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Acute postoperative pain is common, occurring in more than 80% of patients, with approximately 75% of these having moderate, severe, or extreme pain. Postoperative pain relief is inadequate in more than half of patients, which can negatively affect quality of life, function, and functional recovery, as well as increasing the risks for postsurgical complications and persistent postsurgical pain.
The American Pain Society (APS), in collaboration with the American Society of Anesthesiologists, commissioned an evidence-based guideline on postoperative pain management to promote effective and safer postoperative pain management in children and adults. Topics include preoperative education, perioperative pain management planning, use of different pharmacologic and nonpharmacologic modalities, organizational policies and procedures, and transition to outpatient care.
The APS has released a new evidence-based clinical practice guideline that includes 32 recommendations related to postoperative pain management in children and adults.
The guideline is based on the findings of an interdisciplinary expert panel. The APS commissioned the panel with input from the American Society of Anesthesiologists, and the document was subsequently approved by the American Society of Regional Anesthesia and Pain Management.
Research shows that most surgical patients receive inadequate pain relief, which can increase the risks for prolonged postoperative pain, mood disorders, and physical impairment, said lead author Roger Chou, MD, Departments of Medicine and Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Pacific Northwest Evidence Based Practice Center, Portland.
A key recommendation in the guideline, published in the February issue of the Journal of Pain, is wider use of multimodal techniques, Dr Chou told Medscape Medical News.
"This means using different medications, for example opioids and nonopioid therapies such as non-steroidal anti-inflammatories (NSAIDs), gabapentin/pregabalin, ketamine, lidocaine, administered in different ways, for example, systemically or via neuraxial/peripheral regional anesthetic techniques, as well as medications and nonpharmacological therapies."
Multimodal strategies help achieve better pain relief while using lower doses of opioids and potentially fewer adverse effects, by affecting pain via different mechanisms of actions and pathways, added Dr Chou.
The recommendation on individualizing therapy is also critical, said Dr Chou. "The same strategy is not going to be ideal in all patients. For example, in patients who are already on long-term opioid therapy prior to surgery, managing their pain is not going to be the same as someone not on opioids."
The guideline was developed by a 23-member expert panel representing anesthesia, pain management, surgery, nursing, and other medical specialties. It is based on the panel's review of more than 6500 scientific abstracts and primary studies.
The panel rated each recommendation as strong, moderate, or weak and based each on the quality of the scientific evidence. Of the 32 recommendations, the panel rated only 4 as supported by high-quality evidence, and 11 recommendations were based on low-quality evidence. The guideline authors noted that there were "numerous research gaps."
In addition to using multimodal therapies, the 3 other strong recommendations with high-quality evidence included the following:
Strong recommendations with moderate-quality evidence included the following:
Despite low-quality evidence, the panel strongly recommended that clinicians carry out the following strategies:
For cognitive behavioral therapy, the panel had a "weak" recommendation based on moderate-quality evidence to consider this technique as part of a multimodal approach.
The panel found that there was insufficient evidence to recommend or discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments. For transcutaneous electrical nerve stimulation, the panel had a "weak" recommendation that clinicians consider this treatment.
As evidence increases on newer techniques for managing postoperative pain, it is important to incorporate these techniques into current practice to improve management of postoperative pain, said Dr Chou. He noted that the APS has not previously issued guidelines on management of postoperative pain and recognizes that this as an important area where evidence-based guidelines could help improve clinical practice.
Dr Chou has disclosed no relevant financial relationships.
J Pain. 2016;17:131-157.[1]