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

The Journal of Pain, Vol 17, No 2 (February), 2016: pp 131-157 Available online at www.jpain.org and www.sciencedirect.com

Guidelines on the Management of Postoperative Pain

Management of Postoperative Pain: A Clinical Practice Guideline

From the American Pain Society, the American Society of Regional

Anesthesia and Pain Medicine, and the American Society of

Anesthesiologists’ Committee on Regional Anesthesia, Executive

Committee, and Administrative Council

Roger Chou,* Debra B. Gordon,y Oscar A. de Leon-Casasola,z Jack M. Rosenberg,x

Stephen Bickler,{ Tim Brennan,k Todd Carter,** Carla L. Cassidy,yy Eva Hall Chittenden,zz

Ernest Degenhardt,xx Scott Griffith,{{ Renee Manworren,kk Bill McCarberg,*** Robert Montgomery,yyy Jamie Murphy,zzz Melissa F. Perkal,xxx Santhanam Suresh,{{{

Kathleen Sluka,kkk Scott Strassels,**** Richard Thirlby,yyyy Eugene Viscusi,zzzz

Gary A. Walco,xxxx Lisa Warner,{{{{ Steven J. Weisman,kkkk and Christopher L. Wuzzz

*Departments of Medicine, and Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Pacific Northwest Evidence Based Practice Center, Portland, Oregon. yDepartment of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington. zDepartment of Anesthesiology and Pain Medicine, Roswell Park Cancer Institute and University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York. xVeterans Integrated Service Network, Department of Veterans Affairs and Departments of Physical Medicine and Rehabilitation and Anesthesiology, University of Michigan, Ann Arbor, Michigan. {Pediatric Surgery, University of California, San Diego, San Diego, California. kDepartment of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa. **Department of Anesthesia, University of Cincinnati, Cincinnati, Ohio. yyDepartment of Veterans Affairs, Veterans Health Administration, Washington, DC. zzDepartment of Palliative Care, Massachusetts General Hospital, Boston, Massachusetts. xxQuality Management Division, United States Army Medical Command, San Antonio, Texas. {{Critical Care Medicine, Walter Reed Army Medical Center, Bethesda, Maryland. kkDepartment of Pediatrics, University of Connecticut School of Medicine, Mansfield, Connecticut. ***American Academy of Pain Medicine, San Diego, California. yyyDepartment of Anesthesiology, University of Colorado, Denver, Denver, Colorado. zzzDepartment of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland. xxxDepartment of Surgery, Veterans Affairs Medical Center, West Haven, Connecticut. {{{Department of Pediatric Anesthesia, Children’s Hospital of Chicago, Chicago, Illinois. kkkDepartment of Physical Therapy and Rehabilitation, University of Iowa, Iowa City, Iowa. ****College of Pharmacy, University of Texas at Austin, Austin, Texas. yyyyBariatric Weight Loss Surgery Center, Virginia Mason Medical Center, Seattle, Washington. zzzzDepartment of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania. xxxxDepartment of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, Washington. {{{{Department of Veteran Affairs, Phoenix, Arizona. kkkkDepartment of Anesthesiology, Children’s Hospital of Wisconsin, Wauwatosa, Wisconsin.

Received October 28, 2015; Revised December 11, 2015; Accepted December 14, 2015. Funding for this guideline was provided by the American Pain Society. The guideline was submitted for approval by the partnering organiza- tions, but the content of the guideline is the sole responsibility of the au- thors and panel members. All panelists were required to disclose conflicts of interest within the pre- ceding 5 years at all face-to-face meetings and before submission of the guideline for publication, and to recuse themselves from votes if a

conflict was present. Conflicts of interest of the authors and panel members are listed in Supplementary Appendix 1. Supplementary data accompanying this article are available online at www.jpain.org and www.sciencedirect.com. Address reprint requests to Roger Chou, MD, 3181 SW Sam Jackson Park Road, Mail code BICC, Portland, OR 97239. E-mail: [email protected]

1526-5900/$36.00

ª 2016 by the American Pain Society http://dx.doi.org/10.1016/j.jpain.2015.12.008

131

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132 The Journal of Pain Management of Postoperative Pain

Abstract: Most patients who undergo surgical procedures experience acute postoperative pain, but ev- idence suggests that less than half report adequate postoperative pain relief. Many preoperative, intra-

operative, and postoperative interventions and management strategies are available for reducing and

managing postoperative pain. The American Pain Society, with input from the American Society of Anes-

thesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to

promote evidence-based, effective, and safer postoperative pain management in children and adults.

The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of

the guideline development process, a systematic review was commissioned on various aspects related

to various interventions and management strategies for postoperative pain. After a review of the evi-

dence, the expert panel formulated recommendations that addressed various aspects of postoperative

pain management, including preoperative education, perioperative pain management planning, use of

different pharmacological and nonpharmacological modalities, organizational policies, and transition

tooutpatient care. The recommendations are based on the underlying premise that optimalmanagement

begins in the preoperative period with an assessment of the patient and development of a plan of care

tailored to the individual and the surgical procedure involved. The panel found that evidence supports

the use of multimodal regimens in many situations, although the exact components of effective multi-

modal care will vary depending on the patient, setting, and surgical procedure. Although these guide-

lines are based on a systematic review of the evidence on management of postoperative pain, the

panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported

by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient

assessment, organizational structures and policies, and transitioning to outpatient care) were made on

the basis of low-quality evidence.

Perspective: This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effec-

tivepostoperativepain management should beonthebasisofaplan ofcaretailoredtothe individualand

the surgical procedure involved, and multimodal regimens are recommended in many situations.

ª 2016 by the American Pain Society Key words: Postoperative pain management, clinical practice guidelines, analgesia, education, multi-

modal therapy, patient assessment, regional analgesia, neuraxial analgesia.

ore than 80% of patients who undergo surgical procedures experience acute postoperative pain and approximately 75% of those with post-

operative pain report the severity as moderate, severe, or extreme.12,96 Evidence suggests that less than half of patients who undergo surgery report adequate postoperative pain relief.12 Inadequately controlled pain negatively affects quality of life, function, and func- tional recovery, the risk of post-surgical complications, and the risk of persistent postsurgical pain.165

Many preoperative, intraoperative, and postoperative interventions and management strategies are available and continue to evolve for reducing and managing post- operative pain. The American Pain Society (APS), with input from the American Society of Anesthesiologists (ASA), commissioned a guideline on management of post- operative pain to promote evidence-based, effective, and safer postoperative pain management in children and adults, addressing areas that include preoperative educa- tion, perioperative pain management planning, use of different pharmacological and nonpharmacological mo- dalities, organizational policies and procedures, and tran- sition to outpatient care. The ASA published a practice guideline for acute painmanagement inthe perioperative setting in 20126; the APS has not previously published guidelines on management of postoperative pain. After completion, the guideline was also reviewed for approval by the American Society of Regional Anesthesia and Pain Medicine.

Methods

Panel Composition The APS, with input from the ASA, convened a panel of

23 members with expertise in anesthesia and/or pain medicine, surgery, obstetrics and gynecology, pediatrics, hospital medicine, nursing, primary care, physical therapy, and psychology to review the evidence and formulate recommendations on management of postoperative pain (see Supplementary Appendix 1 for a list of panel members). Three cochairs (D.B.G. [selected by the APS], O.d.L.-C. [selected by the ASA], and J.M.R.) were selected to lead the panel, which also included the APS Director of Clinical Guidelines Development (R.C.).

Target Audience and Scope The intent of the guideline is to provide evidence-

based recommendations for management of postopera- tive pain. The target audience is all clinicians who manage postoperative pain. Management of chronic pain, acute nonsurgical pain, dental pain, trauma pain, and periprocedural (nonsurgical) pain are outside the scope of this guideline.

Evidence Review This guideline is informed by an evidence review con-

ducted at the Oregon Evidence-Based Practice Center

Chou et al The Journal of Pain 133

and commissioned by APS.51 With the Oregon Evidence- Based Practice Center, the panel developed the key ques- tions, scope, and inclusion criteria used to guide the evi- dence review. Literature searches were conducted through November 2012. The full search strategy, including the search terms and databases searches, is available in the evidence review. Investigators reviewed 6556 abstracts from searches for systematic reviews and primary studies from multiple electronic databases, reference lists of relevant articles, and suggestions from expert reviewers. A total of 107 systematic reviews and 858 primary studies (not included in previously published systematic reviews) were included in the evidence report.51 Updated searches were conducted through December 2015. New evidence was reviewed and judged to be consistent with the recommendations in this guide- line, which was updated with new citations as relevant.

Grading of the Evidence and Recommendations The panel used methods adapted from the Grading of

Recommendations Assessment, Development, and Eval- uation Working Group to rate the recommendations included in this guideline.118 Each recommendation received a separate grade for the strength of the recom- mendation (strong or weak) and for the quality of evi- dence (high, moderate, or poor) (Supplementary Appendix 2). In general, a strong recommendation is on the basis of the panel’s assessment that the potential benefits of following the recommendation clearly outweigh potential harms and burdens. In light of the available evidence, most clinicians and patients would choose to follow a strong recommendation. A weak recommendation is on the basis of the panel’s assessment that benefits of following the recommendation outweigh potential harms and burdens, but the balance of benefits to harms or burdens is smaller or evidence is weaker. Decisions to follow a weak recommendation could vary depending on specific clinical circumstances or patient preferences and values. For grading the qual- ity of a body of evidence that supports a recommenda- tion, we considered the type, number, size, and quality of studies; strength of associations or effects; and consis- tency of results among studies.118

Guideline Development Process The guideline panel met in person in August 2009 and

January 2011. At the first meeting, the panel developed the scope and key questions used to guide the systematic evidence review. At the second meeting, the panel re- viewed the results of the evidence review and drafted initial potential recommendation statements. After the second meeting, additional draft recommendation state- ments were proposed. The panelists then participated in a multistage Delphi process, in which each draft recom- mendation was ranked and revised. At each stage of the Delphi process, the lowest-ranked recommendations were eliminated. A two-thirds majority was required for a recommendation to be approved, although unanimous or near-unanimous consensus was achieved for all rec-

ommendations. Persons who had conflicts of interest were recused from voting on recommendations poten- tially affected by the conflicts. After finalization of the recommendations, the guideline was written by panel subgroups and drafts distributed to the panel for feed- back and revisions. More than 20 external peer reviewers were solicited for additional comments on the draft guideline. After another round of revisions and panel approval, the guideline was submitted to the APS and ASA for approval. The guideline was approved by the APS Board of Directors in April 2015 and by the ASA’s Committee on Regional Anesthesia, Executive Commit- tee, and Administrative Council in October 2015. It was also approved by the American Society of Regional Anes- thesia Board of Directors in August 2015. The APS intends to update this guideline and the evi-

dence report used to develop it by 2021, or earlier if crit- ical new evidence becomes available. Recommendations that do not specifically state that they are for adults or children are general recommendations across age groups.

Recommendations

Preoperative Education and Perioperative Pain Management Planning

Recommendation 1

� The panel recommends that clinicians provide pa- tient and family-centered, individually tailored edu- cation to the patient (and/or responsible caregiver), including information on treatment options for management of postoperative pain, and document the plan and goals for postoperative pain manage- ment (strong recommendation, low-quality evi- dence).

Individually tailored programs of education and sup- port for patients with more intensive needs (eg, due to medical or psychological comorbidities or social factors) who undergo surgery are associated with beneficial ef- fects including reduced postoperative opioid consump- tion,73,172 less preoperative anxiety,9,42,57,69 fewer requests for sedative medications,172 and reduced length of stay after surgery.15,57,73,308 Although studies of patients without more intensive needs did not clearly show beneficial clinical effects of preoperative educational interventions, the panel believes such interventions remain of value for helping to inform patients regarding perioperative treatment options and to engage them in the decision-making process. Educational interventions can range from single epi- sodes of face-to-face instruction or provision of written materials, videos, audiotapes, or Web-based educational information to more intensive, multicomponent preop- erative interventions including individualized and super- vised exercise, education, and telephone calls. There is insufficient evidence to determine the comparative effectiveness of different educational interventions or to recommend specific interventions, but the diversity

134 The Journal of Pain Management of Postoperative Pain

of clinical situations, patient needs, and patient prefer- ences support the need for an individualized approach. Such an individualized approach to preoperative educa- tion includes provision of information that is ‘‘age- appropriate, geared to the person’s and family’s level of comprehension and general health literacy, cultural and linguistic competency, and supported by timely op- portunities to ask questions and receive authoritative and useful answers.’’56

Although the optimal timing and content of preoper- ative education is uncertain, the panel suggests that preoperative education routinely include information regarding indicated changes in use of analgesics before surgery (eg, discontinuation of aspirin for procedures in which hemorrhage would present high risks or in pa- tients at high risk of hemorrhage) and continuation of medications (eg, opioids, benzodiazepines, gabapenti- noids, or baclofen) to avoid a withdrawal syndrome, unless there is a specific plan to taper. Although use of opioids before surgery is associated with greater postop- erative analgesic requirements,221 there is insufficient evidence to recommend routinely decreasing opioid doses or discontinuing opioids before surgery. Patients receiving long-term opioid therapy before surgery might benefit from routine use of nonopioid adjuvant medications that might reduce postoperative opioids requirements (see Recommendation 30). Education or counseling should also include information about how pain is reported and assessed (including use of pain assessment tools), when to report pain, individualized options for perioperative pain management (in many cases including a multimodal pharmacologic and non- pharmacologic approach), and realistic goals for pain control. When certain cognitive modalities are planned, preoperative training of patients can enhance effective- ness (see Recommendation 9). Education should also aim to correct any underlying misperceptions about pain and analgesics (eg, beliefs that pain after surgery does not warrant treatment, that health care providers will only respond to extreme expressions of pain, that opioids are always required for postoperative pain, or that opioid use inevitably leads to addiction).56 Pregnant women who undergo surgery should be informed about potential effects of treatment options on the fetus and newborn, including effects of in utero and breastfeeding exposure to opioids or other medications for manage- ment of postoperative pain.148

Recommendation 2

� The panel recommends that the parents (or other adult caregivers) of children who undergo surgery receive instruction in developmentally-appropriate methods for assessing pain as well as counseling on appropriate administration of analgesics and mo- dalities (strong recommendation, low-quality evi- dence).

The panel recommends that clinicians provide devel- opmentally appropriate information to children and their parents, to better inform and engage them in care. Research showing effectiveness of preoperative

child or parental educational interventions on postoper- ative clinical outcomes in children who undergo surgery is limited.46,143,258 However, preoperative education might help address parental barriers to appropriate management of postoperative pediatric pain, such as uncertainty regarding how to evaluate pain and reluctance to use pain medication because of fears of addiction, although more research is needed to understand optimal methods of preoperative parental education.159,160 Reduction of parental anxiety regarding postoperative pain might be associated with decreased reports of pain and pain behaviors in children, perhaps mediated in part by changes in how analgesics are administered by the parents.121 Suggested components of education include parental preparation for what to expect regarding the child’s postoperative course and information on how to help children cope with perioperative pain.143,200

Studies on the accuracy and usefulness of parents’ assessment of children’s pain are mixed. Although some studies indicate better correlation between parent and child pain ratings than those of health care providers and children, other studies indicate that parents frequently under- or overestimate their child’s postsur- gical pain.49,121,143,159,264 Therefore, although the panel recommends that parents receive education on methods for assessing postoperative pain in children, there is insufficient evidence to recommend a specific method. Better validation of pain assessment tools for parents to assess their children’s pain and evaluations of the usefulness of explicit written instructions to supplement verbal discharge directions would help to better inform optimal methods for providing postdischarge pain management in children.88,160

Recommendation 3

� The panel recommends that clinicians conduct a pre- operative evaluation including assessment of medi- cal and psychiatric comorbidities, concomitant medications, history of chronic pain, substance abuse, and previous postoperative treatment regi- mens and responses, to guide the perioperative pain management plan (strong recommendation, low-quality evidence).

Clinicians should perform a thorough history and phys- ical examination to develop an individually tailored pain management plan through a shared decision-making approach. The pain management plan should be on the basis of evidence regarding effective interventions for the specific surgery or surgical site in question, modi- fied by factors unique to the patient, including previous experiences with surgery and postoperative treatment, medication allergies and intolerances, cognitive status, comorbidities, preferences for treatment, and treatment goals. Research in other areas of pain and health care in- dicates that patients engaged in collaborative care including shared decision-making with their providers experience better health outcomes.70,133

Although no study has specifically evaluated the use- fulness of individual components of the preoperative

Chou et al The Journal of Pain 135

history and physical, an assessment of past and current history of pain (including the use of, response to, and preferences regarding analgesics), and presence of med- ical comorbidities (eg, bleeding disorders or previous spi- nal surgery are relative contraindications to the use of epidural or spinal techniques) and psychiatric comorbid- ities (eg, anxiety, depression, and maladaptive coping behaviors such as catastrophizing) are critical for devel- oping an appropriate postoperative pain management plan. It is also important to assess for a history of physical dependence or tolerance to opioids and previous or cur- rent substance use disorder because their presence might be associated with increased opioid requirements and delayed recovery in the postoperative period,221 and to assess for risk factors for opioid misuse, which might affect medication choices, follow-up, monitoring, and tapering protocols. In addition to use of opioids, the his- tory should also attempt to identify in a nonjudgmental manner use and abuse of benzodiazepines, cocaine, alcohol, and other psychoactive substances that might affect pain management.

Recommendation 4

� The panel recommends that clinicians adjust the pain management plan on the basis of adequacy of pain relief and presence of adverse events (strong recommendation, low-quality evidence).

Provision of optimal pain management requires ongoing reassessments to determine the adequacy of pain relief, detect adverse events early, and help monitor progress toward functional goals. Clinicians should be prepared to adjust the pain management plan postoper- atively when pain relief is inadequate or to address or avert adverse events. For example, some patients might develop respiratory depression requiring rapid reduction of opioids and close monitoring, or other measures de- pending on the urgency of the situation. Individual dif- ferences in response to analgesics and other interventions are well recognized and support an individ- ualized and flexible approach to pain management.5,108

Table 1. Examples of Validated Pain Intensity Assessment Scales

NAME OF SCALE RATING SYSTEM

NRSs Six-point NRS (NRS 0-5)207

Eleven-point NRS (NRS 0-10)24,25,53,95

Twenty-one point NRS (NRS 0-20)50,131,281

VRS Four-point VRS53

Seven-point Graphic Rating Scale24,25

Six-point Present Pain Inventory

(PPI)94,95,157,201,223

Visual Analogue

Scales

Commonly rated 0 to 10 cm or 0 to 100 mm.

Pain Thermometer Combines a visual thermometer with

verbal descriptions of pain130,131

Faces Rating Scales Faces Pain Scale-

Revised31,53,83,93,131,157,273,281

Wong-Baker FACES pain rating scale309,314

Oucher scale27,29

Abbreviations: NRS, Numeric Rating Scale; VRS, Verbal Rating Scale.

Methods of Assessment

Recommendation 5

� The panel recommends that clinicians use a vali- dated pain assessment tool to track responses to postoperative pain treatments and adjust treatment plans accordingly (strong recommendation, low- quality evidence).

Pain assessment and reassessment are required to pro- vide optimal postoperative pain care. Pain assessment helps determine whether pain management is adequate, whether analgesic or analgesic dose changes are required, whether changes in the postoperative pain management plan or additional interventions are war- ranted, and in the case of difficult to manage pain whether specialty consultation or other measures are needed. Because pain is inherently subjective, patient self-report is the primary basis of all pain assess- ments.5,293 For patients who cannot adequately report

their pain because of cognitive deficits, sedation, developmental stage, or other factors, clinicians might need to use behavioral assessment tools and solicit input from caregivers to assess pain.129 In all cases, clini- cians should not rely solely on ‘‘objective’’ measures such as pain-related behaviors or vital signs in lieu of patient self-report to determine the presence of or intensity of pain because such measures are neither valid nor reli- able. At similar levels of pain, pain behaviors might vary markedly between individuals. Therefore, although assessments of pain behaviors might supplement infor- mation from self-reported pain, it is important to inter- pret behavioral observations cautiously. A number of pain assessment tools have been vali-

dated for accuracy in detecting the presence of and quantifying the severity of pain, and have been tested for intrapatient and inter-rater reliability (Table 1).28,30, 41,43,45,100,131,137,140,185,195,197,202,224,225,234,254,276,280,295,

297,309 Validated pain assessment tools use different methods to measure pain, including visual analogue scales, numeric or verbal rating scales, symbols, and others. The panel recommends that clinicians use a validated pain assessment tool, although there is inadequate evidence on the effects of different pain assessment tools on postoperative pain outcomes to guide recommendations on which specific tools to use. Therefore, the selection of a particular pain assessment tool should be on the basis of factors such as developmental status, cognitive status, level of consciousness, educational level, and cultural and language differences. In children, the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials group suggests the use of the Face, Legs, Arms, Cry, Consolability and Parents Post-operative Pain Measure for assessing acute pain in preverbal and nonverbal children298 on the basis of the reliability, validity, and ease of use. Tools that have been developed for use in the intensive care unit setting include the Behavioral Pain Scale and the Critical-Care Pain Observation Tool.3,98

Table 2. Suggested Elements of Postoperative Pain Assessment

ELEMENT QUESTIONS USED FOR ASSESSMENT

1. Onset and pattern When did the pain start? How often does it occur? Has its intensity changed?

2. Location Where is the pain? Is it local to the incisional site, referred, or elsewhere?

3. Quality of pain What does the pain feel like?

4. Intensity How severe is the pain? (See Table 1)

5. Aggravating and relieving

factors

What makes the pain better or worse?

6. Previous treatment What types of treatment have been effective or ineffective in the past to relieve the pain?

7. Effect How does the pain affect physical function, emotional distress, and sleep?

8. Barriers to pain assessment What factors might affect accuracy or reliability of pain assessments128 (eg, cultural or language barriers,

cognitive barriers, misconceptions about interventions)?

136 The Journal of Pain Management of Postoperative Pain

Pain assessment involves more than just quantifying the intensity of pain. High pain intensity ratings or behav- ioral scale scores that do not respond to usual care should be investigated to determine whether the pain might be due to a new medical issue or surgical complication and the potential role of opioid tolerance and psychological distress. Assessment should determine what interven- tions have been effective for the pain, how the pain af- fects function, the type of pain (eg, neuropathic, visceral, somatic, muscle spasms), and whether there are barriers to effective pain management, such as cultural or language differences, cognitive deficits, or patient mis- conceptions about pain management (Table 2). In addi- tion, it is not sufficient to assess pain only at rest. Pain that is relatively well controlled at rest can be severe dur- ing movement or with specific activities that cause increased pain (eg, swallowing after tonsillectomy), with important implications for symptom management and recovery. The panel suggests that clinicians assess pain at rest and with activities, as the latter is often more severe and difficult to control than pain at rest.110,270 Presence of pain with activity has important implications for use of additional interventions and discharge planning. For example, pain that is well controlled at rest but severe with movement can have major effects on a patient’s ability to participate in postsurgical rehabilitation and return to normal function, and pain with swallowing after tonsillectomy could increase risk for dehydration. Assessments for other clinical issues such as sedation, delirium, and nausea or other side effects related to interventions are also important to help guide decisions regarding adjustment of the postoperative pain management plan. There is insufficient evidence to guide firm recom-

mendations on optimal timing or frequency of patient reassessments in the postoperative setting. The timing of assessments after administration of an intervention should be informed by the time to achieve peak ef- fects, which is typically 15 to 30 minutes after paren- teral drug therapy or 1 to 2 hours after administration of an oral analgesic. With nonpharma- cologic interventions, pain relief often occurs during or immediately after their application. The optimal fre- quency of reassessment is likely to depend on a num- ber of factors, including the type of surgical procedure, the adequacy of initial pain relief, the pres- ence of side effects, presence of comorbidities, and

changes in clinical status. Reassessments might be per- formed less frequently for patients with more stable pain (eg, patients who have exhibited good pain con- trol without side effects after 24 hours of stable ther- apy). Pain reassessments might be useful at the time of nursing shift changes or with new caregivers to establish a baseline and promote continuity of care, although evidence showing that routine reassessment of pain at nursing shift changes is associated with improved clinical outcomes is not available.

General Principles Regarding the Use of Multimodal Therapies

Recommendation 6

� The panel recommends that clinicians offer multi- modal analgesia, or the use of a variety of analgesic medications and techniques combined with non- pharmacological interventions, for the treatment of postoperative pain in children and adults (strong recommendation, high-quality evidence).

Multimodal analgesia, defined as the use of a variety of analgesic medication and techniques that target different mechanisms of action in the peripheral and/or central nervous system (which might also be combined with nonpharmacological interventions) might have ad- ditive or synergistic effects and more effective pain relief compared with single-modality interventions. For example, clinicians might offer local anesthetic-based regional (peripheral and neuraxial) analgesic techniques in combination with systemic opioids and other analge- sics as part of a multimodal approach to perioperative pain. Because of the availability of effective nonopioid analgesics and nonpharmacologic therapies for postop- erative pain management, the panel suggests that clini- cians routinely incorporate around the clock nonopioid analgesics and nonpharmacologic therapies into multi- modal analgesia regimens. Systemic opioids might not be required in all patients. One study suggests that it should be avoided when not needed, because limited ev- idence suggests that perioperative opioid therapy might be associated with increased likelihood of long-term opioid use, with its attendant risks.4

Randomized trials76,194 have shown that multimodal analgesia involving simultaneous use of combinations of several medications acting at different receptors or 1 or

Chou et al The Journal of Pain 137

more medications administered through different techniques (eg, systemically and neuraxially) is associated with superior pain relief and decreased opioid consumption compared with use of a single medication administered through 1 technique, even after excluding trials that were retracted because of scientific fraud or were not retracted but authored by an investigator who admitted to fraud in other work.238,260 The addition of nonpharmacological interventions might result in additional effects consistent with the biopsychosocial model of pain. For any given situation, a number of potential multimodal combinations are possible, and different multimodal regimens might be appropriate, depending on the specific surgery, individual clinical factors, and patient preferences. Subsequent sections of this guideline provide more specific recommendations on the different components of multimodal analgesia. In general, the use of local anesthetic-based regional anesthesia tech- niques for surgical procedures of the extremities, abdomen, and thorax is encouraged, because of the mul- tiple trials that showed their effectiveness in combination with systemic analgesics (see Recommendation 23). Selec- tion of multimodal therapies is a challenge because for each surgical procedure, many potential multimodal ther- apy combinations are possible, but relatively few have been evaluated in rigorous trials. On the basis of the avail- able evidence and panel consensus, the options for com- ponents of multimodal therapy for several commonly performed surgeries are summarized in Table 3. Techniques not typically used together are intra- articular, peripheral regional, and neuraxial techniques. When using multimodal analgesia, clinicians should be

aware of the different side effect profile for each anal- gesic medication or technique used, and provide appro- priate monitoring to identify and manage adverse events. Studies varied in showing whether multimodal approaches were associated with a decreased risk of adverse events than single-modality approaches, de- pending in part on the specific regimens and compari- sons evaluated.194

Use of Physical Modalities

Recommendations 7 and 8

� The panel recommends that clinicians consider transcutaneous electrical nerve stimulation (TENS) as an adjunct to other postoperative pain treat- ments (weak recommendation, moderate-quality evidence).

� The panel can neither recommend nor discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments (insufficient evidence).

Physical modalities include transcutaneous TENS, acupuncture and related interventions, massage, cold therapy (with and without compression), localized heat, warm insufflation, continuous passive motion, and immobilization or bracing. Although these therapies

are generally considered to be safe, evidence on their effectiveness as adjunctive therapies as part of a multi- modal approach to perioperative pain management varies substantially. TENS are small portable devices that deliver low-

voltage electrical currents through the skin. TENS is thought to activate endogenous descending inhibitory pathways activating opioid receptors to produce reduced central excitability and reduce pain through stimulatory effects on large diameter afferent fibers.266

A fair-quality systematic review of >20 randomized trials found use of TENS associated with approximately 25% less postoperative analgesic use compared with no TENS.32 Therefore, the panel recommends clinicians consider use of TENS as an adjunct to other postoperative pain management treatments. There is insufficient evi- dence to recommend specific TENS regimens, although effects appear stronger in trials in which TENS was applied using optimal predefined parameters for the stimulation.23,102,122,132,151,179,267,300 Studies of TENS most commonly evaluated its effectiveness when applied near the surgical incision area, although in some studies TENS was applied to acupoints away from the incision, with similar effects. Acupuncture involves the placement of needles into the

body at defined acupuncture points. Related interven- tions that also involve stimulation of defined acupuncture points include acupressure (pressure rather than needles applied to acupuncture points), auricular acupuncture (acupuncture applied at the ear), electroacupuncture (electric current applied to needles placed at acupuncture points on the body), and others. Evidence on the effec- tiveness of needle acupuncture to the body for postoper- ative pain in adults is mixed, with some trials showing no beneficial effects on postoperative pain or analgesic use compared with sham acupuncture or analgesic use.65,111,116,170,284,301 Evidence on acupressure,85 auric- ular acupuncture,291,292,313 and electroacupuncture in adults,180,190,262,310 and needle acupuncture in children302,316 is limited and does not clearly show beneficial effects in management of postoperative pain. Evidence on massage was limited, and also did not clearly demonstrate benefits for postoperative pain.91,124,141,203,230,271

Although other physical modalities are generally considered to be safe, lack of demonstrated effectiveness preclude recommendations supporting their use. Costs for equipment and care provider time should be consid- ered in relationship to the low probability of patient benefit before initiating these therapies as adjuvants to other multimodal postoperative pain treatments. Cold therapy refers to the superficial application of cold

to the surface of the skin, with or without compression and with or without a mechanical recirculating device to maintain cold temperatures. Localized cold therapy has commonly been used in acute pain, including postopera- tive pain, with potential benefits at the site of injury thought to be related to reductions in tissue temperature, resulting in reduced edema and local analgesia. Trials of cold therapy were inconsistent and frequently found no

Table 3. Options for Components of Multimodal Therapy for Commonly Performed Surgeries

TYPE OF SURGERY SYSTEMIC PHARMACOLOGIC THERAPY LOCAL, INTRA-ARTICULAR OR TOPICAL

TECHNIQUES* REGIONAL ANESTHETIC TECHNIQUES* NEURAXIAL ANESTHETIC TECHNIQUES* NONPHARMACOLOGIC THERAPIESy Thoracotomy Opioidsz

NSAIDsx and/or acetaminophen Gabapentin or pregabalinx i.v. ketamine{

Paravertebral block Epidural with local anesthetic (with

or without opioid), or intrathecal

opioid

Cognitive modalities

TENS

Open laparotomy Opioidsz NSAIDsx and/or acetaminophen Gabapentin or pregabalinx i.v. ketamine{ i.v. lidocaine

Local anesthetic at incision

i.v. lidocaine infusion

Transversus abdominis plane block Epidural with local anesthetic (with

or without opioid), or intrathecal

opioid

Cognitive modalities

TENS

Total hip replacement Opioidsz NSAIDsx and/or acetaminophen Gabapentin or pregabalinx i.v. ketamine{

Intra-articular local anesthetic and/

or opioid

Site-specific regional anesthetic

technique with local anesthetic

Epidural with local anesthetic (with

or without opioid), or intrathecal

opioid

Cognitive modalities

TENS

Total knee replacement Opioidsz NSAIDsx and/or acetaminophen Gabapentin or pregabalinx i.v. ketamine{

Intra-articular local anesthetic and/

or opioid

Site-specific regional anesthetic

technique with local anesthetic

Epidural with local anesthetic (with

or without opioid), or intrathecal

opioid

Cognitive modalities

TENS

Spinal fusion Opioidsz Acetaminopheny Gabapentin or pregabalinx i.v. ketamine{

Local anesthetic at incision Epidural with local anesthetic (with

or without opioid), or intrathecal

opioid

Cognitive modalities

TENS

Cesarean section Opioidsz NSAIDsx and/or acetaminophen

Local anesthetic at incision Transversus abdominal plane block Epidural with local anesthetic (with

or without opioid), or intrathecal

opioid

Cognitive modalities

TENS

CABG Opioidsz Acetaminophen

Gabapentin or pregabalinx i.v. ketamine{

Cognitive modalities

TENS

Abbreviation: CABG, coronary artery bypass grafting.

NOTE. Blank cells indicate techniques generally not used for the procedure in question.

*Intra-articular, peripheral regional, and neuraxial techniques typically not used together.

yUse as adjunctive treatments. zUse i.v. PCA when parenteral route needed for more than a few hours and patients have adequate cognitive function to understand the device and safety limitations. xMay be administered preoperatively. {On the basis of panel consensus, primarily consider for use in opioid-tolerant or otherwise complex patients.

1 3 8

T h e Jo u rn a l o f P a in

M a n a g e m e n t o f P o sto

p e ra tive

P a in

Chou et al The Journal of Pain 139

differences compared with no cold therapy in postopera- tive pain or analgesic use.8,20,26,38,54, 61,67,72,87,101,125,136,168,169,176,214,236,253,255,269,299,306,311 Si- milarly, there is no clear evidence of beneficial effects from immobilization, bracing,312 or continuous passive motion.55,235,299 Evidence on warm insufflation of the abdominal cavity251 was limited and insufficient to guide recommendations.

Use of Cognitive–Behavioral Modalities

Recommendation 9

� The panel recommends that clinicians consider the use of cognitive–behavioral modalities in adults as part of a multimodal approach (weak recommenda- tion, moderate-quality evidence).

A number of cognitive–behavioral modalities have been evaluated as adjunctive treatments in patients who undergo surgery. These include guided imag- ery11,58,119,174,186,229,286,287 and other relaxation methods,44,60,86,89,106,107,119,204,229,256,304,305,308 hypnosis,16, 79,80,112,123,152,206,277 and intraoperative suggestions33, 34,36,82,150,181,196 (which involve positive suggestions to patients, usually under anesthesia, about the patient’s ability to manage and cope with postoperative pain and recovery from surgery). Music has been evaluated as a part of multicomponent relaxation interventions, or as a separate intervention.71,106,107,126,145,174,192,210,211,241, 259,263,282,285,319 Cognitive–behavioral modalities can be provided to patients by a variety of practitioners, including psychologists, psychotherapists, nurses, physicians, social workers, and child life specialists. Most studies of cognitive–behavioral modalities

showed some positive effects on postoperative pain, analgesic use, or anxiety, with inconsistent or unclear ef- fects on duration of hospitalization. In general, cogni- tive–behavioral modalities are noninvasive, and do not appear to be associated with significant harm. Although studies of cognitive–behavioral modalities have primar- ily been conducted in adults, a small number of studies of guided imagery and music have been conducted in children.142,156,171,187,188 Results have been inconsistent in terms of showing benefit on outcomes related to postoperative pain, with studies reporting limited detail on how interventions addressed specific developmental considerations in children. The panel recommends that clinicians consider the use

of cognitive–behavioral modalities as part of a multi- modal approach in adults. There is insufficient evidence to recommend one specific cognitive–behavioral modality over another, or to recommend specific techniques. Some of these techniques, such as guided imagery and some relaxation methods, appear to require patient engage- ment in preoperative training for optimal results. A num- ber of relaxation methods are available and it is uncertain which method is most effective, or whether the relaxation intervention is more effective if started before rather than after surgery. There is insufficient evidence to recommend for or against cognitive–behavioral modalities in children. When considering use of cognitive–behavioral modalities,

clinicians should discuss their use with patients and fam- ilies as part of an overall perioperative management plan.

Use of Systemic Pharmacological Therapies

Recommendation 10

� The panel recommends oral over intravenous (i.v.) administration of opioids for postoperative anal- gesia in patients who can use the oral route (strong recommendation, moderate quality evidence).

Most evidence suggests that i.v. administration of opi- oids is not superior for postoperative analgesia compared with oral administration.245,268 Therefore, oral administration of opioids is generally preferred for management of postoperative pain in patients who can use the oral route. Postoperative pain is often continuous initially and often requires round-the-clock dosing during the first 24 hours. Long-acting oral opioids are generally not recommended or labeled for use in the immediate postoperative period289 because of the need to titrate doses and the lack of evidence showing superi- ority over short-acting oral opioids, with the possible exception of patients who receive long-acting opioids before surgery. Preoperative administration of opioids is not recom-

mended as an intervention to decrease postoperative pain and/or opioid consumption, because studies show no clear benefit from this practice.215 Clinicians should counsel patients to continue regularly prescribed opioids during the preoperative period unless there is a plan to taper or discontinue opioids.

Recommendation 11

� The panel recommends that clinicians avoid using the intramuscular route for the administration of analgesics for management of postoperative pain (strong recommendation, moderate-quality evi- dence).

The use of the intramuscular route for the administra- tion of analgesics for management of postoperative pain is discouraged because intramuscular administration can cause significant pain and is associated with unreliable absorption, resulting in inconsistent postoperative anal- gesia. The intramuscular route also has no clearly shown advantages over other routes (eg, oral, i.v., rectal, or topical) of medication administration.268,283

Recommendation 12

� The panel recommends that i.v. patient-controlled analgesia (PCA) be used for postoperative systemic analgesia when the parenteral route is needed (strong recommendation, moderate-quality evi- dence).

When postoperative parenteral administration of an- algesics is necessary in hospitalized patients because of ileus, aspiration risk, or after surgical procedures that affect the ability to take medications orally or enterally,

140 The Journal of Pain Management of Postoperative Pain

the panel recommends the use of i.v. PCA. Patients appropriate for i.v. PCA are those who will require anal- gesia for more than a few hours and have adequate cognitive function to understand the device and its safety limitations. Research indicates that developmen- tally appropriate children as young as 6 years are able to use i.v. PCA appropriately.246,252 On the basis of evidence showing greater effectiveness and patient satisfaction,139 i.v. PCA is recommended over health care provider–initiated intermittent bolus dosing of opi- oids in adults. Administration by proxy should be avoided in adults, particularly when patients are sleeping, although limited evidence suggests that it can be done safely in children.10,205 I.v. boluses of opioids might be considered in the immediate (first several hours) postoperative period for more rapid pain relief and analgesic titration, and in patients with postoperative sedation who are closely monitored.215

Recommendation 13

� The panel recommends against routine basal infu- sion of opioids with i.v. PCA in opioid-naive adults (strong recommendation, moderate-quality evi- dence).

In patients who receive i.v. PCA, the panel does not recommend the routine use of basal infusion of opioids in opioid-naive patients, because most evidence shows no improved analgesia compared with PCA without a basal infusion.115,219,220,248 In addition, basal infusion of opioids is associated with an increased risk of nausea and vomiting, and in some studies with increased risk of respiratory depression in adults.99 Evidence on the utility of basal infusion of opioids in opioid-tolerant pa- tients who use PCA is lacking, but there might be a stron- ger rationale for its use because of the potential for underdosing and uncontrolled pain, as well as opioid withdrawal, particularly in patients who received long- term opioid therapy before surgery. There is insufficient evidence to guide recommendations on use of basal infusion of opioids in children, although some evidence suggests that a low basal rate can be used safely.317

Recommendation 14

� The panel recommends that clinicians provide appropriate monitoring of sedation, respiratory sta- tus, and other adverse events in patients who receive systemic opioids for postoperative analgesia (strong recommendation, low-quality evidence).

Because of the risk of excess sedation and respiratory depression, patients who receive systemic opioids for postoperative analgesia should be monitored closely in the initial hours after surgery or subsequent dose changes.149 Such monitoring should include assessments of alertness and signs or symptoms of hypoventilation or hypoxia. Although pulse oximetry is frequently used to monitor respiratory status in the postoperative period, it is unclear whether pulse oximetry is superior to nurse observation of respiratory rate and mental status, because randomized trials show no clear effect on clinical out- comes226 and pulse oximetry has low sensitivity for hypo-

ventilation when supplemental oxygen is being administered. Limited evidence suggests that capnogra- phy might be more sensitive than pulse oximetry in iden- tifying respiratory depression in patients receiving supplemental oxygen.193 However, there is insufficient ev- idence to guide firm recommendations on the use of cap- nography or other more sophisticated methods for monitoring. Risk factors for respiratory depression include a history of obstructive or central sleep apnea178,182 and use of other central nervous system depressant medications.149 In patients with excess sedation or signs of respiratory depression, clinicians should be prepared to change or reduce the opioid medication, support respi- ratory effort, and administer opioid antagonists when necessary. Clinicians should also assess for other common side effects associated with opioids, such as postoperative nausea and vomiting and opioid-induced constipation, which might be dose-limiting or require dose reductions if unresponsive to bowel regimens.

Recommendation 15

� The panel recommends that clinicians provide adults and children with acetaminophen and/or nonste- roidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoper- ative pain in patients without contraindications (strong recommendation, high-quality evidence).

Acetaminophen and NSAIDs have been evaluated as part of multimodal analgesia in patients also receiving opioids for management of postoperative pain. Most studies show use of acetaminophen or NSAIDs in conjunction with opioids is associated with less postoper- ative pain or opioid consumption than opioids alone.17,63,103,114,127,166,199 In addition, acetaminophen and NSAIDs have different mechanisms of action and research indicates that the combination of acetaminophen with NSAIDs might be more effective than either drug alone.216 Most research indicates no clear differences between i.v. versus oral administration of acetaminophen or NSAIDs in reducing postoperative pain,39,228,283 although onset of action might be faster with i.v. administration. NSAIDs are associated with increased risk of gastrointestinal bleeding and ulceration, cardiovascular events, and renal dysfunction that should be considered when selecting therapy; gastrointestinal risks are thought to be lower with the cyclooxygenase 2-selective NSAID celecoxib. Although animal studies suggest a link between bone nonunion after orthopedic surgeries and NSAID use, high-quality evidence on the effect of NSAIDs on nonunion rates after orthopedic surgical procedures is not available. Although some observational data suggest a possible as- sociation between high-dose NSAID use and nonunion in spinal fusion,68,177 the association was not statistically significant in an analysis restricted to higher-quality studies,68 and was not observed in children.274 Observa- tional studies suggest that NSAID use might be associ- ated with increased risk of anastomotic leakage after colorectal surgery.109,247,250 The panel found insufficient evidence to recommend against use of

Chou et al The Journal of Pain 141

NSAIDs in patients who undergo surgery for orthopedic fractures, spinal fusion, or colorectal surgery, but acknowledges the uncertainty about potential harms and that decisions be made after discussions with the surgeon, the patient, and consideration of alternatives. NSAIDs are contraindicated for management of perioperative pain in patients who undergo coronary artery bypass graft surgery because of an increased risk of cardiovascular events.290

Recommendation 16

� The panel recommends that clinicians consider giv- ing a preoperative dose of oral celecoxib in adult patients without contraindications (strong recom- mendation, moderate-quality evidence).

The panel recommends that clinicians consider use of preoperative celecoxib in patients who undergo major surgery. Celecoxib is associated with reduced opioid re- quirements after surgery, and some studies reported lower postoperative pain scores.74,138,146,161,239,275,303

The most common doses of celecoxib in the trials were 200 to 400 mg, administered 30 minutes to 1 hour preoperatively. Celecoxib is contraindicated in patients who undergo coronary artery bypass graft surgery, because of an increased risk of cardiovascular events.290

The panel found insufficient evidence to recommend a preoperative dose of nonselective NSAIDs. No trial compared benefits or harms of nonselective NSAIDs versus celecoxib or placebo in patients who underwent nondental surgical procedures.

Recommendation 17

� The panel recommends that clinicians consider use of gabapentin or pregabalin as a component of multimodal analgesia (strong recommendation, moderate-quality evidence).

The panel recommends use of gabapentin or pregaba- lin as part of a multimodal regimen in patients who un- dergo surgery. Both medications are associated with reduced opioid requirements after major or minor surgi- cal procedures, and some studies reported lower postop- erative pain scores.2,48,92,105,147,153,191,217,272,318 Both medications appear effective when administered as a preoperative dose (typical doses evaluated in trials were 600 or 1200 mg of gabapentin or 150 or 300 mg of pregabalin, administered 1–2 hours preoperatively), although some trials also found regimens that included postoperative dosing to be effective (typically gabapentin 600 mg as a single or in multiple doses and pregabalin 150 or 300 mg after 12 hours). The panel found insufficient evidence to determine optimal gabapentin and pregabalin doses; although higher doses might be more effective, they might also be associated with more sedation. Both drugs are only available in oral form, potentially limiting their use in the immediate postoperative period. The panel suggests that clinicians consider a preoperative dose of gabapentin or pregabalin, particularly in patients who undergo major surgery or other surgeries associated with substantial pain, or as part of multimodal therapy

for highly opioid-tolerant patients. Potential adverse ef- fects include dizziness and sedation that has not been linked to respiratory depression; dose reductions are rec- ommended in patients with impaired renal function. Although evidence on effectiveness of gabapentin or

pregabalin in children is limited, some randomized trials found beneficial effects of preoperative gabapentin on postoperative pain and opioid use.7,249

Recommendation 18

� The panel recommends that clinicians consider i.v. ketamine as a component of multimodal analgesia in adults (weak recommendation, moderate- quality evidence).

I.v. ketamine has been evaluated as a part of multi- modal analgesia. In adults and children, studies found i.v. ketamine infusions were associated with decreased postoperative pain medication use compared with pla- cebo, and in some studies with decreased postoperative pain scores.1,22,59,75,173,213 I.v. ketamine was also associated with decreased risk of persistent postsurgical pain.198 In the trials, ketamine was administered preop- eratively, intraoperatively, and/or postoperatively, at widely varying doses (ranging from boluses of .15– 2 mg/kg before incision and at closure, with or without infusions ranging from .12 mg/kg/h [2 mg/kg/min] to 2 mg/kg/h). There was insufficient evidence to determine the optimal method for dosing ketamine, but the panel suggests using a preoperative bolus of .5 mg/kg followed by an infusion at 10 mg/kg/min intraoperatively, with or without a postoperative infusion at a lower dosage.183

Ketamine was associated with increased risk of hallucina- tions and nightmares. Clinicians who administer keta- mine should be familiar with its use and adverse effects, and the panel suggests that ketamine be reserved for major surgeries. Some situations in which ketamine might be particularly useful include manage- ment of highly opioid-tolerant patients183 and patients who have difficulty tolerating opioids.

Recommendation 19

� The panel recommends that clinicians consider i.v. lidocaine infusions in adults who undergo open and laparoscopic abdominal surgery who do not have contraindications (weak recommendation, moderate-quality evidence).

I.v. lidocaine has been evaluated as a part of multimodal analgesia. In patients who underwent open or laparo- scopic abdominal surgical procedures, studies showed perioperative or intraoperative i.v. lidocaine infusions were associated with shorter duration of ileus and better quality of analgesia compared with placebo.189,296 In the trials, lidocaine was typically administered as a bolus (100–150 mg or 1.5–2.0 mg/kg) followed by an infusion of 2 to 3 mg/kg/h through the end of surgery. The panel found insufficient evidence to determine optimal dosing of lidocaine, but on the basis of clinical experience suggest an induction dose of 1.5 mg/kg followed by 2 mg/kg/h intraoperatively.66,84 Continuation of lidocaine in the postoperative period has not been well studied.

142 The Journal of Pain Management of Postoperative Pain

Use of Local and/or Topical Pharmacological Therapies

Recommendation 20

� The panel recommends that clinicians consider surgi- cal site–specific local anesthetic infiltration for surgi- cal procedures with evidence indicating efficacy (weak recommendation, moderate-quality evi- dence).

The use of subcutaneous and/or intraarticular infiltra- tion of long-acting local anesthetics at the surgical site has been shown to be effective as a component of multi- modal analgesia in several surgical procedures, including total knee replacement, arthroscopic knee surgeries, ce- sarean section, laparotomy, and hemorrhoid sur- gery,19,21,35,40,47,77,81,117,164,167,218,265 although some studies showed no benefit. Because evidence is somewhat mixed and because of the availability of alternative methods of postoperative analgesia, the panel does not recommend routine use of local anesthetic infiltration. Rather, use of local anesthetic infiltration should be on the basis of evidence showing benefit for the surgical procedure in question. Clinicians should be knowledgeable regarding specific local anesthetic infiltration techniques (including the use of extended-release formulations of local anesthetics such as liposomal bupivacaine),62 which vary depending on the surgical procedure. In addition, although data are limited, continuous intra-articular bupivacaine in pa- tients who undergo shoulder surgery might be associ- ated with chondrolysis,104,113,237 suggesting caution when considering this technique.

Recommendation 21

� The panel recommends that clinicians use topical local anesthetics in combination with nerve blocks before circumcision (strong recommendation, moderate-quality evidence).

In infants who undergo circumcision, evidence indi- cates effectiveness of topical anesthetics in combination with penile nerve block. Although studies indicate effec- tiveness of eutectic mixture of local anesthetics for this procedure, eutectic mixture of local anesthetics is associ- ated with risk of methemoglobinemia in infants younger than 3 months of age, with excessive applications, or when using other drugs associated with methemoglobi- nemia.175,278,279,288

Recommendation 22

� The panel does not recommend intrapleural analgesia with local anesthetics for pain control after thoracic surgery (strong recommendation, moderate-quality evidence).

Intrapleural analgesia with local anesthetics after thoracic surgery is not associated with clear beneficial ef- fects on postoperative pain, although results of studies were somewhat inconsistent.154 In addition, this tech- nique might be associated with potential toxicity because of the high systemic absorption of local anes- thetics from the intrapleural space. If intrapleural anal-

gesia with local anesthetics is used, it should be as part of a multimodal approach with close monitoring for po- tential toxicity.64

Use of Peripheral Regional Anesthesia

Recommendation 23

� The panel recommends that clinicians consider surgi- cal site–specific peripheral regional anesthetic tech- niques in adults and children for procedures with evidence indicating efficacy (strong recommenda- tion, high-quality evidence).

The use of peripheral regional anesthetic techniques have been shown to be effective as a component of multimodal analgesia for management of postoperative pain associated with a number of surgical procedures, including thoracotomy,154,155 lower extremity joint surgery,97,158,162,184,227,242,257,261,307,315 shoulder surgery,242 cesarean section,19 hemorrhoid surgery,209

and circumcision.14,135,163 Clinicians should consider use of surgical site–specific peripheral regional analgesic techniques in adults and children as part of multimodal analgesia, particularly in patients who undergo lower extremity and upper extremity surgical procedures. Clinicians should be familiar with the specific regional anesthetic techniques used, including use of ultrasound guidance, as well as the potential for motor blockade and risk of falls. Clinicians should also be aware of case reports of critical failures involving elastomeric pumps resulting in early delivery or complete emptying of the pump, in some cases resulting in death. Unlike electronic pumps, elastomeric pumps do not have alarms; if used, they require staff and patient and/or caregiver monitoring for pump failure and education regarding the signs and symptoms and emergency management of local anesthetic toxicity.

Recommendation 24

� The panel recommends that clinicians use contin- uous, local anesthetic–based peripheral regional analgesic techniques when the need for analgesia is likely to exceed the duration of effect of a single injection (strong recommendation, moderate- quality evidence).

Although single injection and continuous peripheral regional analgesic techniques are effective for postoper- ative analgesia in patients who undergo a number of sur- gical procedures,222,242 the use of continuous rather than single-injection peripheral techniques is preferred when the duration of postoperative pain is likely to be more prolonged, because of the limited duration of analgesia expected with a single injection.

Recommendation 25

� The panel recommends that clinicians consider the addition of clonidine as an adjuvant for prolonga- tion of analgesia with a single-injection peripheral neural blockade (weak recommendation, moderate-quality evidence).

Chou et al The Journal of Pain 143

For single-injection peripheral neural blockade with a local anesthetic, the combination of adjuvant agents administered as part of the injection might prolong the duration of analgesia and potentially reduce the need for a continuous infusion. In such circumstances, clini- cians might consider the use of clonidine as an adjuvant agent in persons who receive a single-injection periph- eral neural blockade. However, potential side effects must be weighed against any possible gains related to prolongation of analgesia. For instance, a meta-anal- ysis78,231 indicated that the addition of clonidine prolongs the duration of a single-injection peripheral neural blockade by approximately 2 hours, but is also associated with increased risk of hypotension, syncope, and sedation.

Use of Neuraxial Therapies

Recommendation 26

� The panel recommends that clinicians offer neurax- ial analgesia for major thoracic and abdominal pro- cedures, particularly in patients at risk for cardiac complications, pulmonary complications, or pro- longed ileus (strong recommendation, high-quality evidence).

Epidural analgesia with local anesthetics (with or without opioids) or spinal analgesia (intrathecal opioid) in adults and children is associated with lower postoper- ative pain scores or decreased rescue analgesic use compared with placebo injections or systemic opioid analgesia in patients who underwent a variety of sur- geries.154,212 Epidural or spinal analgesia might be associated with a decreased risk of postoperative mortality, venous thromboembolism, myocardial infarction, pneumonia, and respiratory depression, and decreased duration of ileus versus systemic analgesia, although such benefits were primarily observed in older trials that might have used outdated systemic analgesia techniques.18,232,233,243 Therefore, clinicians should routinely consider use of epidural or spinal analgesia for management of postoperative pain in patients who undergo major thoracic and abdominal procedures, cesarean section, and hip and lower extremity surgeries, particularly in patients at risk for cardiac complications, pulmonary complications, or prolonged ileus. A potential advantage of epidural analgesia is that it can be performed as a continuous infusion or as PCA with local anesthetics, whereas spinal analgesia is limited to a single dose of opioids. The coadministration of epidural clonidine with local anesthetics might be associated with improved analgesia in the postoperative period compared with epidural local anesthetic alone, but there is insufficient evidence to recommend its routine use and it is associated with increased risk of hypotension.90

Recommendation 27

� The panel recommends that clinicians avoid the neu- raxial administration of magnesium, benzodiaze- pines, neostigmine, tramadol, and ketamine in the

treatment of postoperative pain (strong recommen- dation, moderate-quality evidence).

Evidence on the effectiveness of adjuvant medications administered using the epidural or spinal route with local anesthetics (with or without opioids) is limited.90

Neuraxial administration of magnesium, benzodiaze- pines, neostigmine, tramadol, and ketamine in the treat- ment of postoperative pain is not recommended because of no clear benefit and insufficient evidence to deter- mine safety.13,52,208,294 In addition, most of these medications are not available in a preservative-free formulation.90

Recommendation 28

� The panel recommends that clinicians provide appropriate monitoring of patients who have received neuraxial interventions for perioperative analgesia (strong recommendation, low-quality evi- dence).

Although neuraxial analgesia is associated with a decreased risk of perioperative mortality and pulmonary and cardiac complications compared with systemic opi- oids, adverse effects including respiratory depression, hypotension, and motor weakness from spinal cord compression (due to infection or hematoma) can occur.154 In patients with hip and lower extremity sur- geries, neuraxial analgesia might mask symptoms of compartment syndrome. Therefore, clinicians should monitor patients who have received neuraxial interven- tions for these adverse effects and be prepared to treat with dose reductions, removal of catheters, opioid an- tagonists, decompression surgery for cord-impinging epidural hematoma or abscess, antibiotics, or other mea- sures as needed.

Organizational Structure, Policies, and Procedures

Recommendation 29

� The panel recommends that facilities in which surgery isperformedhaveanorganizationalstructureinplace to develop and refine policies and processes for safe and effective delivery of postoperative pain control (strong recommendation, low-quality evidence).

Facilities in which surgery is performed should have an organizational structure to oversee the development, im- plementation, and evaluation of policies and practices to assure safe, evidence-based, and effective postoperative pain control. Whether through an existing quality improvement committee or a designated pain manage- ment team, the process should ideally be interdisci- plinary. Findings in other areas of health care highlight the critical role of administrative and physician leadership including those most integrally involved in perioperative pain management for the success of such efforts.37

Measurement-driven models of care through outcomes assessment might be useful to guide quality improve- ment efforts in postoperative pain control. Although the specific measurement tools and methodology might vary, outcomes management should drive refinement of

144 The Journal of Pain Management of Postoperative Pain

policies and processes and health systems are encouraged to standardize and use valid and reliable measures.

Recommendation 30

� The panel recommends that facilities in which sur- gery is performed provide clinicians with access to consultation with a pain specialist for patients with inadequately controlled postoperative pain or at high risk of inadequately controlled postoperative pain (eg, opioid-tolerant, history of substance abuse) (strong recommendation, low-quality evidence).

Management of postoperative pain can be a chal- lenge, and require advanced assessment and manage- ment skills available from pain specialists. In some cases, postoperative pain might be inadequately controlled despite the use of standard multimodal in- terventions. Consultation or referral to a pain specialist might be necessary to assist in the manage- ment of such patients, to assist with diagnosis, inter- ventional treatment, or management of comorbid conditions. Facilities in which surgery is performed should ensure that access to such expertise is readily available when needed. Consultative expertise might also be required in pa-

tients with opioid tolerance, particularly in those with a history of substance abuse or addiction.120,144,244

Adequate pain treatment should not be withheld from patients with active or previous opioid addiction because of fears of worsening addiction or precipitation of relapse. In addition to the ethical requirement to address postoperative pain, poorly treated pain can be a trigger for relapse. Successful treatment of such individuals might include measures to prevent relapse and require the involvement of a specialist trained in the assessment and management of chemical dependency and addiction disorders. The clinical problems of underlying chronic pain, persistent acute pain, and addiction are each complex entities with biological, psychosocial, and functional components.134 An interdisciplinary approach using pharmacologic and nonpharmacologic interventions might be required to achieve successful postoperative outcomes and should be considered as part of the peri- operative management plan in these patients (Table 4).

Table 4. Management of Postoperative Pain in Pat

� Conduct preoperative evaluation to determine preoperative opioid use a � Provide education regarding use of opioids before surgery � Recognize that postoperative opioid requirements will typically be great � Consider pain specialty consultation (and in some cases behavioral and/or cases

� Consider nonpharmacological interventions � Transcutaneous electrical nerve stimulation � Cognitive–behavioral therapies

� Consider nonopioid systemic medications � Gabapentin or pregabalin � Ketamine

� Consider local anesthetic-based peripheral regional and neuraxial local a � Consider PCA with basal infusion of opioids for difficult to manage pain � Provide education and instructions on tapering opioids to target dose af

Recommendation 31

� The panel recommends that facilities in which neu- raxial analgesia and continuous peripheral blocks are performed have policies and procedures to sup- port their safe delivery and trained individuals to manage these procedures (strong recommendation, low-quality evidence).

Providers managing regional or neuraxial techniques should have the commensurate education, training, oversight, and experience to assure safe and effective therapy. Facilities that provide regional or neuraxial techniques should have clearly defined policies and pro- cedures in place for appropriate patient monitoring and competency based training and education for staff involved in caring for these patients. This should include clear and reliable means for hospital and nursing staff to reach the specialists managing these techniques.

Transitioning to Outpatient Care

Recommendation 32

� The panel recommends that clinicians provide edu- cation to all patients (adult and children) and pri- mary caregivers on the pain treatment plan including tapering of analgesics after hospital discharge (strong recommendation, low-quality evi- dence).

Research on methods and outcomes of discharge plan- ning and follow-up are scarce and insufficient to provide strong guidance on optimal methods.240 Nonetheless, anecdotal reports and clinical experience suggest the need for appropriate discharge teaching and coordina- tion of transition to the medical home as part of the post- operative pain management plan. A coordinated approach to discharge instruction is important, including advice from prescribers, nurses, physiotherapists, and pharmacists. Clarity should be established about with whom and when to follow-up for questions and transi- tion of care back to the primary provider. Patients should be counseled on how to take pain

medications safely and to manage side effects to opti- mize pain control and recovery with return to usual activ- ities. This might be particularly important for the

ients Receiving Long-Term Opioid Therapy

nd doses

er and that pain might be more difficult to control addiction consultation) for pain that is difficult to manage and complex

nalgesic techniques with appropriate monitoring ter discharge

Table 5. Summary of Interventions for Management of Postoperative Pain

INTERVENTION SUGGESTED USE COMMENTS CONTRAINDICATIONS AND CAUTIONS

Nonpharmacologic therapies

Transcutaneous electrical nerve

stimulation

Consider as an adjunct to other postoperative pain

management treatments

Typically applied at incision site Pacemaker or implanted defibrillator, lymphedema,

broken skin

Cognitive modalities Consider as an adjunct to other postoperative pain

management treatments

Includes guided imagery and other relaxation

methods, hypnosis, intraoperative suggestions, and

music

Might require preoperative education and patient

training for optimal results

None, caution in patients with history of psychosis

Systemic pharmacologic therapies

Acetaminophen and NSAIDs Use as component of multimodal analgesia No clear difference between i.v. and oral

administration

Reduces use of postoperative opioids

Celecoxib usually dosed at 200 to 400 mg

30 minutes to 1 hour preoperatively and then

200 mg b.i.d. postoperatively

Acetaminophen usually dosed at 500 to 1000 mg

p.o. or i.v. every 6 hours

Some observational evidence of association

between high-dose NSAIDs and nonunion in spinal

fusion and surgery for fractures, and between

NSAID use and anastomotic leak in intestinal

surgery.

NSAIDs contraindicated in patients who undergo

coronary artery bypass surgery.

Acetaminophen: hepatotoxicity

NSAIDs: gastrointestinal bleeding and ulceration,

cardiovascular events, renal dysfunction

Oral opioids Use as component of multimodal analgesia Oral is the preferred route for patients who can take

oral medications

Respiratory depression, potential for addiction and

abuse, sedation, nausea and vomiting, constipation

Patient controlled i.v. analgesia

with opioids

Use when the parenteral route is needed for

postoperative systemic analgesia for more than a

few hours

Avoid basal infusion of opioids in opioid naive adults See oral opioids

Gabapentin and pregabalin Consider as a component of multimodal analgesia,

primarily studied in patients who underwent major

surgery, opioid-sparing

Gabapentin doses vary; in trials usually dosed at 600 to

1200 mg 1 to 2 hours preoperatively, 600 mg

postoperatively (single or multiple doses)

Pregabalin doses vary; in trials usually dosed at 100

or 300 mg preoperatively, or 150 or 300 mg

preoperatively followed by the same dose 12 hours

later

Higher doses might be more effective, but might

also be associated with increased sedation

Dizziness, sedation; reduced dose with renal

dysfunction

C h o u e t a l

T h e Jo u rn a l o f P a in

1 4 5

Table 5. Continued

INTERVENTION SUGGESTED USE COMMENTS CONTRAINDICATIONS AND CAUTIONS

Ketamine i.v. Consider as a component of multimodal analgesia, in

patients who undergo major surgery, opioid-

sparing

Dosing varies widely, consider preoperative bolus of

.5 mg/kg followed by an infusion at 10 mg/kg/min

intraoperatively, with or without a postoperative

infusion at a lower dose

Limited evidence for use in children

Patients with history of psychosis.

Hallucinations, nightmares, dissociative symptoms

Lidocaine i.v. Consider as a component of multimodal analgesia in

patients who undergo open and laparoscopic

abdominal surgery

Dosing varies, consider induction dose of 1.5 mg/kg

followed by 2 mg/kg/h intraoperatively

Conduction block

Dizziness, seizures, bradycardia

Local, intra-articular, and topical

therapies

Local anesthetic infiltration Use local anesthetic infiltration at incision site for

surgical procedures for which there is evidence

showing benefit (examples: cesarean section,

laparotomy, and hemorrhoid surgery)

Clinicians should be knowledgeable regarding specific

local anesthetic infiltration techniques

See Lidocaine i.v. above; also local pain, infection,

bleeding

Intra-articular local anesthetic

and/or opioid

Use intra-articular injections for surgical procedures

for which there is evidence of benefit (examples:

hip, knee, and shoulder surgery)

Clinicians should be knowledgeable regarding specific

intra-articular injection techniques.

Caution with use of continuous intra-articular

bupivacaine in shoulder surgery because of

association with chondrolysis

See Lidocaine i.v. and Oral opioids; also local pain,

infection, bleeding; potential chondrolysis with

intra-articular shoulder injections

Topical local anesthetics Use in combination with penile nerve block in infants

undergoing circumcision

4% Liposomal lidocaine or eutectic mixture of local

anesthetics, lidocaine and procaine

See Lidocaine i.v.; also local pain, infection, bleeding,

rash

Peripheral regional and neuraxial

analgesic therapies

Peripheral regional anesthetic

techniques

Use as part of multimodal analgesia for surgical

procedures for which there is evidence of benefit

(examples: thoracotomy, lower or upper extremity

surgery, hemorrhoid surgery, circumcision)

Clinicians should be familiar with specific regional

anesthetic techniques

Use continuous over single injection techniques

when longer duration of analgesia is required

See Lidocaine; also potential for falls

Neuraxial analgesia (epidural with

local anesthetic [with or without

opioids] or intrathecal opioid)

Use for major thoracic, abdominal, cesarean section,

and lower extremity surgery

No clear difference between continuous infusion with

epidural catheter versus single dose of intrathecal

morphine

See Lidocaine and Oral opioids; also motor weakness

and risk of falls

Abbreviations: b.i.d., twice per day; p.o., orally.

NOTE. Table data are not listed in order of preference or strength of evidence. The choice of treatments must be made on the basis of comprehensive patient assessment and the available evidence with consideration of multiple factors

including individual risk factors for adverse events, comorbidities, cost, patient response; combinations of medications and techniques are often indicated. Doses are for typical adults.

1 4 6

T h e Jo u rn a l o f P a in

M a n a g e m e n t o f P o sto

p e ra tive

P a in

Chou et al The Journal of Pain 147

growing number of outpatient surgical patients. Pa- tients and families should be informed that the use of other central nervous depressants (including alcohol) or illicit drugs in combination with opioids can result in acci- dental overdose and death. Discharge teaching should include a discussion of the plan for reduction and discon- tinuation of opioids as the acute pain resolves, as well as appropriate disposal of unused supplies of opioids and other medications. There is insufficient evidence to guide firm recommendation on how to wean patients with postoperative pain off of opioids. Although severe pain after surgery tends to diminish rapidly in the first few days, postoperative pain can persist for months, highlighting the need for an individualized approach. For some minor surgeries, it might be appropriate to discharge patients with use of acetaminophen or NSAIDs or a very limited supply of opioids before the transition to acetaminophen or NSAIDs. In general, patients not receiving long-term opioid therapy before surgery and treated with opioids for more than 1 to 2 weeks should be instructed to gradually reduce the opioid dose to pre- vent signs and symptoms of severe withdrawal. Dose re- ductions of approximately 20–25% of the discharge dose every day or two can be tolerated by most patients when pain is improving. Patients chronically prescribed opioids before surgery should be instructed on how to taper their opioid to their target maintenance dose.

Conclusions After a review of the evidence, an expert panel

convened by the APS, with input from the ASA, devel- oped recommendations to promote effective manage- ment of postoperative pain; the recommendations were subsequently approved by the APS, the American Society of Regional Anesthesia and Pain Medicine, and the ASA Committee on Regional Anesthesia, Executive Committee, and Administrative Council. The recommen- dations are on the basis of the underlying premise that optimal management begins in the preoperative period and is on the basis of an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved, with follow-up as- sessments and adjustments as needed. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the pa- tient, setting, and surgical procedure. Suggested uses for

various interventions for management of postoperative pain are summarized in Table 5. Although these guidelines are based on a systematic

review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, the panel rated only 4 as sup- ported by high-quality evidence, and 11 recommenda- tions were on the basis of low-quality evidence. Nonetheless, the panel came to near-unanimous consensus on almost all of its recommendations. Research is urgently needed on optimal methods for managing patients who receive opioids before surgery, effectiveness of opioid-sparing multimodal regimens, optimal methods of pain assessment and monitoring, and a number of areas related to management of periop- erative pain in infants and children. There is also an ur- gent need to fund and conduct research on practice gaps regarding use of evidence-based interventions for management of postoperative pain.

Note Clinical practice guidelines are ‘‘guides’’ only and

might not apply to all patients and all clinical situations. As part of a shared decision-making approach, it might be appropriate for the clinician to inform a patient that a particular recommendation might not be appli- cable, after considering all circumstances pertinent to that individual. This guideline was approved by the ASA Committee on Regional Anesthesia, Executive Com- mittee, and Administrative Council in October 2015. It has not been approved by ASA’s House of Delegates or Board of Directors and does not represent an official or approved statement or policy of the ASA.

Acknowledgments The authors thank Leelee K. Thames, Tracy Dana, and

Miranda Pappas for reviewing literature and data abstraction, and Miranda Pappas for administrative sup- port.

Supplementary Data Supplementary data related to this article can be

found online at http://dx.doi.org/10.1016/j.jpain.2015. 12.008.

References

1. Abu-Shahwan I: Ketamine does not reduce postoperative morphine consumption after tonsillectomy in children. Clin J Pain 24:395-398, 2008

2. Agarwal A, Gautam S, Gupta D, Agarwal S, Singh PK, Singh U: Evaluation of a single preoperative dose of prega- balin for attenuation of postoperative pain after laparo- scopic cholecystectomy. Br J Anaesth 101:700-704, 2008

3. Aissaoui Y, Zeggwagh A, Zekraoui A, Abidi K, Abougal R: Validation of a behavioral pain scale in critically ill, sedated,

and mechanically ventilated patients. Anesth Analg 101: 1470-1476, 2005

4. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM: Long-term analgesic use after low-risk surgery: A retrospectivecohortstudy.ArchInternMed172:425-430,2012

5. American Pain Society: Management of Acute Pain and Cancer Pain with Analgesics. In: American Pain Society. Principles of Analgesic Use. 8th ed. Glenview, IL, American Pain Society, 22-23, 2008

6. American Society of Anesthesiologists: Practice guide- lines for acute pain management in the perioperative

148 The Journal of Pain Management of Postoperative Pain

setting: An updated report by the American Society of Anes- thesiologists Task Force on Acute Pain Management. Anes- thesiology 116:248-273, 2012

7. Amin SM, Amr YM: Comparison between preemptive gabapentin and paracetamol for pain control after ad- enotonsillectomy in children. Anesth Essays Res 5: 167-170, 2011

8. Amin-Hanjani S, Corcoran J, Chatwani A: Cold therapy in the management of postoperative cesarean section pain. Am J Obstet Gynecol 167:108-109, 1992

9. Anderson EA: Preoperative preparation for cardiac sur- gery facilitates recovery, reduces psychological distress, and reduces the incidence of acute postoperative hyperten- sion. J Consult Clin Psychol 55:513-520, 1987

10. Anghelescu D, Faughnan L, Oakes L, Windsor K, Pei D: Parent-controlled PCA for pain management in pediatric oncology: Is it safe? J Pediatr Hematol Oncol 34:416-420, 2013

11. Antall GF, Kresevic D: The use of guided imagery to manage pain in an elderly orthopaedic population. Orthop Nurs 23:335-340, 2004

12. Apfelbaum JL, Chen C, Mehta SS, Gan TJ: Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 97:534-540, 2003

13. Arcioni R, Palmisani S, Tigano S, Santorsola C, Sauli V, Romano S, Mercieri M, Masciangelo R, De Blasi RA, Pinto G: Combined intrathecal and epidural magnesium sulfate supplementation of spinal anesthesia to reduce post-operative analgesic requirements: A prospective, ran- domized, double-blind, controlled trial in patients undergo- ing major orthopedic surgery. Acta Anaesthesiol Scand 51: 482-489, 2007

14. Arnett RM, Jones JS, Horger EO: Effectiveness of 1% lidocaine dorsal penile nerve block in infant circumcision. Am J Obstet Gynecol 163:1074-1080, 1990

15. Arthur HM, Daniels C, McKelvie R, Hirsh J, Rush B: Effect of a preoperative intervention on preoperative and postop- erative outcomes in low-risk patients awaiting elective coro- nary artery bypass graft surgery. A randomized, controlled trial. Ann Intern Med 133:253-262, 2000

16. Ashton C Jr, Whitworth GC, Seldomridge JA, Shapiro PA, Weinberg AD, Michler RE, Smith CR, Rose EA, Fisher S, Oz MC: Self-hypnosis reduces anxiety following coronary ar- tery bypass surgery. A prospective, randomized trial. J Cardi- ovasc Surg (Torino) 38:69-75, 1997

17. Aubrun F, Langeron O, Heitz D, Coriat P, Riou B: Rando- mised, placebo-controlled study of the postoperative anal- gesic effects of ketoprofen after spinal fusion surgery. Acta Anaesthesiol Scand 44:934-939, 2000

18. Ballantyne JC, Carr DB, deFerranti S, Suarez T, Lau J, Chalmers TC, Angelillo IF, Mosteller F: The comparative ef- fects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 86:598-612, 1998

19. Bamigboye AA, Hofmeyr GJ: Local anesthetic wound infiltration and abdominal nerves block during caesarean section for postoperative pain relief. Cochrane Database Syst Rev CD006954, 2009

20. Barber FA, McGuire DA, Click S: Continuous-flow cold therapy for outpatient anterior cruciate ligament recon- struction. Arthroscopy 14:130-135, 1998

21. Batra YK, Mahajan R, Kumar S, Rajeev S, Singh Dhillon M: A dose-ranging study of intraarticular midazo- lam for pain relief after knee arthroscopy. Anesth Analg 107:669-672, 2008

22. Bell RF, Dahl JB, Moore RA, Kalso EA: Perioperative keta- mine for acute postoperative pain. Cochrane Database Syst Rev CD004603, 2009

23. Benedetti F, Amanzio M, Casadio C, Cavallo A, Cianci R, Giobbe R, Mancuso M, Ruffini E, Maggi G: Control of post- operative pain by transcutaneous electrical nerve stimula- tion after thoracic operations. Ann Thorac Surg 63: 773-776, 1997

24. Bergh I, Sjostrom B, Oden A, Steen B: An application of pain rating scales in geriatric patients. Aging Clin Exp Res 12: 380-387, 2000

25. Bergh I, Sj€ostr€om B, Od�en A, Steen B: Assessing pain and pain relief in geriatric patients with nonpathological frac- tures with different rating scales. Aging Clin Exp Res 13: 355-361, 2001

26. Bert J: The effect of cold therapy on morbidity subse- quent to arthroscopic lateral retinacular release. Orthop Rev 20:755-758, 1991

27. Beyer JE, Aradine C: The convergent and discriminant validity of a self-report measure of pain intensity for chil- dren. Child Health Care 16:274-282, 1988

28. Beyer JE, Bournaki MC: Assessment and management of postoperative pain in children. Pediatrician 16:30-38, 1989

29. Beyer JE, Denyes MJ, Villarruel AM: The creation, valida- tion, and continuing development of the Oucher: A measure of pain intensity in children. J Pediatr Nurs 7:335-346, 1992

30. Beyer JE, Villarruel AM, Deynes MJ: The Oucher: User’s Manual and Technical Report. Available at: http://www. oucher.org/downloads/2009_Users_Manual.pdf. Accessed January 8, 2016

31. Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB: The faces pain scale for the self-assessment of the severity of pain experienced by children: Development, initial valida- tion, and preliminary investigation for ratio scale properties. Pain 41:139-150, 1990

32. Bjordal JM, Johnson MI, Ljunggreen AE: Transcutaneous electrical nerve stimulation (TENS) can reduce postoperative analgesic consumption. A meta-analysis with assessment of optimal treatment parameters for postoperative pain. Eur J Pain 7:181-188, 2003

33. Block RI, Ghoneim MM, Sum Ping ST, Ali MA: Efficacy of therapeutic suggestions for improved postoperative recov- ery presented during general anesthesia. Anesthesiology 75:746-755, 1991

34. Boeke S, Bonke B, Bouwhuis-Hoogerwerf ML, Bovill JG, Zwaveling A: Effects of sounds presented during general anaesthesia on postoperative course. Br J Anaesth 60: 697-702, 1988

35. Bondok RS, Abd El-Hady AM: Intra-articular magnesium is effective for postoperative analgesia in arthroscopic knee surgery. Br J Anaesth 97:389-392, 2006

36. Bonke B, Schmitz PI, Verhage F, Zwaveling A: Clinical study of so-called unconscious perception during general anesthesia. Br J Anaesth 58:957-964, 1986

37. Bradley EH, Herrin J, Mattera JA, Holmboe ES, Wang Y, Frederick P, Roumanis SA, Radford MJ, Krumholz HM:

Chou et al The Journal of Pain 149

Quality improvement efforts and hospital performance: Rates of beta-blocker prescription after acute myocardial infarction. Med Care 43:282-292, 2005

38. Brandsson S, Rydgren B, Hedner T, Eriksson BI, Lundin O, Sward L, Karlsson J: Postoperative analgesic effects of an external cooling system and intra-articular bupivacaine/ morphine after arthroscopic cruciate ligament surgery. Knee Surg Sports Traumatol Arthrosc 4:200-205, 1996

39. Brett CN, Barnett SG, Pearson J: Postoperative plasma paracetamol levels following oral or intravenous paraceta- mol administration: A double-blind randomised controlled trial. Anaesth Intensive Care 40:166-171, 2012

40. Brunat G, Pouzeratte Y, Mann C, Didelot JM, Rochon JC, Eledjam JJ: Posterior perineal block with ropivacaine 0.75% for pain control during and after hemorrhoidectomy. Reg Anesth Pain Med 28:228-232, 2003

41. Buchholz M, Karl HW, Pomietto M, Lynn A: Pain scores in infants: A modified infant pain scale versus visual analogue. J Pain Symptom Manage 15:117-124, 1998

42. Butler GS, Hurley CAM, Buchanan KL, Smith-VanHorne J: Prehospital education: Effectiveness with total hip replace- ment surgery patients. Patient Educ Couns 29:189-197, 1996

43. Buttner W, Finke W: Analysis of behavioural and physio- logical parameters for the assessment of postoperative anal- gesic demand in newborns, infants and young children: A comprehensive report on seven consecutive studies. Pae- diatr Anaesth 10:303-318, 2000

44. Ceccio CM: Postoperative pain relief through relaxation in elderly patients with fractured hips. Orthop Nurs 3:11-19, 1984

45. Chambers CT, Reid GJ, McGrath PJ, Finley GA: Develop- ment and preliminary validation of a postoperative pain measure for parents. Pain 68:307-313, 1996

46. Chambers CT, Reid GJ, McGrath PJ, Finley GA, Ellerton ML: A randomized trial of a pain education booklet: Effects on parents’ attitudes and postoperative pain man- agement. Child Health Care 26:1-13, 1997

47. Chan ST: Intra-articular morphine and bupivacaine for pain relief after therapeutic arthroscopic knee surgery. Singapore Med J 36:35-37, 1995

48. Chang SH, Lee HW, Kim HK, Kim SH, Kim DK: An evalu- ation of perioperative pregabalin for prevention and atten- uation of postoperative shoulder pain after laparoscopic cholecystectomy. Anesth Analg 109:1284-1286, 2009

49. Cheng SF, Foster RL, Hester NO: A review of factors pre- dicting children’s pain experiences. Issues Compr Pediatr Nurs 26:203-216, 2003

50. Chibnall JT, Tait RC: Pain assessment in cognitively impaired and unimpaired older adults: A comparison of four scales. Pain 92:173-186, 2001

51. Chou R, Thames LL, Dana T, Pappas M, Mitchell JP: Evi- dence Review on the Management of Postoperative Pain. Glenview, IL, American Pain Society, 2016

52. Chung CJ, Kim JS, Park HS, Chin YJ: The efficacy of intra- thecal neostigmine, intrathecal morphine, and their combi- nation for post-cesarean section analgesia. Anesth Analg 87: 341-346, 1998

53. Closs SJ, Barr B, Briggs M, Cash K, Seers K: A comparison of five pain assessment scales for nursing home residents

with varying degrees of cognitive impairment. J Pain Symp- tom Manage 27:196-205, 2004

54. Cohn BT, Draeger RI, Jackson DW: The effects of cold therapy in the postoperative management of pain in pa- tients undergoing anterior cruciate ligament reconstruc- tion. Am J Sports Med 17:344-349, 1989

55. Colwell CW, Morris BA: The influence of continuous pas- sive motion on the results of total knee arthroplasty. Clin Or- thop Relat Res 276:225-228, 1992

56. Committee on Advancing Pain Research, Care, and Ed- ucation: Relieving Pain in America: A Blueprint for Trans- forming Prevention, Care, Education, and Research. Washington, DC, Institute of Medicine of the National Academies, 2011

57. Crowe J, Henderson J: Pre-arthroplasty rehabilitation is effective in reducing hospital stay. Can J Occup Ther 70: 88-96, 2003

58. Daake DR, Gueldner SH: Imagery instruction and the control of postsurgical pain. Appl Nurs Res 2:114-120, 1989

59. Dal D, Celebi N, Elvan EG, Celiker V, Aypar U: The efficacy of intravenous or peritonsillar infiltration of ketamine for postoperative pain relief in children following adenotonsil- lectomy. Paediatr Anaesth 17:263-269, 2007

60. Daltroy LH, Morlino CI, Eaton HM, Poss R, Liang MH: Pre- operative education for total hip and knee replacement pa- tients. Arthritis Care Res 11:469-478, 1998

61. Daniel DM: The effect of cold therapy on pain, swelling and range of motion after anterior cruciate ligament recon- structive surgery. Arthroscopy 10:530-533, 1994

62. Dasta J, Ramamoorthy S, Patou G, Sinatra R: Bupivacaine liposome injectable suspension compared with bupivacaine HCl for the reduction of opioid burden in the postsurgical setting. Curr Med Res Opin 28:1609-1615, 2012

63. DeAndrade JR, Maslanka M, Reines HD, Howe D, Rasmussen GL, Cardea J, Brown J, Bynum L, Shefrin A, Chang YL, Maneatis T: Ketorolac versus meperidine for pain relief after orthopaedic surgery. Clin Orthop Relat Res;301-312, 1996

64. Demmy TL, Nwogu C, Solan P, Yendamuri S, Wilding G, DeLeon O: Chest tube-delivered bupivacaine improves pain and decreases opioid use after thoracoscopy. Ann Thorac Surg 87:1040-1046, 2009. discussion: 1046-1047

65. Deng G, Rusch V, Vickers A, Malhotra V, Ginex P, Downey R, Bains M, Park B, Rizk N, Flores R, Yeung S, Cassiletha B: Randomized controlled trial of a special acupuncture technique for pain after thoracotomy. J Thorac Cardiovasc Surg 136:1464-1469, 2008

66. De Oliveira GS, Duncan K, Fitzgerald P, Nader A, Gould RW, McCarthy RJ: Systemic lidocaine to improve qual- ity of recovery after laparoscopic bariatric surgery: A ran- domized double-blinded placebo-controlled trial. Obes Surg 24:212-218, 2014

67. Dervin GF: Effects of cold and compression dressings on early postoperative outcomes for the arthroscopic anterior cruciate ligament reconstruction patient. J Orthop Sports Phys Ther 27:403-406, 1998

68. Dodwell ER, Latorre JG, Parisini E, Zwettler E, Chandra D, Mulpuri K: NSAID exposure and risk of nonunion: A meta- analysis of case-control and cohort studies. Calcif Tissue Int 87:193-202, 2010

150 The Journal of Pain Management of Postoperative Pain

69. Doering S, Katzlberger F, Rumpold G, Roessler S, Hofstoetter B, Schatz DS, Behensky H, Krismer M, Luz G, Innerhofer P, Benzer H, Saria A, Schuessler G: Videotape preparation of patients before hip replacement surgery re- duces stress. Psychosom Med 62:365-373, 2000

70. Donovan M, Evers K, Jacobs P, Mandleblatt S: When there is no benchmark: Designing a primary care-based chronic pain management program from the scientific basis up. J Pain Symptom Manage 18:38-48, 1999

71. Ebneshahidi A, Mohseni M: The effect of patient- selected music on early postoperative pain, anxiety, and he- modynamic profile in cesarean section surgery. J Altern Complement Med 14:827-831, 2008

72. Edwards DJ, Rimmer M, Keene GC: The use of cold ther- apy in the postoperative management of patients undergo- ing arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med 24:193-195, 1996

73. Egbert LD, Battit GE, Welch CE, Bartlett MK: Reduction of postoperative pain by encouragement and instruction of patients. A study of doctor-patient rapport. N Engl J Med 270:825-827, 1964

74. Ekman EF, Wahba M, Ancona F: Analgesic efficacy of perioperative celecoxib in ambulatory arthroscopic knee surgery: A double-blind, placebo-controlled study. Arthros- copy 22:635-642, 2006

75. Elhakim M, Khalafallah Z, El-Fattah HA, Farouk S, Khattab A: Ketamine reduces swallowing-evoked pain after paediatric tonsillectomy. Acta Anaesthesiol Scand 47: 604-609, 2003

76. Elia N, Lysakowski C, Tramer MR: Does multimodal anal- gesia with acetaminophen, nonsteroidal anti-inflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient- controlled analgesia morphine offer advantages over morphine alone? Anesthesiology 103:1296-1304, 2005

77. Elsharnouby NM, Eid HE, Abou Elezz NF, Moharram AN: Intraarticular injection of magnesium sulphate and/or bupi- vacaine for postoperative analgesia after arthroscopic knee surgery. Anesth Analg 106:1548-1552, 2008

78. Engelman E, Marsala C: Efficacy of adding clonidine to intrathecal morphine in acute postoperative pain: Meta- analysis. Br J Anaesth 110:21-27, 2013

79. Enqvist B, Bjorklund C, Engma M, Jakobsson J: Preoper- ative hypnosis reduces postoperative vomiting after surgery of the breasts: A prospective, randomized, and blinded study. Acta Anaesthesiol Scand 41:1028-1032, 1997

80. Enqvist B, von Konow L, Bystedt H: Stress reduction, pre- operative hypnosis and perioperative suggestion in maxillo- facial surgery: Somatic response and recovery. Stress Med 11: 229-233, 1995

81. Ersayli DT, Gurbet A, Bekar A, Uckunkaya N, Bilgin H: Ef- fects of perioperatively administered bupivacaine and bupivacaine-methylprednisolone on pain after lumbar dis- cectomy. Spine 31:2221-2226, 2006

82. Evans C, Richardson PH: Improved recovery and reduced postoperative stay after therapeutic suggestions during general anaesthesia. Lancet 2:491-493, 1988

83. Faces Pain Scale - Revised (FPS-R). Available at: http:// www.iasp-pain.org/files/Content/ContentFolders/Resources 2/FPSR/FPS-R_English.pdf. Accessed October 30, 2014

84. Farag Erial M, Sessle DI, Ghobrial M, Dalton JE, Liu J, Lee JH, Zaky S, Benzel E, Bingaman W, Kurz A: Effect of

perioperative intravenous lidocaine administration on pain, opioid consumption, and quality of life after complex spine surgery. Anesthesiology 119:932-940, 2013

85. Felhendler D, Lisander B: Pressure on acupoints de- creases postoperative pain. Clin J Pain 12:326-329, 1996

86. Field PB: Effects of tape-recorded hypnotic preparation for surgery. Int J Clin Exp Hypn 22:54-61, 1974

87. Finan MA, Roberts WS, Hoffman MS, Fiorica JV, Cavanagh D, Dudney BJ: The effects of cold therapy on post- operative pain in gynecologic patients: A prospective, ran- domized study. Am J Obstet Gynecol 168:542-544, 1993

88. Finley GA, Chambers CT, McGrath PJ, Walsh TM: Construct validity of the parents’ postoperative pain mea- sure. Clin J Pain 19:329-334, 2003

89. Flaherty GG, Fitzpatrick JJ: Relaxation technique to in- crease comfort level of postoperative patients: A prelimi- nary study. Nurse Res 27:352-355, 1978

90. Fogarty DJ, Carabine UA, Milligan KR: Comparison of the analgesic effects of intrathecal clonidine and intra- thecal morphine after spinal anaesthesia in patients undergoing total hip replacement. Br J Anaesth 71: 661-664, 1993

91. Forchuk C, Baruth P, Prendergast M, Holliday R, Bareham R, Brimner S, Schulz V, Chan YCL, Yammine N: Post- operative arm massage: A support for women with lymph node dissection. Cancer Nurs 27:25-33, 2004

92. Freedman BM, O’Hara E: Pregabalin has opioid-sparing effects following augmentation mammoplasty. Aesthet Surg J 28:421-424, 2008

93. Freeman K, Smyth C, Dallam L, Jackson B: Pain measure- ment scales: A comparison of the visual analogue and faces rating scales in measuring pressure ulcer pain. J Wound Os- tomy Continence Nurs 28:290-296, 2001

94. Gagliese L, Katz J: Age differences in postoperative pain are scale dependent: A comparison of measures of pain in- tensity and quality in younger and older surgical patients. Pain 103:11-20, 2003

95. Gagliese L, Weizblit N, Ellis W, Chan VW: The measure- ment of postoperative pain: A comparison of intensity scales in younger and older surgical patients. Pain 117:412-420, 2005

96. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL: Incidence, patient satisfaction, and perceptions of post- surgical pain: Results from a US national survey. Curr Med Res Opin 30:149-160, 2014

97. Ganapathy S, Wasserman RA, Watson JT, Bennett J, Armstrong KP, Stockall CA, Chess DG, MacDonald C: Modi- fied continuous femoral three-in-one block for postopera- tive pain after total knee arthroplasty. Anesth Analg 89: 1197-1202, 1999

98. Gelinas C, Fillion L, Puntillo K, Viens C, Fortier M: Valida- tion of the critical-care pain observation tool in adult pa- tients. Am J Crit Care 15:420-427, 2006

99. George JA, Lin EE, Hanna MN, Murphy JD, Kumar K, Ko PS, Wu CL: The effect of intravenous opioid patient- controlled analgesia with and without background infusion on respiratory depression: A meta-analysis. J Opioid Manag 6:47-54, 2010

100. Ghai B, Makkar JK, Wig J: Postoperative pain assess- ment in preverbal children and children with cognitive impairment. Paediatr Anaesth 18:462-477, 2008

Chou et al The Journal of Pain 151

101. Gibbons CE, Solan MC, Ricketts DM, Patterson M: Cryo- therapy compared with Robert Jones bandage after total knee replacement: A prospective randomized trial. Int Or- thop 25:250-252, 2001

102. Gilbert JM: Controlled trial of transcutaneous electrical nerve stimulation (TENS) for postoperative pain relief following inguinal herniorrhaphy. Br J Surg 73:749-751, 1986

103. Gimbel JS, Brugger A, Zhao W, Verburg KM, Geis GS: Ef- ficacy and tolerability of celecoxib versus hydrocodone/acet- aminophen in the treatment of pain after ambulatory orthopedic surgery in adults. Clin Ther 23:228-241, 2001

104. Gomoll A, Kang R, Williams J, Bach B, Cole B: Chondrol- ysis after continuous intra-articular bupivacaine infusion: An experimental model investigating chondrotoxicity in the rabbit shoulder. Arthroscopy 22:813-819, 2006

105. Gonano C, Latzke D, Sabeti-Aschraf M, Kettner SC, Chiari A, Gustorff B: The anxiolytic effect of pregabalin in outpatients undergoing minor orthopedic surgery. J Psycho- pharmacol 25:249-253, 2011

106. Good M: A comparison of the effects of jaw relaxation and music on postoperative pain. Nurse Res 44:52-57, 1995

107. Good M, Stanton-Hicks M, Grass JA, Cranston Anderson G, Choi C, Schoolmeesters LJ, Salman A: Relief of postoperative pain with jaw relaxation, music and their combination. Pain 81:163-172, 1999

108. Gordon DB, Dahl J, Phillips P, Frandsen J, Cowley C, Foster RL, Fine PG, Miaskowski C, Fishman S, Finley RS: The use of ‘‘as-needed’’ range orders for opioid analgesics in the management of acute pain: A consensus statement of the American Society for Pain Management Nursing and the American Pain Society. Pain Manag Nurs 5:53-58, 2004

109. Gorissen KJ, Benning D, Berghmans T, Snoeijs MG, Sosef MN, Hulsewe KW, Luyer MD: Risk of anastomotic leakage with non-steroidal anti-inflammatory drugs in colo- rectal surgery. Br J Surg 99:721-727, 2012

110. Gould TH, Crosby DL, Harmer M, Lloyd SM, Lunn JN, Rees GAD, Roberts DE, Webster JA: Policy for controlling pain after surgery: Effect of sequential changes in manage- ment. BMJ 305:1187-1193, 1992

111. Grabow L: Controlled study of the analgetic effectivity of acupuncture. Arzneimittelforschung 44:554-558, 1994

112. Greenleaf M, Fisher S, Miakowki C, DuHamel K: Hypno- tizability and recovery from cardiac surgery. Am J Clin Hypn 35:119-128, 1992

113. Greis P, Burks R: Bilateral shoulder chondrolysis following arthroscopy. A report of two cases. J Bone Joint Surg Am 90:2547-2548, 2008

114. Grundmann U, Wornle C, Biedler A, Kreuer S, Wrobel M, Wilhelm W: The efficacy of the non-opioid anal- gesics parecoxib, paracetamol and metamizol for postoper- ative pain relief after lumbar microdiscectomy. Anesth Analg 103:217-222, 2006

115. Guler T, Unlugenc H, Gundogan Z, Ozalevli M, Balcioglu O, Topcuoglu MS: A background infusion of morphine enhances patient-controlled analgesia after car- diac surgery. Can J Anaesth 51:718-722, 2004

116. Gupta S, Francis JD, Tillu AB, Sattirajah AI, Sizer J: The effect of pre-emptive acupuncture treatment on analgesic requirements after day-case knee arthroscopy. Anaesthesia 54:1204-1207, 1999

117. Gurbet A, Bekar A, Bilgin H, Korfali G, Yilmazlar S, Tercan M: Pre-emptive infiltration of levobupivacaine is su- perior to at-closure administration in lumbar laminectomy patients. Eur Spine J 17:1237-1241, 2008

118. Guyatt G, Gutterman D, Baumann MH, Addrizzo- Harris D, Hylek EM, Phillips B, Raskob G, Lewis SZ, Schunemann H: Grading strength of recommendations and quality of evidence in clinical guidelines: Report from an American College of Chest Physicians Task Force. Chest 129:174-181, 2006

119. Haase O, Schwenk W, Hermann C, Muller JM: Guided imagery and relaxation in conventional colorectal resec- tions: A randomized, controlled, partially blinded trial. Dis Colon Rectum 48:1955-1963, 2005

120. Hadi I, Morely-Forster P, Dain S, Horrill K, Moulin D: Brief review: Perioperative management of the patient with chronic non-cancer pain. Can J Anaesth 53:1190-1199, 2006

121. Hagan JF Jr, Coleman WL, Foy JM, Goldson E, Howard BJ, Navarro A, Tanner JL, Tolmas HC: The assessment and management of acute pain in infants, children, and ad- olescents. Pediatrics 108:793-797, 2001

122. Hamza MA, White PF, Ahmed HE, Ghoname EA: Ef- fect of the frequency of transcutaneous electrical nerve stimulation on the postoperative opioid analgesic requirement and recovery profile. Anesthesiology 91: 1232-1238, 1999

123. Hart RR: The influence of a taped hypnotic induction treatment procedure on the recovery of surgery patients. Int J Clin Exp Hypn 28:324-332, 1980

124. Hattan J, King L, Griffiths P: The impact of foot massage and guided relaxation following cardiac surgery: A random- ized controlled trial. J Adv Nurs 37:199-207, 2002

125. Healy WL, Seidman J, Pfeifer BA, Brown DG: Cold compressive dressing after total knee arthroplasty. Clin Or- thop Relat Res 143-146, 1994

126. Heitz L, Symreng T, Scamman F: Effect of music therapy in the postanesthesia care unit: A nursing intervention. J Post Anesth Nurs 7:22-31, 1992

127. Hernandez-Palazon J, Tortosa JA, Martinez-Lage JF, Perez-Flores D: Intravenous administration of propacetamol reduces morphine consumption after spinal fusion surgery. Anesth Analg 92:1473-1476, 2001

128. Herr K: Neuropathic pain: A guide to comprehensive assessment. Pain Manag Nurs 5:9-18, 2004

129. Herr K, Coyne PJ, Manworren RC, McCaffrey M, Merkel S: Pain assessment in the patients unable to self- report: Position statement update. Pain Manag Nurs 12: 230-250, 2011

130. Herr KA, Mobily PR, Kohout FJ, Wagenaar D: Evalua- tion of the faces pain scale for use with the elderly. Clin J Pain 14:29-38, 1998

131. Herr KA, Spratt K, Mobily PR, Richardson G, Herr KA, Spratt K, Mobily PR, Richardson G: Pain intensity assess- ment in older adults: Use of experimental pain to compare psychometric properties and usability of selected pain scales with younger adults. Clin J Pain 20:207-219, 2004

132. Hershman M: Transcutaneous electrical nerve stimula- tion as adjunctive analgesia in patients undergoing abdom- inal procedures. Surg Res Commun 7:65-69, 1989

152 The Journal of Pain Management of Postoperative Pain

133. Hibbard J: Engaging health care consumers to improve the quality of care. Med Care 41(Suppl):161-170, 2003

134. Hinrichs-Rocker A, Schulz K, Jarvinen I, Lefering R, Simanski C, Neugebauer EA: Psychosocial predictors and cor- relates for chronic post-surgical pain (CPSP) - a systematic re- view. Eur J Pain 13:719-730, 2009

135. Holliday MA, Pinckert TL, Kiernan SC, Kunos I, Angelus P, Keszler M: Dorsal penile nerve block vs. topical placebo for circumcision in low-birth-weight neonates. Arch Pediatr Adolesc Med 153:476-480, 1999

136. Holmstrom A, Hardin BC: Cryo/Cuff compared to epidural anesthesia after knee unicompartmental arthro- plasty: A prospective, randomized and controlled study of 60 patients with a 6-week follow-up. J Arthroplasty 20: 316-321, 2005

137. Horgan M, Choonara I: Measuring pain in neonates: An objective score. Paediatr Nurs 8:24-27, 1996

138. Huang YM, Wang CM, Wang CT, Lin WP, Horng LC, Jiang CC: Perioperative celecoxib administration for pain management after total knee arthroplasty - a random- ized, controlled study. BMC Musculoskelet Disord 9:77, 2008

139. Hudcova J, McNicol ED, Quah CS, Lau J, Carr DB: Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev CD003348, 2009

140. Hullett B, Chambers N, Preuss J, Zamudio I, Lange J, Pascoe E, Ledowski T: Monitoring electrical skin conduc- tance: A tool for the assessment of postoperative pain in children? Anesthesiology 111:513-517, 2009

141. Hulme J, Waterman H, Hillier VF: The effect of foot massage on patients’ perception of care following laparo- scopic sterilization as day case patients. J Adv Nurs 30: 460-468, 1999

142. Huth MM, Broome ME, Good M: Imagery reduces chil- dren’s post-operative pain. Pain 110:439-448, 2004

143. Huth MM, Broome ME, Mussatto KA, Morgan SW: A study of the effectiveness of a pain management education booklet for parents of children having cardiac surgery. Pain Manag Nurs 4:31-39, 2003

144. Huxtable C, Roberts L, Somogyi A, Macintyre PE: Acute pain management in opioid-tolerant patients: A growing challenge. Anaesth Intensive Care 39:804-823, 2011

145. Ikonomidou E, Rehnstrom A, Naesh O: Effect of music on vital signs and postoperative pain. AORN J 80:269-274, 2004

146. Issioui T, Klein KW, White PF, Watcha MF, Coloma M, Skrivanek GD, Jones SB, Thornton KC, Marple BF: The effi- cacy of premedication with celecoxib and acetaminophen in preventing pain after otolaryngologic surgery. Anesth Analg 94:1188-1193, 2002

147. Ittichaikulthol W, Virankabutra T, Kunopart M, Khamhom W, Putarawuthichai P, Rungphet S: Effects of pre- gabalin on post-operative morphine consumption after abdominal hysterectomy with/without salphingo- oophorectomy: A randomized, double-blind trial. J Med As- soc Thai 92:1318-1323, 2009

148. Jansson L, Velez M, Harrow C: The opioid-exposed newborn: Assessment and pharmacologic management. J Opioid Manag 5:47-55, 2009

149. Jarzyna D, Jungquist CR, Pasero C, Willens JS, Nisbet A, Oakes L, Dempsey SJ, Santangelo D, Polomano RC: American Society for Pain Management Nursing Guidelines on Moni- toring for Opioid-Induced Sedation and Respiratory Depres- sion. Pain Manag Nurs 12:118-145, 2011

150. Jelicic M, Bonke B, Millar K: Effect of different thera- peutic suggestions presented during anaesthesia on post- operative course. Eur J Anaesthesiol 10:343-347, 1993

151. Jensen JE, Conn RR, Hazelrigg G, Hewett JE: The use of transcutaneous neural stimulation and isokinetic testing in arthroscopic knee surgery. Am J Sports Med 13:27-33, 1985

152. John M, Parrino J: Practical hypnotic suggestion in ophthalmic surgery. Am J Opthalmol 96:540-542, 1983

153. Jokela R, Ahonen J, Tallgren M, Haanpaa M, Korttila K: Premedication with pregabalin 75 or 150 mg with ibuprofen to control pain after day-case gynaecological laparoscopic surgery. Br J Anaesth 100:834-840, 2008

154. Joshi GP, Bonnet F, Shah R, Wilkinson RC, Camu F, Fischer B, Neugebauer EA, Rawal N, Schug S, Simanski C, Kehlet H: A systematic review of randomized trials evalu- ating regional techniques for postthoracotomy analgesia. Anesth Analg 107:1026-1040, 2008

155. Joucken K, Michel L, Schoevaerdts JC, Mayne A, Randour P: Cryoanalgesia for post-thoracotomy pain relief. Acta Anaesthesiol Belg 38:179-183, 1987

156. Joyce BA, Keck JF, Gerkensmeyer J: Evaluation of pain management interventions for neonatal circumcision pain. J Pediatr Health Care 15:105-114, 2001

157. Kaasalainen S, Crook J: An exploration of seniors’ abil- ity to report pain. Clin Nurs Res 13:199-215, 2004

158. Kaloul I, Guay J, Cote C, Fallaha M: The posterior lumbar plexus (psoas compartment) block and the three- in-one femoral nerve block provide similar postoperative analgesia after total knee replacement. Can J Anaesth 51: 45-51, 2004 [erratum in: 52:119, 2005]

159. Kankkunen P, Pietil€a AM, Vehvil€ainen-Julkunen K: Families’ and children’s postoperative pain - literature re- view. J Pediatr Nurs 19:133-139, 2004

160. Kankkunen P, Vehvil€ainen-Julkunen K, Pietil€a AM, Halonen P: Is the sufficiency of discharge instructions related to children’s postoperative pain at home after day surgery? Scand J Caring Sci 17:365-372, 2003

161. Karamanlioglu B, Arar C, Alagol A, Colak C, Gemlik I, Sut N: Preoperative oral celecoxib versus preoperative oral rofecoxib for pain relief after thyroid surgery. Eur J Anesthe- siol 20:490-495, 2003

162. Kardash K, Hickey D, Tessler MJ, Payne S, Zukor D, Velly AM: Obturator versus femoral nerve block for anal- gesia after total knee arthroplasty. Anesth Analg 105: 853-858, 2007

163. Kass FC, Holman JR: Oral glucose solution for analgesia in infant circumcision. J Fam Pract 50:785-788, 2001

164. Kehlet H, Andersen LO: Local infiltration analgesia in joint replacement: The evidence and recommendations for clinical practice. Acta Anaesthesiol Scand 55:778-784, 2011

165. Kehlet H, Jensen T, Woolf C: Persistent postsurgical pain: Risk factors and prevention. Lancet 367:1618-1625, 2006

Chou et al The Journal of Pain 153

166. Kinsella J, Moffat AC, Patrick JA, Prentice JW, McArdle CS, Kenny GN: Ketorolac trometamol for postoper- ative analgesia after orthopaedic surgery. Br J Anaesth 69: 19-22, 1992

167. Klein SM, Nielsen KC, Martin A, White W, Warner DS, Steele SM, Speer KP, Greengrass RA: Interscalene brachial plexus block with continuous intraarticular infusion of ropi- vacaine. Anesth Analg 93:601-605, 2001

168. Koc M, Tez M, Yoldas O, Dizen H, Gocmen E: Cooling for the reduction of postoperative pain: prospective random- ized study. Hernia 10:184-186, 2006

169. Konrath GA: The use of cold therapy after anterior cru- ciate ligament reconstruction. A prospective, randomized study and literature review. Am J Sports Med 24:629-633, 1996

170. Kotani N, Hashimoto H, Sato Y, Sessler D, Yoshioka H, Kitayama M, Yasuda T, Matsuki A: Preoperative intradermal acupuncture reduces postoperative pain, nausea and vomit- ing, analgesic requirement and sympathoadrenal responses. Anesthesiology 95:349-356, 2001

171. Lambert SA: The effects of hypnosis/guided imagery on the postoperative course of children. J Dev Behav Pediatr 17: 307-310, 1996

172. Langer EJ, Janis IL, Wolfer JA: Reduction of psycholog- ical stress in surgical patients. J Exp Soc Psychol 11:155-165, 1975

173. Laskowski K, Stirling A, McKay WP, Lim HJ: A systematic review of intravenous ketamine for postoperative anal- gesia. Can J Anaesth 58:911-923, 2011

174. Laurion S, Fetzer SJ: The effect of two nursing interven- tions on the postoperative outcomes of gynecologic laparo- scopic patients. J Perianesth Nurs 18:254-261, 2003

175. Lehr VT, Cepeda E, Frattarelli DA, Thomas R, LaMothe J, Aranda JV: Lidocaine 4% cream compared with lidocaine 2.5% and prilocaine 2.5% or dorsal penile block for circum- cision. Am J Perinatol 22:231-237, 2005

176. Levy A, Marmar E: The role of cold compression dress- ings in the postoperative treatment of total knee arthro- plasty. Clin Orthop 297:174-178, 1993

177. Li Q, Zhang Z, Cai Z: High-dose ketorolac affects adult spinal fusion: A meta-analysis of the effect of perioperative nonsteroidal anti-inflammatory drugs on spinal fusion. Spine 36:E461-E468, 2011

178. Liao P, Yegneswaran B, Vairavanathan S, Zilberman P, Chung F: Postoperative complications in patients with obstructive sleep apnea: A retrospective matched cohort study. Can J Anaesth 56:819-828, 2009

179. Lim AT: Postoperative pain control: Contribution of psychological factors and transcutaneous electrical stimula- tion. Pain 17:179-188, 1983

180. Lin JG, Lo MW, Wen YR, Hsieh CL, Tsai SK, Sun WZ: The effect of high and low frequency electroacupuncture in pain after lower abdominal surgery. Pain 99:509-514, 2002

181. Liu WH, Stranden PJ, Aitkenhead AR: Therapeutic sug- gestions during general anaesthesia in patients undergoing hysterectomy. Br J Anaesth 68:277-281, 1992

182. Loadsman J, Hillman D: Anaesthesia and sleep apnoea. Br J Anaesth 86:254-266, 2001

183. Loftus RW, Yeager MP, Clark JA, Brown JR, Abdu W, Sengupta DK, Beach ML: Intraoperative ketamine reduces

perioperative opiate consumption in opiate-dependent pa- tients with chronic back pain undergoing back surgery. Anesthesiology 113:639-646, 2010

184. Macalou D, Trueck S, Meuret P, Heck M, Vial F, Ouologuem S, Capdevila X, Virion JM, Bouaziz H: Postoper- ative analgesia after total knee replacement: The effect of an obturator nerve block added to the femoral 3-in-1 nerve block. Anesth Analg 99:251-254, 2004

185. Macintyre PE, Schug SA, Scott DA, Visser EJ, Walker SM (eds): Acute pain management: Scientific evidence, 3rd ed. Melbourne, Australia, Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2010

186. Manyande A, Berg S, Gettins D, Stanford SC, Mazhero S, Marks DF, Salmon P: Preoperative rehearsal of active coping imagery influences subjective and hormonal responses to abdominal surgery. Psychosom Med 57:177-182, 1995

187. Marchette L, Main R, Redick E: Pain reduction during neonatal circumcision. Pediatr Nurs 15:207-210, 1989

188. Marchette L, Main R, Redick E, Bagg A: Pain reduction interventions during neonatal circumcision. Nurse Res 40: 241-244, 1991

189. Marret E, Rolin M, Beaussier M, Bonnet F: Meta-anal- ysis of intravenous lidocaine and postoperative recovery af- ter abdominal surgery. Br J Surg 95:1331-1338, 2008

190. Martelete M, Fiori AM: Comparative study of the anal- gesic effect of transcutaneous nerve stimulation (TNS); elec- troacupuncture (EA) and meperidine in the treatment of postoperative pain. Acupunct Electrother Res 10:183-193, 1985

191. Mathiesen O, Moiniche S, Dahl JB: Gabapentin and postoperative pain: A qualitative and quantitative system- atic review, with focus on procedure. BMC Anesthesiol 7:6, 2007

192. McCaffrey R, Locsin R: The effect of music on pain and acute confusion in older adults undergoing hip and knee surgery. Holist Nurs Pract 20:218-224, 2006

193. McCarter T, Shaik Z, Scarfo K, Thompson LJ: Capnogra- phy monitoring enhances safety of postoperative patient- controlled analgesia. Am Health Drug Benefits 1:28-35, 2008

194. McDaid C, Maund E, Rice S, Wright K, Jenkins BJ, Woolacott N: Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for the reduction of morphine-related side effects after major sur- gery: A systematic review. Health Technol Assess 14:1-153, 2010. iii-iv

195. McGrath P, Johnson G, Goodman J, Schillinger J, Dunn J, Chapman J-A: CHEOPS: A behavioral scale for rating postoperative pain in children. In: Fields H, Dubner R, Cervero F (eds): Advances in Pain Research and Therapy. New York, Raven Press, 1985, pp 395-402

196. McLintock TT, Aitken H, Downie CF, Kenny GN: Postop- erative analgesic requirements in patients exposed to posi- tive intraoperative suggestions. BMJ 301:788-790, 1990

197. McNair C, Ballantyne M, Dionne K, Stephens D, Stevens B: Postoperative pain assessment in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 89: F537-F541, 2004

198. McNicol ED, Schumann R, Haroutounian S: A systematic review and meta-analysis of ketamine for the prevention of persistent post-surgical pain. Acta Anaesthesiol Scand 58: 1199-1213, 2014

154 The Journal of Pain Management of Postoperative Pain

199. McNicol ED, Tzortzoloulou A, Cepeda MS, Francia MB, Farhat T, Schumann R: Single-dose intravenous paracetamol or propacetamol for prevention or treatment of postopera- tive pain: A systematic review and meta-analysis. Br J Anaesth 106:764-775, 2011

200. Melnyk BM, Small L, Carno MA: The effectiveness of parent-focused interventions in improving coping/mental health outcomes of critically ill children and their parents: An evidence base to guide clinical practice. Pediatr Nurs 30:143-148, 2004

201. Melzack R, Katz J, Coderre TJ: Methods of postopera- tive pain control. Cah Anesthesiol 40:309-315, 1992

202. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S, The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 23:293-297, 1997

203. Mitchinson AR, Kim HM, Rosenberg JM, Geisser M, Kirsh M, Cikrit D, Hinshaw DB: Acute postoperative pain management using massage as an adjuvant therapy. Arch Surg 142:1158-1167, 2007

204. Mogan J, Wells N, Robertson E: Effects of preoperative teaching on postoperative pain: A replication and expan- sion. Int J Nurs Stud 22:267-280, 1985

205. Monitto CL, Greenberg RS, Kost-Byerly S, Wetzel R, Billett C, Lebet RM, Yaster M: The safety and efficacy of parent-/nurse-controlled analgesia in patients less than six years of age. Anesth Analg 91:573-579, 2000

206. Montgomery GH, Bovbjerg DH, Schnur JB, David D, Goldfarb A, Weltz CR, Schechter C, Graff-Zivin J, Tatrow K, Price DD, Silverstein JH: A randomized clinical trial of a brief hypnosis intervention to control side effects in breast sur- gery patients. J Natl Cancer Inst 99:1304-1312, 2007

207. Morrison RS, Ahronheim JC, Morrison GR, Darling E, Baskin SA, Morris J, Choi C, Meier DE: Pain and discomfort associated with common hospital procedures and experi- ences. J Pain Symptom Manage 15:91-101, 1998

208. Murali Krishna T, Panda NB, Batra YK, Rajeev S: Combi- nation of low doses of intrathecal ketamine and midazolam with bupivacaine improves postoperative analgesia in or- thopaedic surgery. Eur J Anaesthesiol 25:299-306, 2008

209. Naja Z, Ziade MF, Lonnqvist PA: Nerve stimulator guided pudendal nerve block decreases posthemorrhoidec- tomy pain. Can J Anaesth 52:62-68, 2005

210. Nilsson U, Rawal N, Enqvist B, Unosson M: Analgesia following music and therapeutic suggestions in the PACU in ambulatory surgery; a randomized controlled trial. Acta Anaesthesiol Scand 47:278-283, 2003

211. Nilsson U, Rawal N, Unestahl LE, Zetterberg C, Unosson M: Improved recovery after music and therapeutic suggestions during general anaesthesia: A double-blind randomised controlled trial. Acta Anaesthesiol Scand 45: 812-817, 2001

212. Nishimori M, Ballantyne JC, Low JH: Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev CD005059, 2006

213. O’Flaherty JE, Lin CX: Does ketamine or magnesium affect posttonsillectomy pain in children? Paediatr Anaesth 13:413-421, 2003

214. Ohkoshi Y: The effect of cryotherapy on intraarticular temperature and postoperative care after anterior cruciate ligament reconstruction. Am J Sports Med 27:357-362, 1999

215. Ong CK, Lirk P, Seymour RA, Jenkins BJ: The efficacy of preemptive analgesia for acute postoperative pain manage- ment: A meta-analysis. Anesth Analg 100:757-773, 2005

216. Ong CK, Seymour RA, Lirk P, Merry AF: Combining para- cetamol (acetaminophen) with nonsteroidal antiinflamma- tory drugs: A qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 110: 1170-1179, 2010

217. Paech MJ, Goy R, Chua S, Scott K, Christmas T, Doherty DA: A randomized, placebo-controlled trial of pre- operative oral pregabalin for postoperative pain relief after minor gynecological surgery. Anesth Analg 105:1449-1453, 2007

218. Parker RD, Streem K, Schmitz L, Martineau PA, Marguerite G: Efficacy of continuous intra-articular bupiva- caine infusion for postoperative analgesia after anterior cruciate ligament reconstruction: A double-blinded, pla- cebo-controlled, prospective, and randomized study. Am J Sports Med 35:531-536, 2007

219. Parker RK, Holtmann B, White PF: Effects of a night- time opioid infusion with PCA therapy on patient comfort and analgesic requirements after abdominal hysterectomy. Anesthesiology 76:362-367, 1992

220. Parker RK, Holtmann B, White PF: Patient-controlled analgesia. Does a concurrent opioid infusion improve pain management after surgery? JAMA 266:1947-1952, 1991

221. Patanwala AE, Jarzyna DL, Miller MD, Erstad BL: Com- parison of opioid requirements and analgesic response in opioid-tolerant versus opioid-naive patients after total knee arthroplasty. Pharmacotherapy 28:1453-1460, 2008

222. Paul JE, Anya A, Hulrlburt L, Cheng JC, Thabane L, Tidy A, Murthy Y: Femoral nerve block improves analgesia outcomes after total knee arthroplasty. Anesthesiology 113:1144-1162, 2010

223. Pautex S, Herrmann F, Le Lous P, Fabjan M, Michel JP, Gold G: Feasibility and reliability of four pain self- assessment scales and correlation with an observational rating scale in hospitalized elderly demented patients. J Ger- ontol A Biol Sci Med Sci 60:524-529, 2005

224. Peden V, Choonara I, Vater M: Validating the Derby- shire Children’s Hospital Pain Tool in children aged 6-12 years. J Child Health Care 9:59-71, 2005

225. Peden V, Vater M, Choonara I: Validating the Derby- shire Children’s Hospital Pain Tool: a pilot study. Paediatr Anaesth 13:109-113, 2003

226. Pedersen T, Dyrlund Pedersen B, Moller AM: Pulse ox- imetry for perioperative monitoring. Cochrane Database Syst Rev CD002013, 2003

227. Peng P, Claxton A, Chung F, Chan V, Miniaci A, Krishnathas A: Femoral nerve block and ketorolac in pa- tients undergoing anterior cruciate ligament reconstruc- tion. Can J Anaesth 46:919-924, 1999

228. Pettersson PH, Jakobsson J, Owall A: Intravenous acet- aminophen reduced the use of opioids compared with oral administration after coronary artery bypass grafting. J Car- diothorac Vasc Anesth 19:306-309, 2005

229. Pickett C, Clum GA: Comparative treatment strategies and their interaction with locus of control in the reduction of postsurgical pain and anxiety. J Consult Clin Psychol 50: 439-441, 1982

Chou et al The Journal of Pain 155

230. Piotrowski MM, Paterson C, Mitchinson A, Kim HM, Kirsh M, Hinshaw DB: Massage as adjuvant therapy in the management of acute postoperative pain: A preliminary study in men. J Am Coll Surg 197:1037-1046, 2003

231. Popping D, Elia N, Marret E, Wenk M, Tram�er MR: Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: A meta-analysis of randomized tri- als. Anesthesiology 111:4006-4415, 2009

232. Popping D, Elia N, Van Aken H, Marret E, Schug SA, Kranke P, Wenk M, Tram�er MR: Impact of epidural analgesia on mortality and morbidity after surgery: Systematic review and meta-analysis of randomized controlled trials. Ann Surg 259:1056-1067, 2014

233. Popping DM, Elia N, Marret E, Remy C, Tramer MR: Pro- tective effects of epidural analgesia on pulmonary complica- tions after abdominal and thoracic surgery: A meta-analysis. Arch Surg 143:990-999, 2008. discussion: 1000

234. Prowse M: Postoperative pain in older people: A review of the literature. J Clin Nurs 16:84-97, 2007

235. Raab MG, Rzeszutko D, O’Connor W: Early results of continuous passive motion after rotator cuff repair. Am J Or- thop 25:214, 1996

236. Radkowski CA, Pietrobon R, Vail TP, Nunley JA 2nd, Jain NB, Easley ME: Cryotherapy temperature differences af- ter total knee arthroplasty: A prospective randomized trial. J Surg Orthop Adv 16:67-72, 2007

237. Rapley J, Beavis R, Barber F: Glenohumeral chon- drolysis after shoulder arthroscopy associated with continuous bupivacaine infusion. Arthroscopy 12: 1367-1373, 2009

238. Rawal N, Viscusi E, Buvanendran A, Kehlet H: Multi- modal minus Reuben. Anesthesiol News 35, 2009

239. Recart A, Issioui T, White PF, Klein K, Watcha MF, Stool L, Shah M: The efficacy of celecoxib premedication on postoperative pain and recovery times after ambulatory surgery: A dose-ranging study. Anesth Analg 96:1631-1635, 2003

240. Reynolds MA: Postoperative pain management discharge teaching in a rural population. Pain Manag Nurs 10:76-84, 2009

241. Reza N, Ali SM, Saeed K, Abul-Qasim A, Reza TH: The impact of music on postoperative pain and anxiety following cesarean section. Middle East J Anesthesiol 19: 573-586, 2007

242. Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Cohen SR, Wu CL: Does contin- uous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 102:248-257, 2006

243. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S: Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: Results from overview of randomised trials. BMJ 321:1-11, 2000

244. Rozen D, DeGaetano N: Perioperative management of opioid-tolerant chronic pain patients. J Opioid Manag 2: 353-363, 2006

245. Ruetzler K, Blome C, Nabecker S, Makarova N, Fischer H, Rinoesl H, Goliasch G, Sessler D, Koinig H: A rand- omised trial of oral versus intravenous opioids for treatment of pain after cardiac surgery. J Anesth 28:580-586, 2014

246. Ruggiero A, Barone G, Liotti L, Chiaretti A, Lazzareschi I, Riccardi R: Safety and efficacy of fentanyl administered by patient controlled analgesia in children with cancer pain. Support Care Cancer 15:569-573, 2007

247. Rushfeldt CF, Sveinbjornsson B, Soreide K, Vonen B: Risk of anastomotic leakage with use of NSAIDs after gastro- intestinal surgery. Int J Colorectal Dis 26:1501-1509, 2011

248. Russell AW, Owen H, Ilsley AH, Kluger MT, Plummer JL: Background infusion with patient-controlled analgesia: Ef- fect on postoperative oxyhaemoglobin saturation and pain control. Anaesth Intensive Care 21:174-179, 1993

249. Rusy LM, Hainsworth KR, Nelson TJ, Czarnecki ML, Tassone JC, Thometz JG, Lyon RM, Berens RJ, Weisman SJ: Gabapentin use in pediatric spinal fusion patients: A ran- domized, double-blind, controlled trial. Anesth Analg 110: 1393-1398, 2010

250. Rutegard J, Rutegard M: Non-steroidal anti- inflammatory drugs in colorectal surgery: A risk factor for anastomotic complications? World J Gastroinest Surg 4: 278-280, 2012

251. Sammour T, Kahokehr A, Hill AG: Meta-analysis of the effect of warm humidified insufflation on pain after lapa- roscopy. Br J Surg 95:950-956, 2008

252. Saudan S, Habre W, Ceroni D, Meyer PA, Greenberg RS, Kaelin A, Von Ungern-Sternberg BS: Safety and efficacy of patient controlled epidural analgesia following pediatric spinal surgery. Paediatr Anaesth 18:132-139, 2008

253. Scarcella J, Cohn B: The effect of cold therapy on the postoperative course of total hip and knee arthroplasty pa- tients. Am J Orthop 24:847-852, 1995

254. Schade JG, Joyce BA, Gerkensmeyer J, Keck JF: Compar- ison of three preverbal scales for postoperative pain assess- ment in a diverse pediatric sample. J Pain Symptom Manage 12:348-359, 1996

255. Schroder D: Combination of cold and compression af- ter knee surgery. A prospective randomized study. Knee Surg Sports Traumatol Arthrosc 2:158-165, 1994

256. Seers K, Crichton N, Tutton L, Smith L, Saunders T: Effectiveness of relaxation for postoperative pain and anxiety: Randomized controlled trial. J Adv Nurs 62: 681-688, 2008

257. Seet E, Leong WL, Yeo AS, Fook-Chong S: Effectiveness of 3-in-1 continuous femoral block of differing concentra- tions compared to patient controlled intravenous morphine for post total knee arthroplasty analgesia and knee rehabil- itation. Anaesth Intensive Care 34:25-30, 2006

258. Seid M, Varni JW: Pediatric surgery outcomes manage- ment: The role of preoperative anxiety and a home pain management protocol. J Clin Outcomes Manag 6:24-30, 1999

259. Sendelbach SE, Halm MA, Doran KA, Miller EH, Gaillard P: Effects of music therapy on physiological and psy- chological outcomes for patients undergoing cardiac sur- gery. J Cardiovasc Nurs 21:194-200, 2006

260. Shafer SL: Retraction notice. Available at: http://www. aaeditor.org/HWP/Retraction.Notice.pdf.AccessedNovember 22, 2010

261. Shum CF, Lo NN, Yeo SJ, Yang KY, Chong HC, Yeo SN: Continuous femoral nerve block in total knee arthroplasty: Immediate and two-year outcomes. J Arthroplasty 24: 204-209, 2009

156 The Journal of Pain Management of Postoperative Pain

262. Sim CK, Xu PC, Pua HL, Zhang G, Lee TL: Effects of elec- troacupuncture on intraoperative and postoperative anal- gesic requirements. Acupunct Med 20:56-65, 2002

263. Simcock XC, Yoon RS, Chalmers P, Geller JA, Kiernan HA, Macaulay W: Intraoperative music reduces perceived pain after total knee arthroplasty: A blinded, pro- spective, randomized, placebo-controlled clinical trial. J Knee Surg 21:275-278, 2008

264. Simons J, Franck L, Roberson E: Parent involvement in children’s pain care: Views of parents and nurses. J Adv Nurs 36:591-599, 2001

265. Singelyn FJ, Lhotel L, Fabre B: Pain relief after arthro- scopic shoulder surgery: A comparison of intraarticular anal- gesia, suprascapular nerve block, and interscalene brachial plexus block. Anesth Analg 99:589-592, 2004

266. Sluka KA, Walsh DM: Transcutaneous electrical nerve stimulation and interferential therapy. In: Sluka KA (ed): Mechanisms and Management of Pain for the Physical Ther- apist. Seattle, Washington, Intl Assoc for the Study of Pain, 2009, pp 167-190

267. Smith CM, Guralnick MS, Gelfand MM, Jeans ME: The effects of transcutaneous electrical nerve stimulation on post-cesarean pain. Pain 27:181-193, 1986

268. Snell P, Hicks C: An exploratory study in the UK of the effectiveness of three different pain management regimens for post-caesarean section women. Midwifery 22:249-261, 2006

269. Speer K, Warren WF, Horowitz L: The efficacy of cryo- therapy in the postoperative shoulder. J Shoulder Elbow Surg 5:62-68, 1996

270. Srikandarajah S, Gilron I: Systematic review of movement-evoked pain versus pain at rest in postsurgical clinical trials and meta-analyses: A fundamental distinction requiring standardized measurement. Pain 152:1734-1739, 2011

271. Stevensen CJ: The psychophysiological effects of aromatherapy massage following cardiac surgery. Comple- ment Ther Med 2:27-35, 1994

272. Straube S, Derry S, Moore RA, Wiffen PJ, McQuay HJ: Single dose oral gabapentin for established acute postoper- ative pain in adults. Cochrane Database Syst Rev CD008183, 2010

273. Stuppy DJ: The faces pain scale: Reliability and validity with mature adults. Appl Nurs Res 11:84-89, 1998

274. Sucato DJ, Lovejoy JF, Agrawal S, Elerson E, Nelson T, McClung A: Postoperative ketorolac does not predispose to pseudoarthrosis following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis. Spine 33:1119-1124, 2008

275. Sun T, Sacan O, White PF, Coleman J, Rohrich RJ, Kenkel JM: Perioperative versus postoperative celecoxib on patient outcomes after major plastic surgery procedures. Anesth Analg 106:950-958, 2008

276. Suraseranivongse S, Montapaneewat T, Manon J, Chainchop P, Petcharatana S, Kraiprasit K: Cross-validation of a self-report scale for postoperative pain in school-aged children. J Med Assoc Thai 88:412-418, 2005

277. Surman OS, Hackett TP, Silverberg EL, Behrendt DM: Usefulness of psychiatric intervention in patients under- going cardiac surgery. Arch Gen Psychiatry 30:830-835, 1974

278. Taddio A, Ohlsson A, Einarson TR, Stevens B, Koren G: A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics 101:E1, 1998

279. Taddio A, Stevens B, Craig K, Rastogi P, Ben-David S, Shennan A, Mulligan P, Koren G: Efficacy and safety of lido- caine–prilocaine cream for pain during circumcision. N Engl J Med 336:1197-1201, 1997

280. Tarbell SE, Cohen IT, Marsh JL: The Toddler-Preschooler Postoperative Pain Scale: An observational scale for measuring postoperative pain in children aged 1-5. Prelimi- nary report. Pain 50:273-280, 1992

281. Taylor LJ, Herr K: Pain intensity assessment: A compar- ison of selected pain intensity scales for use in cognitively intact and cognitively impaired African American older adults. Pain Manag Nurs 4:87-95, 2003

282. Taylor LK, Kuttler KL, Parks TA, Milton D: The effect of music in the postanesthesia care unit on pain levels in women who have had abdominal hysterectomies. J Peria- nesth Nurs 13:88-94, 1998

283. Tramer MR, Williams JE, Carroll D, Wiffen PJ, Moore RA, McQuay HJ: Comparing analgesic efficacy of non-steroidal anti-inflammatory drugs given by different routes in acute and chronic pain: A qualitative systematic review. Acta Anaesthesiol Scand 42:71-79, 1998

284. Tsang RC, Tsang PL, Ko CY, Kong BC, Lee WY, Yip HT: Ef- fects of acupuncture and sham acupuncture in addition to physiotherapy in patients undergoing bilateral total knee arthroplasty–a randomized controlled trial. Clin Rehabil 21:719-728, 2007

285. Tse MM, Chan MF, Benzie IF: The effect of music ther- apy on postoperative pain, heart rate, systolic blood pres- sures and analgesic use following nasal surgery. J Pain Palliat Care Pharmacother 19:21-29, 2005

286. Tusek D, Church JM, Fazio VW: Guided imagery as a coping strategy for perioperative patients. AORN J 66: 644-649, 1997

287. Tusek DL: Guided imagery: A powerful tool to decrease length of stay, pain, anxiety, and narcotic consumption. J Invasive Cardiol 11:265-267, 1999

288. U.S. Food and Drug Administration: EMLA cream pre- scription insert. Available at: http://www.accessdata.fda. gov/drugsatfda_docs/label/2000/19941S11LBL.PDF. Accessed October 30 , 2014

289. U.S. Food and Drug Administration: Extended Release - Long Acting Opioid Analgesics. Available at: http://www. fda.gov/Safety/MedWatch/SafetyInformation/ucm396503. htm. Accessed December 9, 2015

290. U.S. Food and Drug Administration: Information for Healthcare Professionals: Non-Selective Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)*. Available at: http:// www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafety InformationforPatientsandProviders/DrugSafetyInformation forHeathcareProfessionals/ucm085282.htm. Accessed October 30, 2014

291. Usichenko TI, Dinse M, Hermsen M, Witstruck T, Pavlovic D, Lehmann C: Auricular acupuncture for pain relief after total hip arthroplasty - a randomized controlled study. Pain 114:320-327, 2005

292. Usichenko TI, Kuchling S, Witstruck T, Pavlovic D, Zach M, Hofer A, Merk H, Lehmann C, Wendt M: Auricular

Chou et al The Journal of Pain 157

acupuncture for pain relief after ambulatory knee surgery: A randomized trial. CMAJ 176:179-183, 2007

293. VA/DoD: Clinical Practice Guideline for the Management of Post-Operative Pain. Guideline Sum- mary, 2002, Available at: http://www.healthquality.va. gov/guidelines/Pain/pop/pop_sum.pdf. Accessed January 9, 2016

294. Valentine JM, Lyons G, Bellamy MC: The effect of intra- thecal midazolam on post-operative pain. Eur J Anaesthesiol 13:589-593, 1996

295. van Dijk M, de Boer JB, Koot HM, Tibboel D, Passchier J, Duivenvoorden HJ: The reliability and validity of the COM- FORT scale as a postoperative pain instrument in 0 to 3- year-old infants. Pain 84:367-377, 2000

296. Vigneault L, Turgeon AF, Cote D, Lauzier F, Zarychanski R, Moore L, McIntyre LA, Nicole PC, Fergusson DA: Perioperative intravenous lidocaine infusion for postoperative pain control: A meta-analysis of random- ized controlled trials. Can J Anaesth 58:22-37, 2011

297. Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S: The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in chil- dren with cognitive impairment. Anesth Analg 95: 1224-1229, 2002

298. von Baeyer CL, Spagrud L: Systematic review of obser- vational (behavioral) measures of pain in children and ado- lescents aged 3 to 18 years. Pain 127:140-150, 2007

299. Walker R: Postoperative use of continuous passive mo- tion, transcutaneous electrical nerve stimulation, and continuous cooling pad following total knee arthroplasty. J Arthroplasty 6:151-156, 1991

300. Wang B, Tang J, White PF, Naruse R, Sloninsky A, Kariger R, Gold J, Wender RH: Effect of the intensity of transcutaneous acupoint electrical stimulation on the postoperative analgesic requirement. Anesth Analg 85: 406-413, 1997

301. Wang R, Tronnier V: Effect of acupuncture on pain management in patients before and after lumbar disc pro- trusion surgery - a randomized control study. Am J Chin Med 28:25-33, 2000

302. Wang SM, Kain ZN: P6 acupoint injections are as effective as droperidol in controlling early postoperative nausea and vomiting in children. Anesthesiology 97: 359-366, 2002

303. Watcha MF, Issioui T, Klein KW, White PF: Costs and effectiveness of rofecoxib, celecoxib, and acetaminophen for preventing pain after ambulatory otolaryngologic sur- gery. Anesth Analg 96:987-994, 2003

304. Wells JK, Howard GS, Nowlin WF, Vargas MJ: Presurgi- cal anxiety and postsurgical pain and adjustment: Effects of a stress inoculation procedure. J Consult Clin Psychol 54: 831-835, 1986

305. Wells W: The effect of relaxation on postoperative muscle tension and pain. Nurse Res 31:236-238, 1982

306. Whitelaw GP, DeMuth KA, Demos HA, Schepsis A, Jacques E: The use of the Cryo/Cuff versus ice and elastic wrap in the postoperative care of knee arthroscopy patients. Am J Knee Surg 8:28-30, 1995

307. Williams BA, Kentor ML, Vogt MT, Irrgang JJ, Bottegal MT, West RV, Harner CD, Fu FH, Williams JP: Reduc- tion of verbal pain scores after anterior cruciate ligament reconstruction with 2-day continuous femoral nerve block: A randomized clinical trial. Anesthesiology 104:315-327, 2006

308. Wilson JF: Behavioral preparation for surgery: Benefit or harm? J Behav Med 4:79-102, 1981

309. Wong DL, Baker CM: Pain in children: Comparison of assessment scales. Pediatr Nurs 14:9-17, 1988

310. Wong RH, Lee TW, Sihoe ADL, Wan IYP, Ng CS, Chan SK, Wong WW, Liang YM, Yim AP: Analgesic effect of electroa- cupuncture in postthoracotomy pain: A prospective ran- domized trial. Ann Thorac Surg 81:2031-2036, 2006

311. Woolf SK, Barfield WR, Merrill KD, McBryde AM Jr: Comparison of a continuous temperature-controlled cryo- therapy device to a simple icing regimen following outpa- tient knee arthroscopy. J Knee Surg 21:15-19, 2008

312. Wright RW, Fetzer GB: Bracing after ACL reconstruc- tion. Clin Orthop Relat Res 455:162-168, 2007

313. Wu HP, Bi LY, Xu CS, Zhu PT: Clinical observation of 50 cases of postoperative incisional pain treated by auricular- acupoint pressure. J Tradit Chin Med 9:187-189, 1989

314. Wynne CF: Comparison of pain assessment instruments in cognitively intact and cognitively impaired nursing home residents. Geriatr Nurs 21:20-23, 2000

315. YaDeau JT, LaSala VR, Paroli L, Kahn RL, Jules- Elysee KM, Levine DS, Wukovits BL, Lipnitsky JY: Clonidine and analgesic duration after popliteal fossa nerve blockade: Randomized, double-blind, placebo-controlled study. Anesth Analg 106:1916-1920, 2008

316. Yentis S, Bissonnette B: P6 acupuncture and postopera- tive vomiting after tosillectomy in children. Br J Anaesth 67: 779-780, 1991

317. Yildiz K, Tercan E, Dogru K, Ozkan U, Boyaci A: Compar- ison of patient-controlled analgesia with and without a background infusion after appendicectomy in children. Pae- diatr Anaesth 13:427-431, 2003

318. Zhang J, Ho KY, Wang Y: Efficacy of pregabalin in acute postoperative pain: A meta-analysis. Br J Anaesth 106: 454-462, 2011

319. Zimmerman L, Nieveen J, Barnason S, Schmaderer M: The effects of music interventions on postoperative pain and sleep in coronary artery bypass graft (CABG) patients. Sch Inq Nurs Pract 10:153-170, 1996. discussion: 171-154