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New Guidelines for Post-Op Pain Management

February 18, 2016
New guidelines published by the American Pain Society provide a comprehensive consensus on essential pain management topics for both adult and children patients and acknowledge significant gaps in clinical knowledge.

Managing acute postoperative pain is a major challenge for practitioners, given that more than 80% of patients report pain after surgery, and 75% report the pain as moderate, severe, or even extreme.1-2 In more than half of cases, patients report not receiving adequate pain management following their procedure,1 which raises concerns over the development of chronic pain down the line.

To address these issues, the American Pain Society (APS) has published a new set of guidelines for managing postoperative pain.3 A collaboration with the American Society of Anesthesiologists (ASA), these guidelines are the first postoperative guideline published by the APS, designed to promote more evidence-based pain management for both children and adult.

The guidelines were developed by a diverse panel of 23 experts, who reviewed thousands of abstracts to assemble a focused consensus on essential pain management topics for the perioperative setting, including the use of pharmacological and nonpharmacological modalities, pain management planning, and transitioning to outpatient care. The guidelines were reviewed for approval by the American Society of Regional Anesthesia and Pain Medicine.

The guidelines include a number of strong recommendations, such as properly educating patients (or the caregivers/parents of a patient) about treatment options for managing pain and the goals of care for postoperative pain management.

For children undergoing surgery, the parents should be taught developmentally-appropriate methods for assessing pain, as well as proper administration of analgesics and other pain therapies.

Multimodal Therapies Recommended

The guidelines strongly recommend the use of multimodal analgesia, using a variety of medication and techniques to have a more synergistic, effective approach to pain relief than single-modality interventions.

“There is also a much bigger emphasis now on trying to use regimens that are more opioid-sparing, in how to manage patients who are already on opioids, often at high doses, as well as multimodal therapy can be very useful in these situations,” said Roger Chou, MD, from the Oregon Health & Science University in Portland, Oregon, and a co-author of the new guidelines.

For instance, the guidelines recommend clinicians consider using site-specific peripheral regional anesthetic techniques, particularly for conditions with clinical evidence of efficacy, including thoracotomy,4-5 cesarean section,6 and shoulder,7 lower extremity joint,8-9 and hemorrhoid surgeries. 2-9

Adult and pediatric patients without contraindications should receive acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs). Given their differing mechanisms of action, studies suggest the combination approach is more effective than either drug alone,10 which can further reduce postoperative pain and opioid consumption.11-14

Although some evidence has suggested that high-dose NSAIDs could contribute to complications like nonunion in spinal fusion15-16 or anastomotic leakage after colorectal surgery,17-19 the APS’s panel recognizes an “uncertainty” about these potential harms, given the scarcity of evidence, and recommends clinicians discuss these concerns with patients before making a treatment decision.

“Another aspect we point out in the guideline is that multimodal therapy doesn’t just include using different drugs administered using different techniques, it also includes nonpharmacological therapies such as TENS and cognitive-behavioral therapies,” Dr. Chou told Practical Pain Management.

Unfortunately, very few combinations of multimodal analgesic approaches have been evaluated in rigorous clinical trials, and while some multimodal approaches may be opioid-sparing and reduce adverse events (AE) compared to single-modality approaches, this can vary depending on what combination therapy is used.20

Proper Use of Systemic Pharmacological Therapies

According to the new quidellines, when administering opioids:

  • The oral route should be taken over intravenous (IV) administration, given that IV administration has not been shown to be superior.21 However, when administering acetaminophen and/or NSAIDs, IV administration may have a more rapid response. When the parental route is needed, IV patient-controlled analgesia (PCA) is recommended for postoperative systemic analgesia.
  • However, long-acting opioids should be avoided in the immediate post-operative period.22 There may be some exception with patients that take them before the surgery. The intramuscular route also should be avoided, given its known to associate with significant pain and reduced absorption.
  • When treating opioid-naïve adults, clinicians should avoid routine basal infusion of opioids with IV PCA, given that there is no known improvements to analgesia with this technique and it’s been associated with increased risk of AEs, including nausea, vomiting, and respiratory depression.

Important Gaps in the Research

Unfortunately, as much as the APS guidelines formed solid consensus on many aspects of perioperative pain management, it also unearthed significant gaps in clinical knowledge.23 A complete lack of research existed on the topic of transitioning postoperative patients from inpatient to outpatient care, a significant subject given that inadequate tapering and improper disposal of unused opioids can lead to devastating consequences.

“One common area that we think is problematic is patients being sent home with large amounts of opioids. They often don’t need them after 3 or 5 days (or need much lower doses) and end up with unused pills that are then in the medicine cabinet and can be accessed by other people for whom the opioids aren’t prescribed.” There are also logistical issues to consider, like making sure patients have enough opioids at discharge so they don’t run out of medication over the weekend, Dr. Chou explained.

According to Debra B. Gordon, RN-BC, MS, ACNS-BCSFANN, from the University of Washington in Seattle, Washington, what clinicians need now more so than research is more facilitated communication and planning for patients moving into outpatient care. The Washington State Agency Medical Directors’ Group’s (AMDG) Current Interagency Guideline on Prescribing Opioids for Pain states that patients of major surgeries should be tapered to preoperative or lower doses within 6 weeks after the procedure, and patients should be discharged with only a limited supply (2 to 3 days) of short acting opioid, even if they were taking opioids preoperatively. 24

Patient Monitoring: How Useful is the Tech?

The APS guidelines strongly recommend clinicians provide appropriate monitoring for sedation, respiratory status, and other known adverse events to systemic opioids, especially in the initial hours after surgery or a dose change.25 Although pulse oximetry and capnography technologies could be useful tools for patient monitoring—pulse oximetry commonly is used to monitor postoperative respiratory status— the guidelines do not make any specific recommendation for or against them. This is largely due to the fact that studies have yet to succinctly prove they present a clear effect on clinical outcomes. 26

“Many of these technologies are expensive and are being pushed by manufacturers without hard data that they improve patient outcomes,” Dr. Chou said. “There are also potential concerns that there could be an overreliance on technologies rather than assessments by nurses."

“So while the technologies may be helpful, the guideline basically says that there are different ways that patients can be monitored, which should include close nurse monitoring with or without the assistance of additional technologies. If these technologies really are effective, perhaps the guideline will help spur the research to prove that; consensus based on good evidence will always be more credible than consensus based on lousy evidence.”

Ms. Gordon, who was lead author of the APS guideline’s critical review, had a similar view about the use of patient monitoring technologies. “My personal take on the literature and clinical experience is that tech monitoring has a place in certain patients and settings but also has great implications for cost and alarm desensitization. Most of the literature on this seems to be driven by companies that sell the equipment. I’m an old fashioned nurse and think it’s critical nursing assessment and monitoring that is most valuable.”

The APS guidelines may not apply to all patients and clinical situations. This guideline was approved by the ASA Committee on Regional Anesthesia, Executive Committee, and Administrative Council in October 2015. However, it has not been approved by ASA’s House of Delegates or Board of Directors and does not represent an official or approved statement or policy of the ASA. The official abstract and supplementary data related to this article can be found here. Funding for this guideline was provided by the APS, and all statements related to it are the responsibility of the authors and panel members. All panelists have been required to submit relevant conflict of interest information pertaining to the last 5 years.

Last updated on: March 1, 2016
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