The results were then summarized to obtain a directional assessment for each evidence linkage before conducting formal meta-analyses. N Engl J Med 1964; 270:825–7, Elsass P, Eikard B, Junge J, Lykke J, Staun P, Feldt-Rasmussen M: Psychological effect of detailed preanesthetic information. Preoperative patient evaluation and planning is integral to perioperative pain management. Surg Endosc 2001; 15:1030–3, Vinson-Bonnet B, Coltat JC, Fingerhut A, Bonnet F: Local infiltration with ropivacaine improves immediate postoperative pain control after hemorrhoidal surgery. A comparison of epidural and intramuscular morphine analgesia. 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. Moreover, the ASA members agree and the consultants strongly agree that, unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen. Meta-analyses of RCTs221,–,226report equivocal findings for pain scores, analgesic use, or nausea scores when intravenous morphine combined with ketamine is compared with intravenous morphine (Category C1 evidence ). The literature cannot determine whether there are beneficial or harmful relationships among clinical interventions and clinical outcomes. Arch Surg 1997; 132:766–9, Cnar SO, Kum U, Cevizci N, Kayaoglu S, Oba S: Effects of levobupivacaine infiltration on postoperative analgesia and stress response in children following inguinal hernia repair. For these Guidelines, acute pain is defined as pain that is present in a surgical patient after a procedure. Anesthesiology. 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. Pain assessment and therapy should be integrated into the perioperative care of geriatric patients. Eur J Anaesthesiol 1996; 13:571–6, Vercauteren MP, Vandeput DM, Meert TF, Adriaensen HA: Patient-controlled epidural analgesia with sufentanil following caesarean section: The effect of adrenaline and clonidine admixture. This article addresses the management of acute postoperative pain with a focus on patient assessment, commonly used medications, routes of administration, and patient follow-up. Eur J Anaesthesiol 2001; 18:450–7, Kampe S, Weigand C, Kaufmann J, Klimek M, König DP, Lynch J: Postoperative analgesia with no motor block by continuous epidural infusion of ropivacaine 0.1% and sufentanil after total hip replacement. fentanyl and epidural infusions with and without fentanyl. Sixty-five percent of the respondents indicated that the Guidelines would have no effect on the amount of time spent on a typical case, and 24% indicated that there would be an increase of the amount of time spent on a typical case with the implementation of these Guidelines (mean time increase = 3.4 min). Anesthesiology, 116, 248-273. Practice Guidelines for Acute Pain Management in the Perioperative Setting 2 Title: Practice Guidelines for Acute Pain Management in the Perioperative Setting: Bibliography Author: Richard T. Connis, Ph.D. Last modified by: Tom Smith Created Date: 1/24/2002 7:37:00 PM Other titles: Int J Nurs Stud 1976; 13:11–24, Griffin MJ, Brennan L, McShane AJ: Preoperative education and outcome of patient controlled analgesia. Meta-analysis of RCTs is equivocal for pain scores when epidural opioids combined with clonidine is compared with epidural opioids (Category C1 evidence ).207,–,212, Multimodal techniques with systemic analgesics: Meta-analyses of RCTs213,–,220report improved pain scores and reduced analgesic use (Category A1 evidence ) when intravenous morphine combined with ketorolac is compared with intravenous morphine; equivocal findings are reported for nausea and vomiting (Category C1 evidence ). “The new ASA recommendations update guidelines that were previously released in 2004,” says … In this leadership role, anesthesiologists improve quality of care by developing and directing institution-wide, interdisciplinary perioperative analgesia programs. Anesth Analg 1988; 67:1138–41, Hesselgard K, Strömblad LG, Reinstrup P: Morphine with or without a local anaesthetic for postoperative intrathecal pain treatment after selective dorsal rhizotomy in children. Anesthesiology. , randomized controlled trials [RCTs], observational studies, case reports) relevant to each topic was considered when evaluating the findings. Anesthesiologists responsible for perioperative analgesia should be available at all times to consult with ward nurses, surgeons, or other involved physicians, and should assist in evaluating patients who are experiencing problems with any aspect of perioperative pain relief. Reg Anesth 1997; 22:343–6, Sevarino FB, Sinatra RS, Paige D, Silverman DG: Intravenous ketorolac as an adjunct to patient-controlled analgesia (PCA) for management of postgynecologic surgical pain. 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. Acta Orthop Scand 2000; 71:280–5, Heard SO, Edwards WT, Ferrari D, Hanna D, Wong PD, Liland A, Willock MM: Analgesic effects of intraarticular bupivacaine or morphine after arthroscopic knee surgery: A randomized, prospective, double-blind study. Anesth Analg 1988; 67:137–43, Gall O, Aubineau JV, Bernière J, Desjeux L, Murat I: Analgesic effect of low-dose intrathecal morphine after spinal fusion in children. Acta Anaesthesiol Scand 1997; 41:466–72, Hannibal K, Galatius H, Hansen A, Obel E, Ejlersen E: Preoperative wound infiltration with bupivacaine reduces early and late opioid requirement after hysterectomy. , confounding in study design or implementation). American Society of Anesthesiologists Task Force on Acute Pain Management. The ASA members agree and the consultants strongly agree that behavioral techniques, especially important in addressing the emotional component of pain, should be applied whenever feasible. 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. Elderly patients suffer from conditions such as arthritis or cancer that render them more likely to undergo surgery. N Engl J Med. PubMed PMID: 22227789. We’re pleased to announce that the 2020 edition of the internationally-renowned Acute Pain Management: Scientific Evidence is now available. 2012 Feb;116(2):248-73.doi: 10.1097/ALN.0b013e31823c1030. Anesth Analg 2004; 99:589–92, Tree-Trakarn T, Pirayavaraporn S: Postoperative pain relief for circumcision in children: Comparison among morphine, nerve block, and topical analgesia. J Cardiothorac Vasc Anesth 1998; 12:654–8, Murphy DF, Graziotti P, Chalkiadis G, McKenna M: Patient-controlled analgesia: A comparison with nurse-controlled intravenous opioid infusions. Anesthesiology. 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. 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). One observational study in a neonatal intensive care unit suggests that the implementation of a pain management protocol may be associated with reduced analgesic use, shorter time to extubation, and shorter times to discharge (Category B2 evidence ).21. After completion, the guideline was also reviewed for approval by the American Society of Regional Anesthesia and Pain Medicine. These drugs may be administered via the same route or by different routes. Even the valuable technique of topical analgesia before injections may not lessen this fear. These linkages were: (1) epidural or intrathecal opioids, (2) patient-controlled analgesia, (3) regional analgesia, and (4) two or more anesthetic drugs versus a single drug. Anesth Analg 2001; 93:116–20, Sveticic G, Farzanegan F, Zmoos P, Zmoos S, Eichenberger U, Curatolo M: Is the combination of morphine with ketamine better than morphine alone for postoperative intravenous patient-controlled analgesia? American Society of Anesthesiologists Task Force on Acute Pain Management. 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. Fifth, opinion-based information obtained during an open forum for the original Guidelines, held at a major national meeting,†was reexamined. Ann Thorac Surg 1992; 53:449–54, Mozell EJ, Sabanathan S, Mearns AJ, Bickford-Smith PJ, Majid MR, Zografos G: Continuous extrapleural intercostal nerve block after pleurectomy. Can J Anaesth 1995; 42:12–5, Toivonen J, Permi J, Rosenberg PH: Effect of preincisional ilioinguinal and iliohypogastric nerve block on postoperative analgesic requirement in day-surgery patients undergoing herniorrhaphy under spinal anaesthesia. Anesth Analg 1996; 82:8–12, Stevens RD, Van Gessel E, Flory N, Fournier R, Gamulin Z: Lumbar plexus block reduces pain and blood loss associated with total hip arthroplasty. Intrathecal hydromorphone and morphine for postcesarean … An odds ratio procedure based on the Mantel-Haenszel method for combining study results using 2 × 2 tables was used with outcome frequency information. Scand J Thorac Cardiovasc Surg 1992; 26:219–23, Rademaker BM, Sih IL, Kalkman CJ, Henny CP, Filedt Kok JC, Endert E, Zuurmond WW: Effects of interpleurally administered bupivacaine 0.5% on opioid analgesic requirements and endocrine response during and after cholecystectomy: A randomized double-blind controlled study. administration of ketorolac. The electronic and manual searches covered a 49-yr period from 1963 through 2011. Level 1: The literature contains observational comparisons (e.g. Such education may also include instruction in behavioral modalities for control of pain and anxiety. Anesth Analg 1988; 67:261–7, Broekema AA, Kuizenga K, Hennis PJ: Does epidural sufentanil provide effective analgesia per- and postoperatively for abdominal aortic surgery? This was highlighted in the first practice guideline published on acute pain management 20 yr ago by the Agency for Health Care Policy and Research . Psychosom Med 2000; 62:365–73, Egbert LD, Battit GE, Welch CE, Bartlett MK: Reduction of postoperative pain by encouragement and instruction of patients. Eighty-nine percent indicated that new equipment, supplies, or training would not be needed to implement the Guidelines, and 92% indicated that implementation of the Guidelines would not require changes in practice that would affect costs. Unless contraindicated, patients should receive an around-the-clock regimen of COXIBs, NSAIDs, or acetaminophen. J Consult Clin Psychol 1987; 55:513–20, Daltroy LH, Morlino CI, Eaton HM, Poss R, Liang MH: Preoperative education for total hip and knee replacement patients. 2012 Feb;116(2):248-73. doi: 10.1097/ALN.0b013e31823c1030. Meta-analyses of RCTs49,172,176,189,–,194report improved pain scores, greater pain relief, and a higher frequency of pruritus (Category A1 evidence ) when epidural morphine combined with bupivacaine is compared with epidural bupivacaine alone; equivocal findings are reported for nausea and vomiting (Category C1 evidence ). Clinical evidence of neuroplasticity contributing to postoperative pain. J Clin Anesth 1992; 4:277–81, Harrison DM, Sinatra R, Morgese L, Chung JH: Epidural narcotic and patient-controlled analgesia for post-cesarean section pain relief. Volkow ND and McLellan T. Opioid Abuse in Chronic Pain –Misconception and Mitigation Strategies. Acta Anaesth Scand 1991; 35:108–12, Barron DJ, Tolan MJ, Lea RE: A randomized controlled trial of continuous extra-pleural analgesia post-thoracotomy: Efficacy and choice of local anaesthetic. An acceptable significance level was set at P < 0.01 (one-tailed). , relaxation, imagery, hypnotic methods). h�b```c``Z�����^� Ȁ �,@9�h`��f7ǰ�J4\|N����0w:�W���������|��n��DFu�)>WT���s�500�؞>kƎ3;[\]]`�y���eHH�t��r������ ,�y-���*��$L�gc�J�l慐��qll���'@� N���A���Ղ̼[���L6n�. Anesth Analg 2002; 95:746–50, Ding Y, White PF: Post-herniorrhaphy pain in outpatients after pre-incision ilioinguinal-hypogastric nerve block during monitored anaesthesia care. The Task Force believes that genetics and gender modify the pain experience and response to analgesic therapies. 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 institution. This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. This article, part of the acute pain learning series, has been developed to highlight when and why pharmacists should review guidelines and the evidence base to support clinical decision making in patients presenting with symptoms of acute pain. Anesthesiology. 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. Acta Anaesthesiol Scand 2000; 44:1093–8, Johansson B, Hallerbäck B, Stubberöd A, Janbu T, Edwin B, Glise H, Solhaug JH: Preoperative local infiltration with ropivacaine for postoperative pain relief after inguinal hernia repair. A. 2004; 100(6):1573-81 (ISSN: 0003-3022) Whenever possible, anesthesiologists should use multimodal pain management therapy. Proactive individualized planning is an anticipatory strategy for postoperative analgesia that integrates pain management into the perioperative care of patients. This article highlights some of the promising new advances and approaches in postoperative pain management. , ordering, administering, and transitioning therapies, transferring responsibility for pain therapy, outcomes assessment, continuous quality improvement) should be used to minimize analgesic gaps. Anaesthesia 1996; 51:1093–6, Harmer M, Davies KA: The effect of education, assessment and a standardised prescription on postoperative pain management. 7. Coleman SA, Booker-Milburn J: Audit of postoperative pain control: Influence of a dedicated acute pain nurse. 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). 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. Anesth Analg 1986; 65:385–8, Fitzpatrick GJ, Moriarty DC: Intrathecal morphine in the management of pain following cardiac surgery. Acute Pain Management: Scientific Evidence 5th edition. Lancet 1999;353:2051-8. Surg Gynecol Obstet 1983; 157:338–40, Russell WC, Ramsay AH, Fletcher DR: The effect of incisional infiltration of bupivacaine upon pain and respiratory function following open cholecystectomy. Extensive and proactive evaluation and questioning may be necessary to overcome barriers that hinder communication regarding unrelieved pain. Br J Anaesth 1993; 71:670–3, McNeely JK, Trentadue NC: Comparison of patient-controlled analgesia with and without nighttime morphine infusion following lower extremity surgery in children. Anesthesiology 2012;116:248-73. All comments will be kept confidential and evaluated by a task force prior to finalizing the recommendations. Can J Anaesth 1992; 39:214–9, Ngan Kee WD, Lam KK, Chen PP, Gin T: Comparison of patient-controlled epidural analgesia with patient-controlled intravenous analgesia using pethidine or fentanyl. Multimodal techniques with central regional analgesics: Meta-analyses of RCTs46,49,172,–,176report improved pain scores (Category A1 evidence ) and equivocal findings for nausea and vomiting and pruritus (Category C1 evidence ) when epidural morphine combined with local anesthetics is compared with epidural morphine alone. J Clin Anesth 1994; 6:23–7, Sutters KA, Shaw BA, Gerardi JA, Hebert D: Comparison of morphine patient-controlled analgesia with and without ketorolac for postoperative analgesia in pediatric orthopedic surgery. The survey rate of return was 62% (n = 53 of 85) for the consultants (table 2), and 268 surveys were received from active ASA members (table 3). Acute Pain Management: Scientific Evidence. Definition of Acute Pain Management in the Perioperative Setting For these Guidelines, acute pain is defined as pain that is present in a surgical patient after a procedure. Fourth, opinions about the updated Guideline recommendations were solicited from a sample of active members of the ASA. Spine 2006; 31:2529–33, Binsted RJ: Epidural morphine after caesarean section. BMJ 1992; 305:1187–93, Mackintosh C, Bowles S: Evaluation of a nurse-led acute pain service. 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. Agreement levels using a kappa (k) statistic for two-rater agreement pairs were as follows: (1) type of study design, k = 0.63–0.94; (2) type of analysis, k = 0.39–0.89; (3) evidence linkage assignment, k = 0.74–0.96; and (4) literature inclusion for database, k = 0.75–0.88. Anaesthesia 1991; 46:438–41, Guler T, Unlugenc H, Gundogan Z, Ozalevli M, Balcioglu O, Topcuoglu MS: A background infusion of morphine enhances patient-controlled analgesia after cardiac surgery. Initially, each pertinent outcome reported in a study was classified as supporting an evidence linkage, refuting a linkage, or equivocal. Meta-analysis of RCTs reports lower pain scores when preincisional plexus and other blocks are compared with no block (Category A1 evidence ).123,–,127RCTs report equivocal findings for pain scores and analgesic use when postincisional plexus and other blocks are compared with saline or no block (Category C2 evidence ).124,128,–,132RCTs report equivocal findings for pain scores and analgesic use when postincisional intraarticular opioids or local anesthetics are compared with saline (Category C2 evidence ).133,–,139, Meta-analysis of RCTs reports improved pain scores when preincisional infiltration of bupivacaine is compared with saline (Category A1 evidence )140,–,148; findings for analgesic use are equivocal (Category C1 evidence ).140,145,147,148,–,150Meta-analyses of RCTs are equivocal for pain scores and analgesic use when postincisional infiltration of bupivacaine is compared with saline (Category C1 evidence ).140,151,–,160Meta-analysis of RCTs reports equivocal pain score findings when preincisional infiltration of bupivacaine is compared with postincisional infiltration of bupivacaine (Category C1 evidence ).140,145,161,–,164Meta-analysis of RCTs reports improved pain scores and reduced analgesic use when preincisional infiltration of ropivacaine is compared with saline (Category A1 evidence ).164,–,171. The literature is insufficient to evaluate the application of pain assessment methods or pain management techniques specific to these populations (Category D evidence ). 2004;100(6):1573-1581. In particular, the discussion highlights multi-modal treatment strategies relevant to managing postoperative pain in patients undergoing common outpatient and inpatient surgeries. ANESTHESIOLOGY 1998; 89:1354–61, Cooper DW, Ryall DM, McHardy FE, Lindsay SL, Eldabe SS: Patient-controlled extradural analgesia with bupivacaine, fentanyl, or a mixture of both, after Caesarean section. 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. This site uses cookies. Educational content should range from basic bedside pain assessment to sophisticated pain management techniques (e.g. 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. 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 P RACTICE Guidelines are systematically developed rec-ommendations that assist the practitioner and patient in making decisions about health care. Level 2: The literature contains multiple RCTs, but the number of studies is insufficient to conduct a viable meta-analysis for the purpose of these Guidelines. 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).