional policies and procedures include (but are not limited to) (1) education and training for healthcare providers, (2) monitoring of patient outcomes, (3) documentation of monitoring activities, (4) monitoring of outcomes at an institutional level, (5) 24-h availability of anesthesiologists providing perioperative pain management, and (6) use of a dedicated acute pain service.Observational studies report that education and training programs for healthcare providers are associated with decreased pain levels,1–4decreased nausea and vomiting,2and improved patient satisfaction1(Category B2 evidence ), although the type of education and training provided varied across the studies. Published evidence is insufficient to evaluate the impact of monitoring patient outcomes at either the individual patient or institutional level, and the 24-h availability of anesthesiologists (Category D evidence ). Observational studies assessing documentation activities suggest that pain outcomes are not fully documented in patient records (Category B2 evidence ).5–11Observational studies indicate that acute pain services are associated with reductions in perioperative pain (Category B2 evidence ),12–20although treatment components of the acute pain services varied across the studies.The consultants and ASA members strongly agree that anesthesiologists offering perioperative analgesia services should provide, in collaboration with other healthcare professionals as appropriate, ongoing education and training of hospital personnel regarding the effective and safe use of the available treatment options within the The consultants and ASA members also strongly agree that anesthesiologists and other healthcare providers should use to facilitate the and documentation of pain the of pain and by the The ASA members agree and the consultants strongly agree (1) anesthesiologists for perioperative analgesia should be available at all to with or other and should assist in evaluating patients who are with any of perioperative pain (2) anesthesiologists should provide analgesia services within the of an Acute Pain and participate in developing institutional policies and and (3) an to perioperative pain management (e.g. , and for pain outcomes quality should be used to offering perioperative analgesia services should provide, in collaboration with other healthcare professionals as appropriate, ongoing education and training to that hospital personnel are and with to the effective and safe use of the available treatment options within the content should from basic pain to pain management (e.g. , patient controlled and various and (e.g. , pain management, ongoing education and training are for to maintain and are and other healthcare providers should use to facilitate the and documentation of pain the of pain and by the risk for adverse that may require medical Anesthesiologists for perioperative analgesia should be available at all to with or other and should assist in evaluating patients who are with any of perioperative pain providing perioperative analgesia services should do within the of an Acute Pain and participate in developing institutional policies and An to perioperative pain management that includes and and for perioperative pain as well as outcomes and quality patient and is to perioperative pain management. is an for postoperative analgesia that pain management the perioperative care of to in a include type of of postoperative medical (e.g. , of respiratory or the for the available and a patient's or previous with the literature is insufficient regarding the of a pain a physical or with other healthcare providers (Category D evidence ), the Task Force the of these observational study in a intensive care unit that the of a pain management may be associated with time to and to (Category B2 evidence ASA members agree and the consultants strongly agree that a a physical and a pain should be included in the pain a physical and a pain should be included in the patient includes (1) or of may a (2) to reduce pain and (3) before as of a pain management and (4) patient and pain is insufficient literature to evaluate the impact of or of may an (Category D evidence ). there is insufficient literature to evaluate the of the of treatment either to reduce pain or as of a pain management (Category D evidence ). are regarding the impact of patient and education on patient and time to although of patient and education varied across the studies (Category evidence consultants and ASA members strongly agree that patient for perioperative pain management should include appropriate or of to an treatment of or of for postoperative pain management. The ASA members agree and the consultants strongly agree that anesthesiologists offering perioperative analgesia services should provide, in collaboration with as appropriate, patient and The consultants and ASA members agree that perioperative patient education should include in for of pain and for perioperative pain management should include appropriate or of to an treatment of or of for postoperative pain offering perioperative analgesia services should provide, in collaboration with as appropriate, patient and education regarding their in reporting and in use of the that the risk of adverse and should be education for use of analgesia and other such as include of these at the time of the and to patients about and at the during postoperative Such education may also include in for of pain and for postoperative pain management include are not limited to the following (1) (i.e. , opioid (2) with and (3) not limited to and local of opioid controlled trials report improved pain when use of or is with or intramuscular (Category evidence or or with report findings regarding pain (Category evidence or or with postoperative or are regarding postoperative pain (Category evidence of improved pain and of in of and (Category evidence findings for the of nausea or were (Category evidence ). of with intramuscular report improved pain and an of (Category evidence improved pain and use when is with no treatment (Category evidence improved pain when postoperative is with postoperative (Category evidence of improved pain and a higher of and urinary when postoperative is with intramuscular (Category evidence findings for nausea and are (Category evidence ). from are regarding the of postoperative with postoperative (Category evidence findings are for nausea and and (Category evidence with controlled trials report findings regarding the of with or intravenous analgesia (Category evidence of improved pain when is with intramuscular (Category evidence from of and are regarding (Category evidence from of use when with a of is with a (Category evidence findings were regarding pain nausea and vomiting, pruritus, and sedation (Category evidence these Guidelines, include (e.g. , or and of indicate that or with is associated with improved pain (Category evidence report improved pain and when or is with (Category evidence of report findings for pain and used when postoperative or are with (Category evidence controlled trials report pain findings when with are with (Category evidence of use when with are with (Category evidence findings are for nausea and (Category evidence ). of pain when and other are with no (Category evidence report findings for pain and use when and other are with or no (Category evidence report findings for pain and use when or local anesthetics are with (Category evidence of improved pain when of is with (Category evidence findings for use are (Category evidence of are for pain and use when of is with (Category evidence of pain score findings when of is with of (Category evidence of improved pain and use when of is with (Category evidence consultants and ASA members strongly agree that anesthesiologists who manage perioperative pain should use options such as or opioid and after the and for the individual they also strongly agree that these should be used in to intramuscular “as The consultants and ASA members also strongly agree that the should the individual as well as the for safe of the in each the consultants and ASA members strongly agree that should be when are as may to adverse who manage perioperative pain should use options such as (i.e. , opioid and after the and for the individual These should be used in to intramuscular “as The should the individual as well as the for safe of the in each includes the to and adverse that after of should be when are as may to adverse for pain management include the of two or that by for providing These may be the or by with of improved pain (Category evidence and findings for nausea and and (Category evidence when with local anesthetics is with of improved pain and when with local anesthetics is with (Category evidence findings are reported for nausea and and (Category evidence ). of improved pain pain and a higher of (Category evidence when with is with findings are reported for nausea and (Category evidence ). report findings when with is with (Category evidence of for the higher of (Category evidence findings for nausea and (Category evidence report findings for pain nausea and vomiting, pruritus, and when with is with (Category evidence of for pain (Category evidence and a higher of when with is with (Category evidence ). of is for pain when with is with (Category evidence with of improved pain and use (Category evidence when intravenous with is with intravenous findings are reported for nausea and (Category evidence ). of findings for pain or nausea when intravenous with is with intravenous (Category evidence ). report findings for pain and use when intravenous opioid analgesia with with findings for are (Category evidence of report pain and opioid use when with (i.e. , is with (Category evidence no differences in nausea or are reported (Category evidence consultants and ASA members strongly agree that anesthesiologists should use pain management The ASA members agree and the consultants strongly agree that should be considered as of a postoperative pain management the consultants and ASA members agree that and and should be considered as of a postoperative pain management the ASA members agree and the consultants strongly agree patients should an of or the consultants and ASA members strongly agree that (1) with local anesthetics should be considered as of a for pain (2) should be to the risk of adverse and (3) the of and of should be anesthesiologists should use pain management with local anesthetics should be patients should an of or should be to the risk of adverse The of and of should be patient are at risk for pain and require additional populations at risk include (1) pediatric (2) and (3) or or other patients who may The Task Force that and the pain and response to In addition, the Task Force that patient and to treatment as well as pain by healthcare Task Force that care for and (including to the of pain. specific patient differences in their and of pain and suffering, and their response to in the and hospital may regarding the of analgesia as well as and In the of a clear of pain or pain may that pain is not present and for providing analgesia are in pediatric patients for of respiratory of pain is in and of and may as as the surgical of injections intramuscular or other of the of analgesia before injections may not this of may be effective in providing analgesia in pediatric are the as for although (e.g. , are used in The Task Force that it is for to that pediatric patients require to perioperative ASA members and consultants strongly agree that (1) perioperative care for undergoing painful procedures or appropriate pain and (2) should and and should a and (3) are with it is that appropriate monitoring be used during the procedure and The ASA members agree and the consultants strongly agree that in the of should be and pain management is to the undertreatment of pain in Perioperative care for undergoing painful procedures or appropriate pain and should and and should a in the of should be and local anesthetics are all components of appropriate for painful are with it is that appropriate monitoring be used during the procedure and patients from such as or cancer that to surgery. The Task Force that pain is and individuals may be to the of such The physical, social, emotional, and associated with an impact on perioperative pain management. These patients may than adult patients in pain and appropriate the and local anesthetics are distributed and and effective in may also benefit patients an in adverse observational study that perioperative analgesics are provided in to than to (Category B2 evidence Task Force although the for perioperative in the are undertreatment of pain in is ASA members and consultants strongly agree that (1) pain and should be the perioperative care of (2) pain appropriate to a patient's should be and (3) should be to treatment adverse such as in this who may be other The ASA members agree and the consultants strongly agree that and and should be to that regarding and should be the perioperative care of Pain appropriate to a patient's should be and and may be to that regarding pain. Anesthesiologists should that patients may than patients to pain and of is to treatment adverse such as in this who are other (including and who are (e.g. , or who (e.g. , or present to perioperative pain management. The Task Force that that reduce to provide effective analgesia (e.g. , analgesia and may be for such and such as that of analgesics are for the The literature is insufficient to evaluate the of pain or pain management specific to these populations (Category D evidence consultants and ASA members strongly agree that anesthesiologists should that patients who are or may require additional interventions to perioperative pain management. the ASA members agree and the consultants strongly agree that anesthesiologists should a of an in patients with and or when other than pain should that patients who are or may require additional interventions to perioperative pain management. Anesthesiologists should a of an in patients with and or when other than pain these updated Guidelines, a review of studies used in the development of the original Guidelines was with studies published to of the original Guidelines in The scientific of these Guidelines was based on evidence or regarding relationships between clinical interventions and outcomes. The interventions were to assess their to a of outcomes related to the management of acute pain in the perioperative and for Perioperative Pain Management of the of the Perioperative for Pain Management or the literature relevant clinical studies were identified and of the The and a from than were identified a of that addressed related to the evidence the were studies not provide evidence and were A of evidence. A complete used to these Guidelines, by is available as 2, each reported in a study was as an evidence a or The were summarized to a for each evidence before formal to evidence categories studies with and information for These (1) or (2) (3) and (4) two or a or were obtained for and were obtained for were used as (1) the based on of the reported from the studies, and (2) the providing of the studies by each of the by the of the An procedure based on the for study using 2 2 was used with An level was at < for of the studies were to among the study were obtained when significant was found (P < for a was No for studies was and no for research were be as significant agree with of are In the of findings from the and agree with each other to be as the previous update of the Guidelines, among Task Force members and two methodologists was by using a for were as (1) type of study (2) type of (3) evidence and (4) literature for (1) study (2) type of (3) (4) literature These of the updated Guidelines, the two methodologists in the original Guidelines the literature findings of the literature were by the opinions of Task Force members after opinions from a of and from of the draft document on the ASA In addition, opinions obtained from consultant open forum commentary, and other used in the original Guidelines were reviewed and was obtained from (1) survey opinion from consultants who were based on their or expertise in acute pain management, (2) survey opinions solicited from active members of the (3) testimony from of a held open forum at a national Guidelines (4) commentary, and (5) Task Force opinion and The survey of was of for the consultants and surveys were from active ASA members the previous update of the Guidelines, an additional survey was to the expert consultants to indicate of the evidence their clinical practices the Guidelines were The of was of The of consultants no associated with each were as (1) (2) education and training (3) education or of patient and (4) monitoring or documentation (5) availability of anesthesiologists (6) institutional use of or use of organizational pediatric and of the that the Guidelines no on the of time spent on a and that there be an of the of time spent on a case with the of these Guidelines time that or training not be to the Guidelines, and that of the Guidelines not require in that