28687919 acute pain management scientific evidence 3rd edition

Acute Pain Management: Scientific EvidenceAustralian and New Zealand College of Anaesthetists and Faculty of Pain Medicine

Endorsed by: FacultyofPainMedicine,RoyalCollegeof Anaesthetists,UnitedKingdom RoyalCollegeofAnaesthetists, UnitedKingdom AustralianPainSociety AustralasianFacultyofRehabilitationMedicine CollegeofAnaesthesiologists, AcademyofMedicine,Malaysia CollegeofAnaesthesiologists, AcademyofMedicine,Singapore CollegeofIntensiveCareMedicine ofAustraliaandNewZealand FacultyofPainMedicine,Collegeof AnaesthetistsofIreland HongKongCollegeofAnaesthesiologists HongKongPainSociety MalaysianAssociationfortheStudyofPain NewZealandPainSociety PainAssociationofSingapore RoyalAustralianandNewZealandCollegeof Psychiatrists RoyalAustralasianCollegeofPhysicians RoyalAustralasianCollegeofSurgeons

Recommended to members: AmericanAcademyofPainMedicine

Approved by the NHM RC on 4 February 2010

AustralianandNewZealandCollegeofAnaesthetists2010 ISBNPrint:9780977517442Online:9780977517459 Thisworkiscopyright.ApartfromanyuseaspermittedundertheCopyrightAct1968,nopartmaybe reproducedbyanyprocesswithoutpriorwrittenpermissionfromANZCA.Requestsandenquiries concerningreproductionandrightsshouldbeaddressedtotheChiefExecutiveOfficer,Australianand NewZealandCollegeofAnaesthetists,630StKildaRoad,Melbourne,Victoria3004,Australia.Website: www.anzca.edu.auEmail:[email protected] Thisdocumentshouldbecitedas: MacintyrePE,SchugSA,ScottDA,VisserEJ,WalkerSM;APM:SEWorkingGroupoftheAustralianand NewZealandCollegeofAnaesthetistsandFacultyofPainMedicine(2010),AcutePainManagement: ScientificEvidence(3rdedition),ANZCA&FPM,Melbourne.

CopyrightinformationforTables11.1and11.2ThematerialpresentedinTable11.1andTable11.2ofthisdocumenthasbeenreproducedby permissionbutdoesnotpurporttobetheofficialorauthorisedversion.TheCommonwealthdoesnot warrantthattheinformationisaccurate,comprehensiveoruptodateandyoushouldmake independentinquiries,andobtainappropriateadvice,beforerelyingontheinformationinanyimportant matter.EnquiriesonthecontentofthematerialshouldbedirectedtotheTherapeuticGoods Administration(www.tga.gov.au).

AcknowledgementsTheproductionofadocumentsuchasthisrequiresaconsiderableamountoftimeoveralongperiod. Althoughinstitutionalsupportintermsoftimeandresourcescamefromanumberofcentres,in particulartheeditorswouldliketothanktheDepartmentofAnaesthesia,HyperbaricMedicineandPain MedicineattheRoyalAdelaideHospitalforitsgeneroussupportandassistanceduringthedevelopment ofthisedition.TheyalsowishtoacknowledgethesupportoftheDepartmentofAnaesthesiaandPain MedicineattheRoyalPerthHospital,theDepartmentofAnaesthesia,StVincentsHospital,Melbourne andThePortexUnit:PainResearchUCLInstituteofChildHealthandGreatOrmondStHospital,London. SpecialthanksarealsoextendedtoProfessorPaulMylesforhisassistanceinrelationtoassessmentof themetaanalysesthatcouldhavebeenaffectedbyretractedarticles(seeIntroductionandAppendixB fordetails),toDrDanCarrforhisguidanceinthismatter,toDrRowanThomasforhissignificant contributiontothewebsitedevelopmentwhichunderpinnedthereviewprocess,andtoProfessor MichaelCousinsforhisadviceandassistancethroughoutthedevelopmentprocess.

NHM RC approvalTheseguidelineswereapprovedbytheNHMRCon4February2010,undersection14AoftheNational HealthandMedicalResearchCouncilAct1992.ApprovalfortheguidelinesbyNHMRCisgrantedfora periodnotexceedingfiveyears,atwhichdatetheapprovalexpires.TheNHMRCexpectsthatall guidelineswillbereviewednolessthanonceeveryfiveyears.ReadersshouldcheckwiththeAustralian andNewZealandCollegeofAnaesthetistsforanyreviewsorupdatesoftheseguidelines.

DisclaimerThisdocumentaimstocombineareviewofthebestavailableevidenceforacutepainmanagementwith currentclinicalandexpertpractice,ratherthantoformulatespecificclinicalpracticerecommendations. Itisdesignedtoprovideinformationbasedonthebestevidenceavailableatthetimeofpublicationto assistindecisionmaking.Theinformationprovidedisnotintendedtooverridetheclinicalexpertiseof healthcareprofessionalsanditsuseissubjecttothecliniciansjudgementandthepatientspreference ineachindividualcase.Thereisnosubstitutefortheskilledassessmentofeachindividualpatients healthstatus,circumstancesandperspectives,whichhealthcarepractitionerswillthenusetoselectthe treatmentsthatarerelevantandappropriatetothatperson. ThisdocumentcanbedownloadedfromtheANZCAwebsite: http://www.anzca.edu.au/resources/booksandpublications/.Copiesofthedocumentcanbeordered throughtheAustralianandNewZealandCollegeofAnaesthetistson+61391506299.

FOREWORDFOREWORDLessthanagenerationagotheprevalentattitudetowardsacutepainwaswidespread acceptanceasinevitable,andfrequentindifferencetoitssuboptimalmanagement.Now, properpainmanagementisunderstoodtobeafundamentalhumanrightandintegraltothe ethical,patientcentredandcosteffectivepracticeofmodernmedicine.Thisprogressisthe resultofdedicatedeffortsbyhealthcareprofessionalsworldwide,includingmanyinAustralia andNewZealandwhohavecontributedtopastandpresenteditionsofAcutePain:Scientific Evidence.TheconsistentlyhighstandardsofAcutePain:ScientificEvidencehaveestablishedit astheforemostEnglishlanguageresourceofitstypeworldwide.Changesbetweensuccessive editionsreflectnotsimplyaccumulationofclinicalevidenceinthisdynamicfield,butalso advancingsophisticationinmethodsofevidencesynthesisanddecisionsupport.Chairedby AssociateProfessorPamMacintyre,assistedbymanycontributorsandadistinguished editorialsubgroupofProfessorStephanSchug,AssociateProfessorDavidScott,DrEricVisser andDrSuellenWalker,theworkingpartyresponsiblefortheThirdEditionofAcutePain: ScientificEvidencehavecontinuedtoaggregatenewclinicalevidenceandtoexpandtherange oftopics.Evenmore,theyhavesynthesisedandpresentedtheconsolidatedevidenceina clear,userfriendlyfashionandhighlightedinstanceswhereprioreditionsconclusionshave beenalteredbynewfindings. Theuseofobjectiveclinicalevidencetoprovidearationalbasisforpracticeisanoldconcept. IntheOldTestament,theBookofDanielclearlyrecountsaprospectivecasecontrolledtrial. Socratesadvocatedclinicaloutcomesassessmentasthebasisforannualreappointmentof statephysicians.Yet,awarethatanevidenceinformedapproachtopatientcarehasrecently attimesinappropriatelybeenusedasarationaleforrestrictingtherangeoftherapeutic optionsavailabletopatients,theauthorsofthethirdeditioncounselthatwhileknowledgeof currentbestevidenceisimportant,itplaysonlyapartinthemanagementofacutepainfor anyindividualpatientandmorethanevidenceisneededifsuchtreatmentistobeeffective. Personalisedmedicineandindividualisedcareinpartnecessitatedbygeneticdifferencesin drugmetabolismandaction,asdiscussedinthethirdeditionrequiresuchabalanced approach.Cochranehimselfvoiceddisdainfortheconsiderablepressuretoprovide physicianswithasimpleruletotellthemwhatitallmeant[CochraneAL:Effectivenessand Efficiency:RandomReflectionsonHealthServices.Cambridge(UK):CambridgeUniversity Press,1989,p.41]. ThefirsteditionofAcutePain:ScientificEvidence(ledbyMJC)anditscounterpartUSfederal guidelineoveradecadeago(ledbyDBC)notedtheclinicalimpressionthatundertreatedacute painmayhavedamaginglongtermconsequences.Subsequentepidemiologicevidencenow affirmsthisclinicalinsightandindicatesthatforsomepatientsdebilitatingpersistentpaincan beavertedbyminimisationofacutepainaftersurgeryortrauma.Evenifitisnotpossibleto preventthetransitionfromacutetochronicpainineverycase,earlyrecognitionand treatmentofincipientchronicpainbyavigilanthealthcaresystemisnecessaryforcost effectiveintervention.TheNationalPainStrategydocumentthatunderpinsthe2010 AustralianPainSummitsummarisestheemergingliteratureonsocial,humanandeconomic costsofundertreatedacuteandchronicpainestablishingpainasamajordiseaseburden (www.painsummit.org.au)andproposinganintegratednewframeworkformanagementof acute,chronicandcancerpain.Thishistoricsummitalsoreiteratedthatapartfrom considerationsofreducedcostandincreasedefficiency,ethicalmedicalpracticemandates preventionofunnecessarypainandsuffering.FurthertheSummitStrategydrawsheavilyiv Acutepainmanagement:scientificevidence

uponthescientificevidenceandclinicalpracticeofacutepainmanagementthatisthesubject ofthisvolume.ThededicatedeffortsofDrMacintyreandcolleaguestosummarisethe scientificevidenceonacutepainmanagementplayanimportantroleinshapingpainrelated practiceandpolicyworldwide.Allthosewhocareforpatientsorfamilymembersinpain,or whomayonedaysufferpainthemselves,areintheirdebt. MichaelJCousinsAMMBBSMDDScFRCAFANZCAFFPMANZCAFAChPM(RACP) ProfessorandDirector PainManagementResearchInstitute UniversityofSydneyandRoyalNorthShoreHospital Sydney,Australia

FOREWORD

DanielBCarr

MDDABPMFFPMANZCA(Hon) SaltonstallProfessorofPainResearch DepartmentofAnesthesia TuftsMedicalCenter Boston,USA

Acutepainmanagement:scientificevidence

v

INTRODUCTIONThisisthethirdeditionofthedocumentAcutePainManagement:ScientificEvidence.Thefirst editionwaswrittenbyamultidisciplinarycommitteeheadedbyProfessorMichaelCousinsand publishedbytheNationalHealthandMedicalResearchCouncil(NHMRC)ofAustraliain1999. ThesecondeditionwaswrittenbymultiplecontributorsandaworkingpartychairedbyAssoc ProfPamMacintyre.ItwasapprovedbytheNHMRCandpublishedbytheAustralianandNew ZealandCollegeofAnaesthetists(ANZCA)anditsFacultyofPainMedicine(FPM)in2005.It wasalsoendorsedbyanumberofmajororganisationstheInternationalAssociationforthe StudyofPain(IASP),theRoyalCollegeofAnaesthetists(UnitedKingdom),theAustralasian FacultyofRehabilitationMedicine,theRoyalAustralasianCollegeofPhysicians,theRoyal AustralasianCollegeofSurgeons,theRoyalAustralianandNewZealandCollegeof PsychiatristsandtheAustralianPainSocietyandrecommendedtoitsmembersbythe AmericanAcademyofPainMedicine. Afterpublication,acompaniondocumentforconsumersManagingAcutePain:aGuidefor PatientswaspreparedandapprovedbytheNHMRC(ANZCA&FPM2005). InaccordwithNHMRCrequirementsthatdocumentssuchastheseberevisedasfurther evidenceaccumulates,andastherehadbeenanongoingandsubstantialincreaseinthe quantityandqualityofinformationavailableaboutacutepainmanagement,itwasseenas timelytoreassesstheavailableevidence.ANZCAandtheFPMthereforeagaintook responsibilityforrevisingandupdatingthedocumentthisthirdedition.Aswiththesecond edition,thisthirdeditionhasbeenendorsedbyanumberofkeyprofessionalorganisations (seelistonthetitlepage).ItwasalsoapprovedbytheNHMRCon4thFebruary2010,under section14AoftheNationalHealthandMedicalResearchCouncilAct1992. Aworkingpartywasconvenedtocoordinateandoverseethedevelopmentprocess.An editorialsubgroupoftheworkingparty(AssocProfPamMacintyre,ProfStephanSchug,Assoc ProfDavidScott,DrEricVisserandDrSuellenWalker)coordinatedthedevelopmentprocess andeditedand/orwrotethesections.TheworkingpartyalsoincludedDrDouglasJustins, DeanoftheFacultyofPainMedicine,RoyalCollegeofAnaesthetistsintheUnitedKingdom, andProfKarenGrimmerSomersfromtheUniversityofSouthAustralia,whowastheNHMRC appointedGuidelinesAssessmentRegisterrepresentativeforthesecondeditionandprovided expertadviceontheuseofevidencebasedfindingsandtheapplicationofNHMRCcriteriafor thisedition. Alargepanelofcontributorswasappointedtodraftsectionsofthedocumentanda multidisciplinaryconsultativecommitteewaschosentoreviewtheearlydraftsofthe documentandcontributemorebroadlyasrequired.Toensuregeneralapplicabilityand inclusiveness,therewasaverywiderangeofexpertsonthecontributorandmultidisciplinary committee,includingmedical,nursing,alliedhealthandcomplementarymedicineclinicians andaconsumer.Commentsonthedocumentwerealsoinvitedduringapublicconsultation period.DetailsoftheprocessesinvolvedareoutlineinAppendixB,ProcessReport. AcutePainManagement:ScientificEvidencecoversawiderangeofclinicaltopics.Thepurpose ofthedocumentis,aswiththefirsttwoeditions,tocombineareviewofthebestavailable evidenceforacutepainmanagementwithcurrentclinicalandexpertpractice,ratherthanto formulatespecificclinicalpracticerecommendations.Accordingly,thedocumentaimsto summarisethesubstantialamountofevidencecurrentlyavailableforthemanagementof acutepaininaconciseandeasilyreadableformtoassistthepractisingclinician.Newandvi AcutePainManagement:ScientificEvidence

INTRODUCTION

updatedcontenthasbeenincorporatedwiththecontentofthepreviousversionofthe document. Itisrecognisedthatwhileknowledgeofcurrentbestevidenceisimportant,itplaysonlyapart inthemanagementofacutepainforanyindividualpatientandmorethanevidenceisneeded ifsuchtreatmentistobeeffective. Evidencebasedmedicinehasbeendefinedastheconscientious,explicitandjudicioususeof currentbestevidenceinmakingdecisionsaboutthecareofindividualpatientsandthatit mustintegrateresearchevidence,clinicalexpertiseandpatientvalues(Sackettetal,1996). Thereforeevidence,clinicalexpertiseand,importantly,patientparticipation(ieincludingthe patientaspartofthetreatinganddecisionmakingteam,takingintoaccounttheirvalues, concernsandexpectations)arerequiredifeachpatientistogetthebesttreatment.The informationprovidedinthisdocumentisnotintendedtooverridetheclinicalexpertiseof healthcareprofessionals.Thereisnosubstitutefortheskilledassessmentofeachindividual patientshealthstatus,circumstancesandperspectives,whichhealthcareprofessionalswill thenusetohelpselectthetreatmentsthatarerelevantandappropriatetothatpatient. Review of the evidence ThisdocumentisarevisionofthesecondeditionofAcutePainManagement:Scientific Evidence,publishedin2005.Therefore,mostofthenewevidenceincludedinthethirdedition hasbeenpublishedfromJanuary2005onwards.Evidencebasedguidelineshavebeen publishedintheareasofacutebackandmusculoskeletalpain,andrecommendationsrelevant tothemanagementoftheacutephaseoftheseconditionsweredrawndirectlyfromthese. FormoredetailsonthereviewoftheevidenceseeAppendixB,ProcessReport. Levels of evidence LevelsofevidenceweredocumentedaccordingtotheNHMRCdesignation(NHMRC,1999).Levelsofevidence I Evidenceobtainedfromasystematicreviewofallrelevantrandomisedcontrolledtrials II Evidenceobtainedfromatleastoneproperlydesignedrandomisedcontrolledtrial III1 Evidenceobtainedfromwelldesignedpseudorandomisedcontrolledtrials(alternateallocationor someothermethod) III2 Evidenceobtainedfromcomparativestudieswithconcurrentcontrolsandallocationnot randomised(cohortstudies),casecontrolledstudiesorinterruptedtimeserieswithacontrolgroup III3 Evidenceobtainedfromcomparativestudieswithhistoricalcontrol,twoormoresinglearm studies,orinterruptedtimeserieswithoutaparallelcontrolgroup IV Evidenceobtainedfromcaseseries,eitherposttestorpretestandposttest Clinicalpracticepoints Recommendedbestpracticebasedonclinicalexperienceandexpertopinion

INTRODUCTION

Key messages Keymessagesforeachtopicaregivenwiththehighestlevelofevidenceavailabletosupport them,orwithasymbolindicatingthattheyarebasedonclinicalexperienceorexpertopinion. Inthekeymessages,LevelIevidencefromtheCochraneDatabaseisidentified.Levelsof evidenceweredocumentedaccordingtotheNHMRCdesignationand,asforthesecond editionofthisdocument,clinicalpracticepointshavebeenadded. Itwasfeltthatthereshouldbeanindicationofhowthekeymessagesinthisthirdedition relatedtothoseinthesecondedition.ThesystemusedbyJohnstonetal(Johnstonetal,2003) toreflecttheimplicationsofnewevidenceonclinicalrecommendationswastherefore Acutepainmanagement:scientificevidence vii

reviewedandadapted.Wherethenewevidenceledtoreversalofaconclusionandkey message,thiswasnotedinthetext.

INTRODUCTION

Reviewandrevisionofkeymessages New Unchanged Strengthened Newevidenceleadstonewkeymessage(s). Thenewevidenceisconsistentwiththedatausedtoformulatetheoriginalkey message.Thekeymessageintheoriginalreportremainsunchanged. Thenewevidenceisconsistentwiththedatausedtoformulatetheoriginalkey message.Thekeymessageintheoriginalreportremainsunchangedorexpanded. Thelevelofevidenceand/orcontentofthekeymessageintheoriginalreporthas beenstrengthenedtoreflectthisadditionalevidence. Thenewevidenceisinconsistentwiththedatausedtoinformtheoriginalkey message(s).However,thenewevidencedoesnotalterthekeymessagebutweakens thelevelofevidence. Thenewevidenceisconsistentwiththedatausedtoformulatetheoriginalkey message.Thekeymessageintheoriginalreportremainsunchangedbutapplicability maybelimitedtospecificpatientgroups/circumstances. Thenewevidenceisinconsistentwiththedatausedtoinformtheoriginalkey message(s).Thestrengthofthenewevidencealterstheconclusionsoftheoriginal document. ClinicalandscientificjudgmentinformedthechoicesmadebytheWorkingParty members;therewasnomandatorythresholdofnewevidence(egnumberofstudies, typesofstudies,magnitudeofstatisticalfindings)thathadtobemetbefore classificationtocategoriesoccurred. Thefirstletterofeachofthewords(New,Unchangedetc)wasusedtodenotethe changes(ifany)fromthelasteditionofthisdocument.

Weakened Qualified Reversed NB

Management of retracted publications InMay2009,twoeditorials(Shaferetal,2009;Whiteetal,2009)werepublishedinAnesthesia andAnalgesiagivingdetailsof21publicationsthathadbeenretractedbyanumberof journalsbecauseofallegationsofscientificfraud.TheeditorialbyShafer(Shaferetal,2009) containsalistoftheretractedarticles.Thislistcanalsobefoundat http://www.aaeditor.org/HWP/Retraction.Notice.pdf. Thepositionofthejournalwasthatunretractedarticlesremainpartoftheunimpeached literature,atleastfornow.InacompanioneditorialWhiteetal(Whiteetal,2009)reviewed boththeretractedandunimpeachedliterature,distinguishingourunderstandingsthat remainfullysupportedfromthosethatarenolongersupportedbytheunimpeached literature.AlsoinMay2009,Eisenach(Eisenach,2009),theeditorofAnesthesiology,presented agraphofnumbersofcitationsofretractedandunretractedarticlesaffectedbythisissueand calledforresearchreexaminingtheconclusionsoftheretractedarticles. AJuly2009editorialbyNeal(Neal,2009)describedcontactwiththeleadorhighranking authorsofsixoriginalarticlesandonereviewarticleinthateditorsjournalandwhichhadnot beenretracted.Thesearticlesarelistedinthiseditorial.HeconcludedthatBasedonthe attestationsoftheinvolvedcoauthorsandtheinvestigationsoftheChiefAcademicOfficerof BaystateMedicalCenter,theEditorialBoardofRegionalAnesthesiaandPainMedicineis comfortablerecommendingthatpractitionerscontinuetomakeclinicaldecisionsbasedonthe informationcontainedwithinthesevenbelowcitedarticles.

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AcutePainManagement:ScientificEvidence

OfthereferenceslistedintheMay2009retractionnotice(Shafer,2009),fourwereincludedin thesecondeditionofAcutePainManagement:ScientificEvidencealongwithafurthertwo publicationsthatwerenotincludedinthislistofretractions. Therearenoprecedentsforhowbesttomanageaproblemsuchasthis.However,theeditors responsibleforthedevelopmentofthisthirdeditionofAcutePainManagement:Scientific Evidencedecidedagainstincludinganypublicationsbytheindividualsaffectedbythese retractionswhenlistedasfirstauthoronthepapers.Anassessmentwasmadeofeachofthe metaanalysesthatcitedaffectedarticles.Thiswasbasedupontheotherpapersincludedin thesemetaanalyses,othersupportingevidenceandindependentconsiderationbyanexpert inbiostatistics.Insomecases,althoughcited,theaffectedreferenceswerenotactually includedinthemetaanalysisperformed.Inothercases,assessmentindicatedthatthe strengthoftheevidencemaybereducedbecauseoftheinclusionofaffectedpublications. Followingtheconsensusthatappearedtorapidlyemergeamongeditorsoftheleadingpeer reviewedjournalsinanaesthesiologyandpainmedicinedespiteinitialconcernsaboutmeta analysesthatincludedthiswork(Whiteetal,2009),theeditorsofthethirdeditionofAcute PainManagement:ScientificEvidencefeltthatindiscriminatelyomittingallmetaanalyses purelyonthebasisofinclusionofoneortwoofthosepaperswouldbetodenyinclusionof someimportantcredibleinformationinthedocument.Indeed,thepurposeofmetaanalysisis toaggregateresultsfromtheliteratureasawhole,therebydilutingtheimpactofanyone specificstudy. JustpriortofinalisationofthisthirdeditionofAcutePainManagement:ScientificEvidence,an articlewaspublishedinAnesthesiologyinDecember2009(Marretetal,2009)whichexamined indetailtheeffectthatexcludingdataobtainedfromtheretractedarticleswouldhaveonthe resultsof14systematicreviews(sixquantitativeandeightqualitative)inwhichtheywere cited.Marretetal(2009)reanalysedthedataafterexcludingresultsfromaffectedarticlesand concludedthatwithdrawalofthesearticlesdidnotaltertheconclusionsoffiveoutofthesix quantitativereviews(metaanalyses):thesixthmetaanalysishasnotbeenincludedinAcute PainManagement:ScientificEvidence.Thustherewasagreementwiththeassessmentsthat hadalreadymadeaboutthevalidityofthesemetaanalyseswhichincludedtheretracted articles.Marretetal(2009)concludedthatmetaanalyseswerevulnerableifdatafrom retractedstudiesmadeupmorethan30%ofthetotal. Afootnotehasbeenaddedtotherelevantsectionsindicatingthesystematicreviews (quantitativeandqualitative)thatincludedaffectedarticlesalongwithasummaryofthe effect,ifany,ontheresultsobtained.Also,specificnotehasbeenmadeinthetextofthethird editionofAcutePainManagement:ScientificEvidencewhereretractionoftheaffectedpapers involvedkeymessagesthatwerepublishedinthesecondedition.Shouldadditional informationbecomeavailableitwillbeaddedasneededbeforepublicationofthisdocument. InformationthatcomestolightafterpublicationwillbepostedasappropriateontheAcute PainManagement:ScientificEvidencewebsite. INN drug names ThisdocumentusesthegenericnamesofdrugsthatapplyinAustraliaandNewZealand. WherethisdiffersfromtheInternationalNonproprietaryName(INN),theINNisgivenin bracketsonfirstusewithineachofthemajorsections. PamMacintyreOnbehalfoftheWorkingGroupoftheAustralianandNewZealandCollegeofAnaesthetistsandFacultyof PainMedicine Acutepainmanagement:scientificevidence ix

INTRODUCTION

ReferencesAustralianandNewZealandCollegeofAnaesthetistsandFacultyofPainMedicine(2005)Managing AcutePain:aGuideforPatients.http://www.anzca.edu.au/resources/booksand publications/ManagingAcutePain.pdf. EisenachJC(2009)Datafabricationandarticleretraction:hownottogetlostinthewoods. Anesthesiology110(5):9556. JohnstonM,BrouwersM&BrowmanG(2003)Keepingcancerguidelinescurrent:resultsofa comprehensiveprospectiveliteraturemonitoringstrategyfortwentyclinicalpracticeguidelines.IntJ TechnolAssessHealthCare19:64655. MarretE,EliaN,DahlJBetal(2009)Susceptibilitytofraudinsystematicreviews.Anesthesiology111: 127989. NealJM(2009)Retraction.RegAnesthPainMed34(4):385. NHMRC(1999)AGuidetotheDevelopment,ImplementationandEvaluationofClinicalPractice Guidelines.NationalHealthandMedicalResearchCouncil,Canberra. http://www.nhmrc.gov.au/publications/synopses/cp30syn.htm SackettDL,RosenbergWM,GrayJAetal(1996)Evidencebasedmedicine:whatitisandwhatitisn't. BMJ312:712. ShaferSL(2009)Tatteredthreads.AnesthAnalg108:13613. WhitePF,KehletH&LiuS(2009)Perioperativeanalgesia:whatdowestillknow?AnesthAnalg108: 13647.

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ContentsFOREWORD......................................................................................................................... iv INTRODUCTION................................................................................................................... vi SUMMARYOFKEYMESSAGES............................................................................................xix 1. PHYSIOLOGYANDPSYCHOLOGYOFACUTEPAIN .......................................................... 1

CONTENTS

1.1 Appliedphysiologyofpain ........................................................................................... 1 1.1.1 Definitionofacutepain.........................................................................................1 1.1.2 Painperceptionandnociceptivepathways...........................................................1 1.1.3 Neuropathicpain...................................................................................................6 1.2 Psychologicalaspectsofacutepain .............................................................................. 6 1.2.1 Psychologicalfactors .............................................................................................7 1.2.2 Acutepainsettings ................................................................................................8 1.3 Progressionofacutetochronicpain............................................................................. 9 1.3.1 Predictivefactorsforchronicpostsurgicalpain ..................................................11 1.3.2 Mechanismsfortheprogressionfromacutetochronicpain .............................12 1.4 Preemptiveandpreventiveanalgesia ....................................................................... 12 1.5 Adversephysiologicalandpsychologicaleffectsofacutepain.................................... 15 1.5.1 Acutepainandtheinjuryresponse.....................................................................15 1.5.2 Adversephysiologicaleffects ..............................................................................16 1.5.3 Painandanalgesia:effectsoninjuryinducedorgandysfunction.......................19 1.5.4 Acuterehabilitationandfasttracksurgery.......................................................20 1.5.5 Adversepsychologicaleffects .............................................................................21 1.6 Pharmacogenomicsandacutepain ............................................................................ 21 1.6.1 Lossofpainsensation .........................................................................................22 1.6.2 Reducedsensitivitytopain .................................................................................22 1.6.3 Drugmetabolism .................................................................................................23 References ......................................................................................................................... 25 2. ASSESSMENTANDMEASUREMENTOFPAINANDITSTREATMENT ............................. 34 2.1 Assessment ................................................................................................................ 34 2.2 Measurement ............................................................................................................ 35 2.2.1 Unidimensionalmeasuresofpain .......................................................................36 2.2.2 Functionalimpactofacutepain ..........................................................................38 2.2.3 Multidimensionalmeasuresofpain....................................................................38 2.2.4 Patientswithspecialneeds .................................................................................39 2.3 Outcomemeasuresinacutepainmanagement.......................................................... 40 2.3.1 Outcomemeasures .............................................................................................40 References ......................................................................................................................... 42


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3. PROVISIONOFSAFEANDEFFECTIVEACUTEPAINMANAGEMENT .............................. 45 3.1 Education ................................................................................................................... 45 3.1.1 Patients ...............................................................................................................45 3.1.2 Staff .....................................................................................................................46 3.2 Organisationalrequirements...................................................................................... 47 3.2.1 Generalrequirements .........................................................................................48 3.2.2 Acutepainservices..............................................................................................48 References ......................................................................................................................... 50 4. SYSTEMICALLYADMINISTEREDANALGESICDRUGS..................................................... 55 4.1 Opioids ...................................................................................................................... 55 4.1.1 Choiceofopioid...................................................................................................55 4.1.2 Specificopioids....................................................................................................55 4.1.3 Determinantsofopioiddose...............................................................................61 4.1.4 Adverseeffectsofopioids ...................................................................................62 4.2 Paracetamol,nonselectivenonsteroidalantiinflammatorydrugsandcoxibs .......... 71 4.2.1 Paracetamol ........................................................................................................71 4.2.2 Nonselectivenonsteroidalantiinflammatorydrugs ........................................73 4.2.3 Cyclooxygenase2selectiveinhibitors(coxibs) ..................................................75 4.3 Adjuvantdrugs........................................................................................................... 79 4.3.1 Inhalationalagents ..............................................................................................79 4.3.2 NMDAreceptorantagonists ...............................................................................83 4.3.3 Antidepressantdrugs ..........................................................................................87 4.3.4 Anticonvulsantdrugs...........................................................................................89 4.3.5 Membranestabilisers..........................................................................................91 4.3.6 Alpha2agonists ..................................................................................................92 4.3.7 Salmoncalcitoninandbisphosphonates .............................................................92 4.3.8 Cannabinoids.......................................................................................................93 4.3.9 Glucocorticoids....................................................................................................94 4.3.10 Complementaryandalternativemedicines ........................................................96 References ......................................................................................................................... 97 5. REGIONALLYANDLOCALLYADMINISTEREDANALGESICDRUGS................................ 121 5.1 Localanaesthetics .................................................................................................... 121 5.1.1 Shortdurationlocalanaesthetics .....................................................................121 5.1.2 Longdurationlocalanaesthetics ......................................................................121 5.1.3 Localanaesthetictoxicity ..................................................................................124 5.2 Opioids .................................................................................................................... 126 5.2.1 Neuraxialopioids...............................................................................................126 5.2.2 Peripheralopioids .............................................................................................129

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5.3 AdjuvantDrugs ........................................................................................................ 131 5.3.1 Alpha2agonists ................................................................................................131 5.3.2 Adrenaline .........................................................................................................132 5.3.3 Ketamine ...........................................................................................................133 5.3.4 Midazolam.........................................................................................................134 5.3.5 Neostigmine ......................................................................................................134 5.3.6 Magnesium........................................................................................................135 5.3.7 BotulinumtoxinA..............................................................................................135 5.4 Antiinflammatorydrugs .......................................................................................... 136 5.4.1 Corticosteroids ..................................................................................................136 5.4.2 Nonsteroidalantiinflammatorydrugs.............................................................137 References ....................................................................................................................... 138 6. ADMINISTRATIONOFSYSTEMICANALGESICDRUGS ................................................. 150 6.1 Oralroute ................................................................................................................ 150 6.1.1 Opioidsandtramadol........................................................................................153 6.1.2 Nonselectivenonsteroidalantiinflammatorydrugsandcoxibs ....................154 6.1.3 Paracetamol ......................................................................................................155 6.2 Intravenousroute .................................................................................................... 155 6.2.1 Opioidsandtramadol........................................................................................155 6.2.2 Nonselectivenonsteroidalantiinflammatorydrugsandcoxibs ....................156 6.2.3 Paracetamol ......................................................................................................156 6.3 Intramuscularandsubcutaneousroutes................................................................... 157 6.3.1 Opioidsandtramadol........................................................................................157 6.3.2 Nonselectivenonsteroidalantiinflammatorydrugsandcoxibs ....................158 6.4 Rectalroute ............................................................................................................. 158 6.4.1 Opioids ..............................................................................................................158 6.4.2 Nonselectivenonsteroidalantiinflammatorydrugs ......................................158 6.4.3 Paracetamol ......................................................................................................159 6.5 Transdermalroute ................................................................................................... 159 6.5.1 Opioids ..............................................................................................................159 6.5.2 Otherdrugs .......................................................................................................160 6.6 Transmucosalroutes ................................................................................................ 160 6.6.1 Intranasalroute.................................................................................................160 6.6.2 Sublingualandbuccalroutes.............................................................................162 6.6.3 Inhaled...............................................................................................................163 References ....................................................................................................................... 164

CONTENTS


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7. PCA,REGIONALANDOTHERLOCALANALGESIATECHNIQUES................................... 171 7.1 Patientcontrolledanalgesia..................................................................................... 171 7.1.1 EfficacyofintravenousPCA...............................................................................171 7.1.2 DrugsusedforparenteralPCA ..........................................................................172 7.1.3 ProgramparametersforintravenousPCA ........................................................175 7.1.4 EfficacyofPCAusingothersystemicroutesofadministration.........................176 7.1.5 ComplicationsrelatedtoPCA............................................................................177 7.1.6 Equipment .........................................................................................................178 7.1.7 Patientandstafffactors ....................................................................................179 7.1.8 PCAinspecificpatientgroups ...........................................................................180 7.2 Epiduralanalgesia .................................................................................................... 182 7.2.1 Efficacy ..............................................................................................................182 7.2.2 Drugusedforepiduralanalgesia.......................................................................184 7.2.3 Patientcontrolledepiduralanalgesia ...............................................................185 7.2.4 Adverseeffects..................................................................................................186 7.3 Intrathecalanalgesia ................................................................................................ 190 7.3.1 Drugsusedforintrathecalanalgesia .................................................................190 7.3.2 Combinedspinalepiduralversusepiduralanalgesiainlabour.........................192 7.4 Regionalanalgesiaandconcurrentanticoagulantmedications................................. 193 7.4.1 Neuraxialblockade ............................................................................................193 7.4.2 Plexusandotherperipheralregionalblockade.................................................195 7.5 Otherregionalandlocalanalgesictechniques .......................................................... 195 7.5.1 Continuousperipheralnerveblockade .............................................................195 7.5.2 Intraarticularanalgesia ....................................................................................199 7.5.3 Woundinfiltrationincludingwoundcatheters .................................................200 7.5.4 Topicalapplicationoflocalanaesthetics...........................................................200 7.5.5 Safety.................................................................................................................201 References ....................................................................................................................... 204 8. NONPHARMACOLOGICALTECHNIQUES ................................................................... 221 8.1 Psychologicalinterventions...................................................................................... 221 8.1.1 Provisionofinformation....................................................................................221 8.1.2 Stressandtensionreduction.............................................................................222 8.1.3 Attentionaltechniques......................................................................................223 8.1.4 Cognitivebehaviouralinterventions .................................................................224 8.2 Transcutaneouselectricalnervestimulation ............................................................ 226 8.3 Acupuncture ............................................................................................................ 227 8.4 Otherphysicaltherapies .......................................................................................... 228 8.4.1 Manualandmassagetherapies.........................................................................228 8.4.2 Heatandcold ....................................................................................................228 8.4.3 Othertherapies .................................................................................................228 References ....................................................................................................................... 229xiv AcutePainManagement:ScientificEvidence

CONTENTS

9. SPECIFICCLINICALSITUATIONS ................................................................................. 233 9.1 Postoperativepain ................................................................................................... 233 9.1.1 Risksofacutepostoperativeneuropathicpain .................................................233 9.1.2 Acutepostamputationpainsyndromes ............................................................234 9.1.3 Otherpostoperativepainsyndromes ...............................................................236 9.1.4 Daystayorshortstaysurgery ..........................................................................238 9.1.5 Cranialneurosurgery .........................................................................................241 9.2 Acutepainfollowingspinalcordinjury..................................................................... 243 9.3 Acuteburninjurypain.............................................................................................. 245 9.3.1 Managementofproceduralpain ......................................................................246 9.3.2 Nonpharmacologicalpainmanagement ..........................................................247 9.4 Acutebackpain........................................................................................................ 248 9.5 Acutemusculoskeletalpain...................................................................................... 249 9.6 Acutemedicalpain................................................................................................... 250 9.6.1 Acuteabdominalpain .......................................................................................250 9.6.2 Herpeszosterassociatedpain ..........................................................................253 9.6.3 Acutecardiacpain .............................................................................................255 9.6.4 Acutepainassociatedwithhaematologicaldisorders ......................................256 9.6.5 Acuteheadache.................................................................................................260 9.6.6 Acutepainassociatedwithneurologicaldisorders ...........................................272 9.6.7 Orofacialpain ....................................................................................................273 9.6.8 AcutepaininpatientswithHIVinfection..........................................................278 9.7 Acutecancerpain..................................................................................................... 280 9.7.1 Thescopeofacutecancerpain .........................................................................280 9.7.2 Principlesofmanagementofacutecancerpain ...............................................281 9.7.3 Breakthroughpain.............................................................................................281 9.7.4 Postoperativeandproceduralpain ...................................................................282 9.7.5 Acutecancerpainduetoboneinvolvement ....................................................283 9.7.6 Otheracutecancerpainsyndromes .................................................................284 9.7.7 Interventionaltherapiesforacutecancerpain .................................................285 9.8 Acutepainmanagementinintensivecare ................................................................ 286 9.8.1 Painassessmentintheintensivecareunit .......................................................287 9.8.2 Nonpharmacologicalmeasures........................................................................287 9.8.3 Pharmacologicaltreatment...............................................................................287 9.8.4 GuillainBarresyndrome ...................................................................................288 9.8.5 Procedurerelatedpain .....................................................................................289 9.9 Acutepainmanagementinemergencydepartments ............................................... 290 9.9.1 Systemicanalgesics ...........................................................................................290 9.9.2 Analgesiainspecificconditions.........................................................................291 9.9.3 Nonpharmacologicalmanagementofpain......................................................293

CONTENTS


xv

9.10 Prehospitalanalgesia ............................................................................................... 294 9.10.1 Assessmentofpainintheprehospitalenvironment ........................................295 9.10.2 Systemicanalgesics ...........................................................................................295 9.10.2 Anxiolytics .........................................................................................................297 9.10.3 Regionalanalgesia.............................................................................................297 9.10.4 Nonpharmacologicalmanagementofpain......................................................297 9.10.5 Analgesiainspecificconditions.........................................................................298 References ....................................................................................................................... 299 10. THEPAEDIATRICPATIENT ......................................................................................... 335 10.1 Developmentalneurobiologyofpain ....................................................................... 335 10.2 Longtermconsequencesofearlypainandinjury..................................................... 336 10.3 Paediatricpainassessment ...................................................................................... 336 10.3.1 Painassessmentinneonates ............................................................................337 10.3.2 Observationalandbehaviouralmeasuresininfantsandchildren ....................338 10.3.3 Selfreportinchildrenandadolescents ............................................................338 10.3.4 Childrenwithcognitiveimpairment..................................................................339 10.4 Managementofproceduralpain .............................................................................. 342 10.4.1 Proceduralpainintheneonate.........................................................................343 10.4.2 Proceduralpainininfantsandolderchildren ...................................................343 10.4.3 Immunisationpainininfantsandchildren........................................................345 10.4.4 Proceduralpainmanagementintheemergencydepartment..........................345 10.5 Analgesicagents ...................................................................................................... 347 10.5.1 Paracetamol ......................................................................................................347 10.5.2 Nonselectivenonsteroidalantiinflammatorydrugs ......................................348 10.5.3 Coxibs ................................................................................................................349 10.5.4 Opioidsandtramadol........................................................................................350 10.5.5 Corticosteroids ..................................................................................................352 10.5.6 Otherpharmacologicaltherapies......................................................................352 10.6 OpioidinfusionsandPCA ......................................................................................... 353 10.6.1 Opioidinfusions.................................................................................................353 10.6.2 Patientcontrolledanalgesia .............................................................................354 10.6.3 Nursecontrolledanalgesia ...............................................................................354 10.7 Regionalanalgesia ................................................................................................... 355 10.7.1 Peripheralnerveblocks .....................................................................................355 10.7.2 Centralneuralblockade ....................................................................................357 10.8 Acutepaininchildrenwithcancer ........................................................................... 361 10.8.1 Cancerrelatedpain ...........................................................................................361 10.8.2 Procedurerelatedpain .....................................................................................361 10.8.3 Treatmentrelatedpain .....................................................................................362 References ....................................................................................................................... 363

CONTENTS

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11. OTHERSPECIFICPATIENTGROUPS ............................................................................ 381 11.1 Thepregnantpatient ............................................................................................... 381 11.1.1 Managementofacutepainduringpregnancy ..................................................381 11.1.2 Managementofpainduringdelivery ................................................................386 11.1.3 Painmanagementduringlactation ...................................................................390 11.1.4 Painmanagementinthepuerperium ...............................................................394 11.2 Theolderpatient ..................................................................................................... 396 11.2.1 Pharmacokineticandpharmacodynamicchanges ............................................397 11.2.2 Physiologyandperceptionofpain ....................................................................398 11.2.3 Assessmentofpain............................................................................................400 11.2.4 Drugsusedinthemanagementofacutepaininolderpeople .........................402 11.2.5 Patientcontrolledanalgesia .............................................................................405 11.2.6 Epiduralanalgesia .............................................................................................405 11.2.7 Intrathecalopioidanalgesia ..............................................................................406 11.2.8 Otherregionalanalgesia ...................................................................................406 11.3AboriginalandTorresStraitIslanderpeoples ........................................................... 408 11.4Differentethnicandculturalgroups......................................................................... 409 11.5Thepatientwithobstructivesleepapnoea............................................................... 411 11.6Thepatientwithconcurrenthepaticorrenaldisease ............................................... 414 11.6.1 Patientswithrenaldisease ...............................................................................414 11.6.2 Patientswithhepaticdisease............................................................................415 11.7 Theopioidtolerantpatient ...................................................................................... 422 11.7.1 Definitionsandclinicalimplications ..................................................................422 11.7.2 Patientgroups ...................................................................................................423 11.7.3 Managementofacutepain ...............................................................................423 11.8Thepatientwithanaddictiondisorder..................................................................... 427 11.8.1 Managementofacutepaininpregnantpatientswithanaddictiondisorder ..429 11.8.2 CNSdepressantdrugs .......................................................................................430 11.8.3 CNSstimulantdrugs ..........................................................................................431 11.8.4 Drugsusedinthetreatmentofaddictiondisorders .........................................431 11.8.5 Recoveringpatients...........................................................................................433 References ....................................................................................................................... 433 APPENDIXA ..................................................................................................................... 452 Theworkingparty,contributorsandmembersofthemultidisciplinaryconsultative committee ....................................................................................................................... 452 APPENDIXB ..................................................................................................................... 462 Processreport.................................................................................................................. 462 ABBREVIATIONSANDACRONYMS.................................................................................... 473 INDEX............................................................................................................................... 478 Acutepainmanagement:scientificevidence xvii

CONTENTS

ListoftablesandfiguresTables 1.1 1.2 1.3 1.4 1.5 1.6 2.1 3.1 4.1 6.1 9.1 9.2 9.3 9.4 10.1 10.2 10.3 11.1 11.2 11.3 11.4 Examplesofprimaryafferentanddorsalhornreceptorsandligands ............................. 2 Incidenceofchronicpainaftersurgery .......................................................................... 11 Riskfactorsforchronicpostsurgicalpain ....................................................................... 11 Definitionsofpreemptiveandpreventiveanalgesia .................................................... 13 Summaryofstudiesaccordingtotargetagentadministered ........................................ 14 Metabolicandendocrineresponsestoinjury ................................................................ 17 Fundamentalsofapainhistory ...................................................................................... 35 PossiblebenefitsofanAcutePainService ..................................................................... 49 Antidepressantsforthetreatmentofneuropathicpain ................................................ 87 The2007Oxfordleaguetableofanalgesicefficacy ..................................................... 151 Taxonomyofacutepainassociatedwithspinalcordinjury......................................... 244 Simpleanalgesicsforthetreatmentofmigraine ......................................................... 262 Tableoftriptans ........................................................................................................... 263 Pooledeffectivenessdatafromemergencydepartmentstudiesofthe treatmentofmigraine .................................................................................................. 292 Acutepainintensitymeasurementtoolsneonates ................................................. 340 Compositescalesforinfantsandchildren.................................................................... 341 Selfreporttoolsforchildren ........................................................................................ 342 ADECdrugcategorisationaccordingtofetalrisk ......................................................... 383 Categorisationofdrugsusedinpainmanagement...................................................... 384 Thebreastfeedingpatientanddrugsusedinpainmanagement................................. 392 Directionandapproximatemagnitudeofphysiologicalchangesapparentinanolder population(>70years)andtheeffectsofindividualchangesonpharmacokinetic variables ....................................................................................................................... 397 Analgesicdrugsinpatientswithrenalimpairment ...................................................... 415 Analgesicdrugsinpatientswithhepaticimpairment .................................................. 419 Definitionsfortolerance,physicaldependenceandaddiction .................................... 422

CONTENTS

11.5 11.6 11.7

Figures 1.1 1.2 1.3 1.4 Themainascendinganddescendingspinalpainpathways ............................................. 5 Theinjuryresponse ........................................................................................................ 16 Proposedpathwaysofglucoseinducedcellulartoxicity................................................ 18 Acutepainmanagementandrehabilitation................................................................... 20

10.1 FacesPainScaleRevised .......................................................................................... 340

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SUMMARY OF KEY MESSAGESAdescriptionofthelevelsofevidenceandassociatedsymbolscanbefoundinthe Introduction(seepagesviitoviii). 1. PHYSIOLOGY AND PSYCHOLOGY OF ACUTE PAIN

Psychologicalaspectsofacutepain

SUMMARY

1. 2.

Preoperativeanxiety,catastrophising,neuroticismanddepressionareassociatedwith higherpostoperativepainintensity(U)(LevelIV). PreoperativeanxietyanddepressionareassociatedwithanincreasednumberofPCA demandsanddissatisfactionwithPCA(U)(LevelIV). Painisanindividual,multifactorialexperienceinfluencedbyculture,previouspain events,beliefs,moodandabilitytocope(U).

Progressionofacutetochronicpain1. 2. 3. Somespecificearlyanaestheticand/oranalgesicinterventionsreducetheincidenceof chronicpainaftersurgery(S)(LevelII). Chronicpostsurgicalpainiscommonandmayleadtosignificantdisability(U)(LevelIV). Riskfactorsthatpredisposetothedevelopmentofchronicpostsurgicalpainincludethe severityofpreandpostoperativepain,intraoperativenerveinjuryandpsychosocial factors(U)(LevelIV).

4. Allpatientswithchronicpostherniorrhaphypainhadfeaturesofneuropathicpain(N) (LevelIV). 5 Spinalanaesthesiaincomparisontogeneralanaesthesiareducestheriskofchronic postsurgicalpainafterhysterectomyandCaesareansection(N)(LevelIV).

Preemptiveandpreventiveanalgesia1. Thetimingofasingleanalgesicintervention(preincisionalratherthanpostincisional), definedaspreemptiveanalgesia,hasasignificanteffectonpostoperativepainrelief withepiduralanalgesia(R)(LevelI). 2. Thereisevidencethatsomeanalgesicinterventionshaveaneffectonpostoperativepain and/oranalgesicconsumptionthatexceedstheexpecteddurationofactionofthedrug, definedaspreventiveanalgesia(U)(LevelI). NMDAreceptorantagonistdrugsinparticularshowpreventiveanalgesiceffects(U) (LevelI). Perioperativeepiduralanalgesiacombinedwithketamineintravenouslydecreases hyperalgesiaandlongtermpainupto1yearaftercolonicsurgerycomparedwith intravenousanalgesiaalone(N)(LevelII).

3. 4.


xix

Adversephysiologicalandpsychologicaleffectsofacutepain1. Recognitionoftheimportanceofpostoperativerehabilitationincludingpharmacological, physical,psychologicalandnutritionalcomponentshasledtoenhancedrecovery(N) (LevelII). Acutepainandinjuryofvarioustypesareinevitablyinterrelatedandifsevereand prolonged,theinjuryresponsebecomescounterproductiveandcanhaveadverseeffects onoutcome(U).

SUMMARY

Pharmacogenomicsandacutepain1. 2. CYP2D6polymorphismsaffectplasmaconcentrationsofactivemetabolitesofcodeine andtramadol(N)(LevelII). Geneticpolymorphismsexplainthewideinterindividualvariabilityinplasma concentrationsofagivendoseofmethadone(N). ASSESSM ENT AND M EASUREM ENT OF PAIN AND ITS TREATM ENT

Measurement1. 2. Regularassessmentofpainleadstoimprovedacutepainmanagement(U)(LevelIII3). Thereisgoodcorrelationbetweenthevisualanalogueandnumericalratingscales(U) (LevelIII2). Selfreportingofpainshouldbeusedwheneverappropriateaspainisbydefinitiona subjectiveexperience(U). Thepainmeasurementtoolchosenshouldbeappropriatetotheindividualpatient; developmental,cognitive,emotional,languageandculturalfactorsshouldbe considered(U). Scoringshouldincorporatedifferentcomponentsofpainincludingthefunctional capacityofthepatient.Inthepostoperativepatientthisshouldincludestatic(rest)and dynamic(egpainonsitting,coughing)pain(U). Uncontrolledorunexpectedpainrequiresareassessmentofthediagnosisand considerationofalternativecausesforthepain(egnewsurgical/medicaldiagnosis, neuropathicpain)(U).

Outcomemeasuresinacutepainmanagement 3. Multipleoutcomemeasuresarerequiredtoadequatelycapturethecomplexityofthe painexperienceandhowitmaybemodifiedbypainmanagementinterventions(U). PROVISION OF SAFE AND EFFECTIVE ACUTE PAIN M ANAGEM ENT

Education1. 2. 3. Preoperativeeducationimprovespatientorcarerknowledgeofpainandencouragesa morepositiveattitudetowardspainrelief(U)(LevelII). Videoeducationofpatientswithawhiplashinjuryreducestheincidenceofpersistent pain(N)(LevelII). Writteninformationgiventopatientspriortoseeingananaesthetistisbetterthanverbal informationgivenatthetimeoftheinterview(N)(LevelIII2).AcutePainManagement:ScientificEvidence

xx

4. Whileevidenceforthebenefitofpatienteducationintermsofbetterpainreliefis inconsistent,structuredpreoperativeeducationmaybebetterthanroutineinformation, andinformationpresentedinvideoformatmaybebetterstill(N)(LevelIII2). Implementationofanacutepainservicemayimprovepainreliefandreducethe incidenceofsideeffects(U)(LevelIII3). Staffeducationandtheuseofguidelinesimprovepainassessment,painreliefand prescribingpractices(U)(LevelIII3). Evensimpletechniquesofpainreliefcanbemoreeffectiveifattentionisgivento education,documentation,patientassessmentandprovisionofappropriateguidelines andpolicies(U)(LevelIII3). Successfulmanagementofacutepainrequirescloseliaisonwithallpersonnelinvolvedin thecareofthepatient(U). Moreeffectiveacutepainmanagementwillresultfromappropriateeducationand organisationalstructuresforthedeliveryofpainreliefratherthantheanalgesic techniquesthemselves(U). SYSTEM ICALLY ADM INISTERED ANALGESIC DRUGS

5. 6. 7.

SUMMARY

4.

Opioids1. 2. 3. 4. Dextropropoxyphenehaslowanalgesicefficacy(U)(LevelI[CochraneReview]). Tramadolisaneffectivetreatmentforneuropathicpain(U)(LevelI[CochraneReview]). Gabapentin,nonsteroidalNSAIDsandketamineareopioidsparingmedicationsand reduceopioidrelatedsideeffects(N)(LevelI). Inappropriatedoses,droperidol,metoclopramide,ondansetron,tropisetron,dolasetron, dexamethasone,cyclizineandgranisetronareeffectiveinthepreventionof postoperativenauseaandvomiting(N)(LevelI[CochraneReview]). Alvimopanandmethylnaltrexoneareeffectiveinreversingopioidinducedslowingof gastrointestinaltransittimeandconstipation(N)(LevelI[CochraneReview]). Droperidol,dexamethasoneandondansetronareequallyeffectiveinthepreventionof postoperativenauseaandvomiting(U)(LevelI). Pairedcombinationsof5HT3antagonist,droperidolordexamethasoneprovidesuperior prophylaxisofpostoperativenauseaandvomitingthaneithercompoundalone(N) (LevelI). Naloxone,naltrexone,nalbuphine,droperidoland5HT3antagonistsareeffective treatmentsforopioidinducedpruritus(N)(LevelI). Opioidsinhighdosescaninducehyperalgesia(N)(LevelI).

5. 6. 7.

8. 9.

10. Tramadolhasalowerriskofrespiratorydepressionandimpairsgastrointestinalmotor functionlessthanotheropioidsatequianalgesicdoses(U)(LevelII). 11. Pethidineisnotsuperiortomorphineintreatmentofpainofrenalorbiliarycolic(U) (LevelII). 12. Morphine6glucuronideisaneffectiveanalgesic(N)(LevelII). 13. Inthemanagementofacutepain,oneopioidisnotsuperioroverothersbutsome opioidsarebetterinsomepatients(U)(LevelII). Acutepainmanagement:scientificevidence xxi

14. Theincidenceofclinicallymeaningfuladverseeffectsofopioidsisdoserelated(U) (LevelII). 15. HighdosesofmethadonecanleadtoprolongedQTinterval(N)(LevelII). 16. Haloperidoliseffectiveinthepreventionofpostoperativenauseaandvomiting(N) (LevelII). 17. Opioidantagonistsareeffectivetreatmentsforopioidinducedurinaryretention(N) (LevelII).

SUMMARY

18. Inclinicallyrelevantdoses,thereisaceilingeffectforrespiratorydepressionwith buprenorphinebutnotforanalgesia(N)(LevelIII2). 19. Assessmentofsedationisamorereliablewayofdetectingearlyopioidinduced respiratorydepressionthanadecreasedrespiratoryrate(S)(LevelIII3). 20. Theevidenceforriskofcardiacarrhythmiasfollowinglowdosedroperidolispoor(N) (LevelIII3). 21. Inadults,patientageratherthanweightisabetterpredictorofopioidrequirements, althoughthereisalargeinterpatientvariation(U)(LevelIV). 22. Impairedrenalfunctionandtheoralrouteofadministrationresultinhigherlevelsofthe morphinemetabolitesmorphine3glucuronideandmorphine6glucuronidewith increasedriskofsedationandrespiratorydepression(S)(LevelIV). Theuseofpethidine(U)anddextropropoxyphene(N)shouldbediscouragedinfavourof otheropioids.

Paracetamol,nonselectivenonsteroidalantiinflammatorydrugsandcoxibs1. 2. 3. 4. 5. 6. 7. 8. 9. Paracetamolisaneffectiveanalgesicforacutepain;theincidenceofadverseeffects comparabletoplacebo(S)(LevelI[CochraneReview]). NonselectiveNSAIDsareeffectiveinthetreatmentofacutepostoperativeandlowback pain,renalcolicandprimarydysmenorrhoea(N)(LevelI[CochraneReview]). Coxibsareeffectiveinthetreatmentofacutepostoperativepain(N)(LevelI[Cochrane Review]). Withcarefulpatientselectionandmonitoring,theincidenceofnsNSAIDinduced perioperativerenalimpairmentislow(U)(LevelI[CochraneReview]). NonselectiveNSAIDsdonotincreasetheriskofreoperationforbleedingafter tonsillectomyinpaediatricpatients(Q)(LevelI[CochraneReview]). Coxibsdonotappeartoproducebronchospasminindividualsknowntohaveaspirin exacerbatedrespiratorydisease(U)(LevelI). Ingeneral,aspirinincreasesbleedingaftertonsillectomy(N)(LevelI). NonselectiveNSAIDsgiveninadditiontoparacetamolimproveanalgesiacomparedwith paracetamolalone(U)(LevelI). ParacetamolgiveninadditiontoPCAopioidsreducesopioidconsumptionbutdoesnot resultinadecreaseinopioidrelatedsideeffects(N)(LevelI).

10. NonselectiveNSAIDsgiveninadditiontoPCAopioidsreduceopioidconsumptionand theincidenceofnausea,vomitingandsedation(N)(LevelI).

xxii


11. NonselectiveNSAIDsandcoxibsareeffectiveanalgesicsofsimilarefficacyforacutepain (U)(LevelI). 12. Preoperativecoxibsreducepostoperativepainandopioidconsumption,andincrease patientsatisfaction(N)(LevelI). 13. CoxibsgiveninadditiontoPCAopioidsreduceopioidconsumptionbutdonotresultina decreaseinopioidrelatedsideeffects(N)(LevelI). 14. CoxibsandnonselectiveNSAIDshavesimilaradverseeffectsonrenalfunction(U) (LevelI).

SUMMARY

15. NonselectiveNSAIDsdonotsignificantlyincreasebloodlossaftertonsillectomybutdo increasetheneedforreoperationduetobleeding(N)(LevelI). 16. Parecoxiband/orvaldecoxibcomparedwithplacebodonotincreasetheriskof cardiovascularadverseeventsafternoncardiacsurgery(N)(LevelI). 17. CoxibsandnonselectiveNSAIDsareassociatedwithsimilarratesofadverse cardiovasculareffects,inparticularmyocardialinfarction;naproxenmaybeassociated withalowerriskthanothernonselectiveNSAIDsandcelecoxibmaybeassociatedwitha lowerriskthanothercoxibsandnonselectiveNSAIDsoverall(N)(LevelI). 18. PerioperativenonselectiveNSAIDsincreasetheriskofseverebleedingafteravarietyof otheroperationscomparedwithplacebo(N)(LevelII). 19. Coxibsdonotimpairplateletfunction;thisleadstoreducedperioperativebloodlossin comparisonwithnonselectiveNSAIDs(S)(LevelII). 20. Shorttermuseofcoxibsresultsingastriculcerationratessimilartoplacebo(U)(LevelII). 21. Useofparecoxibfollowedbyvaldecoxibaftercoronaryarterybypasssurgeryincreases theincidenceofcardiovasculareventsandisthereforecontraindicated(S)(LevelII). AdverseeffectsofNSAIDsaresignificantandmaylimittheiruse(U). TheriskofadverserenaleffectsofnonselectiveNSAIDsandcoxibsisincreasedinthe presenceoffactorssuchaspreexistingrenalimpairment,hypovolaemia,hypotension, useofothernephrotoxicagentsandACEinhibitors(U).

AdjuvantdrugsInhalationalagents 1. 2. 3. Nitrousoxidehassomeanalgesicefficacyandissafeduringlabour(U)(LevelI). Nitrousoxideisaneffectiveanalgesicagentinavarietyofotheracutepainsituations(U) (LevelII). Methoxyflurane,inlowconcentrations,maybeaneffectiveanalgesiainthehospitaland prehospitalsetting(N)(LevelIV). Neuropathyandbonemarrowsuppressionarerarebutpotentiallyseriouscomplications ofnitrousoxideuse,particularlyinatriskpatients(U).


xxiii

Theinformationaboutthecomplicationsofnitrousoxideisfromcasereportsonly.There arenocontrolledstudiesthatevaluatethesafetyofrepeatedintermittentexposureto nitrousoxideinhumansandnodatatoguidetheappropriatemaximumdurationor numberoftimesapatientcansafelybeexposedtonitrousoxide.Thesuggestionsforthe useofnitrousoxideareextrapolationsonlyfromtheinformationabove.Consideration shouldbegiventodurationofexposureandsupplementationwithvitaminB12, methionine,andfolicorfolinicacid(U). Ifnitrousoxideisusedwithothersedativeoranalgesicagents,appropriateclinical monitoringshouldbeused(U). Perioperativelowdoseketamineusedinconjunctionwithpatientcontrolledanalgesia morphineisopioidsparingandreducestheincidenceofnauseaandvomiting(N)(LevelI [CochraneReview]). Ingeneral,aperioperativelowdoseketamineinfusionisopioidsparing,butdoesnot produceaclinicallysignificantreductioninpainscoresoropioidrelatedadverseeffects (S)(LevelI). Ketamineisasafeandeffectiveanalgesicforpainfulproceduresinchildren(N)(LevelI). Ketamineanddextromethorphanhavepreventive(U)butnotpreemptiveanalgesic effects(N)(LevelI). Magnesiumdoesnotreducepostoperativepainscoresoropioidconsumptionandhasno preventiveanalgesiceffect(N)(LevelI). Ketaminemayimproveanalgesiainpatientswithsevereacutepainthatispoorly responsivetoopioids,althoughevidenceisconflicting(W)(LevelII). Ketaminereducespostoperativepaininopioidtolerantpatients(N)(LevelII). Theprimaryroleoflowdoseketamineisasanantihyperalgesic,antiallodynic, toleranceprotectiveandpreventiveanalgesic,ratherthanasananalgesicperse(N). Inneuropathicpain,tricyclicantidepressantsaremoreeffectivethanselective serotonergicreuptakeinhibitors(S)(LevelI[CochraneReview]). Duloxetineiseffectiveinpainfuldiabeticneuropathyandfibromyalgia(N)(LevelI [CochraneReview]). Thereisnogoodevidencethatantidepressantsareeffectiveinthetreatmentofchronic lowbackpain(R)(LevelI[CochraneReview]). Tricyclicantidepressantsareeffectiveinthetreatmentofchronicheadaches(U)and fibromyalgia(N)(LevelI). Antidepressantsreducetheincidenceofchronicneuropathicpainafterherpeszoster(U) (LevelII). Note:withdrawalofpreviouskeymessage: Antidepressantsreducetheincidenceofchronicneuropathicpainafterbreastsurgery Thishasbeendeletedastheinformationandevidencesupportingithasbeenwithdrawn.

SUMMARY

NMDAreceptorantagonists 1.

2.

3. 4. 5. 6. 7.

Antidepressantdrugs 1. 2. 3. 4. 5.

xxiv


Basedontheexperienceinchronicneuropathicpainstates,itwouldseemreasonableto usetricyclicantidepressantsandselectiveserotoninreuptakeinhibitorsinthe managementofacuteneuropathicpain(S). Tominimiseadverseeffects,particularlyinelderlypeople,itisadvisabletoinitiate treatmentwithlowdoses(U). Gabapentiniseffectiveinthetreatmentofchronicneuropathicpain(Q);lamotrigineis mostlikelyineffective(N)(LevelI[CochraneReview]).

Anticonvulsantdrugs 1. 2. 3. 4.

SUMMARY

Carbamazepineiseffectiveinthetreatmentoftrigeminalneuralgia(N)(LevelI[Cochrane Review]). Pregabaliniseffectiveinthetreatmentofchronicneuropathicpainrelatedtodiabetic neuropathy(N)(LevelI). Perioperativegabapentinoids(gabapentin/pregabalin)reducepostoperativepainand opioidrequirements(U)andreducetheincidenceofvomiting,pruritusandurinary retention,butincreasetheriskofsedation(N)(LevelI). Basedontheexperienceinchronicneuropathicpainstates,itwouldseemreasonableto useanticonvulsantsinthemanagementofacuteneuropathicpain(U). Bothlignocaine(lidocaine)andmexiletineareeffectiveinthetreatmentofchronic neuropathicpain(S);thereisnodifferenceinefficacyoradverseeffectscomparedwith carbamazepine,amantadine,ormorphine(N)(LevelI[CochraneReview]). Perioperativeintravenouslignocainereducespainandopioidrequirementsfollowing abdominalsurgery(S)aswellasnausea,vomiting,durationofileusandlengthofhospital stay(N)(LevelI). Basedontheexperienceinchronicneuropathicpainstates,itwouldseemreasonableto usemembranestabilisersinthemanagementofacuteneuropathicpain(U). Lignocaine(intravenousorsubcutaneous)maybeausefulagenttotreatacute neuropathicpain(U). Theuseofsystemicalpha2agonistsconsistentlyimprovesperioperativeopioid analgesiabutthefrequencyandseverityofsideeffectsmaylimittheirclinicalusefulness (U)(LevelII). Bisphosphonatesreducebonepainassociatedwithmetastaticcancerandmultiple myeloma(N)(LevelI[CochraneReview]). Salmoncalcitoninreducespainandimprovesmobilisationafterosteoporosisrelated vertebralfractures(S)(LevelI). Salmoncalcitoninreducesacutebutnotchronicphantomlimbpain(N)(LevelII). Pamidronatereducespainassociatedwithacuteosteoporoticvertebralfractures(N) (LevelII).

Membranestabilisers 1.

2.

Alpha2agonists 1.

Salmoncalcitoninandbisphosphonates 1. 2. 3. 4.


xxv

Cannabinoids 1. Currentevidencedoesnotsupporttheuseofcannabinoidsinacutepainmanagement (S)butthesedrugsappeartobemildlyeffectivewhenusedinthetreatmentofchronic neuropathicpain,includingmultiplesclerosisrelatedpain(N)(LevelI). Dexamethasone,comparedwithplacebo,reducespostoperativepain,nauseaand vomiting,andfatigue(LevelII). Thereissomeevidencethatsomecomplementaryandalternativemedicinesmaybe effectiveinsomeacutepainstates.Adverseeffectsandinteractionswithmedications havebeendescribedwithcomplementaryandalternativemedicinesandmustbe consideredbeforetheiruse(N). REGIONALLY AND LOCALLY ADM INISTERED ANALGESIC DRUGS

Glucocorticoids 1.

SUMMARY

Complementaryandalternativemedicines

5.

Localanaesthetics1. 2. 3. Lignocaineismorelikelytocausetransientneurologicsymptomsthanbupivacaine, prilocaineandprocaine(N)(LevelI[CochraneReview]). Thequalityofepiduralanalgesiawithlocalanaestheticsisimprovedwiththeadditionof opioids(U)(Level1). Ultrasoundguidancereducestheriskofvascularpunctureduringtheperformanceof regionalblockade(N)(LevelI).

4. Continuousperineuralinfusionsoflignocaine(lidocaine)resultinlesseffectiveanalgesia andmoremotorblockthanlongactinglocalanaestheticagents(U)(LevelII). 5. Therearenoconsistentdifferencesbetweenropivacaine,levobupivacaineand bupivacainewhengiveninlowdosesforregionalanalgesia(epiduralandperipheral nerveblockade)intermsofqualityofanalgesiaormotorblockade(U)(LevelII). Cardiovascularandcentralnervoussystemtoxicityofthestereospecificisomers ropivacaineandlevobupivacaineislessseverethanwithracemicbupivacaine(U)(Level II). Lipidemulsioniseffectiveinresuscitationofcirculatorycollapseduetolocalanaesthetic toxicity,howeveruncertaintiesrelatingtodosage,efficacyandsideeffectsstillremain andthereforeitisappropriatetoadministerlipidemulsiononceadvancedcardiaclife supporthasbegunandconvulsionsarecontrolled(N)(LevelIV). Casereportsfollowingaccidentaloverdosewithropivacaineandbupivacainesuggest thatresuscitationislikelytobemoresuccessfulwithropivacaine(U).

6.

7.

Opioids1. 2. 3.xxvi

Intrathecalmorphineproducesbetterpostoperativeanalgesiathanintrathecalfentanyl afterCaesareansection(U)(LevelI). Intrathecalmorphinedosesof300mcgormoreincreasetheriskofrespiratory depression(N)(LevelI). Morphineinjectedintotheintraarticularspacefollowingkneearthroscopydoesnot improveanalgesiacomparedwithplacebowhenadministeredaftersurgery(R)(LevelI).AcutePainManagement:ScientificEvidence

4. 5. 6. Evidenceforaclinicallyrelevantperipheralopioideffectatnonarticularsites,including perineural,isinconclusive(U)(LevelI). EpiduralpethidineproducesbetterpainreliefandlesssedationthanIVpethidineafter Caesareansection(U)(LevelII). Extendedreleaseepiduralmorphineprovidesanalgesiaforupto48hours,however centraldepressanteffects,includingrespiratorydepression,mayalsobeincreasedand prolonged(N)(LevelII). Noneurotoxicityhasbeenshownatnormalclinicalintrathecaldosesofmorphine, fentanylandsufentanil(U). Neuraxialadministrationofbolusdosesofhydrophilicopioidscarriesanincreasedriskof delayedsedationandrespiratorydepressioncomparedwithlipophilicopioids(U).

SUMMARY

AdjuvantDrugs1. Intrathecalclonidineimprovesdurationofanalgesiaandanaesthesiawhenusedasan adjuncttointrathecallocalanaesthetics(N)(LevelI). 2. Clonidineimprovesdurationofanalgesiaandanaesthesiawhenusedasanadjunctto localanaestheticsforperibulbar,peripheralnerveandplexusblocks(N)(LevelI).

3. Intrathecalneostigminemarginallyimprovesperioperativeandperipartumanalgesiain combinationwithotherspinalmedicationsbutisassociatedwithsignificantsideeffects (S)(LevelI). 4. Epiduralneostigminecombinedwithanopioidreducesthedoseofepiduralopioidthatis requiredforanalgesia(U)(LevelI). 5. Epiduralketamine(withoutpreservative)addedtoopioidbasedepiduralanalgesia regimensimprovespainreliefwithoutreducingsideeffects(U)(LevelI). 6. Intrathecalmidazolamcombinedwithalocalanaestheticprolongsthetimetofirst analgesiaandreducespostoperativenauseaandvomiting(N)(LevelI). 7. FollowingCaesareansection,intrathecalmorphineprovidesimprovedanalgesia comparedwithplacebo(N)(LevelI)andmoreprolongedanalgesiacomparedwithmore lipophilicopioids(N)(LevelII).

8. Intrathecalclonidineaddedtointrathecalmorphineimprovesandprolongsanalgesia(N) (LevelII). 9. Epiduralclonidinereducespostoperativesystemicopioidrequirements(N)(LevelII). 10. Epiduraladrenaline(epinephrine)incombinationwithalocalanaestheticimprovesthe qualityofpostoperativethoracicepiduralanalgesia(U)(LevelII). 11. Inobstetrics,epiduralneostigmineimprovespostoperativeanalgesiawithoutincreasing theincidenceofadverseevents(N)(LevelII). 12. Additionofeitherclonidineordexmedetomidinetointrathecalbupivacaineincreasesthe speedofonsetanddurationofmotorandsensoryblockwithoutadditionalsideeffects (N)(LevelII).


xxvii

AntiinflammatorydrugsCorticosteroids 1. 2. 3. SubacromialinjectionsofcorticosteroidsaresuperiortooralNSAIDsintreatingrotator cufftendonitis(N)(LevelI). Lumbarepiduralsteroidadministrationiseffectiveforshorttermreliefofacute radicularpain(N)(LevelI). Followingkneejointarthroscopy,intraarticularsteroidsincombinationwitheitherlocal anaestheticoropioidsreducepain,analgesicconsumptionanddurationof immobilisation(N)(LevelII). Intravenousregionalanaesthesiacombiningdexamethasonewithlignocaineimproves analgesiaforupto24hours(N)(LevelII). Thereisariskofsepticarthritiswithintraarticularsteroids(N)(LevelIV).

SUMMARY

4. 5.

Nonsteroidalantiinflammatorydrugs 1. TopicalNSAIDsareoflimitedefficacyinlateralelbowpainandprovideshortterm functionalimprovement;theyresultinfewergastrointestinalsideeffectscomparedwith oralNSAIDs(N)(LevelI[CochraneReview]). 2. NonselectiveNSAIDsaddedtolocalanaestheticsolutionsforIVRAimprove postoperativeanalgesia(N)(LevelI). 3. TopicalNSAIDsareeffectiveintreatingacutestrains,sprainsorsportsinjuriesforupto 1weekwithketoprofenbeingsignificantlybetterthanallothertopicalNSAIDs,and indomethacinsimilartoplacebo(N)(LevelI).

4. Topicaldiclofenacsignificantlyreducespainandinflammationinarangeofsports, traumaticandinflammatoryconditionsandinacutemusculoskeletalinjuriesisatleast comparabletooralnaproxen(N)(LevelI). 5. TopicalNSAIDsareeffectiveanalgesicsfortraumaticcornealabrasions(N)(LevelI). 6. 1. 2. ADM INISTRATION OF SYSTEM IC ANALGESIC DRUGS Paracetamolcombinedwithcodeineismoreeffectivethaneitherdrugaloneandshows adoseresponseeffect(N)(LevelI[CochraneReview]). NSAIDs(bothnsNSAIDsandcoxibs)givenparenterallyorrectallyarenotmoreeffective anddonotresultinfewersideeffectsthanthesamedruggivenorally(U)(LevelI [CochraneReview]). Paracetamolcombinedwithtramadolismoreeffectivethaneitherdrugaloneandshows adoseresponseeffect(N)(LevelI). Earlypostoperativeoraladministrationofparacetamolresultsinhighlyvariableplasma concentrationsthatmayremainsubtherapeuticinsomepatients(N)(LevelII). Rectaladministrationofsingledosesofparacetamolresultsinhighlyvariableplasma concentrationsthatoftenremainsubtherapeutic(N)(LevelII). Intermittentsubcutaneousmorphineinjectionsareaseffectiveasintramuscular injectionsandhavebetterpatientacceptance(U)(LevelII). Intranasalopioids,inparticularthemorelipidsolubledrugssuchasfentanyl,are effectiveforthemanagementofacutepain(N)(LevelII).AcutePainManagement:ScientificEvidence

3. 4. 5. 6. 7.

xxviii

8. Continuousintravenousinfusionofopioidsinthegeneralwardsettingisassociatedwith anincreasedriskofrespiratorydepressioncomparedwithothermethodsofparenteral opioidadministration(U)(LevelIV). Transdermalfentanylshouldnotbeusedinthemanagementofacutepainbecauseof safetyconcernsanddifficultiesinshorttermdoseadjustmentsneededfortitration; furthermore,inmostcountries,itlacksregulatoryapprovalforuseinotherthanopioid tolerantpatients(S)(LevelIV). Otherthaninthetreatmentofsevereacutepain,andprovidingthereareno contraindicationstoitsuse,theoralrouteistherouteofchoicefortheadministrationof mostanalgesicdrugs(U). Titrationofopioidsforsevereacutepainisbestachievedusingintermittentintravenous bolusdosesasitallowsmorerapidtitrationofeffectandavoidstheuncertaintyofdrug absorptionbyotherroutes(U). Controlledreleaseopioidpreparationsshouldonlybegivenatsettimeintervals(U). Immediatereleaseopioidsshouldbeusedforbreakthroughpainandfortitrationof controlledreleaseopioids(U). Theuseofcontrolledreleaseopioidpreparationsasthesoleagentsfortheearly managementofacutepainisdiscouragedbecauseofdifficultiesinshorttermdose adjustmentsneededfortitration(U). Neitheroraltransmucosalfentanylcitratenorfentanylbuccaltabletsshouldbeusedin themanagementofacutepainbecauseofsafetyconcernsand,inmostcountries,lackof regulatoryapprovalforuseinotherthanopioidtolerantpatients(N). PCA, REGIONAL AND OTHER LOCAL ANALGESIA TECHNIQUES

9.

SUMMARY

7.

Patientcontrolledanalgesia1. 2. IntravenousopioidPCAprovidesbetteranalgesiathanconventionalparenteralopioid regimens(S)(LevelI[Cochranereview]). OpioidadministrationbyintravenousPCAleadstohigheropioidconsumption(R),a higherincidenceofpruritus(R),andnodifferenceinotheropioidrelatedadverseeffects (S)orhospitalstay(S)comparedwithtraditionalmethodsofintermittentparenteral opioidadministration(LevelI[Cochranereview]). Insettingswheretherearehighnursepatientratiostheremaybenodifferencein effectivenessofPCAandconventionalparenteralopioidregimens(N)(LevelI). PatientpreferenceforintravenousPCAishigherwhencomparedwithconventional regimens(U)(LevelI). TheadditionofketaminetoPCAmorphinedoesnotimproveanalgesiaorreducethe incidenceofopioidrelatedsideeffects(U)(LevelI). IontophoreticfentanylPCAmaynotbeaseffectiveasintravenousmorphinePCA,with morepatientswithdrawingfromstudiesbecauseofinadequatepainrelief(LevelI). ThereislittleevidencethatoneopioidviaPCAissuperiortoanotherwithregardsto analgesicoradverseeffectsingeneral;althoughonanindividualpatientbasis,one opioidmaybebettertoleratedthananother(U)(LevelII).

3. 4. 5. 6. 7.


xxix

8. 9. ThereisnoanalgesicbenefitinaddingnaloxonetothePCAmorphinesolution;however inultralowdosestheincidenceofnauseaandpruritusmaybedecreased(U)(LevelII). TheadditionofabackgroundinfusiontointravenousPCAdoesnotimprovepainreliefor sleep,orreducethenumberofPCAdemands(U)(LevelII).

10. SubcutaneousPCAopioidscanbeaseffectiveasintravenousPCA(U)(LevelII). 11. IntranasalPCAopioidscanbeaseffectiveasintravenousPCA(U)(LevelII). 12. TheriskofrespiratorydepressionwithPCAisincreasedwhenabackgroundinfusionis used(U)(LevelIV). AdequateanalgesianeedstobeobtainedpriortocommencementofPCA.Initial ordersforbolusdosesshouldtakeintoaccountindividualpatientfactorssuchasa historyofprioropioiduseandpatientage.IndividualPCAprescriptionsmayneedtobe adjusted(U). TheroutineadditionofantiemeticstoPCAopioidsisnotencouraged,asitisofno benefitcomparedwithselectiveadministration(U). PCAinfusionsystemsmustincorporateantisyphonvalvesandinnondedicatedlines, antirefluxvalves(U). Drugconcentrationsshouldbestandardisedwithininstitutionstoreducethechanceof programmingerrors(U). Operatorerrorremainsacommonsafetyproblem(N).

SUMMARY

Epiduralanalgesia1. Thoracicepiduralanalgesiaforopenabdominalaorticsurgeryreducesthedurationof trachealintubationandmechanicalventilation,aswellastheincidenceofmyocardial infarction,acuterespiratoryfailure,gastrointestinalcomplicationsandrenalinsufficiency (N)(LevelI[Cochrane]). Foralltypesofsurgery,epiduralanalgesiaprovidesbetterpostoperativepainrelief comparedwithparenteral(includingPCA)opioidadministration(S)(LevelI[Cochrane review]);exceptepiduralanalgesiausingahydrophilicopioidonly(N)(LevelI).

2.

3. Highthoracicepiduralanalgesiausedforcoronaryarterybypassgraftsurgeryreduces postoperativepain,riskofdysrhythmias,pulmonarycomplicationsandtimeto extubationwhencomparedwithIVopioidanalgesia(N)(LevelI). 4. 5. 6. 7. 8. Epidurallocalanaestheticsimproveoxygenationandreducepulmonaryinfectionsand otherpulmonarycomplicationscomparedwithparenteralopioids(S)(LevelI). Thoracicepiduralanalgesiaimprovesbowelrecoveryafterabdominalsurgery(including colorectalsurgery(S)(LevelI). Thoracicepiduralanalgesiaextendedformorethan24hoursreducestheincidenceof postoperativemyocardialinfarction(U)(LevelI). Epiduralanalgesiaisnotassociatedwithincreasedriskofanastomoticleakageafter bowelsurgery(U)(LevelI). Chlorhexidineimpregnateddressingsofepiduralcathetersincomparisontoplaceboor povidoneiodineimpregnateddressingsreducetheincidenceofcathetercolonisation(N) (LevelI).AcutePainManagement:ScientificEvidence

xxx

9. TheuseofcontinuousbackgroundepiduralinfusioncombinedwithPCEAresultsin improvedmaternalanalgesiaandreducedunscheduledclinicianinterventions(N) (LevelI).

10. Thoracicepiduralanalgesiareducesneedforventilationinpatientswithmultiplerib fractures(S)(LevelI)andreducesincidenceofpneumonia(U)(LevelII). 11. Thecombinationofthoracicepiduralanalgesiawithlocalanaestheticsandnutritional supportleadstopreservationoftotalbodyproteinafterupperabdominalsurgery(U) (LevelII). 12. Theriskofpermanentneurologicaldamageinassociationwithepiduralanalgesiaisvery low;theincidenceishigherwheretherehavebeendelaysindiagnosinganepidural haematomaorabscess(S)(LevelIV). 13. Immediatedecompression(within8hoursoftheonsetofneurologicalsigns)increases thelikelihoodofpartialorgoodneurologicalrecovery(U)(LevelIV). Theprovisionofepiduralanalgesiabycontinuousinfusionorpatientcontrolled administrationoflocalanaestheticopioidmixturesissafeongeneralhospitalwards,as longassupervisedbyananaesthesiabasedpainservicewith24hourmedicalstaffcover andmonitoredbywelltrainednursingstaff(U). Magneticresonanceimaginginvestigationmaybewarrantedifpatientswhohavehadan epiduralcatheterinserteddevelopafeverandinfectionatthecatheterinsertionsite; urgentinvestigationisespeciallyindicatedifothersignsarepresentthatcouldindicate anabscess,suchasbackpainorneurologicalchange(N).

SUMMARY

Intrathecalanalgesia1. 2. 3. Intrathecalmorphineoffersimprovedanalgesiaandopioidsparingforupto24hours especiallyfollowingabdominalsurgery(S)(LevelI). Intrathecalmorphinedosesof300mcgormoreincreasetheriskofrespiratory depression(N)(LevelI). Aftermajorsurgery,theincidenceofrespiratorydepressionandpruritusishigherwith intrathecalmorphinecomparedwithIVPCAopioids,butthereisnodifferenceinthe incidenceofnauseaandvomiting(N)(LevelI). Clinicalexperiencewithmorphine,fentanylandsufentanilhasshownnoneurotoxicityor behaviouralchangesatnormalclinicalintrathecaldoses(U). Theabsenceofconsistentdoseresponsivenesstotheefficacyofintrathecalopioidsor theadverseeventrate,suggeststhatthelowesteffectivedoseshouldbeusedinall circumstances(N).

Regionalanalgesiaandconcurrentanticoagulantmedications1. Anticoagulationisthemostimportantriskfactorforthedevelopmentofepidural haematomaafterneuraxialblockade(U)(LevelIV). Consensusstatementsofexpertsguidethetimingandchoiceofregionalanaesthesiaand analgesiainthecontextofanticoagulation,butdonotrepresentastandardofcareand willnotsubstitutetherisk/benefitassessmentoftheindividualpatientbytheindividual anaesthetist(U).Acutepainmanagement:scientificevidence xxxi

Otherregionalandlocalanalgesictechniques1. TopicalEMLAcream(eutecticmixtureoflignocaine[lidocaine]andprilocaine)is effectiveinreducingthepainassociatedwithvenousulcerdebridement(U)(LevelI [CochraneReview]). Comparedwithopioidanalgesia,continuousperipheralnerveblockade(regardlessof catheterlocation)providesbetterpostoperativeanalgesiaandleadstoreductionsin opioiduseaswellasnausea,vomiting,pruritusandsedation(N)(LevelI).

2.

SUMMARY

3. Femoralnerveblockprovidesbetteranalgesiacomparedwithparenteralopioidbased techniquesaftertotalkneearthroplasty(S)(LevelI). 4. Comparedwiththoracicepiduralanalgesia,continuousthoracicparavertebralanalgesia resultsincomparableanalgesiabuthasabettersideeffectprofile(lessurinaryretention, hypotension,nausea,andvomiting)thanepiduralanalgesiaandleadstoalower incidenceofpostoperativepulmonarycomplications(N)(LevelI). 5. Blocksperformedusingultrasoundguidancearemorelikelytobesuccessful,fasterto perform,withfasteronsetandlongerdurationcomparedwithlocalisationusinga peripheral

28687919 acute pain management scientific evidence 3rd edition

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