New APS Guideline on Postoperative Pain

Pauline Anderson

February 26, 2016

A new evidence-based clinical practice guideline that includes 32 recommendations related to postoperative pain management in children and adults has been released by the American Pain Society (APS).

The guideline is based on the findings of an interdisciplinary expert panel. The APS commissioned the panel with input from the American Society of Anesthesiologists, and the document was subsequently approved also by the American Society of Regional Anesthesia and Pain Management.

Research shows that most surgical patients receive inadequate pain relief, which can increase the risk for prolonged postoperative pain, mood disorders, and physical impairment, said lead author of the guideline, said Roger Chou, MD, Departments of Medicine and Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Pacific Northwest Evidence Based Practice Center, Portland.?

A key recommendation in the guideline, published in the February issue of the Journal of Pain, is wider use of multimodal techniques, Dr Chou told Medscape Medical News.

"This means using different medications, for example opioids and nonopioid therapies such as non-steroidal anti-inflammatories (NSAIDs), gabapentin/pregabalin, ketamine, lidocaine, administered in different ways, for example, systemically or via neuraxial/peripheral regional anesthetic techniques, as well as medications and nonpharmacological therapies."

Multimodal strategies help achieve better pain relief while using lower doses of opioids and potentially fewer adverse effects, by affecting pain via different mechanisms of actions and pathways, added Dr Chou.

The recommendation on individualizing therapy is also critical, said Dr Chou. "The same strategy is not going to be ideal in all patients. For example, in patients who are already on long-term opioid therapy prior to surgery, managing their pain is not going to be the same as someone not on opioids."

The guideline was developed by a 23-member expert panel representing anaesthesia, pain management, surgery, nursing, and other medical specialties. It's based on the panel's review of more than 6500 scientific abstracts and primary studies.

The panel rated each recommendation as strong, moderate, or weak and based each on the quality of the scientific evidence. Of the 32 recommendations, the panel rated only 4 as supported by high-quality evidence, and 11 recommendations were based on low-quality evidence. The guideline authors noted that there were "numerous research gaps."

In addition to using multimodal therapies, the 3 other strong recommendations with high-quality evidence were

  • Use of acetaminophen and/or NSAIDs as part of multimodal analgesia for management of postoperative pain in adults and children without contraindications;

  • Consideration of surgical site–specific peripheral regional anesthetic techniques in adults and children for procedures with evidence indicating efficacy; and

  • Offering neuraxial analgesia for major thoracic and abdominal procedures, particularly in patients at risk for cardiac complications or prolonged ileus.

Strong recommendations with moderate quality evidence included the following:

  • Administering oral over intravenous (IV) opioids in patients who can use the oral route;

  • Avoiding the intramuscular route for administration of analgesic;

  • Choosing IV patient-controlled analgesia (PCA) when the parenteral route is needed;

  • Not using routine basal infusion of opioids with IV PCA in opioid-naive adults;

  • Considering a preoperative dose of oral celecoxib in adults without contraindications;

  • Considering gabapentin or pregabalin as a component of multimodal analgesia;

  • Using topical local analgesics in combination with nerve blocks before circumcision;

  • Avoiding intrapleural analgesia with local anesthetics for pain control after thoracic surgery;

  • Using 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; and

  • Avoiding the neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine.

Despite low-quality evidence, the panel strongly recommended that clinicians

  • Provide patients with education, including information on treatment options;

  • Conduct a preoperative evaluation, including assessment of medical and psychiatric comorbidities, concomitant medications, history of chronic pain, and substance abuse;

  • Adjust the pain management plan on the basis of adequacy of pain relief and presence of adverse events;

  • Use a validated pain assessment tool to track response to postoperative pain treatments and adjust treatment plans accordingly;

  • Appropriately monitor sedation, respiratory status, and other adverse events in patients who receive systemic opioids; and

  • Provide appropriate monitoring of patients who have received neuraxial interventions for perioperative analgesia.

For cognitive-behavioral therapy, the panel had a "weak" recommendation based on moderate-quality evidence to consider this technique as part of a multimodel approach.

The panel found that there was insufficient evidence to recommend or discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments. For transcutaneous electrical nerve stimulation, the panel had a "weak" recommendation that clinicians consider this treatment.

As evidence increases on newer techniques for managing postoperative pain, it's important to incorporate these techniques into current practice to improve management of postoperative pain, said Dr Chou. He noted that the APS has not previously issued guidelines on management of postoperative pain and recognizes that this as an important area where evidence-based guidelines could help improve clinical practice.

Dr Chou has disclosed no relevant financial relationships.

J Pain. 2016;17:131-157. Abstract


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