Paper #2: Research Utilization Paper (Research/Global Health)

PAIN MANAGEMENT

Postoperative Pain Management: Clinical Practice Guidelines

Maureen F. Cooney, DNP, FNP-BC

OVER THE PAST 2 decades, there has been an increased emphasis on the need for effective

management of acute pain. The focus on pain man-

agement was sharpened when the Joint Commis-

sion on Accreditation of Healthcare Organizations

integrated the requirement for pain assessment

and management into their standards in 2000.1

Acute postoperative pain, however, continues to

be inadequately controlled. Among patients who

have had surgical procedures, 80% experience

postoperative pain and 75% ormore of them report

pain that is at a moderate, severe, or extreme level.2

Inadequately treated acute pain is associated with

the risk for the development of persistent postsur-

gical pain.3,4 Poor pain control has significant physiological consequences that can ultimately

result in impaired recovery, decreased function,

and reduced quality of life.2,5

In recent years, the number and types of pharma-

cologic, interventional, and nonpharmacological

options to treat acute postoperative pain have

expanded. Many professional organizations, including the American Society of PeriAnesthesia

Nurses and American Society for Pain Management

Nursing have published guidelines and other doc-

uments related to the management of acute pain.

The American Society of Anesthesiologists (ASA)

published guidelines for perioperative pain man-

agement in 2012.6 In 2016, the American Pain So-

ciety (APS), with input from the ASA, and review and approval by the American Society of Regional

Anesthesia and Pain Medicine, published guide-

lines for the management of postoperative pain.

Maureen F. Cooney, DNP, FNP-BC, is a Nurse Practitioner,

Pain Management, Westchester Medical Center, Valhalla, NY.

Conflict of interest: None to report.

Address correspondence to Maureen F. Cooney, Westchester

Medical Center, Pain Management, Rm 2108 Macy Pavilion,

100 Woods Rd, Valhalla, NY 10595; e-mail address:

[email protected].

� 2016 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00

http://dx.doi.org/10.1016/j.jopan.2016.08.001

Journal of PeriAnesthesia Nursing, Vol 31, No 5 (October), 2016: pp 445-451

These guidelines are somewhat unique because,

in addition to recommendations for pharmacolog-

ical and nonpharmacological pain interventions,

they include recommendations for preoperative

education, perioperative pain management plan-

ning, organizational policies and procedures, and

transition to outpatient care.7 This article summa- rizes the development of the guidelines and high-

lights key recommendations with nursing

practice implications for the care of patients with

acute postsurgical pain.

Methodology for Guideline Development

Aguidelinepanelwas selectedby theAPS,with input from the ASA, and consisted of 23 multidisciplinary

experts representing specialists from fields that

included anesthesia, painmanagement, surgery, hos-

pital medicine, nursing, obstetrics and gynecology,

psychology, primary care, and physical therapy.

The panel was charged with the tasks of reviewing

the evidence related to postoperative pain manage-

ment and formulating recommendations for evidence-based, effective, safer postsurgical pain

management for adults and children.7 The Oregon

Evidence-Based Practice Center conducted an evi-

dence review that included literature searches

through December 2015.7,8 Upon completion of

the literature search, there were 107 systematic

reviews and an additional 858 primary studies in

the final evidence report.8 The quality of randomized trials was assessed using criteria adapted by the Co-

chrane Back Review Group.7,8 Two reviewers

from the Oregon Health Sciences Evidence center

independently reviewed and ranked the strength

(strong or weak) and quality of the evidence (high,

moderate, or low) using methods adapted from

the Grading of Recommendations Assessment,

Development, and Evaluation Working Group and the Agency for Healthcare Research and

Quality (AHRQ) Methods Guide for Effectiveness

and Comparative Effectiveness Reviews.7,8 A

strong recommendation indicates the reviewers’

assessment that the potential benefits of following

the recommendation clearly outweigh potential

445

446 MAUREEN F. COONEY

harms and burdens. A weak recommendation

indicates the reviewers’ assessment that benefits of

following the recommendation outweigh the

potential harms and burdens, but the benefits to

harms or burdens balance is smaller or evidence is weaker.7 The grade of the quality of evidence

(high, moderate, low) reflects the confidence level

of the reviewers that theevidence reflects the trueef-

fect and the likelihood that further research would

change the confidence in the estimate of effect.8

The grading of evidence and recommendations is

further detailed in the published guidelines.

Following the evidence review, the guideline panel drafted recommendations and engaged in a multi-

stage Delphi process to rank and revise the series

of the draft recommendation statements.7 Unani-

mous or near-unanimous consensus was achieved

for all recommendations.7 Subsequently, 20 external

peer reviewers provided additional comments on

the draft guidelines, which underwent an additional

revision and panel approval process.7 The finalized guidelineswere approved by the APSBoard ofDirec-

tors; the ASA’s Committee on Regional Anesthesia,

Executive Committee, and Administrative Council;

and the American Society of Regional Anesthesia

Board of Directors in 2015 and published in early

2016.7

Key Recommendations

Preoperative Education and Perioperative Pain Management Planning

The panel recommends:

1. Clinicians should provide patient- and

family-centered, individually tailored edu- cation to the patient (and/or responsible

caregiver), including information on treat-

ment options for management of postoper-

ative pain, and document the plan and

goals for postoperative pain management

(strong recommendation, low-quality evi-

dence).

2. Parents (or other adult caregivers) of chil- dren who undergo surgery receive instruc-

tion in developmentally appropriate

methods for assessing pain and counseling

on appropriate administration of analgesics

and modalities (strong recommendation,

low-quality evidence).

3. Clinicians conduct a preoperative evaluation

including assessment of medical and psychi-

atric comorbidities, concomitant medica-

tions, history of chronic pain, substance

abuse, and previous postoperative treatment

regimes and responses, to guide the periop- erative pain management plan (strong

recommendation, low-quality evidence).

4. Clinicians adjust the pain management plan

on the basis of adequacy of pain relief and

presence of adverse events (strong recom-

mendation, low-quality evidence).

Methods of Assessment

The panel recommends:

5. Clinicians use a validated pain assessment

tool to track responses to postoperative pain treatments and adjust treatment plans

accordingly (strong recommendation, low-

quality evidence).

General Principles Regarding the Use of Multimodal Therapies

The panel recommends:

6. Clinicians offer multimodal analgesia or the

use of a variety of analgesic medications

and techniques combined with nonpharma-

cological interventions for the treatment of

postoperative pain in children and adults (strong recommendation, high-quality evi-

dence).

Use of Physical Modalities

The panel recommends:

7. Clinicians consider transcutaneous electri-

cal nerve stimulation (TENS) as an adjunct

to other postoperative pain treatments

(weak recommendation, moderate-quality

evidence).

The panel:

8. Neither recommends nor discourages

acupuncture, massage, or cold therapy as ad-

juncts to other postoperative pain treat-

ments (insufficient evidence).

PAIN MANAGEMENT 447

Use of Cognitive Behavioral Modalities

The panel recommends:

9. Clinicians consider the use of cognitive

behavioral modalities in adults as part of a

multimodal approach (weak recommenda-

tion, moderate-quality evidence).

Use of Systemic Pharmacological Therapies

The panel recommends:

10. Oral over intravenous (IV) administration

of opioids for postoperative analgesia in pa-

tients who can use the oral route (strong

recommendation, moderate-quality evi-

dence).

11. Clinicians avoid using the intramuscular

route for the administration of analgesics

for management of postoperative pain (strong recommendation, moderate-

quality evidence).

12. IV patient-controlled analgesia (PCA) use

for postoperative systemic analgesia when

the parenteral route is needed (strong

recommendation, moderate-quality evi-

dence).

13. Against routine use of basal infusion of opioids with IV PCA in opioid-na€ıve adults (strong recommendation, moderate-

quality evidence).

14. Clinicians provide appropriate monitoring

of sedation, respiratory status, and other

adverse events in patients who receive sys-

temic opioids for postoperative analgesia

(strong recommendation, low-quality evi- dence).

15. Clinicians provide adults and children with

acetaminophen and/or nonsteroidal anti-

inflammatory drugs (NSAIDs) as part of

multimodal analgesia for management of

postoperative pain in patients without con-

traindications (strong recommendation,

high-quality evidence). 16. Clinicians consider giving a preoperative

dose of oral celecoxib in adult patients

without contraindications (strong recom-

mendation, moderate-quality evidence).

17. Clinicians consider use of gabapentin

or pregabalin as a component of multi-

modal analgesia (strong recommendation,

moderate-quality evidence).

18. Clinicians consider IV ketamine as a

component of multimodal analgesia in

adults (weak recommendation, moderate-

quality evidence). 19. Clinicians consider IV lidocaine infusions

in adults who undergo open and laparo-

scopic abdominal surgery who do not

have contraindications (weak recommen-

dation, moderate-quality evidence).

Use of Local and/or Topical Pharmacological Therapies

The panel recommends:

20. Clinicians consider surgical site-specific

local anesthetic infiltration for surgical pro-

cedures with evidence indicating efficacy

(weak recommendation, moderate-quality

evidence). 21. Clinicians use topical local anesthetics in

combination with nerve blocks before

circumcision (strong recommendation,

moderate-quality evidence).

The panel does not recommend:

22. Intrapleural analgesia with local anes-

thetics for pain control after thoracic sur- gery (strong recommendation, moderate-

quality evidence).

Use of Peripheral Regional Anesthesia

The panel recommends:

23. Clinicians consider surgical site-specific pe- ripheral regional anesthetic techniques in

adults and children for procedures with ev-

idence indicating efficacy (strong recom-

mendation, high-quality evidence).

24. Clinicians use continuous, local anesthetic-

based peripheral regional analgesic tech-

niques when the need for analgesia is

likely to exceed the duration of effect of a single injection (strong recommendation,

moderate-quality evidence).

25. Clinicians consider the addition of cloni-

dine as an adjuvant for prolongation of anal-

gesia with a single-injection peripheral

448 MAUREEN F. COONEY

neural blockade (weak recommendation,

moderate-quality evidence).

Use of Neuraxial Therapies

The panel recommends:

26. Clinicians offer neuraxial analgesia for ma-

jor thoracic and abdominal procedures,

particularly in patients at risk for cardiac

complications, pulmonary complications,

or prolonged ileus (strong recommenda-

tion, high-quality evidence).

27. Clinicians avoid the neuraxial administra-

tion of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine in

the treatment of postoperative pain (strong

recommendation, moderate-quality evi-

dence).

28. Clinicians provide appropriate monitoring

of patients who have received neuraxial in-

terventions for perioperative analgesia

(strong recommendation, low-quality evi- dence).

Organizational Structure, Policies, and Procedures

The panel recommends:

29. Facilities in which surgery is performed

have an organizational structure in place

to develop and refine policies and proced-

ures for safe and effective delivery of

postoperative pain control (strong recom-

mendation, low-quality evidence).

30. Facilities in which surgery is performed

provide clinicians with access to consulta- tion with a pain specialist for patients

with inadequately controlled postopera-

tive pain or at risk of inadequately

controlled postoperative pain (eg, opioid

tolerant, history of substance abuse)

(strong recommendation, low-quality evi-

dence).

31. Facilities in which neuraxial analgesia and continuous peripheral blocks are per-

formed have policies and procedures to

support their safe delivery and trained in-

dividuals to manage these procedures

(strong recommendation, low-quality evi-

dence).

Transitioning to Outpatient Care

The panel recommends:

32. Clinicians provide education to all patients

(adults and children) and primary care-

givers on the pain treatment plan including

tapering of analgesics after hospital

discharge (strong recommendation, low- quality evidence).

Perianesthesia Nursing Recommendations

Awareness of the content in the APS Guidelines in

the Management of Postoperative Pain7 is impor-

tant for nurses working in perianesthesia settings. A complete review of the article, along with a

focused examination of recommendations specific

to their roles, will provide valuable information.

Recommendations related to preoperative educa-

tion, pain assessment, multimodal therapies, use

of physical and cognitive behavioral modalities,

use of systemic, local, and/or topical pharmacolog-

ical therapies, use of peripheral regional anes- thesia and neuraxial therapies, and outpatient

care transitions have particular applicability to

the nurse in a direct care provider role. Some

specific content applicable to the practice of the

perianesthesia nurse is addressed in the following

paragraphs.

The guideline development panel members

recommend preoperative education and perioper- ative pain management planning, and cite studies

which show that educational programs individu-

ally designed for surgical patients with specific

medical, developmental, psychological, or social

needs have been found to reduce opioid consump-

tion, preoperative anxiety, requests for sedating

medications, and postoperative lengths of stay.7

There is no strong evidence to support the use of one educational intervention over another or the

timing and content of interventions. However, it

is recommended that content includes specific in-

formation related to analgesic use before surgery

(continuation, discontinuation, or changes) to

avoid withdrawal syndrome (such as is possible

with opioids, benzodiazepines, gabapentin, and

baclofen), prevent surgical complications (eg, aspirin and hemorrhage), and improve postopera-

tive pain control (eg, routine use of nonopioid

PAIN MANAGEMENT 449

analgesics).7 Preoperative education related to the

use of pain assessment tools, realistic pain goals,

and how and when to report pain is advised. It is

important to address specific pain-related expecta-

tions and misconceptions, and inform patients about the effects and possible adverse effects of

postoperative pain interventions. If patients will

be using postoperative devices and modalities

(eg, IV PCA), they/significant others should be in-

structed in the use of the modalities preopera-

tively. The pain management plan should be

developed preoperatively through shared

decision-making with the patient/parent/signifi- cant other, based on an assessment of the individ-

ual patient’s history, condition, needs, and risks.

The panel identifies the importance of an assess-

ment of substance use and abuse (opioids, benzo-

diazepines, cocaine, alcohol and other substances

that may affect pain management) to guide devel-

opment of the postoperative pain management

plan. The role of the perianesthesia nurse in assess- ing pain and patient responses to analgesic inter-

ventions is critical in assuring the re-evaluation

and adjustment of the pain management plan.

The panel emphasizes the importance of the use of

validated instruments to assess pain.7 Patient self-

report, not behaviors or vital signs, is the primary

basis of pain assessment. Behaviors and the input from caregivers are used to assess pain when the

patient cannot self-report. Pain should be assessed

during rest and activity. There are no clear recom-

mendations as to the optimal timing and frequency

of assessment, but after analgesic administration,

reassessment should occur by the time the medica-

tion reaches peak effect (15 to 30 minutes after

parenteral analgesics and 1 to 2 hours after oral agents).7

The use of multimodal analgesia, including phar-

macological and nonpharmacological interven-

tions, is recommended in the management of

postoperative pain. It is noted that a number of

different combinations of pharmacological and

nonpharmacological approaches are possible and may vary depending on the type of surgery, patient

condition, and preferences.7 Within the guide-

lines, there are some specific recommendations

for the particular multimodal approach based on

the type of surgical procedure. The use of TENS,

inexpensive, small, portable devices that deliver

a small low-voltage electrical impulse through

electrodes on the skin has been shown to reduce

pain through the descending inhibitory pain path-

ways which activate opioid receptors.7 The panel

cites studies that have demonstrated reductions

in postoperative analgesic requirements. In most cases, TENS electrodes were applied near the sur-

gical incision. There is insufficient evidence to

recommend the use of acupuncture. Other phys-

ical modalities such as acupressure, massage,

cold therapy, immobilization, and bracing are

generally safe, but there is a lack of evidence to

recommend their use. As components of a multi-

modal plan, cognitive behavioral therapies such as hypnosis, guided imagery, music, and relaxation

methods have shown some positive effects on

postoperative pain, anxiety, or analgesic use, but

few studies of these modalities have been conduct-

ed with children.7

Multimodal pharmacological approaches are rec-

ommended. Oral opioids, when possible, are preferred over IV administration as there is no

strong evidence to show that IV therapy provides

superior relief of pain.7 The use of short-acting opi-

oids, administered around the clock in the immedi-

ate postoperative period, is recommended.7

Except if used preoperatively, long-acting opioids

should not be used for postoperative pain manage-

ment. Intramuscular injections should be avoided as they do not provide reliable effects and show

no superiority over other routes.7 The guidelines

support the use of IV PCA, without the use of a

basal infusion, when IV opioids are needed as IV

PCA has been shown to provide greater effective-

ness and patient satisfaction.7 To reduce the risk

of opioid-related adverse events, the panel re-

commends close monitoring of sedation level and respiratory status, especially in the hours

immediately after surgery or with dose changes.7

There is no clear recommendation for the use of

pulse oximetry, capnography, or other monitoring

methods due to a lack of evidence.7 Identification

of patients at increased risk for opioid-related

adverse events is advised, and interventions to

minimize risks, including dose adjustments, are recommended.7

Nonopioids are recommended as components of a

multimodal analgesic plan.7 The panel cites evi-

dence that shows that acetaminophen and NSAIDs

reduce pain and opioid requirements in postsur-

gical patients. NSAIDs are associated with risks,

450 MAUREEN F. COONEY

including gastrointestinal bleeding, anastomotic

leakage in colorectal surgery, and cardiovascular

events and renal dysfunction, which must be

considered and may contraindicate their use in

some postsurgical patients.7 NSAIDs and cele- coxib are contraindicated for perioperative pain

management in patients undergoing coronary ar-

tery bypass grafting.7 Perianesthesia nurses may

be aware of the reluctance of some orthopaedic

surgeons to use NSAIDs for their patients due to

concerns of bone nonunion after certain surgical

procedures, but the panel notes that there is insuf-

ficient evidence to recommend against the use of NSAIDs for orthopaedic fractures and spinal fusion

and identifies the need for informed decision-

making and consideration of alternatives by the

surgeon and the patient.7 Celecoxib, in doses of

200 to 400 mg administered 30 to 60 minutes pre-

operatively to adults is recommended for postsur-

gical pain and opioid requirement reducing

benefits.7 The panel cites evidence that doses of gabapentin (600 or 1,200 mg) or pregabalin (150

or 300 mg) administered 1 to 2 hours preopera-

tively to adults are effective components of a multi-

modal plan, and postoperative dosing has shown

effectiveness in some trials.7

Additional multimodal pharmacological interven-

tions that perianesthesia nurses may be less familiar with are also recommended in the guide-

lines. Although the panel is unable to identify suf-

ficient evidence for optimal dosing of IV ketamine,

it recommends a preoperative bolus of 0.5 mg/kg

followed by an infusion of 10mcg/kg/minute intra-

operatively, and a lower dosage postoperative infu-

sion as a multimodal analgesic component for

adult surgical patients to reduce postoperative pain, analgesic use, and possibly the risk of persis-

tent postsurgical pain.7 Evidence is cited to sup-

port the use of IV lidocaine infusions in adults

undergoing open and laparoscopic abdominal sur-

geries as this intervention is associated with

shorter duration of ileus and improved analgesia.7

The panel recommends an initial bolus dose of

1.5 mg/kg followed by an infusion of 2 mg/kg/ hour during surgery; insufficient evidence is cited

to recommend postoperative use.7

Site-specific peripheral regional local anesthetic in-

jections, and in some cases, continuous infusions

are supported in the guidelines. Neuraxial

(epidural or spinal) analgesia is recommended for

the management of major thoracic, abdominal, ce-

sarean section, hip, and lower extremity sur-

geries.7 The neuraxial approach may reduce risks

of postoperative mortality, venous thromboembo-

lism, myocardial, infarction, pneumonia, respira- tory depression, and may decrease duration of an

ileus.7 The panel notes that epidural analgesia

has the advantage over spinal analgesia as an

epidural can be used as a continuous infusion

with or without PCA and can be used to deliver

local anesthetics. Epidural clonidine is sometimes

used with local anesthetics to improve postopera-

tive pain, but evidence is lacking and it may be associated with increased hypotension.7 Perianes-

thesia nurses need to be competent in the assess-

ment of patients who have received peripheral

regional anesthesia and neuraxial anesthetics/anal-

gesics and must be aware of the signs, symptoms,

and emergencymanagement of any complications,

including local anesthetic toxicity. Some orthopae-

dic surgeries are associated with an increased risk for compartment syndrome, and signs and symp-

toms may be diminished or masked with regional

and neuraxial techniques. When opioids are used

in spinal or epidural analgesia, patients must be

monitored for opioid-related adverse outcomes.

In addition, patients who have received neuraxial

analgesia are at risk for spinal cord compression.

Perianesthesia nurses must be educated about these potential complications and prepared to

implement appropriate emergency measures.

Perianesthesia nurses have significant roles in

assuring appropriate transitions of patient care.

The panel recommends that all patients and/or

caregivers receive a coordinated approach to

discharge planning and discharge teaching from all involved disciplines (surgeons, nurses, thera-

pists, pharmacists). It is necessary to provide in-

structions in the safe and appropriate use of

pain medications and side effect management.

Discharge teaching should include warnings about

the life-threatening risks of concomitant use of

alcohol and other central nervous system depres-

sants when opioids are used. Teaching should also include an individualized plan for opioid weaning

and discontinuation and safe storage and disposal

of opioids and other medications.7 Clear evidence

to guide the method for postsurgical opioid wean-

ing is not available, but the panel notes that severe

postoperative pain usually diminishes rapidly in the

first few days after surgery. For minor surgeries,

PAIN MANAGEMENT 451

pain may be controlled with nonopioid analgesics

or a very limited opioid supply after discharge. In

patients with more involved surgeries, a longer

course of postoperative analgesics, including opi-

oids, may be needed. If used for more than 1 to 2 weeks, a gradual opioid reduction is suggested

to prevent withdrawal, with dose reductions by

20% to 25% of the discharge dose every 1 to 2 days.7

Conclusion

The above statements constitute key recommen-

dations contained in the APS Postoperative Pain

Guidelines. In addition, the guidelines include

elaboration on each of the recommendations, a

list of interventions for the management of postop-

erative pain in patients receiving long-term opioid

therapy, a table of options for components of a multimodal analgesic surgery-specific approach,

and a summary table of interventions for manage-

ment of postoperative pain. Perianesthesia nurses

may find it helpful to review the guidelines to

inform various aspects of their clinical practice.

It is important to note that clinical practice guide-

lines are general statements that do not dictate

practice, but provide guidance for practice based on the evidence available at the time they are writ-

ten. They do not apply to all patients, as individual

patients and clinical scenarios may not be appro-

priate for implementation of the recommenda-

tions, but require patient-specific approaches

based on assessment and consideration of individ-

ual patient needs and resources. In examining each

recommendation, it is important to note that

despite a comprehensive review of the literature,

only 4 of the 32 recommendations have a high-

quality evidence rating.7,8

High-quality evidence was only found to support

the use of multimodal analgesia, including the

use of acetaminophen and NSAIDs, site-specific

peripheral regional anesthetic techniques, and

neuraxial analgesia with opioids and local anes-

thetics for thoracic and abdominal procedures.7,8

Although there are 28 other recommendations,

they are rated with moderate- or low-quality evi- dence because the panel identified significant

research gaps in the evidence review.7,8

However, despite the lack of high-quality evi-

dence, these recommendations reflect the panel’s

near-unanimous consensus on all the recommen-

dations.7 The task of developing evidence-based

guidelines presents challenges; There are limita-

tions in the ability to gather and synthesize all high-quality studies that are available related to

an area as broad as postoperative pain, and even

as available evidence is analyzed and recommen-

dations are developed, additional studies are

completed and newer evidence surfaces.8 This

further highlights the necessity of individualizing

patient care and using informed clinical judgment

over strict adherence to recommendations con- tained in the guidelines. It also demonstrates the

significant need for additional research to address

the gaps in evidence related to the management

of postoperative pain.

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