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surgical
available and considerable progress has been
achieved with respect to peripheral nerve blocks, adjunctive systemic pharmacotherapy, parenteral
local
actually increased from 1995 to 2012.46 The proportion of patients reporting moderate to extreme
surgical pain remained at approximately the same level
over that period.
In 1987, Liebeskind and Melzack wrote by any
reasonable code, freedom from pain should be a basic
human right limited only by our ability to achieve it, 7
yet the importance of adequate and effective surgical
pain management extends far beyond its humanitarian
role. Inadequate pain control has a wide range of undesirable physiologic and immunologic effects, is associated with poor surgical outcomes, increased
probability
of readmission, and adversely affects the overall cost of
care as well as patient satisfaction.
An initiative to define procedure-specific pain management protocols has been underway for some time
and
is producing valuable insights (www.postoppain.org).
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Vol. 80
Congress
was held on March 8 to 10, 2013 (Celebration,
FL) as
a launching initiative embarking on the
challenge of
evaluating current surgical pain management
paradigms
and to identify key components of best
practices.
The Importance of Effective Surgical Pain
Management
perfusion; hyperglycemia, hypercatabolic state, negative nitrogen balance, and tissue wasting; compromised immune function, increased stress response, and
increased risk of infection; hyperalgesia, resulting in
decreased ambulation, poor rehabilitation, and atelectasis; increased risk of pneumonia; central sensitization
and progression to chronic pain; and anxiety, depression, fear, impaired sleep, and demoralization.
The potential for progression of acute pain to
chronic pain is now well established but not widely
appreciated. Chronic pain is defined as pain and pain
disability that persists for more than 3 months after
surgery. Thus, one reason for underrecognition of the
progression of surgical pain to chronic pain may be its
occurrence several months after the actual surgery.
Certain surgical procedures such as amputation and
cardiothoracic surgery are associated with an especially
high rate of chronic pain (Table 1).12 Other risk factors
for development of persistent surgical pain include
psychological vulnerability (e.g., anxiety, depression),
preceding pain that has been present for 1 month or
more
before surgery, severe acute surgical paincommonly
resulting from suboptimal analgesiaand certain genetic factors to mention a few.
Given the wide range of clinical consequences of
acute pain, it is not surprising that severe surgical pain
is often associated with increased rates of hospital
readmission. The impact of pain (both financial and
negative postoperative patient profiles) on readmission
is illustrated well by data from same-day surgeries,
which constitute, by far, the majority of surgeries performed in the United States today. The most common
reason for readmission after same-day surgeries was
shown in 2002 and again in 2010 to be inadequately
controlled pain (Fig. 1).13, 14 When patients do not receive appropriate analgesia before hospital discharge or
are sent home without enough information, instructional
guidance, or medication to manage their pain, there is
an increased probability that they will return to the
physicians office, emergency department (ED), or
Procedure
Amputation
Coronary artery bypass surgery
Thoracotomy
Breast surgery (lumpectomy and
mastectomy)
Cesarean delivery
Inguinal hernia repair
Estimated
Incidence of
Chronic Pain
30%50%
30%50%
30%40%
20%30%
10%
10%
Estimated Incidence
of Chronic Severe
(disabling) Pain*
5%10%
5%10%
10%
5%10%
4%
2%4%
Number of Surgeries
in the United Statesy
159,000 (lower limb only)
598,000
Unknown
479,000
220,000
609,000
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Joshi et al.
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conclusions:
1) it is necessary to be more aggressive in
treating
acute pain because the risk of pain is often
greater than
the risk of the drugs used in management;
analgesic
agents should be adequately dosed to prevent or
halt
the pathophysiological cascade that can result in
acute
pain; 2) pain should be assessed and reassessed
regularly using only validated instruments; 3) patients
must
be taught and encouraged to report pain using an
appropriate instrument; and 4) all hospitals should
establish independent pain management plans with
clearly
defined lines of responsibility.
As was noted earlier, there have been major
advances in the understanding of pain and the
many diverse analgesic options since the development of
AHCPR guidelines; however, their broad
recommendations remain relevant more than 20 years later.
An important and significant barrier to
adequate
pain management is the underestimation of
potential
pain after various surgical procedures. A recent
study
found that some minor surgical procedures
that are
commonly performed in outpatient or short-stay
facilities such as laparoscopic cholecystectomy and
hemorrhoidectomy can often be associated with
a
greater degree of surgical pain than some of the
more
major surgical procedures.3 These
investigators
suggested that this phenomenon may be the
result of
physicians and nurses underestimating a
patients requirement for analgesic medication after minor
surgical procedures.
A procedure-specific approach to pain therapy
and
management was proposed by the Department of
Defense/Veterans Affairs.18 The resulting
guidelines
provided valuable direction because this group
adopted a highly systematic and evidence-based
approach
to assessing the treatment of surgical pain in the
military population. However, improved
understanding and
advances in scientific progress toward
pathophysiology
of pain that has occurred over the last decade
has not
permitted these guidelines to be updated since
2002.
The Joint Commission identified pain as the
fifth
vital sign and has emphasized that thorough
assessment of patients surgical pain should have
guideline
standards.19 These guidelines set target
pain scores
and have also penalized hospitals that fall
short of
those targets. Efforts to achieve these target
pain scores
have resulted in evidence of inappropriate and
overuse of opioids in addition to several studies
showing
an increase in opioid-related morbidity and
mortality
after introduction of the concept of pain as the
fifth
vital sign by the Joint Commission.2022 In
2012, the
Commission issued a Sentinel Event Alert
stating:
The Joint Commission recognizes that not all
pain
can be eliminated; therefore, our standards
provide
for goal-related therapy.23
Several specialty societies have also published independent pain management guidelines. For example,
the American Pain Society has now published six
editions of its Principles of Analgesic Use in the
Treatment of Acute Pain and Cancer Pain.24 Again in
2012, the American Society of Anesthesiologists released an update to its pain management practice
guidelines8 and emphasized that some of the principles of these guidelines have not been consistently
embraced.
A major shortcoming of some of the published existing guidelines is that they provide general recommendations that lack specificity for various surgical
interventions.25 In addition, the nature of surgery is
known to influence type, location, intensity, and duration of surgical/interventional pain as well as potential
complications (e.g., pulmonary or bowel dysfunction)
that may develop. Moreover, efficacy of different analgesics can often vary according to the surgery being
performed and the risk-to-benefit ratio for the many
differing analgesic techniques is also dependent on the
type of surgical procedure. In an effort to more comprehensively address this issue, the PROSPECT group,
a collaborative initiative involving both surgeons and
anesthesiologists, has begun the development and publication of an array of procedure-specific pain recom-
No. 3
mendations (www.postoppain.com).25
Perpetuation of the old paradigm for managing
surgical pain, systemic opioids, can reduce the many
newly developed and recent opportunities to benefit
from some of the evidence-based advances within
perioperative pain therapy. Although physicians today
have access to a broader range of analgesic agents and
pain treatment modalities, in many cases, there still
continues to be heavy reliance on traditional opioid
pain management therapy. In addition, concerns about
opioid side effects and risk of dependence can often
result in inadequate dosing of these agents or in certain
situations where concerned patients may not take them
at all.
Generally, there is an absence of organized acute
pain medicine services in many institutions. These
services have historically been based largely within
anesthesia departments, but economic obstacles encountered, particularly with respect to reimbursement,
has significantly curtailed their continued development.
However, in some hospital facilities, nurse practitioners
have taken over control of this function quite effectively.
Unfortunately, in many other hospitals, this service was
simply disbanded.
Under the existing treatment paradigm in far too
many healthcare facilities, pain often continues to be
managed in a reactionary manner at the end of surgical
procedures rather than preoperatively in a pre-emptive
manner (Fig. 3).26 A more proactive approach would
Joshi et al.
223
of 100, whereas the average pain score in patients receiving multimodal analgesia was higher
approximately
40 out of 100. However, epidural analgesia did not
offer any benefit to either time of oral intake or time to
ambulation, which were the more important outcome
measures for these patients. Therefore, it is essential to
focus attention on clinically relevant outcome measures such as quicker return of bowel and bladder
function, time to oral intake, time to ambulation, length
of hospital stay, readmission rate after discharge, ability
to take an active role in physical therapy, and an ability
to return to work more quickly.
Avoid/Limit Opioid Dose
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No. 3
Joshi et al.
225
NSAIDs can reduce surgical opioid analgesia requirements when given in conjunction
with an opioid analgesic
NSAIDs provide superior analgesic efficacy compared with opioid analgesia alone
NSAIDs should not be used in patients at high risk for either clotting or bleeding
d Because of an increased risk of serious cardiovascular thrombotic events, NSAIDs
should not be used in patients undergoing coronary artery bypass graft
d Mechanism of analgesic action of COX-2 selective inhibitors is similar to that of
NSAIDs
d There is no difference in analgesic efficacy of NSAIDs and COX-2 selective inhibitors
when used at equipotent doses
d Administration of a COX-2 inhibitor together with a opioid analgesic significantly
reduces pain compared with opioid analgesia alone
d No difference appears to exist between COX-2 inhibitors and placebo with respect to
intraoperative bleeding
d Acetaminophen is a viable alternative to NSAIDs with a low incidence of adverse
effects
d Combination of an NSAID or a COX-2 selective inhibitor and acetaminophen may
provide additional efficacy compared with either agent alone
d When administered preoperatively, oral absorption of acetaminophen can be reduced
by fasting and stress
d When administered post-surgically, oral absorption of acetaminophen can be reduced
by stress and opioids
d Intravenous acetaminophen has been associated with significant reductions in pain,
opioid use, surgical nausea and vomiting, and length of hospital stay
d A single-dose steroid should be recommended for the majority of patients unless
there
is a contraindication
d Steroids have anti-inflammatory properties and, theoretically, should decrease
central
and peripheral sensitization resulting from acute surgical pain
d Dexamethasone at 4 mg to 8 mg reduces decrease surgical nausea and vomiting as
well
as surgical pain
d Although dexamethasone increases blood sugar levels, the clinical relevance of that
increase is negligible
d There are very few data on the use of multiple doses of dexamethasone, and
administration of more than one dose is not prudent at this time
d Gabapentinoids are increasingly being used for management of surgical pain, and
they
are particularly beneficial in surgical procedures where there is a high probability of
prolonged, persistent pain
d Gabapentinoids reduce both pain and opioid requirements
d The benefits of gabapentinoid with respect to opioid-related side effects are not clear
d Gabapentinoids can also improve surgical sleep and anxiety
d Although it is known that a single dose of gabapentin is inadequate for the
management
of surgical pain, the optimal dose and duration has not been established
d Side effects of gabapentinoid include sedation and dizziness, which may delay
discharge, and these agents are not recommended for use in outpatient procedures
d Ketamine is a potent N-methyl-D-aspartate (NMDA) receptor antagonist that is
particularly effective when the level of surgical pain is expected to be severe (i.e.,
score
of 7 or greater on a scale of 1 to 10)
d At very low, subanesthetic doses, ketamine decreases surgical pain, opioid
requirements, and, in some cases, opioid-related side effects
d Low-dose ketamine can also prevent central sensitization and prevent or reverse
opioid
tolerance and opioid-induced hyperalgesia
d Patients who are on long-term opioids, and therefore at risk of developing opioid
tolerance, are good candidates for ketamine
d There appears to be a higher occurrence of hallucinations and nightmares in patients
for
whom ketamine is more efficacious; the risk:benefit profile of ketamine, with respect
to
dysphoria and hallucinations, not clear as yet
d These agents exert their analgesic effects within the central nervous system
d Dexmedetomidine provides effective sedation and analgesia of relatively short
duration
d The short duration of action of dexmedetomidine restricts its value for the
management
of postoperative pain
d Infusion of dexmedetomidine in the ICU can be beneficial
d Because of its side effect profile, clonidine has very limited use in surgical pain
d
d
Acetaminophen
Steroids
Gabapentinoids
Ketamine
a2 adrenoceptor agonists
(continued)
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March 2014
Vol. 80
TABLE 2. Continued
Analgesic
Regional nerve blockade
* This information represents an extensive analysis of the body of literature relating to the use of agents together
with the
clinical experience and judgment of individual Congress members.
COX, cyclo-oxygenase; ICU, intensive care unit.
implementing intravenous patient-controlled analgesia represent a complex challenge with respect to pain
management. There is a lack of data about optimal
or
surgical pain management in these individuals, so their
epidural analgesia;
Transfer between hospital services/locations: care tends to be based largely on the subjective views of
the healthcare providers. Concern about feeding the
Pain assessment should be a discharge
opioid addiction must not be allowed to prevent the
criterion;
Transition from intravenous patient-controlled patient from receiving adequate pain management.
Identification of patients who are opioid-dependent or
analgesia or epidural analgesia to oral
medication:
opioid-tolerant is a critical step followed by determining
Initiate oral medications before
what a patients total daily opioid dose may be and
discontinuation
whether they have experienced previous perioperative
of intravenous patient-controlled analgesia or
epidural; and
During physical therapy or movement of the
patient:
Administer additional analgesia through
most
noninvasive means available.
FIG. 5. Frequency of different pain intensities
(pain on movement) on the first postoperative day.32
Reprinted with permission from Oxford University
Press from Usichenko TI, Rottenbacher I, Kohlmann
T, et al. Implementation of the quality management
system improves postoperative pain treatment:
a prospective pre/postinterventional questionnaire
study. Br J Anesth 2013;110:8795.
No. 3
Joshi et al.
227
analgesic
gaps). A clear understanding of the patients
existing
drug use is essential, together with effective
communication and documentation, including a written
pain
management plan.
Develop Clinical Pathways Using a Procedure-specific
Approach
228
March 2014
Vol. 80
22. Smetzer JL, Cohen MR. Pain scales dont weigh every risk.
J Pain Palliat Care Pharmacother 2003;17:6770.
23. Safe use of opioids in hospitals. Sentinel Event Alert 2012;49:
15.
24. American Pain Society. Principles of Analgesic Use in the
Treatment of Acute Pain and Cancer Pain. 6th ed. Glenview, IL:
American Pain Society; 2008.
25. Kehlet H, Wilkinson R, Fischer HBJ, Camu F. on behalf of
the PROSPECT Working Group. PROSPECT: evidence-based,
procedure-specific postoperative pain management. Best Pract Res
Clin Anaesthesiol 2007;21:14959.
26. Sintra RS, Larach S, Ramamoorthy S. . Surgeons Guide to
Postsurgical Pain Management: Colorectal and Abdominal Surgery. West Islip, NY: Professional Communications, Inc.; 2012.
27. Joshi GP, Bonnet F, Kehlet H. PROSPECT Collaboration.
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28. Oderda G. Challenges in the management of acute surgical
pain. Pharmacotherapy 2012;32(suppl):6S11S.
29. Zhao SZ, Chung F, Hanna DB, et al. Doseresponse relationship between opioid use and adverse effects after ambulatory
surgery. J Pain Symptom Manage 2004;28:3546.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.