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Agency for Health Care Policy and Research (US). AHCPR Quick Reference Guides. Rockville (MD): Agency for Health Care Policy and Research (US); 1992-1996.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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AHCPR Quick Reference Guides.

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1aAdult Pain Management: Operative Procedures

Quick Reference Guide for Clinicians No. 1a

Created: .

Attention clinicians

This Quick Reference Guide contains excerpts from the Clinical Practice Guideline for Acute Pain Management: Operative or Medical Procedures and Trauma, which was developed by an interdisciplinary, non-Federal panel made up of health care practitioners, an ethicist, and a consumer. Panel members were: Daniel B. Carr, MD, (co-chair); Ada K. Jacox, RN, PhD, FAAN (co-chair); C. Richard Chapman, PhD; Betty Farrell, RN, PhD, FAAN; Howard L. Fields, MD, PhD; George Heidrich III, RN, MA; Nancy 0. Hester, RN, PhD: C. Stratton Hill, MD; Arthur G. Lipmaii, PharmD; Charles L. McGarvey, MS; Christine Miaskowski, RN, PhD; David Stevenson Mulder, MD; Richard Payne, MD; Neil Schechter, MD: Barbara S. Shapiro, MD; Robert Smith, PhL; Carole V. Tsou, MD; and Loretta Vecchiarelli.

For a description of the guideline development process and information about the sponsoring agency (Agency for Health Care Policy and Research), see: Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline. AHCPR Pub. No. 92-0032. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Feb. 1992.

A second guide presents excerpts from the Clinical Practice Guideline on acute pain management in pediatric patients; see: Acute Pain Management Guideline Panel. Acute Pain Management in Infants, Children and Adolescents: Operative and Medical Procedures. Quick Reference Guide for Clinicians. AHCPR Pub. No. 92-0020. Rockville, MD: Agency of Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services

Users should not rely on these excerpts alone but should refer to the complete Clinical Practice Guideline for more detailed analysis and discussion of available research, critical evaluation of the assumptions and knowledge of the field, considerations for patients with special needs (e.g., intercurrent illness or substance abuse), and references. As stated in the Clinical Practice Guideline, decisions to adopt any particular recommendation must be made by the practitioner in light of available resources and circumstances presented by individual patients.

For further information or to receive additional copies of guideline documents, call: 1-800-358-9295 or 301-495-3453;

or you may write to the:

  • Center for Research Dissemination and Liaison
  • AHCPR Publications Clearinghouse
  • P.O. Box 8547
  • Silver Spring, MD 20907

This document is in the public domain and may be used and reprinted without special permission, except for those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. AHCPR will appreciate citation as to source, and the suggested format is provided below:

Acute Pain Management Guideline Panel. Acute Pain Management in Adults: Operative Procedures. Quick Reference Guide for Clinicians AHCPR Pub. No. 92-0019. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.

Introduction

The obligation to manage pain and relieve a patient's suffering is an important part of a health professional's commitment. The importance of pain management is further increased when benefits for the patient are realized-earlier mobilization, shortened hospital stay and reduced costs. Yet clinical surveys continue to show that routine orders for intramuscular injections of opioid "as needed" result in unrelieved pain due to ineffective treatment in roughly half of postoperative patients. Recognition of the inadequacy of traditional pain management has prompted recent corrective efforts from a variety of health care disciplines including surgery, anesthesiology, nursing, and pain management groups. The challenge for clinicians is to balance pain control with concern for patient safety and side effects of pain treatments. This Quick Reference Guide is intended to assist clinicians with these decisions.

Patients vary greatly in their medical conditions and responses to surgery, responses to pain and interventions, and personal preferences. Therefore, rigid prescriptions for the management of postoperative pain are inappropriate. Several alternative approaches, appropriately and attentively implemented, prevent or relieve pain. This Quick Reference Guide contains excerpts from the Clinical Practice Guideline for Acute Pain Management: Operative or Medical Procedures and Trauma and addresses the assessment and management of postoperative pain in adults. The excerpts contained in this Quick Reference Guide provide clinicians with a practical and flexible approach to acute pain assessment and management. However, users should not rely oil these excerpts alone but should refer the complete Clinical Practice Guideline for a more detailed analysis and discussion of the available research, critical evaluation of tile assumptions and knowledge of the field, considerations for patients with special needs (e.g. intercurrent medical illness substance abuse), and references.

The flow chart, which follows, shows the sequence of activities related to pain assessment and management. This Quick Reference Guide provides information about the events listed in the flow chart.

                 Preoperative patient assessment,
                  preparation, and interventions
                                 |
                                 |
                                 V
   _________   Intraoperative anesthesia and analgesia, ________
  |           with preemptive measures for postoperative        |
  |                         pain control                        |
No pain or pain                  |                     Significant pain,
not requiring                    |                     not explained by
intervention                     V                     surgical trauma
  |           -->  Significant pain consistent with             |
  V           |           surgical trauma                       V
Reassess ------                  |                           Surgical
                                 V                          Evaluation
                    Postoperative drug and nondrug              |
                           interventions                        V
                                 |                            Treat
 Unacceptable                    V
side effects or $-------  Assess effect of $----
  inadequate         -->   interventions        |
   analgesia         |           |              |
      |              |           V              |
      V              |        Optimize          |
 Change drug,        |     dose interval        |
interval, dose,      |           |              |
route, modality;------           V              |
add adjuvant or             Satisfactory        |
treat side effect            response       -----
                                 |
                                 V
                          Discharge Planning

Effective Management of Postoperative Pain

Requirements

  • Pain intensity and relief must be assessed and reassessed at regular intervals.
  • Patient preferences must be respected when determining methods to be used for pain management.
  • Each institution must develop an organized program to evaluate the effectiveness of pain assessment and management. Without such a program, staff efforts to treat pain may become sporadic and ineffectual.

Principles

  • Successful assessment and control of pain depends, in part, on establishing a positive relationship between health care professionals and patients. Patients should be informed that pain relief is an important part of their health care, that information about options to control pain is available to them, and that they are welcome to discuss their concerns and preferences with the health care team.
  • Unrelieved pain has negative physical and psychological consequences. Aggressive pain prevention and control that occurs before, during, and after surgery can yield both short- and long- term benefits.
  • It is not practical or desirable to eliminate all postoperative pain, but techniques now available make pain reduction to acceptable levels a realistic goal.
  • Prevention is better than treatment. Pain that is established and severe is difficult to control.

Pain Assessment and Reassessment

Principles

  • Patients who may have difficulty communicating their pain require particular attention. This includes patients who are cognitively impaired, psychotic or severely emotionally disturbed, children and the elderly, patients who do not speak English, and patients whose level of education or cultural background differs significantly from that of their health care team.
  • Unexpected intense pain, particularly if sudden or associated with altered vital signs such as hypotension, tachycardia, or fever, should be immediately evaluated, and new diagnoses such as wound dehiscence, infection, or deep venous thrombosis considered.
  • Family members should be involved when appropriate.

Pain Assessment Tools

  • The single most reliable indicator of the existence and intensity of pain--and any resultant distress--is the patient's self-report.
  • Self-report measurement scales include numerical or adjective ratings and visual analog scales (see Table 1 for examples).
  • Tools should be reliable, valid, and easy for the patient and the nurse or doctor to use. These tools may be used by showing a diagram to the patient and asking the patient to indicate the appropriate rating. The tools may also be used by simply asking the patient for a verbal response (e.g. "On a scale of 0 to 10 with 0 as no pain and 10 as the worst pain possible, how would you rate your pain?").
  • Tools must be appropriate for the patient's developmental, physical, emotional, and cognitive status.
Simple Descriptive Pain Intensity Scale [1]

|__________|__________|__________|_________|_________|
No      Mild      Moderate    Severe     Very      Worst
pain    pain        pain       paid     severe   possible
                                         pain      pain


0-10 Numeric Pain Intensity Scale [1]
|_____|_____|____|_____|____|_____|_____|____|_____|____|
0     1     2    3     4    5     6     7    8     9    10
No                      Moderate                        Worst
pain                      pain                         possible
                                                         pain
             

Visual Analog Scale (VAS) [2]
|_________________________________________________|
No                                                Pain as bad
pain                                              as it could
                                                  possibly be

[1]  If used as a graphic rating scale, a 10 cm
baseline is recommended.

[2]  A 10 cm baseline is recommended for VAS scales.

Preoperative Preparation

  • Discuss the patient's previous experiences with pain and beliefs about and preferences for pain assessment and management.
  • Give the patient information about pain management therapies that are available and the rationale underlying their use.
  • Develop with the patient a plan for pain assessment and management.
  • Select a pain assessment tool, and teach the patient to use it. Determine the level of pain above which adjustment of analgesia or other interventions will be considered.
  • Provide the patient with education and information about pain control, including training in nonpharmacologic options such as relaxation ( see Table 2 for a sample relaxation exercise).
  • Inform patients that it is easier to prevent pain than to chase and reduce it once it has become established and that communication of unrelieved pain is essential to its relief. Emphasize the importance of a factual report of pain, avoiding stoicism or exaggeration.
Table 2. Sample Relaxation Exercise.

Table

Table 2. Sample Relaxation Exercise.

Postoperative Assessment

  • Assess the patient's perceptions, along with behavioral and physiologic responses. Remember that observations of behavior and vital signs should not be used instead of a self-report unless the patient is unable to communicate.
  • Assess and reassess pain frequently during the immediate postoperative period. Determine the frequency of assessment based on the operation performed and the severity of the pain. For example, pain should be assessed every 2 hours during the first postoperative day after major surgery.
  • Increase the frequency of assessment and reassessment if the pain is poorly controlled or if interventions are changing.
  • Record the pain intensity and response to intervention in an easily visible and accessible place, such as a bedside flow sheet.
  • Revise the management plan if the pain is poorly controlled.
  • Review with the patient before discharge the interventions used and their efficacy and provide specific discharge instructions regarding pain and its management.

Management Options

One or more of these approaches may be used:

  • Cognitive-behavioral interventions such as relaxation, distraction, and imagery. These methods may reduce pain and anxiety and control mild pain, but they do not substitute for pharmacologic management of moderate to severe pain.
  • Systemic administration of opioids and/or nonsteroidal antiinflammatory drugs (NSAIDs), including acetaminophen.
  • Patient-controlled analgesia (PCA) usually denotes selfmedication with intravenous opioids, but may include oral or other routes of administration. PCA offers patients a sense of control over their pain and is preferred by most patients to intermittent injections.
  • Spinal analgesia, usually with an epidural opioid and/or local anesthetic injected intermittently or infused continuously.
  • Intermittent or continuous local neural blockade, such as intercostal nerve blockade or infusion of local anesthetichrough an interpleural catheter.
  • Physical agents such as massage or application of heat or cold.
  • Transcutaneous electrical nerve stimulation (TENS).

Note: The use of spinal analgesia or neural blockade or the infusion of local anesthetic through interpleural catheters require special expertise and well-defined institutional protocols and procedures for accountability. The administration of regional analgesia is best limited to specially trained and knowledgeable staff, typically under the direction of a acute or postoperative pain treatment service.

Pharmacologic Management

  • Pharmacologic management of mild to moderate postoperative pain should begin, unless there is a contraindication, with an NSAID. However, moderately severe to severe pain should normally be treated initially with an opioid analgesic, with or without an NSAID.

NSAIDs

  • Even when insufficient alone to control pain, NSAIDS, including acetaminophen, have significant opioid dose-sparing effects on postoperative pain and hence can be useful in reducing opioid side effects (see Table 4 for information on prescribing NSAIDs).
  • If the patient cannot tolerate oral medication, alternative routes such as rectal administration can be used. At present, one NSAID (ketorolac) is approved by the Food and Drug Administration for parenteral use.
  • NSAIDs must be used with care in patients with thrombocytopenia or coagulopathies and in patients who are at risk for bleeding or gastric ulceration. However, acetaminophen does not affect platelet function, and some evidence exists that two salicylates (salsalate and choline magnesium trisalicylate) do not profoundly affect platelet aggregation.
Table 4. Dosing Data for NSAIDs.

Table

Table 4. Dosing Data for NSAIDs.

Opioid Analgesics

  • Opioid analgesics are the cornerstone for management of moderate to severe acute pain. Effective use of these agents facilitates postoperative activities such as coughing, deep breathing exercises, ambulation, and physical therapy.
  • When pain cannot be adequately controlled despite increasing the opioid dose, a prompt search for residual operative pathology is indicated, and other diagnoses such as neuropathic pain should be considered.
  • Opioid tolerance and physiologic dependence are unusual in short term postoperative use in opioid-naive patients. Likewise, psychologic dependence and addiction are extremely unlikely to develop after the use of opioids for acute pain.

Choice of Opioid Agent

  • Morphine is the standard agent for opioid therapy. If morphine cannot be used because of an unusual reaction or allergy, another opioid such as hydromorphone can be substituted.
  • Meperidine should be reserved for very brief courses in patients who have demonstrated allergy or intolerance to other opioids such as morphine and hydromorphone. Meperidine is contraindicated in patients with impaired renal function or those receiving antidepressants that are monoamine oxidase (MAO) inhibitors. Normeperidine is a toxic metabolite of meperidine, and is excreted through the kidney. Normeperidine is a cerebral irritant, and accumulation can cause effects ranging from dysphoria and irritable mood to seizures.

Dosage of Opioid Analgesics

  • Patients vary greatly in their analgesic dose requirements and responses to opioid analgesics. The recommended starting doses presented in Table 5 may be inadequate. Subsequent opioid doses must be titrated to increase the amount of analgesia and reduce side effects.
  • Relative potency estimates provide a rational basis for selecting the appropriate starting dose, for changing the route of administration (e.g., from parenteral to oral), or for changing from one opioid to another. Equianalgesic doses for opioids are listed in Table 5.
  • Patients who have been receiving opioid analgesics before surgery may require higher starting and maintenance doses post-operatively.
Table 5. Dosing Data for Opioid Analgesics.

Table

Table 5. Dosing Data for Opioid Analgesics.

Dosage Schedule

  • Opioid administration relying on patients' or families' demands for analgesic prn, or "as needed," produces delays in administration and intervals of inadequate pain control.
  • Analgesics should be administered initially on a regular time schedule. For example, if the patient is likely to have pain requiring opioid analgesics for 48 hours after surgery, morphine might be ordered every 4 hours around-the-clock (not prn) for 36 hours. Opioid administration is contraindicated when respiratory depression is present (less than 10 breaths per minute).
  • Once the duration of analgesic action is determined, the dosage frequency should be adjusted to prevent pain from recurring.
  • Orders may be written so that a patient may refuse an analgesic if not in pain or forego it if asleep. However, since a steady-state blood level is required for the drug to be continuously effective, interruption of an around-theclock dosage schedule (e.g., during sleep) may cause a resurgence of pain as blood levels of the analgesic decline.
  • Late in the postoperative course, it may be acceptable to give opioid analgesics prn. Switching to prn dosing later in the postoperative course provides pain relief while reducing the risk of adverse effects as the patient's analgesic dose requirement diminishes.
  • Clinicians should assess patients at regular intervals to determine the efficacy of the intervention, the presence of side effects, the need for adjustments of dosage and/or interval, or the need for supplemental doses for breakthrough pain.

Route

  • Intravenous administration is the parenteral route of choice after major surgery. This route is suitable for bolus administration and continuous infusion (including PCA).
  • Repeated intramuscular injections can themselves cause pain and trauma and may deter patients from requesting pain medication. Rectal and sublingual administration are alternatives to intramuscular or subcutaneous routes when intravenous access is problematic. All routes other than intravenous require a lag time for absorption into the circulation.
  • Oral administration is convenient and inexpensive. It is appropriate as soon as the patient can tolerate oral intake and is the mainstay of pain management in the ambulatory surgical population.

Nonpharmacologic Management

  • Patient teaching should include procedural and sensory information; instruction to decrease treatment and activity-related pain (e.g., pain caused by deep breathing, coughing) and information about the use of relaxation.
  • Cognitive-behavioral (e.g., relaxation, distraction, imagery) and physical interventions (e.g., heat, cold, massage) are intended to supplement, not replace, pharmacologic interventions.
  • Cognitive/behavioral interventions include a variety of methods that help patients understand more about their pain and take an active role in pain assessment and management.
  • Simple relaxation strategies can be effective in helping to manage pain. Basic approaches (see Table 2 for an example) require only a few minutes to teach and can reduce pain and anxiety. Patients benefit from periodic reinforcement and coaching in the use of relaxation techniques.
  • Commonly used physical agents include applications of heat and cold, massage, movement, and rest or immobilization. Applications of heat and cold alter the pain threshold, reduce muscle spasm, and decrease local swelling.
  • Transcutaneous electrical nerve stimulation (TENS) may be effective in reducing pain and improving physical function.

Special considerations for Elderly Persons

The Clinical Practice Guideline contains a more complete discussion of the special considerations for pain management in the elderly. A summary is provided here.

  • Elderly people often suffer multiple chronic, painful illnesses and take multiple medications. They are at greater risk for drug-drug and drug-disease interactions.
  • Pain assessment presents unique problems in the elderly, as these patients may exhibit physiologic, psychologic, and cultural changes associated with aging.
  • Misunderstanding of the relationship between aging and pain is common in the management of elderly patients. Many health care providers and patients alike mistakenly consider pain to be a normal part of aging. Elderly patients sometimes believe that pain cannot be relieved and are stoic in reporting their pain. The frail and oldest-old (>85 years) are at particular risk for undertreatment of pain.
  • Aging need not alter pain thresholds or tolerance. The similarities of pain experience between elderly and younger patients are far more common than are the differences.
  • Cognitive impairment, delirium, and dementia are serious barriers to assessing pain in the elderly. Sensory problems such as visual and hearing changes may also interfere with the use of some pain assessment scales. However, as with other patients, the clinician should be able to obtain an accurate self-report of pain from most patients.
  • When verbal report is not possible, clinicians should observe for behavioral cues to pain such as restlessness or agitation. The absence of pain behaviors does not negate the presence of pain.
  • NSAIDs can be used safely in elderly persons, but their use requires vigilance for side effects, especially gastric and renal toxicity.
  • Opioids are safe and effective when used appropriately in elderly patients. Elderly people are more sensitive to analgesic effects of opiate drugs. They experience higher peak effect and longer duration of pain relief.

Institutional Responsibility for Pain Management

The institutional process of acute pain management begins with the affirmation that patients should have access to the best level of pain relief that may safely be provided. (See Table 3 for a summary of the scientific evidence for interventions to manage pain in adults.) Each institution should develop the resources necessary to provide the best and most modern pain relief appropriate to its patients and should designate who and/or which departments are responsible for the required activities.

Table 3. Scientific Evidence for Interventions to Manage Pain in Adults - Pharmacologic Interventions.

Table

Table 3. Scientific Evidence for Interventions to Manage Pain in Adults - Pharmacologic Interventions.

Nonpharmacologic Interventions.

Table

Nonpharmacologic Interventions.

Table 3. Scientific Evidence for Interventions to Manage Pain in Adults - Type of Evidence Key.

Table

Table 3. Scientific Evidence for Interventions to Manage Pain in Adults - Type of Evidence Key.

Optimal application of pain control methods depends on cooperation among different members of the health care team throughout the patient's course of treatment. To ensure that this process occurs effectively, formal means must be developed and used within each institution to assess pain management practices and to obtain patient feedback to gauge the adequacy of pain control.

The institution's quality assurance procedures should be used periodically to assure that the following pain management practices are being carried out:

  • Patients are informed that effective pain relief is an important part of their treatment, that communication of unrelieved pain is essential, and that health professionals will respond quickly to their reports of pain. They are also told that a total absence of pain is often not a realistic or even a desirable goal.
  • Clear documentation of pain assessment and management is provided.
  • There are institution-defined levels for pain intensity and relief that elicit review of current pain therapy, documentation of the proposed modifications in treatment, and subsequent review of their efficacy.
  • Each clinical unit periodically assesses a randomly selected sample of patients who have had surgery within 72 hours to determine their current pain intensity, the worst pain intensity in the first 24 hours, the degree of relief obtained from pain management interventions, satisfaction with relief, and satisfaction with the staff's responsiveness.

Selected Bibliography - Acute Pain Management in Adults: Operative Procedures

  1. American Nurses Association. (1991). Position statement on the registered nurses' (RN) role in the management of patients receiving I.V. conscious sedation for short-term therapeutic, diagnostic, or surgical procedures. Kansas City: American Nurses Association.
  2. American Pain Society, Committee on Quality Assurance Standards. (1990). Standards for monitoring quality of analgesic treatment of acute pain and cancer pain. Oncology Nursing Forum, 17, 952-954. [PubMed: 2263523]
  3. Armstrong, P.J. & Bersten, A. (1986). Normeperidine toxicity. Anesthesia and Analgesia, 65, 536-538. [PubMed: 3963440]
  4. Flaherty, G.G. & Fitzpatrick, J.J. (1978). Relaxation technique to increase comfort level of postoperative patients: A preliminary study. Nursing Research, 27, 352-355. [PubMed: 362379]
  5. Hodsman, N.B., Burns, J., Blyth, A., Kenny, G.N., McArdle, C.S., & Rotman, H. (1987). The morphine sparing effects of diclofenac sodium following abdominal surgery. Anaesthesia, 42, 1005-1008. [PubMed: 3118730]
  6. Internation Association for the Study of Pain. (In Press). Report of the task force on acute pain management.
  7. Kaiko, R.F., Wallenstein, S.L., Rogers, A.G., Grabinski, P.Y., & Houde, R.W. (1982). Narcotics in the elderly. Medical Clinics of North America, 66, 1079-1089. [PubMed: 7132470]
  8. Kehlet, H. (1989). Postoperative pain. In Committee on Pre- and Postoperative Care, American College of Surgeons, Care of the surgical patient (vol. 1, pp. 3-12). New York: Scientific American Medicine.
  9. McQuay, H. (1989). Opioids in chronic pain. British Journal of Anaesthesia, 63, 213-226. [PubMed: 2669911]
  10. National Institutes of Health. (1987). The integrated approach to the management of pain. Journal of Pain and Symptom Management, 3, 35-44. [PubMed: 3644857]
  11. Porter, J. & Jick, H. (1980). Addiction rare in patients treated with narcotics [letter]. New England Journal of Medicine, 302, 123. [PubMed: 7350425]
  12. Ready, L.B., Oden, R., Chadwick, H.S., Bendetti, C., Rook, G.A., Caplan, R., & Wild, L.M. (1988). Development of an anesthesiology-based postoperative pain service. Anesthesiology, 68, 100-106.
  13. Schmitt, F. & Wooldridge, P.J. (1973). Psychological preparation of surgical patients. Nursing Research, 22, 108-116.
  14. Wood, M.M. & Cousins, M.J. (1989). Iatrogenic neurotoxicity in cancer patients. Pain, 39, 1-3. [PubMed: 2812846]

AHCPR Publication No. 92-0019.

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