Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults.The guideline was subsequently approved by the American Society for Regional Anesthesia.The Guidelines have been published in Journal of Pain.
The summary of the recommendations of the committee has been given below :
Preoperative Education and Perioperative Pain Management Planning
Method of Assessment
Use a validated pain assessment tool to track responses to postoperative pain treatments. The tool should be chosen on the basis of factors such as developmental status, cognitive status, and level of consciousness.
Use of Physical Modalities
- Transcutaneous electrical nerve stimulation (TENS) may be used as an adjunct to other postoperative pain treatments.
- There is insufficient evidence to support or discourage the use of acupuncture, cold therapy or massage.
- When possible use oral route over iv. As most evidence suggests that i.v. administration of opioids is not superior for postoperative analgesia as compared with oral administration.
- Avoid IM route. This is because the intramuscular injections cause significant pain and are associated with unreliable absorption, resulting in inconsistent postoperative analgesia.
- i.v. patient-controlled analgesia (PCA) should be used for postoperative systemic analgesia when the parenteral route is needed. Patients appropriate for i.v. PCA are those who will require analgesia for more than a few hours and have the adequate cognitive function to understand the device and its safety limitations.
- Routine basal infusion of opioids with i.v. PCA in opioid-naive adults should not be used. This is because the evidence does not suggest better analgesia is obtained with the use of basal infusion. Also, basal infusion of opioids is associated with an increased risk of nausea and vomiting, and in some studies with increased risk of respiratory depression in adults.
- Monitor sedation, respiratory status, and other adverse events in patients who receive systemic opioids.
- Use acetaminophen and/or NSAIDs as part of multimodal analgesia for management of postoperative pain in patients without contraindications. Most studies show the use of acetaminophen or NSAIDs in conjunction with opioids is associated with less postoperative pain or opioid consumption than opioids alone. In addition, acetaminophen and NSAIDs have different mechanisms of action and research indicates that the combination of acetaminophen with NSAIDs might be more effective than either drug alone.
- Consider giving a preoperative dose of oral celecoxib in adult patients without contraindications. Celecoxib is associated with reduced opioid requirements after surgery, and some studies reported lower postoperative pain scores.
- Consider use of gabapentin or pregabalin as a component of multimodal analgesia as they reduce the opioid requirement.
- Consider i.v. ketamine as a component of multimodal analgesia in adults.
- Consider i.v. lidocaine infusions in adults who undergo open and laparoscopic abdominal surgery who do not have contraindications. Studies have shown that i.v. lidocaine infusions are associated with shorter duration of ileus and better quality of analgesia compared with placebo
Consider surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures with evidence indicating efficacy.
- Use continuous, local anesthetic–based peripheral regional analgesic techniques when the need for analgesia is likely to exceed the duration of effect of a single injection.
- Consider adding clonidine as an adjuvant for prolongation of analgesia with a single-injection peripheral neural blockade.
- Use neuraxial analgesia for major thoracic and abdominal procedures, particularly in patients at risk for cardiac complications, pulmonary complications, or prolonged ileus.
- Owing to the lack of evidence avoid the neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine in the treatment of postoperative pain.
- Monitor patients who have received neuraxial analgesia.
- Educate all patients (adult and children) and primary caregivers on the pain treatment plan including tapering of analgesics after hospital discharge.
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Dr. Kamal Kant Kohli
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