The American Pain Society has released a new evidence-based clinical practice guideline, appearing in The Journal of Pain, with 32 recommendations to help clinicians achieve optimal pain management following surgery. According to numerous studies, the majority of surgical patients receive inadequate pain relief, which can heighten the risk for prolonged post-surgical pain, mood disorders and physical impairment.
"The intent of the guideline is to provide evidence-based recommendations for better management of postoperative pain, and the target audience is all clinicians who manage pain resulting from surgery," said Roger Chou, MD, lead author and head of the Oregon Evidence-based Practice Center.
Chou said the key recommendation in the guideline, based on high-quality evidence, is wider use of a variety of analgesic medications and techniques.
"The guideline strongly advises use of multimodal anesthesia that target different mechanisms of actions in the peripheral and central nervous systems," he said.
"Randomized trails have shown that multimodal anesthesia involving simultaneous use of combinations of several medications -- acting on different pain receptors or administered through different techniques -- are associated with superior pain relief and decreased opioid consumption compared with use of a single medication administered by one technique."
Chou added that evidence also indicates that non-pharmacological therapies, such as cognitive behavioral therapies and transcutaneous elective nerve stimulation, can be effective adjuncts to pharmacological therapies.
Written by a 23-member expert panel representing anesthesia, pain management, surgery, nursing and other medical specialties, the APS guideline is based on the panel's review of more than 6,500 scientific abstracts and primary studies.
The guideline's 32 recommendations are rated as strong, moderate or weak based on scientific evidence cited as high, moderate or low quality. The recommendations are based on the premise that optimal pain management begins in the preoperative period and should be based on assessment of the patient and development of individual care plans for the surgical procedure involved.
Three other recommendations in the APS guideline are graded strong with high-quality evidence. They are:
•Adults and children can be given acetaminophen and/or non-steroidal anti-inflammatory drugs as part of multimodal analgesia for management of postoperative pain
•Clinicians should consider surgical site-specific peripheral regional anesthetic techniques with proven efficacy in adults and children for certain procedures
•Spinal analgesia is appropriate for major thoracic and abdominal procedures, particularly in patients at risk for cardiac and pulmonary complications or prolonged intestinal distress.
The APS Guideline offers 11 other strong recommendations, based on moderate or weak evidence. They include:
•Clinicians should provide patient and family-centered, individually tailored education to patients and caregivers about treatment options for postoperative pain
•Oral administration of opioids is preferred to intravenous administration for post-operative analgesia
•Intravenous patient-controlled analgesia (PCA) can be used when parenteral administration of analgesics is required
•Clinicians should consider giving preoperative doses of celecoxib (Celebrex) in appropriate adult patients
•Gabapentin (Neurotin, Gralise, Horizant) and pregabalin (Lyrica) can be considered for multimodal postoperative analgesia. The medications are associated with lower opioid requirements after surgery.
•Surgical facilities should provide clinicians with access to a pain specialist for patients with inadequately controlled postoperative pain.
The APS postoperative pain management guideline was endorsed by the American Society for Regional Anesthesia.