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A Guideline Update for Managing Acute Pain in Perioperative Settings

A Guideline Update for Managing Acute Pain in Perioperative Settings
Author Information (click to view)

Michael A. Ashburn, MD, MPH

Professor of Anesthesiology and Critical Care
Director, Penn Pain Medicine Center
Co-Director, Palliative Care
University of Pennsylvania Health System

Michael Ashburn, MD, MPH, has indicated to Physician’s Weekly that he has received grant funding from Pfizer, Cephalon, GW Pharma, AstraZeneca, Endo Pharmaceuticals, GlaxoSmithKline, and Medtronic, Inc. He has also served as a consultant to Teva (Cephalon), Cubist, Maruishi, and Vantia. In addition, he has served as a medical-legal consultant to Becton Dickinson and Teva (Cephalon) and was a co-founder and shareholder of ZARS Pharma.

Figure 2 (click to view)
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Michael A. Ashburn, MD, MPH (click to view)

Michael A. Ashburn, MD, MPH

Professor of Anesthesiology and Critical Care
Director, Penn Pain Medicine Center
Co-Director, Palliative Care
University of Pennsylvania Health System

Michael Ashburn, MD, MPH, has indicated to Physician’s Weekly that he has received grant funding from Pfizer, Cephalon, GW Pharma, AstraZeneca, Endo Pharmaceuticals, GlaxoSmithKline, and Medtronic, Inc. He has also served as a consultant to Teva (Cephalon), Cubist, Maruishi, and Vantia. In addition, he has served as a medical-legal consultant to Becton Dickinson and Teva (Cephalon) and was a co-founder and shareholder of ZARS Pharma.

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The American Society of Anesthesiologists has updated guidelines to assist physicians with preoperative evaluations and preparation. The guidelines also provide recommendations for perioperative and multimodal techniques for pain management.

Pain management is a critical component medical care for patients undergoing surgery, but studies suggest that up to 70% of individuals undergoing surgery complain of moderate-to-severe pain after their procedure. Under-treatment of perioperative pain can lead to unnecessary suffering, decreased physical and psychological health, and delays in patient recovery and hospital discharges. Proper pain care has the potential to reduce the risk of adverse events and to allow patients to actively participate in their recovery.

In the February 2012 issue of Anesthesiology, the American Society of Anesthesiologists (ASA) updated its practice guidelines for acute pain management in the perioperative period. The ASA update focused on adult and pediatric patients undergoing inpatient or outpatient surgery. “The new ASA recommendations update guidelines that were previously released in 2004,” says Michael A. Ashburn, MD, MPH, who served as chair of the ASA’s writing task force. “The document reflects the progress that has been made in acute pain management according to findings from clinical studies over the past several years as well as expert opinion.”

Providing High Quality Pain Care

To provide high quality pain care to surgical patients, the ASA recommends that a dedicated interdisciplinary team consisting of surgeons, nurses, pharmacists, anesthesiologists, pain specialists, and hospital administrators be assembled and included throughout the course of patient care. Furthermore, medical centers should develop institutional plans and foster an environment that allows for effective pain therapy.

“Effective and safe use of available treatment options within the institution are important,” explains Dr. Ashburn. “This requires effective patient education efforts that range from basic bedside pain assessments to sophisticated pain management techniques and non-pharmacologic techniques. Ongoing education and training are essential for all members of the multidisciplinary team. Having standardized, validated processes and instruments in place to facilitate the management of pain can have an important impact on pain care.”

Planning Ahead: Discussing Pain Treatment Options

The education and training of physicians and other healthcare providers has an important role in improving pain control and patient satisfaction. The ASA recommends that institutional plans should include a review of policies and procedures for providing perioperative pain management. “Anesthesiologists who offer perioperative analgesia services should collaborate with other healthcare professionals to establish ongoing education and training programs on the safe and effective use of pain treatment options,” Dr. Ashburn says.

There are also important steps during preoperative evaluation and preparation of patients that should be considered to mitigate pain management after surgery, according to Dr. Ashburn (Table 1). “In addition to conducting appropriate anesthetic preoperative evaluations and preparing patients for perioperative pain management, healthcare providers should offer patient and family education. Both parties have important roles in achieving pain relief and comfort.”

Perioperative Pain Treatment Decisions

The ASA guideline update notes that several treatment options are available to manage pain effectively, including central regional anesthetic techniques, patient-controlled analgesia, and epidural analgesia (Table 2). “It’s important to note that providers who are managing perioperative pain use therapeutic options after thoughtfully considering the risks and benefits for each individual patient,” says Dr. Ashburn. “Multimodal analgesia is recommended for use whenever possible because it can improve pain control while lowering the risk of adverse effects. This is especially important in patients who are at high risk for poorly-controlled pain, such those who are opioid-tolerant, and in those at high risk for adverse events, such as the elderly.

Careful attention should be paid to pain care for vulnerable patient populations, including those at the extremes of age, those with cognitive or communicative impairments, and those at increased risk for experiencing adverse effects or poorly-controlled pain. For these at-risk groups, the ASA guidelines provide assistance on effective strategies and treatment approaches. “The key for providers is to know the patient subpopulations that are at risk and to plan and prepare them accordingly,” Dr. Ashburn says. “The ASA practice guidelines can be used like a road map, especially in these difficult-to-treat patient groups. The recommendations are intended to guide physicians in how they care for their surgery patients postoperatively, but should not be viewed as a ‘one-size-fits-all’ document. Ultimately, an individualized approach is necessary to improve processes in pain care. When decisions are based on evidence rather than opinion, it’s more likely that patient outcomes after surgery will improve.”

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Readings & Resources (click to view)

American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116:248-273. Available at: http://www.asahq.org/publicationsAndServices/~/media/For%20Members/Practice%20Management/PracticeParameters/AcutePainManagementInThePerioperativeSetting.ashx.

American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2004;100:1573-1581.

Lam KK, Chan MT, Chen PP, Ngan Kee WD. Structured preoperative patient education for patient-controlled analgesia. J Clin Anesth. 2001;13:465-469.

Doering S, Katzlberger F, Rumpold G, et al. Videotape preparation of patients before hip replacement surgery reduces stress. Psychosom Med. 2000;62:365-373.

Griffin MJ, Brennan L, McShane AJ. Preoperative education and outcome of patient controlled analgesia. Can J Anaesth. 1998;45:943-948.

Pyati S, Gan TJ. Perioperative pain management. CNS Drugs.  2007;21:185-211

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