Practice Guidelines for Acute Pain Management in the Perioperative Setting

Developed by the Task Force on Pain Management, Acute Pain Section: L. Brian Ready, M.D. (Chair), Seattle, Washington; Michael Ashburn, M.D., Salt Lake City, Utah; Robert A. Caplan, M.D., Seattle, Washington; Daniel B. Carr, M.D., Boston, Massachusetts; Richard T. Connis, Ph.D., Woodinville, Washington; Cheryl L. Dixon M.D., Jacksonville, Florida; Lex Hubbard, M.D., Shreveport, Louisiana; and Linda Jo Rice, M.D., Hartford, Connecticut.Submitted for publication December 27, 1994. Accepted for publication December 27, 1994. Supported by the American Society of Anesthesiologists, under the direction of James F. Arens, M.D. Chairman of the Ad-Hoc Committee on Practice Parameters. Approved by the House of Delegates, October 19, 1994. A list of the articles used to develop these guidelines is available by writing to the American Society of Anesthesiologists.Address reprint requests to the American Society of Anesthesiologists: 520 North Northwest Highway, Park Ridge, Illinois 60068-2573.Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.Key words: Pain: acute; perioperative. Practice guidelines: acute pain management.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.Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision from time to time, as warranted by the evolution of medical knowledge, technology, and practice. The guidelines provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data (Appendix).Acute pain in the perioperative setting has not been specifically defined in the available literature. The Task Force has not given preference to literature based on any particular system of definition or classification. For these guidelines, acute pain in the perioperative setting is defined as pain that is present in a surgical patient because of preexisting disease, the surgical procedure (e.g., associated drains, chest or nasogastric tubes, complications), or a combination of disease-related and procedure-related sources.The purpose of these guidelines is to facilitate the efficacy and safety of acute pain management in the perioperative setting and to reduce the risk of adverse outcomes. A number of adverse outcomes can result from undertreatment of postoperative pain. These include (but are not limited to) thromboembolic and pulmonary complications, extension of time spent in an intensive care unit and/or in a hospital, and reduced patient satisfaction. The principal adverse outcomes associated with management of perioperative pain include (but are not limited to) respiratory depression, brain injury, other neurologic injury, sedation, circulatory depression, nausea and/or vomiting, impairment of bowel function, pruritus, and urinary retention.These guidelines focus on modalities of perioperative pain management that require a higher level of expertise and organizational structure than "as needed" intramuscular or intravenous injections of opioids and that generally provide more effective relief of pain. Examples include (but are not limited to) epidural (and intrathecal) analgesia (EA), intravenous patient-controlled analgesia (PCA), and a number of regional analgesic (RA) techniques. The guidelines are not intended as an exhaustive or detailed consideration of specific techniques or all possible approaches.The specialty of anesthesiology brings an exceptional level of interest and expertise to the area of perioperative pain management. As a consequence, the anesthesiologist is in a unique position to provide leadership in integrating pain management into other aspects of perioperative care and thus improve this area of practice. In this leadership role, the anesthesiologist can contribute further to quality of care by developing and directing institution-wide perioperative analgesia programs that include collaboration with and participation by others, when appropriate.The role of anesthesiologists in managing acute pain extends beyond the perioperative setting. Patients with severe or concurrent medical illness such as sickle cell crisis, pancreatitis, or acute pain related to cancer or cancer treatment 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.These guidelines focus on management of acute pain in the perioperative setting for adult (including geriatric) and pediatric patients. The guidelines apply to inpatient and outpatient surgery. These guidelines are intended for use by anesthesiologists or by individuals who deliver care under the supervision of anesthesiologists.Evidence to support each guideline was carefully sought. The search included a comprehensive review of the published literature, surveys of the opinions of a large panel of consultants with expertise in acute pain management, and the opinions of the members of the Task Force. An indication of the strength of the evidence supporting each guideline is provided.The Task Force defines proactive planning as a process of integrating pain management into the perioperative care of patients. The literature, the panel of consultants, and the Task Force members strongly support the use of proactive planning for postoperative pain management. This support is based on recognized associations between preoperative and intraoperative analgesic techniques for the reduction of pain in the postoperative period.Recommendations: An individualized proactive plan (e.g., a predetermined strategy for postoperative analgesia) should be considered for all surgical patients. Factors that may influence the formulation of a proactive plan include (but are not limited to) type of surgery and expected severity of postoperative pain, underlying medical conditions (e.g., presence of respiratory or cardiac disease, allergies), the risk-benefit ratio of the techniques available, and patients' preferences and/or previous experience with pain. Proactive planning of perioperative pain should be part of the preoperative evaluation by the anesthesiologist and, in collaboration with others (e.g., nurses, surgeons, pharmacists), should be part of an institution's general plan for patient care.Activities that are commonly encompassed by proactive planning include (but are not limited to) (1) obtaining a pain history based on patients' experiences, (2) preoperative pain therapy when appropriate and feasible, (3) intraoperative procedures (e.g., wound infiltration) when appropriate and feasible, and (4) intraoperative or postincisional preparation of patients for postoperative pain management (e.g., initiating EA administration before the completion of surgery). Any treatment plan requires regular assessment and refinement based on the changing responses of individual patients.The available literature suggests that training and experience of hospital personnel (e.g. nurses, house-officers, pharmacists, psychologists) may be helpful in reduction of risk. There is strong agreement among the panel of consultants and the Task Force members that such education, training, and experience also contribute to improved quality of care.Recommendations: Anesthesiologists offering perioperative analgesia services should provide, in collaboration with others 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. The scope of education should include topics ranging from basic bedside skills for evaluation of acute pain to an understanding of sophisticated pharmacologic techniques (e.g., PCA, EA, and various RA techniques) and nonpharmacologic techniques (e.g., relaxation, imagery, hypnotic methods). The need for education and training is ongoing as new personnel enter an institution and as modifications in therapeutic approaches are made.The panel of consultants and the Task Force members regard the concept of education of patients and families in planning and participation in perioperative pain control as being important to their comfort and well-being.Recommendations: Anesthesiologists offering perioperative analgesia services should provide, in collaboration with others as appropriate, education to patients and families regarding their roles in achieving comfort, reporting pain, and using the recommended analgesic methods to optimal benefit. Common misconceptions about the risk of side effects and addiction should be dispelled. Educational methods that facilitate optimal care of patients using PCA and other sophisticated methods might include (but are not limited to) discussion of analgesic methods at the time of the pre-anesthetic evaluation, brochures and video tapes to educate patients about therapeutic options, and discussion at the bedside during postoperative visits.The panel of consultants and the Task Force members strongly support the concept of assessment and documentation of response to perioperative pain therapy as important to effective care. Unless the response to pain therapy is regularly evaluated, there is no basis for rational, individualized therapy.Recommendations: Anesthesiologists offering perioperative analgesia services should use, in collaboration with others as appropriate, pain assessment instruments to facilitate the regular evaluation and documentation of pain, the effects of pain therapy, and side effects caused by the therapy (Table 1and Table 6templates 1 and 6).The panel of consultants and the Task Force members support the concept of 24-hour availability of anesthesiologists providing perioperative pain management as being important for maximizing patient comfort and safety. The condition of patients after surgery is frequently dynamic, and analgesic needs may change at any time.Recommendations: Most analgesic techniques place patients at some risk for side effects of complications that require prompt medical evaluation. Anesthesiologists responsible for perioperative analgesia, in collaboration with others as appropriate, should be available at all times to consult with ward nurses, surgeons, or other involved physicians and assist in evaluating patients who are experiencing problems with any aspect of postoperative pain relief.The available literature suggests that institutional protocols and procedures for ordering, administering, discontinuing, and transferring responsibility for pain management are helpful in providing effective and continuous pain control. The Task Force regards the use of institutional policies and procedures as a logical part of interdisciplinary management of perioperative pain, and there is strong agreement from the panel of consultants that this approach is beneficial. The development of hospital-wide policies and procedures helps standardize clinical practice using techniques such as PCA, EA, and various RA techniques (Table 2and Table 3templates 2 and 3). Standardization promotes safety and creates a framework for customization of care. Routine use of bedside documentation encourages caregivers to continually reevaluate pain treatment and respond to inadequate therapy in a timely manner. Daily evaluation, planning, and written documentation by those who are medically responsible for pain relief help establish the importance of a formal and structured approach to pain management (Table 4, Table 5, Table 6, Table 7templates 4-7).Recommendations: Anesthesiologists offering perioperative analgesia services should participate in developing, in collaboration with others as appropriate (especially nurses), standardized institutional policies and procedures for ordering, administering, discontinuing, and transferring responsibility for postoperative pain management. Policies (the foundation or "ground rules" for practice) and procedures (outlining the "how to" aspects of applying policies to patient care) should be readily available on each patient care unit. The polices and procedures also serve as ongoing educational and informational references.The literature strongly supports the efficacy and safety of three techniques used by anesthesiologists for the control of pain in the perioperative setting: (1) PCA with systemic opioids, (2) EA with opioids or opioid/local anesthetic mixtures (or intrathecal opioids), and (3) RA techniques, including (but not limited to) intercostal blocks, plexus infusions, and local anesthetic infiltration of incisions. The literature indicates that these three techniques used by anesthesiologists have no higher incidence of side effects than less effective techniques for perioperative pain management. The panel of consultants and the Task Force members strongly support the use of PCA, EA, and RA by anesthesiologists when appropriate and feasible.Recommendations: To meet the diverse needs of individual patients, anesthesiologists who manage perioperative pain should make available as appropriate a variety of effective therapeutic options such as PCA, EA, and RA.During the administration of anesthetics for surgery, the needs of many patients may best be met by taking advantage of the combined effects of a number of agents. Similarly, there is growing conviction that a multimodality approach (i.e., two or more analgesic agents or techniques used in combination) to providing postoperative analgesia has advantages over the use of a single modality.The literature supports the efficacy of two or more analgesic techniques (including nonpharmacologic methods) used in combination for the control of perioperative pain, especially when different sites and/or mechanisms of action are involved and/or when synergy of effect is achieved. In addition, the literature indicates that multimodality approaches are associated with side effects no greater than those resulting from single analgesic techniques for perioperative pain management. The panel of consultants and the Task Force members support the use of multimodality techniques when appropriate and feasible.Recommendations: Anesthesiologists managing perioperative pain should make available as appropriate a variety of analgesic techniques and should consider their use in combination under appropriate circumstances.Although dedicated individuals can improve perioperative pain control for the individual patients they treat, comprehensive programs provide optimal analgesia throughout an institution. Such programs have been advocated by national and international pain specialty societies [1,2]and the Federal government.* The Task Force strongly believes that, based on training, knowledge, skills, interest, and historical innovation, anesthesiologists are uniquely qualified to provide leadership within their institutions in developing and managing perioperative pain management programs.The panel of consultants and the Task Force members regard organized interdisciplinary activities (e.g., anesthesiologists in collaboration with nurses, surgeons, and pharmacists) as important and optimal in providing effective, safe, and continuous perioperative pain control (Table 8template 8). An essential feature of such an approach should be an ongoing strong working relationship between anesthesiologists and nurses.Recommendations: Anesthesiologists who manage perioperative pain should develop (in collaboration with nurses, surgeons, pharmacists, and others) an organized, interdisciplinary approach to perioperative pain management within their institutions.Pediatric patients (infants and children) present unique problems regarding perioperative pain management for reasons that include differences in the perception of care-givers regarding the need for analgesia, differences in the pharmacology of analgesic medications when used in this group, and the strong emotional components of pain in children. In the past, safe methods for providing analgesia have been underused in pediatric patients because of fear of opioid-induced respiratory depression.The emotional component of pain is very strong in children. Absence of parents, security objects, and familiar surroundings may be perceived by the child to be as painful as the surgical incision. When clear evidence of physical pain is not seen, the tendency of health-care providers is to assume pain is not present and therefore defer treatment. In addition, young childrens' fear of injections makes intramuscular opioids or other methods, which themselves cause discomfort, less acceptable to this group than to adults. Many children will choose to suffer in silence knowing that an expression of pain will result in a dreaded injection.Pain assessment is more difficult in children because, as they grow and develop, cognitive and emotional responses are different from adults and are constantly changing. Special instruments are available to assist young children in self-reporting of pain, and behavioral and physiologic parameters can be employed to assess preverbal children or in those who cannot self-report.The literature strongly supports the effectiveness of a variety of techniques in providing analgesia in pediatric patients. Many of these are the same techniques used in adults, although some techniques (e.g., caudal analgesia) are more commonly used in children. There is strong agreement among the panel of consultants and the Task Force members that it is important to recognize that pediatric patients represent a unique population with special features when planning and providing perioperative Anesthesiologists who perioperative pain in pediatric patients should be familiar with the special features of this on that knowledge, pharmacologic and nonpharmacologic for perioperative analgesia appropriate for the of the child should be in a that promotes efficacy and patients are a unique population surgery. may experience physical and and may have different than patients with regard to pain and appropriate therapy for with the analgesic and local anesthetics are and frequently alterations in There is strong agreement from the panel of consultants and the Task Force members on the importance of the unique features of patients in planning and providing perioperative literature indicates that single and multimodality techniques that have been to be effective in adult patients are also effective with reduced in patients side Anesthesiologists who perioperative pain in patients should be familiar with the special features of this In reduction for that may cause system should be surgery special problems in perioperative pain management. of the reasons for hospital in this population is inadequate pain control. techniques provide safe, pain relief for patients who the hospital such as EA and intravenous PCA, which require special and are not for such patients, others such as local anesthetic wound infiltration and may be very panel of consultants and the Task Force members strongly that the of effective analgesia to surgery patients is important and beneficial. 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Brian Ready, M.D., of Acute Pain of of Seattle,