Chapter  1:  Acute Pain Management: Operative or Medical Procedures and Trauma: Clinical Practice Guideline No. 1.

Panels Members and Tenure on Panel

• Daniel B. Carr, MD

• Panel Co-Chair 1990 -

• Director, Division of Pain Management

• Department of Anesthesia

• Massachusetts General Hospital

• Ada K. Jacox, RN, PhD, FAAN

• Panel Co-Chair 1990 -

• Independence Foundation Chair in Health Policy

• School of Nursing

• The Johns Hopkins University

• C. Richard Chapman, PhD

• 1990 -

• Professor of Anesthesiology

• School of Medicine

• University of Washington

• Betty Ferrell, RN, PhD, FAAN

• 1991 -

• Research Scientist

• Nursing Research

• City of Hope Medical Center

• Howard L. Fields, MD, PhD

• 1990 - 1991

• Departments of Neurology and Physiology

• University of California,

• San Francisco

• George Heidrich III, RN, MA

• 1990 - 1991

• Instructor, Department of Neurology

• University of Wisconsin

• Medical School

• Nancy K. Hester, RN, PhD

• 1990 -

• Assistant Director, Center for Nursing Research,

• Associate Professor, School of Nursing

• Health Sciences Center

• University of Colorado

• C. Stratton Hill, Jr., MD

• 1990 -

• Professor of Medicine

• MD Anderson Cancer Hospital

• University of Texas

• Arthur G. Lipman, PharmD

• 1990 -

• Professor of Clinical Pharmacy

• College of Pharmacy

• University of Utah

• Charles L. McGarvey, MS

• 1990 -

• Chief, Physical Therapy Service

• Department of Rehabilitation Medicine

• National Institutes of Health

• Christine Miaskowski, RN, PhD

• 1990 -

• Associate Professor,

• Department of Physiological Nursing

• University of California,

• San Francisco

• David Stevenson Mulder, MD

• 1990 -

• Professor of Surgery

• McGill University

• Surgeon-in-Chief

• Montreal General Hospital

• Richard Payne, MD

• 1990 -

• Associate Professor of Neurology

• University of Cincinnati

• Medical Center

• Neil Schecter, MD

• 1990 - 1991

• Associate Professor of Pediatrics

• Head, Division of Developmental and Behavioral Pediatrics,

• University of Connecticut School of Medicine

• Co-Director, Children's Pain Service

• University of Connecticut Health Center

• Barbara S. Shapiro, MD

• 1991 -

• Associate Director

• Multidisciplinary Pain Management Program,

• Division of General Pediatrics, Children's Hospital of Philadelphia

• Robert S. Smith, PhL

• 1990 -

• Director, Institute for Medicine in Contemporary Society

• State University Medical Center at Stony Brook

• Carole V. Tsou, MD

• 1990 -

• Division of Family Medicine

• UCLA Center for Health Sciences

• Loretta Vecchiarelli

• 1990 -

• Rehabilitation Counselor and Burn Survivor

• Rehabilitation Hospital of Western

• New England

Panel Staff

• Jane Ballantyne, MB, BS

• 1990 -

• Technology Assessment Group

• Harvard School of Public Health

• Donna Mahrenholz, RN, PhD

• 1990 -

• School of Nursing

• The Johns Hopkins University

• Janice Fitzgerald Ulmer, RN, PhD

• 1990 -

• School of Nursing

• The Johns Hopkins University

Consultants

• Thomas C. Chalmers, MD

• 1990 -

• Technology Assessment Group

• Harvard School of Public Health

• Frederick Mosteller, PhD

• 1990 -

• Department of Health Policy and Management

• Harvard School of Public Health

• Barker Bausell, PhD

• 1991 -

• Center for Research

• School of Nursing

• University of Maryland

Need for Aggressive Postoperative Pain Control

Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain, 1979 ; Merskey, 1964). No matter how successful or how deftly conducted, operations produce tissue trauma and release potent mediators of inflammation and pain (Hargreaves, and Dionne, 1991).

Pain is just one response to the trauma of surgery, however. In addition to the major stress of surgical trauma and pain, the substances released from injured tissue evoke "stress hormone" responses in the patient. Such responses promote breakdown of body tissue; increase metabolic rate, blood clotting, and water retention; impair immune function; and trigger a "fight or flight" alarm reaction with autonomic features (e.g., rapid pulse) and negative emotions (Dinarello, 1984 ; Egdahl, 1959 ; Kehlet, 1982 ; Kehlet, Brandt, and Rem, 1980). Pain itself may lead to shallow breathing and cough suppression in an attempt to "splint" the injured site, followed by retained pulmonary secretions and pneumonia (Anscombe, and Buxton, 1958 ; Hewlett, and Branthwaite, 1975 ; Latimer, Dickman, Day, Gunn, and Schmidt, 1971 ; Marshall, and Wyche, 1972 ; Sydow, 1989). Unrelieved pain also may delay the return of normal gastric and bowel function in the postoperative patient (Wattwil, 1989).

The physiological and psychosocial risks associated with untreated pain are greatest in frail patients with other illnesses such as heart or lung disease, those undergoing major surgical procedures such as aortic surgery, and the very young or very old. Because of advances in surgical and anesthetic techniques, it is now common for such patients to undergo operations once dismissed as prohibitively risky.

Approximately 23.3 million operations were performed in the United States in 1989 (Peebles, and Schneidman, 1991), and most of these involved some form of pain management. Unfortunately, clinical surveys continue to show that routine orders for intramuscular injections of opioid "as needed" will leave more than half of postoperative patients with unrelieved pain due to undermedication (Marks, and Sachar, 1973 ; Donovan, Dillon, and McGuire, 1987 ; Oden, 1989 ; Sriwatanakul, Weis, Alloza, Kelvie, Weintraub, and Lasagna, 1983). In the past, postoperative pain was thought to be inevitable, a harmless though intense discomfort that the patient had to tolerate. Unrelieved pain after surgery or trauma is often unhealthy; fortunately, it is preventable or controllable in an overwhelming majority of cases. Patients have a right to treatment that includes prevention or adequate relief of pain.

Recognition of the widespread inadequacy of pain management has prompted recent corrective efforts within multiple health care disciplines, including surgery (Kehlet, 1989a ; Royal College of Surgeons, 1990), anesthesiology (Phillips, and Cousins, 1986 ; Ready, Oden, Chadwick, Bendetti, Rooke, Caplan, and Wild, 1988); nursing (Jacox, 1977 ; American Nurses Association, 1991), and pain management groups (National Health and Medical Research Council of Australia, 1988 ; American Pain Society, 1989 ; International Association for the Study of Pain, 1991). Although it is not practical or desirable to eliminate all postoperative pain, this clinical practice guideline sets forth procedures to minimize the incidence and severity of acute pain after surgical or medical procedures and trauma. The guideline is designed to help clinicians, patients, and patients' families understand the assessment and treatment of postoperative and other acute pain in both adults and children.

Health care is both a technical and an ethical enterprise. The ethical obligation to manage pain and relieve the patient's suffering is at the core of a health care professional's commitment. While medical treatments often involve risks and burdens, anything harmful to the patient, including postoperative pain, should be minimized or prevented if possible. The ethical importance of pain management is further increased when additional benefits for the patient are realized -- earlier mobilization, shortened hospital stay, and reduced costs. If inadequate pain management results from a clinician's conflict between reducing pain and avoiding potential side effects and/or legal liability, achieving greater technical competence and knowledge of risks and benefits can help to reduce such conflicts.

Prevention is Better than Treatment

Pain is dynamic. Without treatment, sensory input from injured tissue reaches spinal cord neurons and causes subsequent responses to be enhanced. Pain receptors in the periphery also become more sensitive after injury. Recent studies demonstrate long-lasting changes in cells within spinal cord pain pathways after a brief painful stimulus (Bullit, 1989 ; Fitzgerald, 1990 ; Hanley, 1988 ; Hunt, Pini, and Evan, 1987 ; Przewlocki, Haarmann, Nikolarakis, Herz, and Hollt, 1988). Such physiological studies confirm longstanding clinical impressions that established pain is more difficult to suppress (McQuay, 1989 ; Wall, 1988 ; Woolf, and Wall, 1986). The health care team should encourage patients to request pain medication before the pain becomes severe and difficult to control. Furthermore, the team should teach patients simple relaxation exercises to help decrease postoperative pain (Ceccio, 1984).

Aggressive pain prevention and control that occurs before, during, and after surgery can yield both short- and long-term benefits. In the very short term, for example, a patient's first request for analgesia after orthopedic surgery occurs later after operations performed with opioid premedication and intraoperative nerve blocks than after general anesthesia alone (McQuay, Carroll, and Moore, 1988). In the short term, patients who undergo cesarean section under epidural anesthesia request less postoperative pain medication in the next 3 days than patients who have general anesthesia (Hanson, Hanson, and Matousek, 1984). Also in the short term, postoperative patients able to self-medicate with small intravenous doses of opioids such as morphine metered out by a programmable infusion pump -- patient controlled analgesia or PCA (Ferrante, Ostheimer, and Covino, 1990) -- have less pain and are more satisfied with their pain relief. These patients tend to be discharged earlier from the hospital compared with those given the same drug on an "as-needed" basis (Guideline Report, in press ; Bollish, Collins, Kirking, and Bartlett, 1985 ; Eisenach, Grice, and Dewan, 1988 ; Jackson, 1989 ; Wasylak, Abbott, English, and Jeans, 1990).

In the long term, after elective limb amputation for vascular insufficiency, patients who receive epidural analgesia before an operation are less likely to have chronic phantom limb pain, in contrast to those conventionally treated (Bach, Noreng, and Tjellden, 1988). Pilot studies such as these that show diverse benefits of aggressive pain treatment complement controlled clinical trials which indicate that postoperative morbidity and mortality decrease in high-risk populations such as the very young (Anand, Sippell, and Aynsley- Green, 1987) or very old (Egbert, Parks, Short, and Burnnett, 1990) when postoperative care includes aggressive pain relief.

Figure 1. Pain Treatment Flow Chart: Pre- and Intraoperative (more...)

   Figure 1. Pain Treatment Flow Chart: Pre- and Intraoperative Phases

Figure 2. Pain Treatment Flow Chart: Postoperative (more...)

   Figure 2. Pain Treatment Flow Chart: Postoperative Phases

Figures 1

2

Organization of the Guideline

To derive maximum benefit, clinicians should read the entire guideline. However, the guideline is organized so that users can go easily to those sections of immediate interest. Following a discussion of why clinicians should take an aggressive approach to prevention and control of postoperative pain, methods of pain assessment are described. Pharmacologic and nonpharmacologic methods of pain control are then presented for general control of postoperative pain, followed by discussion of pain control for specific operative sites and for specific types of patients. The final section discusses institutional responsibility for effective pain management. The appendixes contain a brief description of the methods used for scientific review and a table of scientific evidence for pain intervention, pain assessment tools, drug dosage tables for adults and children, and relaxation exercises.

Pharmacologic Management

Pharmacologic management of mild to moderate postoperative pain should begin, unless there is a contraindication, with an NSAID. Moderately severe to severe pain normally should be treated initially with an opioid analgesic. After many relatively noninvasive surgical procedures, NSAIDs alone can achieve excellent pain control (Davie, Slawson, and Burt, 1982 ; Rosen, Absi, and Webster, 1985). NSAIDs decrease levels of inflammatory mediators generated at the site of tissue injury. Even when insufficient alone to control pain, NSAIDs have a significant opioid dose-sparing effect upon postoperative pain and can be useful in reducing opioid side effects (Guideline Report, in press ; Hodsman, Burns, Blythe, Kenny, McArdle, and Rotman, 1987 ; Martens, 1982). The concurrent use of opioids and NSAIDs often provides more effective analgesia than either of the drug classes alone. Although it is likely that NSAIDs also act within the central nervous system, in contrast to opioids, they do not cause sedation or respiratory depression, nor do they interfere with bowel or bladder function. Acetaminophen does not affect platelet aggregation, nor does it provide peripheral anti- inflammatory activity. Some evidence exists that two salicylates do not affect platelet aggregation profoundly; these are salsalate (Estes, and Kaplan, 1980) and choline magnesium trisalicylate (Danesh, Saniabadi, Russell, and Lowe, 1987). All other NSAIDs appear to produce a risk of platelet dysfunction that may impair blood clotting and carry a small risk of gastrointestinal bleeding. At present, one NSAID (ketorolac) is approved by the Food and Drug Administration for parenteral use. The analgesic dosage tables in appendixes B and C include information on NSAIDs, opioids, and other analgesic drugs.

Opioid analgesics are the cornerstone of pharmacological postoperative pain management, especially for more extensive surgical procedures that cause moderate to severe pain. Other agents such as NSAIDs or single injections of local anesthetics may control mild to moderate pain after relatively minor procedures or reduce opioid dose requirements after more extensive operations when this is a goal (Guideline Report, in press ; Egan, Herman, Doucette, Normand, and McLeod, 1988 ; Engberg, 1985a, 1985b ; Kaplan, Miller, and Gallagher, 1975 ; Patel, Lanzafame, Williams, Mullen, and Hinshaw, 1983 ; Sabanathan, Mearns, Bickford Smith, Eng, Berrisford, Bibby, and Majid, 1990 ; Toledo-Pereyra, and DeMeester, 1979). Even in the absence of preemptive efforts targeted at postoperative analgesia, adequate postoperative pain control can usually be achieved with opioid analgesics. When increasing doses of opioids are ineffective in controlling postoperative pain, a prompt search for residual pathology is indicated, and other diagnoses such as neuropathic pain should be considered.

Opioid tolerance or physiological dependence is unusual in short-term postoperative use in opioid naive patients. Likewise, psychologic dependence and addiction are extremely unlikely to develop after patients without prior drug abuse histories use opioids for acute pain (Porter, and Jick, 1980). Proper use of opioids involves selecting a particular drug and route of administration and judging: 1) suitable initial dose; 2) frequency of administration; 3) optimal doses of non- opioid analgesics, if these are also to be given; 4) incidence and severity of side effects; and 5) whether the analgesic will be given in an inpatient or ambulatory setting. Titration to achieve the desired therapeutic effect in the immediate postoperative period and to maintain that effect over time should be emphasized.

Opioids produce analgesia by binding to opioid receptors both within and outside the central nervous system. Opioid analgesics are classified as full agonists, partial agonists, or mixed agonist-antagonists, depending on the manner in which they interact with opioid receptors. Full agonists produce a maximal response within the cells to which they bind; partial agonists produce a lesser response, regardless of their concentration; and mixed agonist- antagonists activate one type of opioid receptor while simultaneously blocking another type. Several types and subtypes of such receptors exist. The most important receptor type for clinical analgesia is named "mu" because of its affinity for morphine. Other commonly used mu opioid agonists include hydromorphone, codeine, oxycodone and hydrocodone, methadone, levorphanol, and fentanyl. All mu opioid agonists have the potential to cause constipation, urinary retention, sedation, and respiratory depression and frequently also produce nausea or confusion. Mixed agonist- antagonists in clinical use include pentazocine [Talwin], butorphanol tartrate [Stadol], and nalbuphine hydrochloride [Nubain]; each of these blocks or is neutral at the mu opioid receptor while simultaneously activating a different type of opioid receptor termed "kappa." Patients receiving mu opioid agonists should not be given a mixed agonist- antagonist because doing so may precipitate a withdrawal syndrome and increase pain. Mixed agonist-antagonists and partial agonists may exhibit a ceiling effect not only with respect to respiratory depression (Nagashima, Karamanian, Malovany, Radnay, Ang, Koerner, and Foldes, 1976 ; Kallos, and Caruso, 1979) but also in regard to their analgesic activity. In the awake patient, there is a clinical ceiling analgesic effect even with morphine because side effects such as respiratory depression limit the dose that may be safely given. However, this does not limit the ability of clinicians to effectively increase the drug dose when the painful stimulus increases and respiratory status is monitored.

Meperidine [Demerol], a mu opioid analgesic, is commonly used for postoperative pain control. Meperidine is commonly underdosed and administered too infrequently even by physicians aware of its pharmacokinetics (Marks, and Sachar, 1973). The common postoperative meperidine order of 75 mg parenterally every 4 hours as needed often is inadequate for several reasons. Meperidine produces clinical analgesia for only 2.5-3.5 hours, and a dose of 75 mg every 4 hours is equivalent to only 5- 7.5 mg of morphine. Therefore, to obtain postoperative analgesia equal to that from 10 mg of morphine sulfate every 4 hours, a clinician would have to use 100-150 mg of meperidine every 3 hours. Because of its unique toxicity, meperidine is often contraindicated in patients with impaired renal function and those receiving antidepressants of the monamine oxidase inhibitor class (Wood, and Cousins, 1989). Normeperidine (6-N-desmethylmeperidine) is a toxic meperidine metabolite excreted through the kidney. In patients with normal renal function, normeperidine has a half-life of 15 to 20 hours; this time is extended greatly in elderly individuals and patients with impaired renal function. Normeperidine is a cerebral irritant that can cause effects ranging from dysphoria and irritable mood to convulsions (Kaiko, Foley, Grabinski, Heidrich, Rogers, Inturissi, and Reidenberg, 1983 ; Szeto, Inturrisi, Houde, Saal, Cheigh, and Reidenberg, 1977). These effects have been observed even in young, otherwise healthy patients given sufficiently high doses of normeperidine postoperatively. Therefore, meperidine should be reserved for very brief courses in otherwise healthy patients who have demonstrated an unusual reaction (e.g., local histamine release at the infusion site) or allergic response during treatment with other opioids such as morphine or hydromorphone.

Titration of opioids should be based on the patient's analgesic response and side effects. Remember that patients vary greatly in their analgesic dose requirements and responses to opioid analgesics. Relative potency estimates provide a rational basis for selecting the appropriate starting dose to initiate analgesic therapy, changing the route of administration (e.g., from parenteral to oral), or when switching to another opioid. Dosage conversion factors based on relative potency estimates may differ somewhat between individual patients. When estimating the initial postoperative dose of an opioid analgesic, a clinician should consider whether patients have been receiving opioid analgesics preoperatively. In such patients, supplemental postoperative doses should be adjusted above the preoperative baseline requirement unless the operation itself is likely to remove the painful stimulus.

An "as-needed" order for opioid administration can result in prolonged delays while the nurse unlocks the controlled substances cabinet and prepares the drug for administration and until the drug takes effect. These delays can be eliminated by administering analgesics on a regular time schedule initially. For example, if the patient is likely to have pain requiring opioid analgesics for 48 hours following surgery, morphine could be ordered every 4 hours by the clock (not "as needed") for 36 hours. Once the duration of analgesic action is determined for a patient, the dosage frequency should be adjusted to prevent pain from recurring. Depending on patient preferences, the orders may be written so that the patient can refuse an analgesic if not in pain or forego it if asleep. However, as in dosing with other drugs that require a steady blood level to remain effective, interruption of an around-the-clock dosage schedule during the hours of sleep may cause the patient to be suddenly awakened by intense pain as blood analgesic levels decline.

It may be acceptable late in the postoperative course to give the same drug every 4 hours as requested. Switching from an around-the-clock to an as- needed dosage schedule later in the patient's course is one way to provide pain relief while minimizing the risk of adverse effects as the patient's analgesic dose requirement diminishes. As part of this schedule, a patient's pain should be assessed at regular intervals to determine the efficacy of the drug intervention, the presence of side effects, or the need for dosage adjustment or supplemental doses for breakthrough pain. Effective use of opioid analgesics should facilitate routine postoperative activities -- e.g., coughing and deep breathing exercises, ambulation, and physical therapy (Alexander, Parikh, and Spence, 1973 ; Rawal, and Sjostrand, 1986 ; Wasylak, Abbott, English, and Jeans, 1990). The opioid should be withheld if the patient is sedated when awake or whenever there is respiratory depression (usually fewer than 10 breaths per minute).

Opioids may be administered by a variety of routes; oral dosing is usually the most convenient and least expensive route of administration. It is appropriate as soon as the patient can tolerate oral intake and is the mainstay of pain management in the ambulatory surgical population.

Preoperative intravenous or epidural access may be appropriate for postoperative management of severe pain, even when the oral route is available. Relatively few side effects will occur ordinarily, providing that these modalities are carefully managed by clinicians with appropriate expertise. Using potent analgesics or invasive techniques postoperatively, at a time when a patient's level of consciousness and physical function are returning to normal, requires careful titration and patient assessment.

Drug dosage, frequency, side effects, and risks differ even more noticeably between the intravenous and epidural routes than between the oral and intravenous routes. Clinicians not familiar with epidural opioid doses and pharmacokinetics must review the literature carefully before using that route. In addition, side effects (e.g., confusion, respiratory depression, hypotension, urinary retention, or pruritus) associated with opioids can be greater with intravenous and epidural administration and require ongoing assessment and monitoring. Other potential problems that dictate expert vigilance and followup during epidural analgesia include abscess development or anesthesia of a nerve root at the site of catheter tip. These routes of administration are best limited to specially trained staff who are knowledgeable and skilled in the management of patients receiving intravenous or epidural opioids, typically under the direction of an acute or postoperative pain treatment service.

Patient controlled analgesia is a safe method for postoperative pain management that many patients prefer to intermittent injections. Systemic PCA usually connotes intravenous drug administration, but it also can be subcutaneous or intramuscular. Few studies of the use of PCA drug delivery to the epidural space exist. A typical intravenous PCA prescription applicable to many contexts relies on a series of "loading" doses; for example, 3-5 mg of morphine, repeated every 5 minutes until the initial postoperative pain (if present) diminishes. A low-dose basal infusion (0.5-1 mg/hr) at night allows uninterrupted sleep. On-demand doses typically add 1 mg of morphine every 6 minutes, with a total hourly limit of 10 mg. Once the patient is able to take oral medications, an around-the-clock schedule of an oral opioid such as a codeine-acetaminophen combination is provided, and the basal infusion rate is discontinued. By observing the number of "on-demand" doses self- administered by the patient, the clinician can assess the adequacy of the oral medication and titrate it further, change to a stronger compound such as oxycodone with acetaminophen, or discontinue the PCA pump.

Intravenous administration is the preferred route for postoperative opioid therapy when the patient cannot take oral medications. When intravenous access is problematic, sublingual and rectal routes should be considered as alternatives to traditional intramuscular or subcutaneous injections. All routes other than intravenous require a lag time for absorption of the drug into the circulation. In addition, repeated injections with associated pain and trauma may deter some patients, especially children, from requesting pain medication. Continuous administration of low doses of opioids intravenously or transdermally and intermittent delivery across the buccal mucosa are relatively new but apparently effective methods to administer opioids postoperatively. Further experience is needed to define the clinical roles of these innovative methods in relation to more well-established methods.

Opioids and local anesthetic agents interact favorably. Continuous administration into the epidural space of low concentrations of opioids in dilute solutions of local anesthetic provides excellent analgesia, while reducing the potential risks (e.g., respiratory depression or motor block) associated with equianalgesic concentrations of either agent administered singly. In a less technologically demanding approach, systemically administered opioids given pre-, intra-, or postoperatively augment the duration and effectiveness of local anesthetics given spinally or epidurally. Local anesthetics alone may be applied intermittently to specific nerves to interrupt pain pathways. For example, injecting local anesthetics around the intercostal nerves after thoracotomy significantly improves pulmonary function (Guideline Report, in press ; Engberg, 1985b ; Kaplan, Miller, and Gallagher, 1975 ; Toledo- Pereyra, and DeMeester, 1979). Catheters for continuous or repeated intermittent dosing of local anesthetic also have been employed postoperatively in the pleural space or adjacent to nerves such as the brachial plexus or cervical sympathetic ganglia. However, a clinical role for interpleural or perineural local anesthetics in the postoperative setting has not yet been defined.

Nonpharmacologic Management

Nonpharmacologic interventions can be classified as either cognitive- behavioral interventions or physical agents. Cognitive and behaviorally based approaches include several ways to help patients understand more about their pain and take an active part in its assessment and control. The goals of interventions classified as cognitive-behavioral therapies are to change patients' perceptions of pain, alter pain behavior, and provide patients with a greater sense of control over pain. The goals of interventions classified as physical agents or modalities are to provide comfort, correct physical dysfunction, alter physiological responses, and reduce fears associated with pain-related immobility or activity restriction. Nonpharmacologic approaches are intended to supplement, not substitute for, the pharmacologic or invasive techniques described above.

Nonpharmacologic interventions are appropriate for the patient who: 1) finds such interventions appealing; 2) expresses anxiety or fear, as long as the anxiety is not incapacitating or due to a medical or psychiatric condition that has a more specific treatment; 3) may benefit from avoiding or reducing drug therapy (e.g., history of adverse reactions, fear of or physiological reason to avoid oversedation); 4) is likely to experience and need to cope with a prolonged interval of postoperative pain, particularly if punctuated by recurrent episodes of intense treatment- or procedure-related pain; or 5) has incomplete pain relief following appropriate pharmacologic interventions. Cognitive- behavioral approaches include preparatory information, simple relaxation, imagery, hypnosis, and biofeedback. Physical therapeutic agents and modalities include application of superficial heat or cold, massage, exercise, immobility, and electroanalgesia such as TENS therapy.

Giving a patient a detailed description of all medical procedures, expected postoperative discomfort, and instruction aimed at decreasing treatment- and mobility-related pain can decrease self-reported pain, analgesic use, and postoperative length of stay (Guideline Report, in press ; Egbert, Battit, Welch, and Bartlett, 1964 ; Fortin, and Kirouac, 1976 ; Schmitt, and Wooldridge, 1973 ; Voshall, 1980). Patients should receive sufficient procedural and sensory information to satisfy their interest and enable them to assess, evaluate, and communicate postoperative pain. In addition, all preoperative patients should receive instruction emphasizing the importance of coughing, deep breathing, turning, and walking, along with suggestions on how to decrease physical discomforts from such activities. When fear or anxiety occur, it is important to assess psychological coping skills and provide practical suggestions for managing pain and maintaining a positive outlook. Patients who appear anxious or fearful before surgery, and others who express an interest in cognitive-behavioral strategies, should be assisted in selecting an intervention (e.g., simple relaxation or imagery) and taught how to use it. In some patients, particularly those with high levels of anxiety, too much information, or too many demanding decisions can exacerbate fear and pain (Johnson, Fuller, Endress, and Rice, 1978 ; Johnson, Rice, Fuller, and Endress, 1978). Psychiatric evaluation is appropriate for patients who manifest disabling or disruptive anxiety symptoms such as emotional instability, restlessness, inability to sleep, and dulled thinking.

Relaxation is the most widely evaluated cognitive-behavioral approach to postoperative pain management. Relaxation strategies, including simple relaxation (Horowitz, Fitzpatrick, and Flaherty, 1984 ; Lawlis, Selby, Hinnant, and McCoy, 1985 ; Levin, Malloy, and Hyman, 1987); imagery (Daake, and Gueldner, 1989 ; Horan, Laying, and Pursell, 1976); hypnosis (Kiefer, and Hospodarsky, 1980); biofeedback (Madden, Singer, Peck, and Nayman, 1978); and music-assisted relaxation (Locsin, 1981 ; Mullooly, Levin, and Feldman, 1988), have all shown some degree of effectiveness in reducing pain. Relaxation strategies and imagery techniques need not be complex to be effective. Relatively simple approaches such as the brief jaw relaxation procedure described on page 25 have been successful in decreasing self- reported pain and analgesic use (Flaherty, and Fitzpatrick, 1978 ; Wells, 1982). These strategies take only a few minutes to teach but require periodic reinforcement through encouragement and coaching. Supportive family members or audiotapes often can sustain patient skills. [Sample relaxation and imagery exercises are included in appendix B and printed resource materials or manuals are available elsewhere (McCaffery, and Beebe, 1989 ; Syrjala, 1990).] A relaxation strategy that can be used informally is music distraction. Both patients' personally preferred music (Locsin, 1981) and "easy listening" music (Mullooly, Levin, and Feldman, 1988) have significantly decreased postoperative pain in clinical studies. Patients who need repeated coaching may benefit from the use of a commercially prepared relaxation or music- assisted relaxation audiotape.

Other cognitive-behavioral strategies require greater professional involvement; these include complex imagery, hypnosis, biofeedback, and combined therapies. Such strategies are commonly applied when patients have chronic pain even before surgery.

Although some data suggest that the use of complex imagery may reduce pain (Daake, and Gueldner, 1989 ; Horan, Laying, and Pursell, 1976), that biofeedback may lessen pain and operative site muscle tension (Madden, Singer, Peck, and Nayman, 1978 ; Moon, and Gibbs, 1984), and that interventions which combine imagery and relaxation may decrease pain (Mogan, Wells, and Robertson, 1985 ; Pickett, and Clum, 1982 ; Swinford, 1987), each requires specialized training and, for biofeedback, the use of special equipment. Findings from studies of hypnosis for control of postoperative pain are inconsistent (Daniels, 1976 ; John, and Parrino, 1983 ; Kiefer, and Hospodarsky, 1980 ; Snow, 1985). Insufficient research to demonstrate effectiveness in reducing postoperative pain and the need for special training or equipment preclude the recommendation of complex imagery, biofeedback, or hypnosis for routine postoperative pain control. This is not to say that patients who have a high level of preoperative anxiety, whose pain is severe and enduring, or who suffer recurrent episodes of procedure-related pain will not benefit from these strategies. However, for such patients a more comprehensive pain management program must include active involvement of professionals skilled in cognitive-behavioral therapy and psychological assessment.

In addition to cognitive-behavioral interventions, several physical therapeutic methods can be used to manage pain (Lee, Itoh, Yang, and Eason, 1990). Commonly used physical agents include applications of heat and cold, massage, exercise, and rest or immobilization. Applications of heat or cold are used to alter pain threshold, reduce muscle spasm, and decrease congestion in an injured area. Applications of cold are used initially to decrease tissue injury response. Later, heat is used to facilitate clearance of tissue toxins and accumulated fluids. Massage and exercise are used to stretch and regain muscle and tendon length. Immobilization is used following many musculoskeletal procedures to provide rest and maintain the alignment necessary for proper healing. With the exception of applications of cold and immobilization, these interventions typically are not used following surgery unless complications occur or an extended postoperative course is expected. When physical modalities are used, it is often for a physiological goal other than pain relief. Of these modalities only cryotherapy (application of cold) has been evaluated in the literature (Cohn, Draeger, and Jackson, 1989 ; Lanham, Powell, and Hendrix, 1984 ; Rooney, Jain, McCormack, Bains, Martini, and Goldiner, 1986). Lanham and colleagues (1984) and Rooney and colleagues (1986) used cryotherapy in association with TENS therapy. There is insufficient evidence to suggest that cryotherapy alone is effective in reducing postoperative pain. Cryotherapy is different from cryoanalgesia (application of a cryoprobe to specific peripheral nerves), which has proven effective for post- thoracotomy pain (Guideline Report, in press).

TENS therapy is one physical modality for which there is some support. TENS therapy has been effective in reducing self-reported pain and analgesic use following abdominal surgery (Cooperman, Hall, Mikalacki, Hardy, and Sadar, 1977 ; Hargreaves, and Lander, 1989), orthopedic surgery (Jensen, Conn, Hazelrigg, and Hewett, 1985 ; Smith, Hutchins, and Hehenberger, 1983), thoracic surgery (Liu, Liao, and Lien, 1985 ; Rooney, Jain, McCormack, Bains, Martini, and Goldiner, 1986), mixed surgical procedures (Neary, 1981 ; Solomon, Viernstein, and Long, 1980 ; VanderArk and McGrath, 1975), and cesarean section (Davies, 1982 ; Smith, Guralnick, Gelfand, and Jeans, 1986). TENS therapy also has improved physical mobility following thoracic (Liu, Liao, and Lien, 1985 ; Warfield, Stein, and Frank, 1985) and orthopedic (Jensen, Conn, Hazelrigg, and Hewett, 1985 ; Smith, Hutchins, and Hehenberger, 1983) surgery. Both TENS therapy and sham TENS therapy (that is, application of electrodes without transmission of electric current) significantly reduced analgesic use and subjective reports of pain (Guideline Report, in press). No significant differences were found between TENS therapy and sham-TENS (Conn, Marshall, Yadav, Daly, and Jaffer, 1986 ; Hargreaves and Lander, 1989 ; Taylor, West, Simon, Skelton, and Rowlingson, 1983). Even though these findings suggest a placebo effect underlies the reduction of perceived pain and analgesic use during TENS therapy, beneficial effects do, in fact, result (Guideline Report, in press). The physical modalities of acupuncture and electroacupuncture also have been clinically evaluated in postoperative patients, with conflicting findings; no clear analgesic effect has been demonstrated (Evron, Schenker, Olshwang, Granat, and Magora, 1981 ; Facco, Manani, Angel, Vincenti, Tambuscio, Ceccherelli, Troletti, Ambrosio, and Giron, 1981 ; Hansson, and Ekblom, 1986 ; Wigram, Lewith, Machin, and Church, 1986).

How each patient's postoperative pain management program is designed and implemented will vary according to the type of medical facility and services available to support a pain management program. At the least, clinicians should be introduced to these methods so they recognize the benefits of cognitive-behavioral and physical interventions, know the indications for their use, and are able to provide information and counseling to patients. In addition, patients should have access to written information about available therapies, why and when to use them, and sources for self- management materials or professional consultations.

Catastrophic postoperative events are rarely, if ever, masked by any of the approaches to postoperative pain control previously described. Any sudden or unexplained change in pain intensity requires immediate evaluation by the surgeon. Likewise, a sudden increase in anxiety may signal cardiac or pulmonary decompensation and requires prompt medical or surgical assessment.

Process of Effective Pain Management

Postoperative pain management

As illustrated in the flow chart on page 10 (Figure 2), the process of postoperative pain management is ongoing. Following intraoperative anesthesia and analgesia, postoperative pain assessment and management begin. Based on the preoperative plan, postoperative drug and nondrug interventions are initiated. Patients should be reassessed at frequent intervals (not less than every 2-4 hours for the first 24 hours) to determine the efficacy of the intervention in reducing pain. If the intervention is ineffective, additional causes of pain should be considered, the plan should then be reevaluated, and appropriate modifications should be made. Pharmacologic interventions should be titrated to achieve optimal pain control with minimal adverse effects. Ongoing reassessment ensures satisfactory pain relief with the most appropriate balance of drug and nondrug strategies.

Head and Neck Surgery

Chest and Chest Wall Surgery

Abdominal and Perineal Surgery

Musculoskeletal Surgery

Soft Tissue Surgery

Surgical procedures involving local soft tissue resections usually obtain pain control with oral opioids. Many of these procedures are done on an ambulatory basis and require careful patient education prior to and immediately after the procedure. Anxiety because of the potential results of a small surgical biopsy (e.g., feared results of a breast biopsy) may demand adjuvant drug or nondrug therapy. Pre- and postoperative education and support by the surgeon and the health care team are supremely important.

Background

Children commonly experience postoperative pain. The incidence of moderate to severe pain in children in any health care setting is influenced by factors such as the child's medical condition, type of procedure performed, and attitudes of health care professionals toward pain management. In three studies on postoperative pain in children, the prevalence of moderate to severe pain varied from about 40 to 60 percent (Hester, Foster, Kristensen, and Bergstrom, 1989 ; Johnston, Jeans, Abbott, Grey-Donald, and Edgar, 1988 ; Mather, and Mackie, 1983).

Many children do not receive any opioid analgesics after surgical procedures, even though painful postoperative courses are expected (Beyer, DeGood, Ashley, and Russell, 1983 ; Eland, and Anderson, 1977; Foster, and Hester, 1990a, 1990b ; Hester, Foster, Kristensen, and Bergstrom, 1989 ; Schechter, and Allen, 1986). Compared with adults undergoing similar procedures, less potent analgesic regimens usually are ordered for and given to children (Beyer, DeGood, Ashley, and Russell, 1983 ; Schechter, and Allen, 1986). When used, opioid doses and intervals of administration are often inadequate; when a physician's order includes a selection of one or more analgesics, the tendency is to choose the least potent drugs (Beyer, DeGood, Ashley, and Russell, 1983 ; Foster, and Hester, 1989, 1990a ; Mather, and Mackie, 1983). In general, although children are less able than adults to articulate their treatment and medication needs, both opioid and non-opioid analgesics are commonly prescribed on an "as-needed" basis (Beyer, DeGood, Ashley, and Russell, 1983 ; Bush, Holmbeck, and Cockrell, 1989). This type of prescription (a) requires the child or the family to describe the presence of pain and the need for analgesia and (b) focuses on the treatment of emerging pain rather than aggressive treatment to prevent pain.

Infants, even when premature, experience pain in response to aversive stimuli (Anand, 1990 ; Anand, and Aynsley-Green, 1988 ; Anand, Sippell, and Ansley-Green, 1987; Fitzgerald, Millard, and MacIntosh, 1988, 1989 ; Fitzgerald, Shaw, and MacIntosh, 1988). However, infants often do not before or after major medical procedures (Franck, 1987). Although the majority of ventilated infants receive postoperative opioid analgesia (but often in less than adequate doses), nonventilated infants often do not (Campbell, Reynolds, and Perkins, 1989 ; Purcell-Jones, Dormon, and Sumner, 1988 ; Schnurrer, Marvin, and Heimbach, 1985). A survey of the beliefs and practices of anesthesiologists in the United Kingdom revealed that, although the majority believed neonates experience pain, few provided opioid analgesics for postoperative pain (Purcell-Jones, Dormon, and Sumner, 1987). Discrepancies between beliefs and practices can occur for many reasons, but they have not been adequately explored.

Invasive and painful procedures are particularly distressing for children. Children often describe repeated invasive procedures as more distressing than any other aspect of illness or treatment (Eland, and Anderson, 1977 ; Fowler- Kerry, 1990 ; Jay, Ozolins, Elliott, and Caldwell, 1983 ; Weekes, and Savedra, 1988). Unlike adults, infants and young children may not understand the reason for procedures and may not participate actively in providing consent. Infants and young children also may not understand the time-limited nature of procedures. Although appropriate preparation and adequate analgesia for painful procedures are crucial for decreasing distress in children, these issues often are not addressed by health care providers, or they are approached haphazardly (Schechter, 1989).

Assessment

Pain is determined by many factors, including the medical condition, developmental level, emotional and cognitive state, personal concerns, meaning of pain, family issues and attitudes, culture, and environment. Caring for the child in pain requires frequent assessment and reassessment of the presence, amount, quality, and location of pain. It also means preventing or reducing anticipated pain and, when prevention is not possible, promptly alleviating pain. Because emotional distress accentuates the experience of pain, exploration of and intervention for possible sources of distress are necessary. For infants and children, the provider should recognize the potential for pain and pursue the possibility that a child is in pain. A knowledge of children, including their developmental level and their behavior, is necessary to adequately assess pain and distress.

Pediatric pain assessment includes a pain history, a search for diagnoses such as infection that could be increasing or causing pain, evaluation of the pain severity and location, and observation of the child and his or her responses to the environment. The inclusion of parents or guardians and other important family members is essential to pain assessment. Strategies for assessment should be tailored to the developmental level and personality of the child and to the context. Children who are developmentally delayed or retarded, learning disabled, emotionally disturbed, or non-English speaking require special assessment. Culturally determined beliefs about pain and medical care also should be considered. Getting to know the individual child is important for assessment and management of pain: obtaining a pain history and involving the parents in the child's care can optimize this process.

The pain history (see appendix D), obtained prior to or at admission, focuses on the language the child uses to describe pain (e.g., hurt, owie, boo- boo), previous pain experiences and coping strategies, how and to whom the child communicates pain, and the child's and the family's preferences to assess and treat pain (Hester, and Barcus, 1986). The provider, child, and family can then decide together on their approach to pain assessment and treatment.

Routine assessment and documentation of pain are critical for effective pain control. The frequency of assessment is tailored to the severity of the pain. For example, after a major surgical procedure, assessment reasonably could occur at least every 2 hours on the day of surgery and the first postoperative day and at least every 4 hours on subsequent days. More frequent assessment is necessary if the pain is poorly controlled despite treatment. Pain intensity and its response to analgesics should be recorded on the bedside chart just as vital signs are recorded for easy review by health care providers. Structured documentation on a bedside flow sheet may increase the frequency of assessment and provision of analgesia (Stevens, 1990). Assessment methods should be easy to administer or perform, and documentation forms should be readily accessible to health care providers for use in recording pain. If the child is old enough to participate in assessment, his or her ease in response is important for accurate measurement. Young children may not understand the relationship between pain assessment and pain relief; therefore, they may not respond to questions if they are anxious or in severe pain.

Management

Pain is managed by the child, his or her parent(s), nurses, physicians, and other health care providers. Effective interaction is key to effective pain management. Although preferences of the child and the family deserve respect and careful consideration, the primary obligation of the health care provider is to ensure safe and competent care.

Children attempt to prevent or alleviate pain whether or not health care providers do so. When in pain, a child often prefers the use of medication and the presence of a parent (Adams, 1990 ; Hester, 1989 ; Savedra, Gibbons, Tesler, Ward, and Wegner, 1982). However, children may not be in control of these strategies. Specific methods initiated by children that may be helpful include: holding someone's hand, a stuffed toy, or favorite blanket; asking questions; using distraction; sleeping and resting; relaxing or using imagery; changing positions; and engaging in humor. Seemingly simple interventions such as holding someone's hand can have powerful effects. Facilitation of the child's usual strategies for decreasing pain is important.

Pharmacologic Strategies for Procedural Pain

The needs of the individual child and the type of procedure to be performed shape the pharmacologic approach. As with assessment, the practitioner's expertise and experience with children are key to successful therapy. A pain-relieving agent, such as an opioid (see appendix C for starting doses) or a local anesthetic, is needed to reduce the pain. Anxiolytics and sedatives are used specifically to reduce anxiety before and during the procedure; if used alone, they may blunt the behavioral response without relieving the pain. When anxiety is present, pharmacologic anxiolysis can complement analgesia to decrease overall distress. The use of systemic analgesics and sedatives must be approached differently in the infant under 6 months of age (see section on Managing Postoperative Pain in Neonates, and Infants).

Agents that have a broad range of applicability include:

• Local anesthetics: These agents may be administered by local infiltration or topically. For topical use, a eutectic mixture of local anesthetics (EMLA) (Maunuksela, and Korpela, 1986) is promising but not yet available in the United States.

• Opioids: These drugs can be given via the intravenous, oral, or transmucosal route. The intravenous route has the advantage of rapid effect and ease of titration. Intravenous opioids can be given in increments (e.g., morphine at 0.03-0.05 mg/kg every 5 minutes) and titrated to analgesic effect. Oral opioids can be used when close and rapid titration to effect is not required.

• Benzodiazepines: These agents can be given either orally or intravenously. Like opioids, intravenous benzodiazepines are given in increments and titrated to sedative effect (Zeltzer, Altman, Cohen, LeBaron, Maunuksela, and Schechter, 1990). Unlike diazepam, midazolam does not cause pain and local sclerosis when given intravenously (Zeltzer, Altman, Cohen, LeBaron, Maunuksela, and Schechter, 1990). Benzodiazepines provide sedation, not analgesia, and hence they often are used with opioids for painful procedures. If the combination of opioid plus benzodiazepine is used, the risk of respiratory depression is increased.

• Barbiturates: These drugs provide excellent sedation. They have no analgesic effects and are used with analgesics for painful procedures. For most patients, the sedation persists for many hours after the procedure is completed (Zeltzer, Jay, and Fisher, 1989); rarely, some patients may have paradoxical reactions. As with benzodiazepines, close observation for respiratory depression is essential, particularly when the intravenous route is employed or if an opioid is coadministered.

NOTE: Exercise caution when using the mixture of meperidine (Demerol), promethazine (Phenergan), and chlorpromazine (Thorazine), also known as DPT. DPT -- given intramuscularly -- has commonly been used for painful procedures. The efficacy of this mixture is poor when compared with alternative approaches, and it has been associated with a high frequency of adverse effects (Nahata, Clotz, and Krogg, 1985). It is not recommended for general use and should be used only in execptional circumstances.

Agents such as nitrous oxide and ketamine can be used if trained personnel and appropriate monitoring procedures are available (Zeltzer, Jay, and Fisher, 1989). General anesthesia is appropriate in certain situations (Zeltzer, Altman, Cohen, LeBaron, Maunuksela, and Schechter, 1990).

Pain Related to Burn Dressing Changes

Burn dressing changes in the child with burns severe enough to require hospitalization are approached in a multidisciplinary fashion, using drug and nondrug strategies. Pain and anxiety coexist in these situations and must be assessed and managed concurrently using opioids and benzodiazepines, respectively. Depending on the child and the level of anxiety, an opioid may be administered alone or used with a benzodiazepine. Since undertreatment of the pain can escalate anxiety, optimal pain control is necessary. Dressing changes occur repeatedly, and tolerance to opioids and benzodiazepines can develop, necessitating higher doses. For efficacy, doses should be increased as needed and titrated according to the response obtained during the previous procedure. The child also may have ongoing pain from the burns in addition to the pain and anxiety of the burn dressing changes. If the ongoing pain is not treated, the child's anxiety during the dressing changes may make it difficult to manage, even with significant doses of opioids and sedatives. Initial regimens for pain management may include a continuous infusion or around- the-clock intermittent doses of an opioid and additional bolus doses of an opioid and a benzodiazepine before the burn dressing changes. For extensive debridement procedures, conscious sedation may not be adequate; general anesthesia may be required.

A variety of nonpharmacologic approaches are effective adjuvants. These include hypnosis (Bernstein, 1963); a multimodal approach involving distraction, relaxation, imagery, and positive reinforcement (Elliott and Olson, 1983); and cartoon viewing with positive reinforcement (Kelley, Jarvie, Middlebrook, McNeer, and Drabman, 1984). Children as young as 18 months do better during burn dressing changes if their participation and control are maximized (Kavanagh, 1983a, 1983b). For example, a child can help to remove his or her own dressings and call for a "time-out" if necessary. Dressing changes are performed in a treatment room or similar place, so that the child can consider his or her room as a safe place. The time and environment for the dressing change should be predictable to the child. The situation causing the burns may be one that produces emotional distress for the child (e.g., burns sustained as a result of the child playing with fire or disobeying rules), and the developing body image of the child may be threatened by the burns. Psychiatric and psychologic intervention should be provided when necessary. Discharge planning initiated soon after admission can help relieve anxiety and increase compliance with the therapeutic regimen, particularly for children with burns on more than 30 percent of the body surface area (Quay, and Alexander, 1983).

Management of Pain Associated With Surgical Procedures

Management of surgical pain involves three phases: preoperative, intraoperative, and postoperative.

Regional Analgesia

Regional analgesia is now widely used for infants and children and may be particularly applicable for young infants as well. Hemodynamic and respiratory effects of major regional analgesia in infants appear minimal (Meignier, Souron, and LeNeel, 1983). The proper use of infusions or intermittent doses of epidural opioids and/or local anesthetics requires expertise and close monitoring, at least equal to that needed for infants receiving systemic opioids. An acute or postoperative pain service is usually necessary to provide the expertise and vigilance required.

Continuous epidural analgesia is effective for thoracic, abdominal, urologic, and orthopedic procedures (Hendrickson, Myre, Johnson, Matlak, Black, and Sullivan, 1990). Epidural infusions can be administered caudally (especially in children under 6 months of age) or via lumbar or thoracic epidural catheters in older children. Solutions infused into the epidural space are similar to but often more dilute than those applied in adults. Other regional techniques available to children include interpleural continuous infusions, brachial plexus infusions, lumbar sympathetic catheter infusions, and peripheral nerve blockade such as penile blocks.

Managing Postoperative Pain in Neonates and Infants

Young infants, especially premature infants or those who have neurologic abnormalities or pulmonary disease, are susceptible to apnea and respiratory depression when systemic opioids are used (Way, Costley, and Way, 1965 ; Purcell-Jones, Dormon, and Sumner, 1987). Metabolism is altered so that the elimination half-life is prolonged, and the blood- brain barrier is more permeable (Collins, Koren, Crean, Klein, Roy, and MacLeod, 1985 ; Koehntop, Rodman, Brundage, Hegland, and Buckley, 1986 ; Koren, Butt, Chinyanga, Soldin, and Pape, 1985 ; Lynn, and Slattery, 1987). Thus, the adequate management of pain in this age group requires special consideration and expertise.

Clearly, neonates and infants experience pain, and adequate analgesia after surgery is necessary for both physiologic and ethical reasons. Institutions in which major surgery on neonates and infants is performed should provide training for personnel in the effective and safe administration of analgesia for children in this age group, as well as the technologic capability to provide appropriate monitoring. Several aspects of care should be noted.

Age. Some evidence suggests that the clearance of opioids increases rapidly over the first few weeks of life, and approaches adult rates by 1 to 2 months of age (Hertzka, Gauntlett, Fisher, and Spellman, 1989 ; Koren, Butt, Chinyanga, Soldin, and Pape, 1985 ; Lynn, and Slattery, 1987). Because the available data are based on small numbers of infants, most practitioners reduce the initial dose and use intensive monitoring for infants up to about 6 months of age; this age is arbitrary and based on a cautious interpretation of the literature. It is reasonable to continue intensive monitoring up to about 1 year of age, as extreme sedation and decreased effort of respiration may be more difficult to assess in this age group than in older children.

Responsibility for Effective Pain Relief in Children

A formal and structured institutional review of pain management is as necessary for children as for adults. It begins with affirming the rights of all children in any institution to receive the best level of pain relief that can be provided safely. The available methods of pain management should be appropriate for the medical conditions of the children and the surgical procedures that are performed. Recommendations in this guideline (see Responsibility for Effective Pain Relief, page 71) apply to children as well as adults. Patient and family feedback is necessary to ascertain and ensure the adequacy of pain management in children of all ages.

An environment centered on the child is necessary for adequate communication and assessment and to decrease the emotional distress of hospitalization. In addition to a staff experienced in caring for children, a child-centered environment lets parents participate in child care and provides adequate toys and age-appropriate activities.

Critical Questions Regarding the Adequacy of Pain Management Strategies

Knowledge of children -- developmentally, behaviorally, and physiologically -- is necessary for optimal assessment and treatment. Children are likely to talk less about pain than adults. Thus, the burden of vigilance for pain rests with the health care provider. The following questions focus on decision points of pain management. These questions serve as a guide for the health care provider to optimize pain management. Some children, however, will present with pain that is difficult to manage. In these situations, consultation is recommended.

Critical questions to consider before and during pharmacologic management include:

• Have the child and parent(s) been asked about their previous experiences with pain and their preferences for use of analgesics?

• Is the child being adequately assessed at appropriate intervals?

• Are analgesics ordered for prevention and relief of pain?

• Is the analgesic strong enough for the pain expected or the pain being experienced?

• Is the timing of drug administration appropriate for the pain expected or experienced?

• Is the route of administration appropriate (preferably oral or intravenous) for the child?

• Is the child adequately monitored for the occurrence of side effects?

• Are side effects appropriately managed?

• Has the analgesic regimen provided adequate comfort and satisfaction from the child's or parents' perspective?

Parallel questions regarding nonpharmacologic strategies include:

• Have the child and parent(s) been asked about their experience with and preferences for a given strategy?

• Is the strategy appropriate for the child's developmental level, condition, and type of pain?

• Is the timing of the strategy sufficient to optimize its effects?

• Is the strategy adequately effective in preventing or alleviating the child's pain?

• Are the child and parent(s) satisfied with the strategy for prevention or relief of pain?

• Are the treatable sources of emotional distress for the child being addressed?

Elderly Patients

Elderly patients present several pain management problems. First, relatively little attention has been paid to the topic of geriatric pain control in medical or nursing texts (Ferrell, 1991). This is ironic because elderly people often suffer acute and chronic painful diseases, have multiple diseases, and take many medications (From the NIH, 1979). They may have more than one source of pain and an increased risk for drug-drug as well as drug-disease interactions (Kane, Ouslander, and Abrass, 1989). It has been estimated from population studies that the prevalence of pain is two-fold higher in those over age 60 (250 per thousand) compared with those under 60 (125 per thousand) (Crook, Rideout, and Browne, 1984). Among institutionalized elderly, the prevalence may be over 70 percent (Ferrell, Ferrell, and Osterweil, 1990). Indeed, more than 80 percent of elderly people suffer various forms of arthritis, and most will have acute pain at some time (Davis, 1988). Many elective or emergent operations are performed in the elderly to correct orthopedic problems (e.g., fractures, degenerative joint disease). Acute and/or postoperative severe pain related to cancer and its treatment are also more common in the elderly (Foley, 1985). Other acutely painful conditions that affect the elderly disproportionately include herpes zoster, temporal arteritis, polymyalgia rheumatica, and atherosclerotic peripheral vascular disease (From the NIH, 1979).

Second, pain assessment may present unique problems in elderly patients. They often report pain very differently from younger patients due to physiologic as well as psychological and cultural changes associated with aging (Fordyce, 1978). Institutionalized elderly are often stoic about pain (Foley, 1985). Age-associated changes in acute pain perception have long been of interest. Elderly patients often demonstrate altered presentations of common illnesses including "silent" myocardial infarctions and "painless" intra- abdominal emergencies (Bayer, Chada, Farag, and Pathy, 1986 ; Bender, 1989). Whether these clinical observations are the result of age-associated changes in pain perception remains to be explained. The widespread belief among clinicians that aging results in increased pain thresholds may be a myth. A variety of experiments using heat, pressure, or electrical current have not disclosed a trend regarding age-associated changes in either pain threshold or tolerance. It should be noted that the clinical relevance of these studies remains questionable, since experimentally induced pain may not be analogous to clinically experienced pain (Harkins, Kwentus, and Price, 1984).

Cognitive impairment, delirium (common among acutely ill frail elderly), and dementia (occurring in as many as 50% of institutionalized elderly) represent serious barriers to pain assessment for which no solution exists in the literature. Whether behavioral observations (e.g., agitation, restlessness, groaning) are sensitive and specific for pain assessment among the demented elderly remains to be shown. Traditional approaches, including the use of visual analog scales, verbal descriptor scales, and numerical scales, have not been psychometrically established in this population. Moreover, a high prevalence of visual, hearing, and motor impairments in the elderly may impede the universal use of such scales by clinicians. Preliminary reports from ongoing work among the nursing home population suggest that many patients with moderate to severe cognitive impairment are able to report acute pain reliably at the moment or when prompted, although pain recall and integration of pain experience over time may be less reliable. If these early observations prove correct, pain assessment among this population may require frequent monitoring. Monitoring may have major implications for quality assurance, quality of care, and quality of life among this large population of elderly people (Ferrell, and Ferrell, personal communication: Work in progress on the epidemiology of pain among community nursing homes, July 1991).

Third, elderly people, especially the frail and old-old (those over 85) are at particular risk for both under- and overtreatment. Unfortunately, few studies of analgesic dosage requirements are performed in the elderly, and most studies have systematically excluded all potential subjects over 65. Age- related observations are extremely variable among elderly people. Indeed, the variance in measurements of most physiologic and pharmacologic parameters increases with age in cross-sectional studies (Kane, Ouslander, and Abrass, 1989). Age-related changes in pharmacokinetics and pharmacodynamics contribute to a variety of adverse drug effects that have been reported in the elderly.

Non-opioid analgesic drugs, including NSAIDs and acetaminophen, are effective and appropriate for a variety of pain complaints in the elderly. However, it is recognized that the risk for gastric and renal toxicity from NSAIDs is increased among elderly patients, and unusual drug reactions including cognitive impairment, constipation, and headaches are also more common in the elderly population (Roth, 1989). If gastric ulceration is a particular concern, coadministration of misoprostol or use of "platelet- sparing" NSAIDs should be considered as a way to lessen the risk of gastrointestinal bleeding.

Opioid analgesic drugs are effective for the management of acute pain in most elderly patients. Cheyne-Stokes breathing patterns are not unusual during sleep in the elderly and need not prompt discontinuation of opioid analgesia unless such analgesia clearly is associated with unacceptable degrees of arterial oxygen desaturation (< 85%). PCA has been shown in at least one study to be safe and effective for postoperative pain relief among selected patients (Egbert, Parks, Short, and Burnett, 1990). If PCA is used, careful titration of dosage is necessary to avoid undesirable effects due to drug accumulation or from a decrease in the arousal effect as painful stimuli subside later in the patient's course. Elderly people are more sensitive to the analgesic effects of opioid drugs as they experience a higher peak and longer duration of pain relief (Bellville, Forrest, Miller, and Brown, 1971 ; Kaiko, 1980 ; Kaiko, Wallenstein, Rogers, Grabinski, and Houde, 1982). They are also more sensitive to sedation and respiratory depression probably as a result of altered distribution and excretion of the drugs. This is especially true in opioid-naive patients. Caution is required in the use of longer acting drugs such as methadone for this reason (Ferrell, 1991).

Elderly people, in general, have increased fat-to-lean body mass ratios and reduced glomerular filtration rates (Kane, Ouslander, and Abrass, 1989). Opioids produce cognitive and neuropsychiatric dysfunction through poorly defined mechanisms that in part include the accumulation of biologically active metabolites such as morphine-6-glucuronide or normeperidine (Wood, and Cousins, 1989). Opioid dosage titration should take account of not only analgesic effects but also side effects that extend beyond cognitive impairment. These side effects may include urinary retention that looms as a larger threat in elderly males with prostatic hypertrophy, constipation and intestinal obstruction, respiratory depression, or exacerbation of Parkinson's disease. The management of nausea using phenothiazines or antihistamines is fraught with problems, because elderly people are exquisitely sensitive to anticholinergic side effects including delirium, bladder and bowel dysfunction, and movement disorders (Ferrell, 1991).

Local anesthetic infusions may result in cognitive impairment if significant blood levels are reached. Yet prior to that point, orthostatic hypotension may result from sympathetic blockade and clumsiness may ensue from partial motor or sensory anesthesia. Thus, appropriate precautions should be taken, such as help with ambulation or the use of side rails at night.

Finally, attitudes among health care professionals, the lay public, and patients themselves may impede appropriate care. Many members of all three groups consider acute and chronic pain a part of normal aging (Ferrell, Ferrell, and Osterweil, 1990 ; Ferrell, 1991).

Patients Who Are Known or Suspected Substance Abusers

Management of acute pain in the substance abuser is a difficult but increasingly common clinical problem. Substance abusers experience traumatic injuries (see section on Patients with Shock, Trauma, and Burns) and a variety of health problems more often than the general population. Often during their postoperative care issues arise that prompt the staff to request consultation with specialized "pain teams." For example, the question of possible withdrawal from preexisting opioid use may be raised because sympathetic nervous system stimulation (restlessness, tachycardia, sleeplessness) may be caused by either undertreated pain or opioid abstinence. The related issue of risk of development of substance abuse behaviors in opioid-naive patients given opioid analgesics postoperatively appears to be small based on survey data by Porter and Jick (1980), who found that only four such instances of iatrogenic drug abuse occurred in approximately 12,000 patients screened through the Boston Collaborative Drug Study.

A variety of reports, increasingly frequent in number, have addressed the difficult questions surrounding postoperative opioid use in substance abusers, and several recommendations have recently emerged from reviews of this literature (Portenoy, and Payne, in press). First, every effort should be made to define the mechanism of the pain and to treat the primary problem. Infection, tissue ischemia, or a new surgical diagnosis in the postoperative period may require specific measures such as antibiotic therapy, fasciotomy, or re-operation rather than an increase in the opioid dose. Attention to the primary cause of pain symptoms may reduce greatly the requirement for and negotiations about opioid analgesics.

Second, clinicians should distinguish between the temporal characteristics of the abuse behavior. For example, a distant history of substance abuse might predispose to re-emergence of substance abuse behaviors with the stress of surgery and postoperative pain but may not require treatment approaches different from those appropriate for nonaddicted patients. The implications are different for patients with a recent history of active drug abuse who may require higher than usual starting doses of opioids and who may not have acquired an ability to set limits on their drug use.

Third, one should follow relevant pharmacological principles of opioid use. For example, treatment with an opioid agonist-antagonist should not be started in the patient who enters tolerant to opioid agonists such as methadone. Mixed agonist-antagonists may precipitate withdrawal if given in this setting. Loading doses of opioids will be required in normal patients as well as in substance abusers to reduce the intensity of postoperative pain to acceptable levels. PCA is being used with increasing frequency for many patients, including known substance abusers. This mode of opioid delivery can be utilized safely in substance abusers when appropriate lockout intervals and hourly dosage limits are programmed, and when the device is "tamper- resistant," so that the patient cannot reprogram the pump or remove any drug. If used for an opioid-tolerant patient, PCA doses must be increased to achieve the same analgesic effect as for opioid-naive or nonaddicted patients.

Fourth, just as for other patients, non-opioid therapies should be given concomitantly with or even to replace opioids. Such therapies include NSAIDs, local anesthetic solutions given via catheter into the epidural space or surrounding peripheral nerves, cryoanalgesia, TENS, and nondrug therapies. Appropriate use of non-opioid therapies frequently will reduce the dosage requirement for opioid analgesia.

Fifth, specific drug abuse behavior in the postoperative patient should be recognized and dealt with firmly. Such behavior includes tampering with PCA machines (or other drug delivery devices), hoarding of oral doses of opioid analgesics, or attempting to self-inject the melted contents of capsules or siphoned infusion solutions. At that point, limits of analgesic dosages and expected patient behavior should be made clear to the patient in a frank discussion that also considers the medical, ethical, and legal consequences to the patient and physician if drug abuse behaviors continue. For the most part, security measures already in place (locked closets, and inventory checks each nursing shift, antitamper features on PCA machines) will frustrate such attempts. A toxicological screen may be ordered on an inpatient's urine or blood specimens to confirm or exclude a diagnosis of surreptitious drug use (e.g., cocaine administration).

In the outpatient setting, clear instructions (preferably written out and copied into the patient's record) should be offered regarding doses and frequency of medication and the number of days the prescription is expected to last. The addition of a random urine testing procedure to outpatient medication contracts should be considered in all outpatients with a known history of substance abuse who are given opioid analgesics for pain. Opioid medications should be prescribed only by one physician, and attempts to circumvent this restriction or to falsify prescriptions should not be tolerated. The claim of needing additional medication to make up for lost or stolen controlled substances should be accompanied by documentation that the patient has reported this to the police.

Sixth, caregivers should set limits to avoid excessive negotiation about drug selections or choices. For example, it is not appropriate to depart from an institutional policy for morphine use for postoperative analgesia just because of a substance abuser's request for meperidine, as long as the patient has no history of adverse reaction to morphine. Once every effort has been made by clinicians to adjust a patient's opioid regimen in light of the extent and site of the operation, the patient's prior tolerance to opioids, and clinical response to initial analgesic titration, it is not unreasonable to adhere to this regimen with few, if any, changes. When possible, the treatment plan should include clear criteria (e.g., number of days postoperatively, ability to ambulate) by which opioid doses will be tapered and stopped. Within such a treatment plan, requests for higher dosage by a patient who can walk easily or spends much of the time resting comfortably may appropriately be denied. Consultation should be obtained with appropriate services early in a difficult patient's course. Consultation should help develop a unified multidisciplinary plan that includes, usually, psychiatric, psychological, and substance abuse expertise. Medical input can be obtained beyond the scope of the immediate caretakers to evaluate these and other problematic behaviors. Medical and/or neurologic input can be valuable when assessing neurologic symptoms such as seizures in patients who have recently discontinued alcohol or barbiturate use.

These guidelines will aid the clinician in distinguishing "drug seeking" behaviors from "pain avoidance" behaviors. Often patients who are undertreated for pain and who voice displeasure are labeled as "addicts." This phenomenon has been called "pseudo-addiction" (Weissman and Haddox, 1989). Careful and objective assessment and reassessment of the postoperative patient with an active or previous substance abuse history will minimize the chance of a clinician being "duped" into providing inappropriate opioids but still provide the patient with legitimate pain complaints the opportunity to obtain meaningful and safe pain relief with opioids.

Patients with Concurrent Medical Conditions

Postoperative pain frequently must be treated in patients who have concurrent medical conditions for which they are taking one or more medications. The medical condition per se or the medications taken for it may influence the choice of analgesic and its dosage. These medical conditions are frequently chronic, and it may not be possible to discontinue problematic medications because of surgery. The most common medications or classes of medications that produce clinically significant drug interactions with opioid analgesics include alcohol and any central nervous system depressants, phenytoin, and monoamine oxidase inhibitors. Drugs whose primary site of action lies outside the central nervous system (e.g., antibiotics such as rifampin) also may interact with opioid analgesics.

Coexisting conditions themselves influence the type and doses of opioid analgesics and the relative risks of pain treatment in the postoperative period. For example, patients with chronic pain who have been treated recently with opioids (e.g., patients with cancer, and sickle cell disease) will usually require higher-than-the-recommended starting doses to overcome opioid tolerance. Coagulopathy, neutropenia, and sepsis may contraindicate the use of epidural catheters or other regional anesthetic techniques in which the risks of bleeding or "seeding" of infection are increased.

Drug pharmacokinetics may change following surgery because of changes in drug absorption and distribution caused by alterations in cardiac output, venous capacitance, extravascular fluid shifts ("third spacing"), and changes in protein binding. Fever and sepsis in the postoperative period may affect drug disposition, as do shock, trauma, and burns. In addition, patients may not attain clinically effective plasma concentrations of opioids following intramuscular and subcutaneous injections due to pharmacokinetic alterations.

The major factor to consider in selecting analgesics for patients with concurrent medical conditions is whether the disorder produces either hepatic or renal impairment. Most analgesics are metabolized by the liver or kidney, so that any impairment of function in these organs influences the pharmacokinetics of the analgesic. The net result can be drug accumulation. Therefore, caution is essential when using opioids in patients with altered hepatic or renal function. Morphine is metabolized in the liver, and the parent compound, along with the metabolites, is excreted through the kidney. Acute or chronic hepatic failure (e.g., viral hepatitis or cirrhosis) appears to lower plasma clearance of morphine, prolong the terminal elimination half-life, and increase oral bioavailability (Hasselstrom, Eriksson, Persson, Rane, Svensson, and Sawa, 1990). Even mild renal failure, such as that associated with a decline in glomerular filtration rate with aging, can impede excretion of the metabolites of many opioids, resulting in clinically significant narcosis and respiratory depression (Sear, Hand, Moore, and McQuay, 1989). Physiological alterations during surgery (e.g., changes in regional blood flow to the liver or kidneys, hepatic enzyme activity, enterohepatic circulation, or hormonal responses) may also alter drug metabolism and excretion. Meperidine, pentazocine, and propoxyphene have increased bioavailability, prolonged half- lives, and decreased systemic clearance and thus accumulate in hepatic and renal dysfunction. Doses of these drugs must be decreased appropriately. In contrast, the disposition and elimination of methadone are not significantly altered in patients with chronic liver disease.

Renal excretion is a major route of elimination for pharmacologically active opioid metabolites: norpropoxyphene, normeperidine, morphine-6- glucuronide, and dihydrocodeine. Elimination is decreased in patients with renal failure, and doses must be lowered or given less frequently.

For individual patients, it is difficult to predict the degree of impairment of metabolism or excretion of the most commonly used analgesics from either the clinical condition or laboratory indicators of hepatic or renal function because many factors impinge on clinical response. A lowered initial dose, careful titration of the opioid to desired effect, and ongoing monitoring of clinical response, level of consciousness, and respiratory effort are indicated. Continuous infusions and opioid administration around-the-clock at conventional intervals can result in accumulation of the parent compound or clinically active metabolites. To avoid undertreatment of pain during as- needed dosage schedules, the patient can be assessed at regular intervals, and if stable, a dose of opioid can be offered. PCA does not necessarily protect against accumulation of opioids and respiratory depression (Covington, Gonsalves-Ebrahim, Currie, Shepard, and Pippenger, 1988). In renal failure, especially, a decreased dose and prolonged lockout interval may be required. Non-opioid analgesics are often contraindicated in patients with hepatic or renal dysfunction.

Other diseases that may influence the control of postoperative pain include psychiatric illnesses requiring tricyclic antidepressants and monoamine oxidase inhibitors for treatment; neurologic disorders; pulmonary diseases; and acute and chronic infections.

Patients with respiratory insufficiency and those with chronic obstructive pulmonary disease, cystic fibrosis, and neuromuscular disorders affecting respiratory effort (e.g., muscular dystrophy, myasthenia gravis) are vulnerable to the respiratory depressant effects of opioids. However, when a patient splints his or her respiratory effort because of uncontrolled pain, that also can impair gas exchange. Therefore, careful planning is required to provide effective and safe postoperative analgesia. Unless specific contraindications exist, the use of non-opioid analgesics can be optimized in this group of patients.

However, severe postoperative pain may not be adequately controlled with just these agents. Epidural opioids have a lesser effect on pulmonary function than do systemic opioids (Bromage, Campoersi, and Chestnut, 1980). Other regional anesthetic techniques can also be applied in this setting as a way to lower the dosage of systemic opioids required for satisfactory postoperative analgesia. If epidural analgesia cannot be used, small doses of opioids given frequently, continuous infusion, or PCA may provide smoother control of pain with less impact on respiratory effort at the time of peak effect. Whichever method is used to administer systemic opioids, a low initial dose is recommended; later doses can then be titrated to the desired effect. Appropriate monitoring of respiratory rate and effort and adequacy of gas exchange is necessary. Oximetry may be useful in selected cases.

Neurologic disorders can influence postoperative pain management if they: 1) produce weakness of the respiratory muscles (e.g., amyotrophic lateral sclerosis, poliomyelitis); 2) impair alertness and mental function so that the sedative effects of opioids are exaggerated, and pain cannot be assessed easily; and 3) cause seizures requiring use of chronic anticonvulsant medications that may interact with analgesics. The first two circumstances have been addressed in the discussion above and other sections of this Guideline. Phenytoin, a very commonly used anticonvulsant, increases the biotransformation of meperidine, causing faster elimination and necessitating increased doses of this analgesic (Foley, and Inturrisi, 1987).

Patients with psychiatric illnesses taking anxiolytics or other psychoactive drugs must be carefully evaluated for drug interactions between the psychotropic and pain medications they take. Because both opioids and psychotropic drugs generally have sedative effects, it is not uncommon for these effects to be additive when the drugs are combined. Further, the tricyclic antidepressants, clomipramine and amitriptyline, may increase morphine levels as measured by an increase in bioavailability and the half-life of morphine (Ventafridda, Ripamonti, DeConno, Bianchi, Pazzuconi, and Panerai, 1987). Of particular importance is avoiding meperidine in patients receiving monoamine oxidase inhibitors. Severe adverse reactions, including death through mechanisms that mimic malignant hyperthermia, have been reported when these drugs have been used together (Armstrong, and Bersten, 1986 ; Foley, and Inturrisi, 1987).

Patients treated with drugs for cardiovascular and metabolic disease frequently must continue their drugs throughout the intra- and postoperative period. Fortunately, severe interactions between these drugs and opioids are unlikely.

Alcoholics who must have surgical procedures should be maintained on benzodiazepines or alcohol throughout the intra- and postoperative period to prevent a withdrawal reaction or delirium tremens.

Clinicians must remain aware that patients in the categories discussed in this section may not respond as expected to medications administered for symptom control following surgery. Careful assessment and reassessment of patients' responses to analgesics and dose titration to response are always necessary. The concomitant use of nonpharmacological treatments as adjunctive therapy of postoperative pain is also strongly recommended.

Patients with Shock, Trauma, and Burns

Victims of injury frequently present in a state of cardiovascular or respiratory instability that mandates immediate life-saving procedures (e.g., endotracheal intubation, defibrillation, cut-down, and chest tube insertion) without analgesia. The trauma patient is usually young (58.4%), frequently male (72.8%), and commonly (51.2%) has used alcohol or drugs prior to injury (Soderstrom, Trifillis, Shankar, Clark, and Cowley, 1988).

Beecher (1959) was the first to point out the difficulties in providing analgesia via the intramuscular route following a significant burn or injury. He noted the variability in absorption from site to site and prolonged absorption times in soldiers with shock. He also provided the basis for modern-day pain control after burns or injuries by suggesting the exclusive use of the intravenous route. Most authorities now recommend incremental small intravenous doses of an opioid analgesic (morphine) carefully titrated to cardiovascular and respiratory stability. Concern for cardiorespiratory instability is particularly important in the first hour after injury. Any analgesic therapy also must allow for continuous monitoring of neurologic status after a head injury and neurovascular status after limb injury.

Once the patient is resuscitated and requires definitive surgical procedures, analgesia should be provided as outlined in this guideline for the various operative sites. The use of NSAIDs in the trauma patient remains controversial. They are undoubtedly of value in the patient with minor trauma, but the risk of excessive bleeding and gastric stress ulcers may prohibit their use following closed head injury, burn injury, or other multisystem injuries. When not contraindicated by sepsis, coagulopathy, or cardiorespiratory instability, the use of regional anesthetic approaches may be beneficial as described earlier for particular operative sites. For example, discomfort and splinting due to flail chest injury may improve with epidural analgesia, and borderline perfusion of an injured limb can increase with a sympathetic blockade by an epidural local anesthetic. On the other hand, surgical evaluation must always take priority over analgesic titration in the face of sudden increases in pain (e.g., extremity swelling) or somnolence (e.g., from an expanding subdural hematoma).

The serious burn injury will require very special pain control after the initial resuscitation. The myth that "third degree burns don't hurt" unfortunately still serves as a basis for widespread institutional denial of pain assessment and treatment for burned patients (Atchison, Osgood, Carr, and Szyfelbein, 1991). Pain control is essentially absent from current reviews of burn management, scientific programs of national burn associations, or funding agendas of the Federal government or major private burn treatment organizations, much as pediatric pain and cancer pain were a decade ago. In reality, after a brief (hours-long) period of endogenous analgesia evoked by the stress of immediate burn injury, pain is often severe and intermittently excruciating for months during burn dressing changes, skin grafts, reconstructive surgery, or other interventions related to needs for prolonged ventilation or intravascular access. Nonviable, insensate tissue is always surrounded by regenerating areas from which pain may arise, considering that viable perfused tissue typically forms the inner margin of an excision. Altered pharmacokinetics and pharmacodynamics in the burn patient, who may be intubated, splinted, and unable to articulate pain, further combine to render pain management an individualized challenge. The almost universal presence of hypotension and vasodilation with or without sepsis generally precludes the use of spinal or epidural routes for pain control until the burn wound is closed. While some authors have described analgesic regimens for burn dressing changes that call for nonnarcotic analgesics, such as ketamine or nitrous oxide, these approaches are best reserved for unusual or refractory instances because of side effects such as dysphoria (Dripps, Eckenhoff, and Vandam, 1982) or bone marrow depression (Skacel, Hewlett, Lewis, Lamb, Nunn, and Chanarin, 1983), respectively. More typically, high doses of opioids are required to bring pain under control. Even then, there may be pain that is relatively refractory to opioid use, particularly if the burn site is deep or extensive. A morphine infusion alone is inadequate to produce anesthesia, such as for operative procedures or prolonged ventilation, since awareness often persists. Recent clinical studies suggest that damage to underlying nerves may account for the opioid-resistant quality of pain after severe burns (Choiniiere, Melzack, and Papillon, 1991 ; Atchison, Osgood, Carr, and Szyfelbein, 1991), and that the continuous infusion of low doses of lidocaine -- known to lessen neuropathic pain in other settings -- may be a useful analgesic option in patients with burns (Jonsson, Cassuto, and Hanson, 1991). For these reasons, and also because fear and anxiety are an almost universal response to burn injury and trauma of any kind, sedatives such as benzodiazepines are useful to supplement opioid analgesics. In addition, cognitive-behavioral strategies such as relaxation, imagery, and hypnosis have been described by burn survivors as very helpful. The large full-thickness burn with its consequences of pain, separation from family and job, and (frequently) disfigurement, is usually accompanied by depression that may require drugs and, in turn, influence analgesic effects.

Patients Who Have Procedures Outside of the Operating Room

Thousands of patients undergo painful procedures each day outside of operating rooms in emergency departments, clinics, wards, and intensive care units. Analgesia issues outside the operating room also broadly apply to patients who have ambulatory surgical procedures, after which same-day discharge is expected. In any of the above settings, many procedures can be safely performed under local infiltration or regional anesthesia or by adopting behavioral, nondrug strategies, but systemic analgesia is often required to provide optimal pain control.

Only when immediate treatment of cardiorespiratory instability is required, or if a competent patient declines treatment, should analgesia be withheld for a painful procedure. The presence of a condition that could eventually result in cardiovascular, hemodynamic, neurologic, or pulmonary instability (e.g., femur fracture, pneumothorax, skull fracture) is not an absolute contraindication to systemic analgesia, although careful titration and monitoring must be provided. Though pain control may not be needed for certain procedures (e.g., diagnostic computerized imaging, intravenous pyelogram, or ultrasound examination), providing analgesia is likely to enhance the accuracy of these studies by reducing patient writhing or restlessness because of pain.

No anesthetic or analgesic agent should be used unless the clinician understands the proper technique of administration, dosage, contraindications, side effects, and treatment of overdose. As described earlier, the intravenous route is the preferred delivery mode because of its rapid onset and easy and reliable dosing. Using an intravenous route sidesteps the pain and the unpredictable absorption, onset, and duration of action associated with intramuscular or subcutaneous injections. An intravenous cannula may be placed painlessly following intradermal injection of 1 ml of 1-2% lidocaine through a 27-30 gauge needle. Most often, intravenous titration of an opioid like morphine, with observation for 5-10 minutes between doses, will provide safe and adequate analgesia. Intravenous morphine doses may range from 1 to 10 mg depending on the age, weight, pain intensity, opioid tolerance, and nature of the procedure to be done. Dose titration must be continued throughout the procedure, since pain may break through, for example, during reduction of a joint or vigorous probing of an abscess.

Contraindications to opioid analgesia include altered sensorium, lung disease, pregnancy near term, or an inability to monitor and manage side effects such as respiratory depression in the setting where care is given. Since respiratory depression is strongly correlated with the degree of sedation, stimulation of the patient as well as the administration of small doses of naloxone (e.g., 0.04 mg), may be adequate to reverse mild degrees of hypoventilation. Of course, assisted ventilation by bag and mask, or (ultimately) endotracheal intubation and repetitive naloxone dosing, may be required to reverse more severe degrees of respiratory depression. If such respiratory depression does occur, the patient should be observed until well after the naloxone effect has worn off (usually after 1 hour). Nausea, bradycardia, and hypotension are other side effects to watch for in the clinic, ward, or emergency department.

Other opioids may be used in place of morphine. Meperidine is suitable for brief, titrated dosing but not for prolonged use. Fentanyl may be used in small doses (25 [mu]g increments in the above example) but carries a higher risk than morphine or meperidine of inducing chest wall rigidity that must be immediately managed by administering a quick-onset muscle relaxant and supporting ventilation. Apart from chest wall rigidity, any opioid may trigger an acute Parkinson's-like syndrome particularly in the elderly or in patients with Parkinson's disease under medical therapy. Some mixed agonist- antagonists have the advantage that they produce lesser degrees of biliary or ureteral smooth muscle spasm, but they also may precipitate a withdrawal syndrome in patients habituated to opioid agonists such as methadone or heroin (or in other patients taking opioids for chronic pain).

NSAIDs currently have a limited role in the management of pain during brief, painful procedures, but two other nonnarcotic agents have proven useful when administered in monitored settings by trained personnel. Intravenous ketamine has a rapid onset of action and produces a state of conscious sedation in which patients respond to verbal commands and maintain airway reflexes but experience analgesia. Possible side effects include dysphoria, tachycardia, increased salivary and tracheal secretions, and myocardial ischemia in patients with preexisting cardiac disease. Inhalation of a nitrous oxide:oxygen mixture can provide prompt anxiolysis and moderate analgesia. As a precaution, the patient should breathe through a face mask that he or she is holding, so that the mask will drop away if the patient becomes somnolent. Appropriate precautions should be taken to prevent environmental contamination with nitrous oxide (i.e., scavenging system), to avoid the possible inhalation of pure nitrous oxide without oxygen, and to withhold nitrous oxide in cases of altered sensorium, entrapped air such as pneumothorax or pulmonary blebs, bowel obstruction, air embolism, chronic pulmonary disease, or suspected decompression sickness.

Benzodiazepines may be valuable adjuncts to opioids in this setting. Although they lack analgesic properties for treatment of pain due to acute tissue injury, benzodiazepines diminish skeletal muscle spasm (e.g., during orthopedic reduction), reduce anxiety, and in higher doses, provide amnesia. Coadministration of an opioid and a benzodiazepine carries a substantially higher risk of inducing respiratory depression than administration of either drug individually, so particular vigilance is necessary. Typically, in a 70-kg adult, midazolam is used in incremental doses of 1 mg intravenously. Other agents such as phenothiazines (as antiemetics) or antihistamines (because of their weak sedative, and analgesic properties) are useful in individual cases.

Regardless of the analgesic or adjuvant given, patients should be monitored closely according to institutional standards. Such standards may include continuous observation of the electrocardiogram, frequent recording of heart rate, blood pressure, and respiratory rate, and pulse oximetry. Considering the risks associated with opioid, benzodiazepine, and other analgesic use, patients should not be left unattended between successive doses of these agents and should be watched for at least 30 minutes after the completion of outpatient procedures for which intravenous analgesia has been provided. In a transient care setting, patients should not be discharged until they are awake and can converse and ambulate. Once discharged they should be accompanied by an adult for at least two half-lives of the agents used (e.g., at least 6 hours for morphine) and should be advised not to drive an automobile or operate dangerous machinery until it is likely that all medication effects are resolved (usually 24-48 hours). Documentation of monitoring during the procedure, observation prior to discharge, and discharge instructions should be part of the patient's permanent record.

At any site where painful procedures may be performed, equipment should be available to promptly treat any untoward effects of the analgesics selected. Apart from monitoring devices, such equipment includes supplemental oxygen, devices to maintain airway patency (e.g., oral, and nasal airways, face masks, endotracheal tubes, laryngoscopes, and a bag-valve device), suction, drugs for resuscitation (e.g., atropine, naloxone), and a defibrillator. Most important, there must be present on site a physician or other provider skilled in resuscitation, particularly airway management.

General Terms

AHCPR: : Agency for Health Care Policy and Research; Federal agency established in 1989.

Best evidence synthesis: : Evidence based on the best evidence principle as used in law, in which the same evidence that would be essential in one case might be disregarded in a second case because better evidence becomes available.

Case study design: : A nonexperimental study that extensively explores a single unit (a unit may be a person, family, or group) or a very small number of units.

Descriptive study: : A nonexperimental study in which variables or subject characteristics are examined as they naturally occur for the purpose of describing or comparing samples or examining relationships among a set of variables.

Experimental study: : (Randomized controlled trial or randomized clinical trial) An experiment that uses random assignment to create treatment and control groups so that changes can be inferred or attributed to the experimental treatment.

Meta-analysis: : The process of combining the results of several related studies to obtain more reliable conclusions.

Peer review: : Evaluation of the present guideline document by an interdisciplinary panel of experts using the Institute of Medicine (Field and Lohr, 1990) attributes of clinical practice guidelines as evaluation criteria.

Pilot review: : Review and testing of the present guideline by clinicians to evaluate aspects of the guideline such as clarity, clinical applicability, flexibility, resource utilization, training needs, and cost of guideline implementation. Review of a consumer version of the present guideline by consumers and clinicians to evaluate its clarity, usefulness, flexibility, and accuracy.

Quasi-experimental study: : (Includes nonrandomized controlled trial or nonrandomized clinical trial) A design that does not use random assignment to create treatment and control groups but uses other methods to control validity threats so that changes can be inferred or attributed to the experimental treatment.

Scientific review: : An exhaustive literature search to define and critically evaluate the knowledge base for pain assessment and interventions.

Pain Physiology

Anxiolysis:: Sedation or hypnosis used to reduce anxiety, agitation, or tension.

Neuropathic pain:: Pain that arises from a damaged nerve.

Nociception:: The process of pain transmission; usually relating to a receptive neuron for painful sensations.

Pain:: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Pain threshold level:: The level of intensity at which pain becomes appreciable or perceptible.

Nonpharmacologic Management

Acupuncture:: The piercing of specific body sites with needles to produce pain relief.

Counterirritant:: An agent that is applied to produce irritation at one site so as to decrease perception of pain at the same or a distant site.

Cryoanalgesia:: The destruction of peripheral nerves by extreme cold to achieve prolonged pain relief.

Cryotherapy:: The therapeutic use of cold to reduce discomfort, limit progression of tissue edema, or break a cycle of muscle spasm.

Patient education:: Providing the patient with an explanation of perioperative procedures, expected postoperative sensations, and instruction to help decrease mobility-related discomfort.

Relaxation methods:: A variety of techniques to help decrease anxiety and muscle tension; these may include imagery, distraction, and progressive muscle relaxation.

Tactile strategies:: Strategies that provide comfort through the sense of touch, such as stroking or massage.

TENS (transcutaneous electrical nerve stimulation):: A method of producing electroanalgesia through electrodes applied to the skin.

Pain Assessment

Conscious sedation:: "Light sedation" during which the patient retains airway reflexes and responses to verbal stimuli.

Oximetry:: Determination of the oxygen saturation of arterial blood, typically by means of an external probe applied around a finger or toe.

Paradoxical reaction:: A response (e.g., to a drug) that is the opposite of the usual response, such as agitation produced in a individual patient by a drug normally considered to be a sedative.

Pharmacologic Management

EMLA (eutectic mixture of local anesthetic):: An ointment that contains local anesthetics so that topical application causes local anesthesia without the need for injection.

Epidural:: Situated within the spinal canal, on or outside the dura mater (tough membrane surrounding the spinal cord); synonyms are "extradural" and "peridural."

Equianalgesic:: Having equal pain killing effect; for example, morphine sulfate 10 mg intramuscular is generally used for opioid analgesic comparisons.

Interpleural:: Situated between the membrane surrounding the lungs and the membrane lining the thoracic cavity.

Intrathecal:: Within a sheath (e.g., cerebrospinal fluid that is contained within the dura mater).

Local nerve block:: Infiltration of a local anesthetic around a peripheral nerve so as to produce anesthesia in the area supplied by the nerve.

Mixed opioid agonist-antagonist:: A compound that has an affinity for two or more types of opioid receptors and blocks opioid effects on one receptor type while producing opioid effects on a second receptor type.

NSAID (nonsteroidal anti-inflammatory drug):: Aspirin-like drug that reduces pain and inflammation arising from injured tissue.

Opioid agonist: : Any morphine-like compound that produces bodily effects including pain relief, sedation, constipation, and respiratory depression.

Opioid partial agonist: : A compound that has an affinity for and stimulates physiological activity at the same cell receptors as opioid agonists but that produces only a partial (i.e., submaximal) bodily response.

PCA (patient controlled analgesia): : Self-administration of an analgesic by a patient instructed in doing so; usually refers to self-dosing with intravenous opioid (e.g., morphine) administered by means of a programmable pump.

Peridural: : Synonym for epidural and extradural.

Perineural: : Surrounding a nerve.

References

• Cook, T.D. & Campbell, D.T. (1979). Quasi-experimentation: Design and analysis issues for field settings. Chicago: Rand McNally College Publishing Co.

• Field, M.D. & Lohr, K.N. (Eds.). (1990). Clinical practice guidelines: Directions for a new program. Committee to Advise the Public Health Service on Clinical Practice Guidelines, Institute of Medicine. Washington: National Academy Press.

• International Association for the Study of Pain. (1979). Pain terms: A list with definitions and notes on usage. Pain, 6, 249.

Methods Used to Develop Clinical Practice Guideline

Three processes were used for the development of the guideline. First was an extensive interdisciplinary clinical review of current needs, therapeutic practices and principles, and emerging technologies for postoperative pain control. This process included review of all pertinent guidelines and standards, receipt of information and opinion from external consultants, a commissioned paper on the ethical aspects of postoperative pain management, an open forum to receive input from concerned parties, and extensive discussion among the panel members.

The second process was a comprehensive review of published research on management of acute postoperative pain and, to a lesser extent, pain associated with trauma and procedure-induced pain. The panel determined that the review should include research related to pain assessment and both pharmacologic and nonpharmacologic treatments. The panel was particularly interested in the effects of the interventions on pain, complications, patient satisfaction, length of stay, and treatment costs.

Articles selected for review were (1) published empirical studies of pain in adults and children after elective and nonelective surgery, pain associated with diagnostic and treatment procedures, and pain associated with post-traumatic injuries and burns; (2) research based articles on measurement and assessment of pain; (3) pain management guidelines; and (4) review articles.

Articles excluded from review included: reports of animal studies and surgical interventions outside the scope of interventions accessible to specialized pain treatment teams or primary caregivers, studies of chronic benign or malignant pain except when also relevant to postoperative or procedural pain, studies comparing within-class analgesic potencies, descriptions of basic pain mechanisms except where specific clinical interventions were tested, editorials and commentaries, discussions of the etiology of pain, studies written in non-English languages, discussions of psychological characteristics, and pure dose-efficacy studies.

The literature review was done at sites in Boston (Harvard University and Massachusetts General Hospital), Baltimore (University of Maryland and The Johns Hopkins University), and Denver (University of Colorado). A group at the School of Public Health, Harvard University performed meta-analyses of drug and TENS studies. Nondrug studies were reviewed at the Baltimore and Denver sites.

The search strategy was developed in conjunction with the National Library of Medicine (NLM). Twelve databases were searched, producing a list of approximately 2,400 drug citations and 2,750 nondrug citations; additional citations were retrieved through other sources, for example another 4,314 nondrug and pain assessment citations and 42 drug citations were obtained from bibliographies of review articles, annotated bibliographies, and the like. From these, approximately 600 drug studies and 500 non-drug articles were reviewed and coded for analysis. Using a best evidence synthesis, the research relevant to particular aspects of pain management was summarized and analyzed. Best- evidence synthesis is based on the best-evidence principle as used in law, in which the same evidence that would be essential in one case might be disregarded in another because better evidence is available (Slavin, 1986). When possible, meta- analyses were performed on the randomized controlled trials. The evidence used for recommendations regarding various interventions in adults is summarized in appendix B (Summary Table of Scientific Evidence for Interventions to Manage Pain in Adults). The table includes the intervention, the type of evidence, and comments regarding use of the intervention.

The third process was peer review of drafts of the guideline and pilot review with intended users. Thirty-three experts in various aspects of pain management reviewed and commented on an early draft of the guideline, using as a framework for their evaluation the attributes of clinical practice guidelines developed by the Institute of Medicine (IOM) of the National Academy of Sciences (Field and Lohr, 1990). Nine additional experts in pain management or practice guideline development reviewed a later draft, using the IOM attributes of guidelines and methods suggested by the Agency for Health Care Policy and Research (AHCPR). Nine additional experts in pain management in children reviewed the section of the guideline on neonates, infants, and children. Pilot review of a later draft was done with physicians, nurses, and others (n = 151) involved in pain management at 15 clinical sites. They reviewed and commented on the clarity, clinical applicability, flexibility, resources or training needed to implement the guideline, and cost implications of the guideline if implemented. A consumer version was developed and tested in clinical sites with 54 patients and 62 nurses and physicians, who reviewed it for clarity and accuracy.

Health policy issues related to ethical, economic, and legal aspects of postoperative pain management were addressed by the panel in several ways. A paper was commissioned on the ethical aspects of postoperative pain management, and the legal implications of pain management were addressed through the limited information available in the literature.

The entire process was anchored by an interdisciplinary panel of experts who used an integrated approach to synthesize the scientific evidence with the knowledge of experts to develop the guideline. Prior to printing of this guidance, drug dosage tables were reviewed by the U.S. Food and Drug Administration. The panel recommends that the guideline be updated 2 years after its publication.

References

• Field, M.D. & Lohr, K.N. (Eds). (1990). Clinical Practice Guidelines: Directions for a New Program. Committee to Advise the Public Health Service on Clinical Practice Guidelines, Institute of Medicine. Washington: National Academy Press.

• Slavin, R.E. (1986). Best-evidence synthesis: An alternative to meta- analytic and traditional reviews. Educational Researcher, 15, 5-11.

Summary Table of Scientific Evidence for Interventions to Manage Pain in Adults

B1. Pharmacologic Interventions

B1. Pharmacologic Interventions

Intervention [1]		Type of Evidence [2]	Comments
NSAIDs	Oral (alone)	Ib, IV	Effective for mild to moderate pain. Begin preoperatively. Relatively contraindicated in patients with renal disease and risk of or actual coagulopathy. May mask fever.
	Oral (adjunct to opioid)	Ia, IV	Potentiating effect resulting in opioid sparing. Begin pre-op. Cautions as above.
	Parenteral (ketorolac)	Ib, IV	Effective for moderate to severe pain. Expensive. Useful where opioids contraindicated, especially to avoid respiratory depression and sedation. Advance to opioid.
Opioids	Oral	IV	As effective as parenteral in appropriate doses. Use as soon as oral medication tolerated. Route of choice.
	Intramuscular	Ib, IV	Has been the standard parenteral route, but injections painful and absorption unreliable. Hence, avoid this route when possible.
	Subcutaneous	Ib, IV	Preferable to intramuscular when a low-volume continuous infusion is needed and intravenous access is difficult to maintain. Injections painful and absorption unreliable. Avoid this route for long-term repetitive dosing.
	Intravenous	Ib, IV	Parenteral route of choice after major surgery. Suitable for titrated bolus or continuous administration (including PCA), but requires monitoring. Significant risk of respiratory depression with inappropriate dosing.
Opioids	PCA (systemic)	Ia, IV	Intravenous or subcutaneous routes recommended. Good steady level of analgesia. Popular with patients but requires special infusion pumps and staff education. See cautions about opioids above.
	Epidural & intrathecal	Ia, IV	When suitable, intrathecal provides good analgesia. Significant risk of respiratory depression, sometimes delayed in onset. Requires careful monitoring. Use of infusion pumps requires additional equipment and staff education. Expensive if infusion pumps are employed.
Local anesthetics	Epidural & intrathecal	Ia, IV	Limited indications. Effective regional analgesia. Opioid sparing. Addition of opioid to local anesthetic may improve analgesia. Risks of hypotension, weakness, numbness. Requires careful monitoring. Use of infusion pump requires additional equipment and staff education.
	Peripheral nerve block	Ia, IV	Limited indications and duration of action. Effective regional analgesia. Opioid sparing.

[1] Selected references are included in this Clinical Practice Guideline. More complete references are available; see Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical Procedures and Trauma. Guideline Report. AHCPR Pub. No. 92-0022. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. In press.

[2] See type of evidence key following B2, page 107.

B2. Nonpharmacologic Interventions

B2. Nonpharmacologic Interventions

Intervention [1]		Type of Evidence [2]	Comments
Simple relaxation (begin preoperatively)	Jaw relaxation Progressive muscle relaxation Simple imagery	Ia, IIa, IIb, IV	Effective in reducing mild to moderate pain and as an adjunct to analgesic drugs for severe pain. Use when patients express an interest in relaxation. Requires 3-5 minutes of staff time for instructions.
	Music	Ib, IIa, IV	Both patient-preferred and "easy listening" music are effective in reducing mild to moderate pain.
Complex relaxation (begin preoperatively)	Biofeedback	Ib, IIa, IIb, IV	Effective in reducing mild to moderate pain and operative site muscle tension. Requires skilled personnel and special equipment.
	Imagery	Ib, IIa, IV	Effective for reduction of mild to moderate pain. Requires skilled personnel.
Education/instruction (begin preoperatively)		Ia, IIa, IIb, IV	Effective for reduction of pain. Should include sensory and procedural information and instruction aimed at reducing activity related pain. Requires 5-15 minutes of staff time.
TENS		Ia, IIa, III, IV	Effective in reducing pain and improving physical function. Requires skilled personnel and special equipment. May be useful as an adjunct to drug therapy.

[1] Selected references are included in this Clinical Practice Guideline. For more complete references, see: Acute Pain Management Guideline Panel. Acute Pain Management: Operative or Medical Procedures and Trauma. Guideline Report. AHCPR Pub. No. 92- 0022. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. In press.

[2] Insufficient scientific evidence is available to provide specific recommendations regarding the use of hypnosis, acupuncture, and other physical modalities for relief of postoperative pain.

Type of Evidence—Key

Type of Evidence—Key

Ia	Evidence obtained from meta-analysis of randomized controlled trials.
b	Evidence obtained from at least one randomized controlled trial.
IIa	Evidence obtained from at least one well-designed controlled study without randomization.
b	Evidence obtained from at least one other type of well-designed quasi-experimental study.
III	Evidence obtained from well-designed nonexperimental studies, such as comparative studies, correlational studies, and case studies.
IV	Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.

Dosage Tables for Adult and Pediatric Patients

C1. Dosing Data for NSAIDs

C1. Dosing Data for NSAIDs

Drug	Usual adult dose	Usual pediatric dose[1]	Comments
Oral NSAIDs
Acetaminophen	650-975 mg q 4hr	10-15 mg/kg q 4 hr	Acetaminophen lacks the peripheral anti-inflammatory activity of other NSAIDs.
Asprin	650-975 mg q 4 hr	10-15 mg/dg q 4 hr[2]	The standard against which other NSAIDs are compared. Inhibits platelet aggregation; may cause postoperative bleeding.
Choline magnesium trisalicylate (Trilisate)	1000-1500 mg bid	25 mg/kg bid	May have minimal anti-platelet activity; also available as oral liquid.
Diflunisal (Dolobid)	1000 mg initial dose followed by 500 mg q 12 hr
Etodolac (Lodine)	200-400 mg q 6-8 hr
Fenoprofen calcium (Nalfon)	200 mg q 4-6 hr
Ibuprofen (Motrin, others)	400 mg q 4-6 hr	10 mg/kg q 6-8 hr	Available as several brand names and as generic; also available as oral suspension
Ketoprofen (Orudis)	25-75 mg q 6-8 hr
Magnesium salicylate	650 mg q 4 hr		Many brands and generic forms available
Meclofenamate sodium (Meclomen)	50 mg q 4-6 hr
Mefenamic acid (Ponstel)	250 mg q 6 hr
Naproxen (Naprosyn)	500 mg initial dose followed by 250 mg q 6-8 hr	5 mg/kg q 12 hr	Also available as oral liquid
Naproxen sodium (Anaprox)	550 mg initial dose followed by 275 mg q 6-8 hr
Salsalate (Disalcid, others)	500 mg q 4 hr		May have minimal anti-platelet activity
Sodium salicylate	325-650 mg q 3-4 hr		Available in generic form from several distributors
Parenteral NSAID
Ketorolac tromethamine (Toradol)	30 or 60 mg IM initial dose followed by 15 or 30 mg q 6 hr Oral dose following IM dosage: 10 mg q 6-8 hr		Intramuscular dose not to exceed 5 days

Note: Only the above NSAIDs have FDA approval for use as simple analgesics, but clinical experience has been gained with other drugs as well.

C2. Dosing Data for Opioid Analgesics

C2. Dosing Data for Opioid Analgesics

	Approximate equianalgesic		Recommended starting dose (adults more than 50kg body weight)		Recommended starting dose (children and adults less than 50kg body weight)[1]
	oral dose	parenteral	oral	parenteral	oral	parenteral
Opioid Agonist Drug
Morphine[2]	30 mg q 3-4 hr (around-the-clock dosing)	10 mg q 3-4 hr	30 mg q 3-4 hr	10 mg q 3-4 hr	0.3 mg/kg q 3-4 hr	0.1 mg/kg q 3-4 hr
	60 mg q 3-4 hr (single dose or intermittent dosing)
Codeine[3]	130 mg q 3-4 hr	75 mg q 3-4 hr	60 mg q 3-4 hr	60 mg q 2 hr (intramulcular/ subcutaneous)	1 mg/kg 3-4 hr [4]	Not recommended
Hydromophone[2] (Dilaudid)	7.5 mg q 3-4 hr	1.5 mg q 3-4 hr	6 mg q 3-4 hr	1.5 mg q 3-4 hr	0.06 mg/kg q 3-4 hr	0.015 mg/kg q 3-4 hr
Hydrocodone (in Lorcet, Lortab, Vicodin, others)	30 mg q 3-4 hr	Not available	10 mg q 3-4 hr	Not available	0.2 mg/kg q 3-4 hr [4]	Not available
Levorphanol (Levo-Dromoran)	4 mg q 6-8 hr	2 mg q 6-8 hr	4 mg q 6-8 hr	2 mg q 6-8 hr	0.04 mg/kg q 6-8 hr	0.02 mg/kg q 6-8 hr
Meperidine (Demerol)	300 mg q 2-3 hr	100 mg q 3 hr	Not recommended	100 mg q 3 hr	Not recommended	0.75 mg/kg q 2-3 hr
Methadone (Dolophine,others)	20 mg q 6-8 hr	10 mg q 6-8 hr	20 mg q 6-8 hr	10 mg q 6-8 hr	0.2 mg/kq q 3-4 hr [4]	0.1mk/kg q 6-8 hr
Oxycodone (Roxicodone, also in Percocet, Percodan, Tylox, others)	30 mg q 3-4 hr	Not available	10 mg q 3-4 hr	Not available	0.2 mg/kg q 3-4 hr [4]	Not available
Oxymorphone2 (Numorphan)	Not available	1 mg q 3-4 hr	Not available	1 mg q 2-3 hr	Not recommended	Not recommended
Opioid Agonist-Antagonist and Partial Agonist
Buprenorphine (Buprenex)	Not available	0.3-0.4 mg q 6-8 hr	Not available	0.4 mg q 6-8 hr	Not available	0.0004 mg/kg q 6-8 hr
Butorphanol (Stadol)	Not available	2 mg q 3-4 hr	Not available	2 mg q 3-4 hr	Not available	Not recommended
Nalbuphine (Nubain)	Not available	10 mg q 3-4 hr	Not available	10 mg q 3-4 hr	Not available	0.1 mg/kg q 3-4 hr
Pentazocine (Talwin, others)	150 mg q 3-4 hr	60 mg q 3-4 hr	50 mg q 4-6 hr	Not recommended	Not recommended	Not recommended

[Pain Assessment Tools]

D2. Initial Pain Assessment Tool

D2. Initial Pain Assessment Tool

Date _______________________________ Patient's Name ______________________ Age ___________ Room ____________ Diagnosis ____________________________ Physician_________________________ Nurse ____________________________ Location: Patient or nurse indicate site of pain. ____________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Intensity: Patient rates the pain. Scale used ________________________ Present: _______________________________________________________ Worst pain gets: _______________________________________________ Best pain gets: ________________________________________________ Acceptable level of pain: ______________________________________ Quality: (Use patient's own words, e.g. prick, ache, burn, throb, pull, sharp ____________________________________ ____________________________________ Onset, duration variations, rhythms: _________________________________ ______________________________________________________________________ Manner of expressing pain: ___________________________________________ ______________________________________________________________________ ______________________________________________________________________ What relieves the pain? ______________________________________________ ______________________________________________________________________ ______________________________________________________________________ What causes or increases the pain? ___________________________________ ______________________________________________________________________ ______________________________________________________________________ Effects of pain: (Note decreased function, decreased quality of life.) Accompanying symptoms (e.g. nausea) ____________________________ Sleep __________________________________________________________ Appetite _______________________________________________________ Physical activity ______________________________________________ Relationship with others (e.g. irratibility) ___________________ Emotions (e.g. anger, suicidal, crying) ________________________ Concentration __________________________________________________ Other __________________________________________________________ Other comments: ______________________________________________________ ______________________________________________________________________ Plan: ________________________________________________________________ ______________________________________________________________________

May be duplicated for use in clinical practice.

Used with permission from McCaffery, M. and Beebe, A. Pain: Clinical Manual for Nursing Practice. (1989). St. Louis: C.V. Mosby.

D3. Flow Sheet—Pain

D3. Flow Sheet—Pain

Patient ____________________________ Date _______________________________
* Pain rating scale used _________________________________________________
Purpose: to evaluate the safety and effectiveness of the analgesic(s).
Analgesic(s) prescribed: _________________________________________________
Time	Pain Rating	Analgesic	R	P	B	Level of Arousal	Other **	Plan & Comments

Relaxation Exercises

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