Last updated January 11, 2022

Acute Pain Management in the Perioperative Setting

Summary of Recommendations

Institutional Policies and Procedures for Providing Perioperative Pain Management

Anesthesiologists offering perioperative analgesia services should provide, in collaboration with other healthcare professionals as appropriate, ongoing education and training to ensure that hospital personnel are knowledgeable and skilled with regard to the effective and safe use of the available treatment options within the institution.
  • Educational content should range from basic bedside pain assessment to sophisticated pain management techniques (e.g. , epidural analgesia, PCA, and various regional anesthesia techniques) and nonpharmacologic techniques (e.g. , relaxation, imagery, hypnotic methods).
  • For optimal pain management, ongoing education and training are essential for new personnel, to maintain skills, and whenever therapeutic approaches are modified.
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Anesthesiologists and other healthcare providers should use standardized, validated instruments to facilitate the regular evaluation and documentation of pain intensity, the effects of pain therapy, and side effects caused by the therapy.
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Anesthesiologists responsible for perioperative analgesia should be available at all times  to consult with ward nurses, surgeons, or other involved physicians.
  • They should assist in evaluating patients who are experiencing problems with any aspect of perioperative pain relief.

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Anesthesiologists providing perioperative analgesia services should do so within the framework of an Acute Pain Service.
  • They should participate in developing standardized institutional policies and procedures.

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Preoperative Evaluation of the Patient

A directed pain history, a directed physical examination, and a pain control plan should be included in the anesthetic preoperative evaluation.
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Preoperative Preparation of the Patient

Patient preparation for perioperative pain management should include appropriate adjustments or continuation of medications to avert an abstinence syndrome, treatment of preexistent pain, or preoperative initiation of therapy for postoperative pain management.
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Anesthesiologists offering perioperative analgesia services should provide, in collaboration with others as appropriate, patient and family education regarding their important roles in achieving comfort, reporting pain, and in proper use of the recommended analgesic methods.
  • Common misconceptions that overestimate the risk of adverse effects and addiction should be dispelled.

  • Patient education for optimal use of PCA and other sophisticated methods, such as patient-controlled epidural analgesia, might include discussion of these analgesic methods at the time of the preanesthetic evaluation, brochures and videotapes to educate patients about therapeutic options, and discussion at the bedside during postoperative visits.
  • Such education may also include instruction in behavioral modalities for control of pain and anxiety.
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Perioperative Techniques for Pain Management

Anesthesiologists who manage perioperative pain should use therapeutic options such as epidural or intrathecal opioids, systemic opioid PCA, and regional techniques after thoughtfully considering the risks and benefits for the individual patient.
  • These modalities should be used in preference to intramuscular opioids ordered “as needed.”
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The therapy selected should reflect the individual anesthesiologist's expertise, as well as the capacity for safe application of the modality in each practice setting.
  • This capacity includes the ability to recognize and treat adverse effects that emerge after initiation of therapy.

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Special caution should be taken when continuous infusion modalities are used because drug accumulation may contribute to adverse events.
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Multimodal Techniques for Pain Management

Whenever possible, anesthesiologists should use multimodal pain management therapy.
  • Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen.

  • Regional blockade with local anesthetics should be considered.

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Dosing regimens should be administered to optimize efficacy while minimizing the risk of adverse events.
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The choice of medication, dose, route, and duration of therapy should be individualized.
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Patient Subpopulations

Pediatric patients
  • Aggressive and proactive pain management is necessary to overcome the historic undertreatment of pain in children.
  • Perioperative care for children undergoing painful procedures or surgery requires developmentally appropriate pain assessment and therapy.
  • Analgesic therapy should depend upon age, weight, and comorbidity, and unless contraindicated should involve a multimodal approach.
  • Behavioral techniques, especially important in addressing the emotional component of pain, should be applied whenever feasible.
  • Sedative, analgesic, and local anesthetics are all important components of appropriate analgesic regimens for painful procedures.
  • Because many analgesic medications are synergistic with sedating agents, it is imperative that appropriate monitoring be used during the procedure and recovery.
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Geriatric patients
  • Pain assessment and therapy should be integrated into the perioperative care of geriatric patients.
  • Pain assessment tools appropriate to a patient's cognitive abilities should be used. Extensive and proactive evaluation and questioning may be necessary to overcome barriers that hinder communication regarding unrelieved pain.
  • Anesthesiologists should recognize that geriatric patients may respond differently than younger patients to pain and analgesic medications, often because of comorbidity.
  • Vigilant dose titration is necessary to ensure adequate treatment while avoiding adverse effects such as somnolence in this vulnerable group, who are often taking other medications (including alternative and complementary agents).
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Other subpopulations
  • Anesthesiologists should recognize that patients who are critically ill, cognitively impaired, or have communication difficulties may require additional interventions to ensure optimal perioperative pain management.
  • Anesthesiologists should consider a therapeutic trial of an analgesic in patients with increased blood pressure and heart rate or agitated behavior when causes other than pain have been excluded.
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Recommendation Grading

Overview

Title

Acute Pain Management in the Perioperative Setting

Authoring Organization

Publication Month/Year

February 1, 2012

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Facilitate the safety and effectiveness of acute pain management in the perioperative setting; reduce the risk of adverse outcomes; maintain the patient's functional abilities, as well as physical and psychologic well-being; and enhance the quality of life for patients with acute pain during the perioperative period.
 

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Emergency care, Hospital, Operating and recovery room

Intended Users

Nurse anesthetist, medical assistant

Scope

Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D059408 - Pain Management, D010149 - Pain, Postoperative, D011182 - Postoperative Care, D011300 - Preoperative Care

Keywords

perioperative care, Pain Management, acute pain management, perioperative pain management

Source Citation

Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012;116(2):248-273. doi: https://doi.org/10.1097/ALN.0b013e31823c1030.