• May 2, 2007, Antidepressant drugs: Update to the existing black box warning on the prescribing information on all antidepressant medications to include warnings about the increased risks of suicidal thinking and behavior in young adults ages 18 to 24 years old during the first one to two months of treatment.

Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI): For a description of what has changed since the previous version of this guidance, refer to Summary of Changes Report -- March 2008.

The recommendations for the assessment and management of acute pain are presented in the form of two algorithms with 26 components, accompanied by detailed annotations. Algorithms are provided for: Assessment of Acute Pain and Acute Pain Treatment; clinical highlights and selected annotations (numbered to correspond with the algorithm) follow.

Class of evidence (A-D, M, R, X) ratings and key conclusion grades (I-III, Not Assignable) are defined at the end of the "Major Recommendations" field.

Clinical Highlights and Recommendations

• Intensity of pain is assessed prior to initiation of appropriate treatment and continually reassessed throughout duration of treatment. (Annotation #3)
• Determine the mechanism of pain (i.e., somatic, visceral, neuropathic) based on the physical examination and detailed history. (Annotation #10)
• Patients often experience more than one type of pain. (Annotation #10)
• Somatic pain is well-localized and may be responsive to acetaminophen, cold packs, corticosteroids, localized anesthetic (topical or infiltrate), nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and tactile stimulation. (Annotations #11, 14)
• Visceral pain is more generalized and is most responsive to opioid treatment. (Annotations #12, 15)
• Neuropathic pain may be resistant to opioid therapy and consideration should be given to adjuvant therapy such as tricyclic antidepressants and anticonvulsants. (Annotations #13, 16)
• While the emphasis of this guideline is on pharmacologic therapy, multimodal treatment approaches are important to consider because patient satisfaction is high when non-pharmacologic approaches are provided. (Annotation #17)

Assessment of Acute Pain Algorithm Annotations

1. Patient Has Pain or Is Likely to Have Pain

   Pain is undertreated by many practitioners, which leads to serious clinical consequences. This guideline encourages aggressive assessment, treatment and reassessment of pain.

2. Critical First Steps

   Key Points:

   • The patient and/or caregiver play a critical role in the assessment and management of pain.
   • Assessing the type and amount of pain is important to good pain control. This is done by describing and rating the pain. Educate the patient and/or caregiver in the selection and use of an appropriate pain scale.
   • Parents can help assess pain in children by what their child says, what their child is doing, and how their child's body is reacting.
   • Pain medications should not be withheld during initial evaluation for potential surgical abdomen.

   Acute pain is not a diagnosis, it is a symptom. Frequently its cause is obvious such as after surgery or an acute trauma. Many times, however, the exact underlying etiology is not clear and a diagnostic work-up is necessary. An interview with the patient or a responsible caregiver is essential to determine etiology. The interview and examination should cover the following:

   General History

   • History of present illness (HPI)
   • Current medications
   • Medication allergies
   • Past medical history
   • Social history

   Pain History

   • Onset
   • Duration
   • Quality, character
   • Ameliorating and provoking factors
   • Patient rating if possible (see Annotation #3, "Pain Assessment")

   Clinical Exam

   • Observation of response to pain (pre-verbal or cognitively impaired patients): e.g., rubbing a particular area, guarding, facial expression
   • Focused physical exam (part of body or region in pain), to include vital signs. Increases in pulse, respiratory rate, and blood pressure are often but not always noted in the presence of acute pain. However, vital signs may be normal as a result of physiologic adaptation.
   • Functional assessment (see Annotation #3, "Pain Assessment" in the original guideline document). See the Support for Implementation section, "Resources Available" in the original guideline document, for examples of assessment tools.
   • Pain medications should not be withheld during initial evaluation for potential surgical abdomen [C].

   Further Diagnostic Work-up

   Lab studies, x-rays or other diagnostic tests may be needed, depending on the results of the history and physical examination.

   Specialty Consult

   General surgical, orthopedic, anesthesiological or other consultation may be deemed necessary.

3. Pain Assessment

   Key Points:

   • The patient self report is the most reliable indicator of pain.
   • The ideal pain assessment tool will facilitate identification of the presence of pain and be valid for use over time.
   • The patient or caretaker should be taught how to use the pain scale.
   • In children and the elderly, pain measures may be influenced by limited cognitive or language skills, or by the positive or negative consequences their pain reports or behavior produce.

   Based on the assumption that patient self-reporting is the "most reliable indicator of the existence and intensity of pain" (National Institutes of Health), the ideal tool for pain will identify the presence of pain and its evolution over time. In addition, tools should be applicable to any person regardless of age, race, creed, socioeconomic status, and psychological or emotional background.

   There are multiple pain assessment tools available for determining the quantity and quality of a patient's pain experience. Proper use of these tools mandates that the assessment occur at the time of presentation, throughout the course of the clinical encounter, and after institution of therapy. In an acute care setting, pain intensity should be reassessed within 30 minutes for parenteral administration of medication and 60 minutes after oral therapy is begun. In an outpatient setting, patients should be instructed to contact their care provider with feedback on the efficacy of the therapy prescribed. Dosing adjustments should be made on the basis of the patient's self-report, pattern of pain response to therapy and other clinical indicators available to the clinician for evaluation.

   In the assessment of pain, the patient and/or caretakers should be actively involved. The patient or caretaker should be taught how to use the pain scale so they can self-report pain intensity or change in quality. Patients may need to understand that although complete relief is the ultimate goal, it is not always possible. They should determine for themselves what level of discomfort is acceptable and will allow for maximal function with activities of daily living.

   The single dimensional scales measure only pain intensity and by their nature are self-report. These scales are reasonable for use in acute pain when the etiology is clear (i.e., trauma, pancreatitis, otitis media). The assessment tools in this classification were initially developed for research trials. One concern is that measuring intensity alone may be an oversimplification of the pain experience.

   The multidimensional scales measure not only the intensity but also the nature and location of the pain and in some cases the impact the pain is having on activity or mood. These are excellent tools in the setting of persistent acute or chronic pain when intensity as well as social support, interference with activities of daily living (ADL) and relationship to depression may need to be assessed. Each of these was developed as a self-report but may be completed with the assistance of an interviewer or health care provider.

   Refer to the original guideline document for Table 1, "Assessment Tools for Adults," and Table 2, "Assessment Tools for Children," and for additional information on pain assessment in the elderly, infants, and young children.

6. Has Pain Persisted Greater Than 6 Weeks?

   If the patient has not been previously evaluated, attempt to differentiate between untreated acute pain and ongoing chronic pain. If a patient's pain has persisted for six weeks (or longer than the anticipated healing time), a thorough evaluation for the cause of the chronic pain is warranted. See the NGC summary of the ICSI guideline Assessment and Management of Chronic Pain for more information.

10. Determine Mechanism(s) of Pain

    Key Points:

    • The physiology of pain guides the practitioner to more effectively and efficiently control pain.
    • The clinician should be aware that the patient may experience a combination of pain types.

    By identifying the type of pain, the provider can more efficiently treat pain by selecting the intervention most appropriate. The clinician should be aware the patient may experience a combination of pain types. See below for an assistive tool in determining mechanism of pain.

    Evidence supporting this recommendation is of classes: D, R

Assistive Tool for Determining Type of Pain

*Most post-operative patients experience A-delta and C fiber pain and respond best to narcotic of any route and NSAIDs.

**Colic and muscle spasms may be less responsive to opioids. Respond best to antispasmodics, NSAIDs, benzodiazepines, baclofen.

***Segmental distribution follows a dermatome chart. This traces the pathway of sensation to its nerve root.

The algorithm acknowledges that in most clinical situations the initial treatment of pain and the diagnostic work-up occur concurrently. In other situations, e.g., central nervous system injury, it may be important to delay treating a patient's pain until the underlying diagnosis is established. These initial efforts to treat pain are based on the clinician's initial hypothesis of the etiology of the patient's pain.

See the clinical pearls section in Annotation #17, "Prevention/Intervention."

Treatment Algorithm Annotations

14. Somatic Pain Treatment

    Treatment of somatic pain includes the use of acetaminophen, cold packs, corticosteroids, localized anesthetic (topical or infiltrate), NSAIDs, opioids, and tactile stimulation [R].

15. Visceral Pain Treatment

    Treatment choices for visceral pain include corticosteroids, intraspinal local anesthetic agents, NSAIDs, and opioids (via any route) [R].

16. Neuropathic Pain Treatment

    Neuropathic pain may be resistant to standard opioid therapies or other nociceptive pain treatment strategies. Anticonvulsants and tricyclic antidepressants are mainstays of therapy. Complaints of continuous burning may best respond to antidepressants, whereas lancinating complaints may best respond to anticonvulsants. The anticonvulsant gabapentin however, can treat both continued burning and episodic neuropathic pain. Failure to adequately relieve neuropathic pain with one anticonvulsant does not imply that alternative therapies will not work. Other potential treatments include local anesthetics (topical or intraspinal), tramadol, and glucocorticoids [R].

17. Prevention/Intervention

    Key Points:

    • Choices for intervention are varied and frequently involve multiple disciplines.
    • With proper education and training of patients prior to a painful experience, the ability to cope and the outcome of pain treatment may be enhanced.
    • The use of pharmacological agents is considered to be the mainstay of therapy for acute pain.
    • Patient satisfaction can be substantially improved with non-pharmacologic approaches.

    Prevention

    Patient Education

    The ability to influence a patient's pain experience may be approached in multiple ways. Choices for intervention are varied and frequently involve multiple disciplines.

    With proper education and training of patients prior to a painful experience, the ability to cope and the outcome of pain treatment may be enhanced.

    See Table 3, "Acute Pain Interventions," in the original guideline document for summary of interventions.

    Key Patient Education Steps and Messages

    • Describe the expected type of pain and how long it will last. (Preparatory Sensory Information - decrease uncertainty and fear of unknown. "Knowledge is power.")
    • Individualize the information for the patient.
    • Discuss goals of pain management and how these goals help the patient: comfort, quicker recovery, and avoidance of complications.
    • Preventing pain is important to manage pain well. "Stay ahead of the pain."
    • Many drug and non-drug treatments can be helpful in preventing and managing pain.
    • Inform the patient of when and how to contact health care providers about his/her pain.
    • Patients, parents of children with pain, and the health care providers will decide as a team which treatments are best to manage the pain.
    • Discuss treatment choices and plan, including schedule of medications, which are most appropriate for the patient.
    • Addiction to opioids used in the treatment of acute pain is rare. There are differences among physical addiction, tolerance, and psychological dependence.

    Medications and interventions are selected based on symptomatology and mechanism of pain. Choosing the profile that is the most responsive to the pain complaint and has the least potential for side effects should be done initially. Visceral, somatic, and neuropathic pain complaints respond most effectively to different treatments. (See the table above). The route of administration often affects patient compliance and dosing requirements.

    Pharmacological Therapy

    Review Safe Medication Use

    Policies and procedures regarding safe medication use should be in place.

    The use of pharmacological agents is considered to be the mainstay of therapy for acute pain. There are three broad categories of medications to consider when treating the patient with acute pain: non-opioid analgesics (NSAIDs), opioid analgesics, and coanalgesics. They are used in this manner:

    Non-opioid Analgesics (NSAIDs and Acetaminophen)

    • Should be considered initially. Often adequate for mild or moderate pain or in the case of ketorolac for moderate to severe pain.
    • Have significant opioid dose-sparing properties and in turn reduce opioid-related side effects [A].
    • A meta-analysis found a 20% decrease in morphine doses when scheduled acetaminophen was combined with patient-controlled analgesia (PCA) morphine for treatment of pain after major surgery [M].
    • Use with caution in patients with coagulopathies or thrombocytopenia and those who are at risk for bleeding.
    • Watch for gastrointestinal effects, especially with these risk factors: age greater than 60 years, previous gastrointestinal events and concomitant corticosteroid use.
    • Ketorolac, either parenteral or oral, should be used for no more than five days; dose reduction is indicated in the elderly and in those with renal impairment. [Conclusion Grade III: See Conclusion Grading Worksheet A -- Annotation #15 (Ketorolac) in the original guideline document].

    Before using NSAIDs, the hematological, gastrointestinal and renal effects should be taken into consideration. All but two NSAIDs, choline magnesium and salicylate, have been shown to inhibit platelet aggregation by inhibiting prostaglandin synthetase. Therefore, care must be used when prescribing NSAIDs in patients with coagulopathies or thrombocytopenia and in those who are at risk for bleeding.

    Ketorolac, either parenteral or oral, should be used for no more than five days; dose reduction is indicated in the elderly and in those with renal impairment. [Conclusion Grade III: See Conclusion Grading Worksheet A -- Annotation # 17 (Ketorolac) in the original guideline document]. [B, D]

    Opioid Analgesics

    • If pain is not adequately controlled with an NSAID or is expected to be moderate to severe, an appropriate opioid should be added to the NSAID.
    • In patients with absolute or strong relative contraindications to NSAIDs, an opioid for mild to moderate pain should be considered.
    • Morphine is considered to be the standard opioid analgesic.
    • Meperidine is not considered a first-line opioid analgesic medication for acute pain syndromes.
    • See the original guideline document, Appendix B, "Opioid Analgesics," also "Managing Acute Pain in Chemically Dependent Patients/Recognizing Substance Abuse" in Annotation #17.

    Meperidine

    Meperidine is an opioid analgesic that has been historically used for the relief of acute pain despite recommendations otherwise.

    Meperidine is not considered a first-line opioid analgesic medication for acute pain syndromes. If used, dosing limitations are necessary to prevent central nervous system (CNS) excitatory toxicity from normeperidine accumulation, a metabolite of meperidine. Patients with impaired renal function and elderly individuals are at particularly high risk of CNS toxicity. Patients receiving meperidine should be monitored for symptoms and signs of CNS excitation. [Conclusion Grade II: See Conclusion Grading Worksheet B – Annotation #17 (Meperidine)]

    Ketamine

    Ketamine is an anesthetic drug with analgesic properties. It is a potent N-methyl-D-aspartate (NMDA) antagonist. The NMDA receptor plays an important role in the development of central sensitization, described as hyperalgesia and the development of the "wind-up" phenomenon. Wind-up describes what is observed during repetitive noxious stimulation resulting in progressively increasing pain intensity. Ketamine may also prevent development of acute tolerance to opioids and opioid induced hyperalgesia. Thus, the ability of a drug to block this receptor is advantageous in acute pain control. However, when administered in high doses, ketamine has significant side effects which limit its usefulness. Hallucinations, paranoia, vivid dreams or delusions, delirium, and floating sensations may be experienced. Limiting the dose and providing a benzodiazepine may help limit these side effects.

    The use of ketamine for acute pain control remains controversial. Human studies show mixed results in its ability to provide effective pain relief when used in combination with opioids. Low dose ketamine infusion has been found useful in limiting opioid requirements in patients undergoing major abdominal surgery. Low dose ketamine may be indicated in opioid resistant pain control in cancer patients who have preexisting opioid tolerance. Combining ketamine with morphine in patient-controlled analgesia (PCA) devices has not been proven to be efficacious [A, M].

    Patient Controlled Analgesia (PCA)

    Patient controlled analgesia (PCA) refers to the method where the patient self-administers analgesics, according to the clinician's order, to control his/her own pain. Most of the time, this refers to a programmable infusion pump that delivers an intravenous opioid to control pain; however, other methods and routes of delivery have been used, such as subcutaneous infusions.

    PCA administration can consist of a patient-controlled demand (bolus) dose given at some frequency and/or some continuous rate of opioid infusion (usually expressed as mg/hour) along with a lockout interval. Lockout interval refers to the time between boluses where the pump will not allow any more bolus doses to be administered.

    Patient-controlled analgesia is more than just intravenous (IV) administration of opioids; however, this guideline will only delineate IV PCA because its use has more potential for dangerous side effects [R].

    • The key to safe use of PCA is close monitoring by the professional. Monitoring parameters should be established to meet individual institutional needs.
    • The first 24 hours after surgery represent a high-risk period for a respiratory event, and sedation is highest within the first 12 hours postoperatively [C].
    • The relative safety of continuous infusion is increased if a patient's opioid requirements are already known and the rate of infusion is based on those requirements.
      • Continuous infusion should be used with caution in patients with sleep apnea and those who are morbidly obese [R].
    • Patients with a history of opioid consumption (whether legally or illegally obtained) may require higher than average PCA dosages.
    • PCA is an effective method of pain relief in the elderly.
    • If stable pain rating, as determined collaboratively by clinician and patient, monitoring may be less frequent.
    • Naloxone should be readily available.
    • Determining dose for equalanalgesic conversions should be based on the calculation of mg used/24 hours.

    The primary advantage of PCA therapy is the patient convenience since the patient controls when a dose of analgesic is given; the patient is not dependent upon a nurse to get a dose of analgesic. If appropriate doses of opioids are prescribed, the patient should not be at risk of respiratory depression because with repeated boluses, the patient falls asleep, avoiding additional doses that might cause respiratory depression. The drawbacks of PCA include the increased expense of administering the medication because the pump and equipment are relatively expensive.

    Safe dosing of opioids for PCA is very patient-dependent. Generally, lower doses are used for the elderly and opioid-naive patients, while equalanalgesic calculations should guide the prescriber for chronic opioid patients who now have acute pain. Opioid doses may be titrated based on analgesia and side effects.

    When intravenous access is not possible, PCA may be administered via the subcutaneous route.

    Inappropriate candidates for PCA therapy include those patients who are physically or cognitively unable to self-administer demand/breakthrough medication. In the treatment of acute pain, each institution should have guidelines delineating who may administer the demand dose, in order to safely provide analgesia.

    Breakthrough Pain

    Expert consensus has suggested the following guide for breakthrough dosages: 10 to 20 percent of the total daily long-acting oral opioid dose. Since the duration of action of many oral short-acting opioids is around four hours, the frequency may be every four hours as needed for breakthrough pain [R].

    Coanalgesics

    Coanalgesics are used to complement NSAIDs and opioids and may be used alone for the treatment of acute pain, especially neuropathic pain.

    Some have been shown to enhance the effect of a particular analgesic, such as caffeine when given with aspirin-like drugs; others have analgesic properties themselves, e.g., tricyclic antidepressants and hydroxyzine.

    The use of adjuvant therapies and medications is frequently helpful in reducing the total drug dose of opioids and NSAIDs, and speeding recovery. These medications may treat acute pain alone but are often used in combination with other analgesic therapies.

    Refer to the original guideline document for information on tricyclic antidepressants, antiepileptic drugs, local anesthetics, and management of acute pain in chemically dependent patients.

    Specialty Consult (if indicated)

    General surgical, orthopedic, anesthesiological or other consultation may be deemed necessary.

    Intervention/Surgical Procedures

    Procedures are used for both diagnostic and therapeutic effects and should be performed by experienced providers.

    Preemptive Analgesia

    Clinical studies have indicated that painful stimuli may produce changes in the spinal cord that in turn influence the response to further stimuli. The hypothesis of preemptive analgesia states that, by preventing the sensitization of the central nervous system which would normally amplify subsequent nociceptive input, one may reduce the severity of postoperative pain. The neuroplastic response may be prevented by appropriate administration of analgesics before the stimulus in order to block painful nerve transmission. Thus, to be considered preemptive, the intervention must be given before the actual insult (e.g., surgical incision). A nerve conduction block is typically required, either by infiltration of local anesthetics near the site of expected injury, or by neuraxis blockade in the epidural or intrathecal spaces, also with local anesthetic. The use of neuraxial opioids may also play a role. Application of local anesthetics or opioids near the spinal cord is usually performed by an anesthesiologist. The N-methyl-D-aspartate (NMDA) receptor is also thought to play a key role in the development of central nervous system sensitization. Thus, the use of an NMDA antagonist may be helpful. However, results of studies evaluating the effects of preemptive analgesia have been mixed and have not shown definitive benefits [A, M].

    Non-Pharmacologic Approaches

    There is growing interest among patients and providers in non-pharmacologic complementary therapies for acute pain. Little conclusive advice can be drawn from studies available to date for several reasons. First, there is a broad range of therapeutic modalities, including:

    • Education
    • Immobilization (e.g., bracing, bed rest)
    • Physical (e.g., massage [A], heat, cold, transcutaneous electrical nerve stimulation [TENS])
    • Cognitive/Behavioral [R] (e.g., biofeedback, relaxation [R])
    • Exercise (e.g., back school, graded exercise) [R])

    Likewise, studies cover diverse conditions, such as headaches, low back pain, blood draws/injections [A]; perioperative pain, neck pain, and tooth extraction [A]. Even when similar conditions and treatments are compared, the method of delivering specific therapies often isn't uniform among providers. Furthermore, the majority of studies focus on chronic pain, not acute. Finally, outcome measures amongst studies tend to be heterogenous or lack statistical significance. Several studies have shown a small positive effect of non-pharmacologic treatments, but it remained unclear if the effect was adequate to justify the cost [A].

    Non-pharmacologic treatment of low back pain appears to be the best studied. A recent extensive review [M] found that for acute low back pain, only heat application bore strong evidence for efficacy [A]. Conflicting evidence has been noted with transcutaneous electrical nerve stimulation and ultrasound and numerous other treatments. Nonetheless, even when a significant decrease in pain isn't shown, patient satisfaction can be substantially improved with non-pharmacologic approaches [A].

    Clinical Pearls

    Pediatric

    • Circumcisions: The March 1999 Task Force Report from the American Academy of Pediatrics states, "If a decision for circumcision is made, procedural analgesia should be provided. Dorsal Penile Nerve Block (DPNB), EMLA (Eutectic Mixture of Local Anesthetics), topical lidocaine, and ringblock have all been shown to be efficacious and safe but none completely eliminate the pain of circumcision" [A, R].
    • Percutaneous procedures: Eutectic mixture of local anesthetics (EMLA): Mixture of lidocaine and prilocaine applied under occlusive dressing (onset of action of 60-90 minutes) has been shown to be useful in venipuncture, intravenous access, circumcision, and meatotomy [A, M]. There have been concerns about methemoglobinemia which thus limits its use in neonates or infants. Recent studies in small populations demonstrate little toxicity.
    • Intramuscular injections should be avoided if possible; most surveys indicate children would rather experience pain [A].
    • Acute musculoskeletal pain: A single dose of ibuprofen was shown to provide better analgesia than codeine or acetaminophen. Despite its superiority, according to the authors, "ibuprofen alone is not adequate for relieving pain in all children with musculoskeletal injuries" [A].

    Adults

    • Acute ureteral colic: Parenteral NSAIDs are more effective than meperidine [M, A].
    • "As needed" basis: For optimal treatment of acute pain, avoid the use of intramuscular injections ordered on an "as needed" basis [A]. Acute pain medications should initially be titrated to effect and then given on a scheduled basis.
    • Suturing non-end-artery sites: Use TAC (tetracaine, adrenaline, and cocaine solution), or LET (lidocaine, epinephrine, and tetracaine solution) [R, A]. See supporting references in the original guideline document for solution concentrations.
    • Head injury and stroke: Avoid strong opioids to allow adequate patient assessment. Strong opioids may also decrease respiration rate, which may adversely affect (increase) intracranial pressure [D]
    .
    • Medication interaction: Oxycodone, hydrocodone, codeine and tramadol may not be effective analgesics when given with other agents that strongly inhibit the Cytochrome P4502D6 liver enzymes [A, R]. Common agents with this characteristic include the selective serotonin reuptake inhibitors [R].
    • Propoxyphene is no more effective than acetaminophen in acute pain [C].
    • "Road rash": NSAIDs (any route) or local anesthetic can be used.

21. Has Pain Persisted Greater than 6 Weeks?

    If the patient has not been previously evaluated, attempt to differentiate between untreated acute pain and ongoing chronic pain. If a patient's pain has persisted for six weeks (or longer than the anticipated healing time), a thorough evaluation for the cause of the chronic pain is warranted. See the NGC summary of the ICSI guideline Assessment and Management of Chronic Pain for more information.

24. Intolerable Symptoms Secondary to Treatment?

    Key Points:

    • Intolerable symptoms could be related to either the pain medication (particularly the opioid) or other causes.
    • Patients should be given information about possible side effects and other symptoms that should be reported to nurse or provider.

    Intolerable symptoms that could be related to either the pain medication (particularly the opioid) or other causes include:

    • Decrease in mental status
    • Confusion or delirium
    • Nausea and vomiting
    • Constipation or prolonged ileus
    • Pruritus
    • Urinary retention

    The identification of pain through patient self report, or when that's not possible through a behavioral rating scale, will dictate the reduction of the opioid dosage or frequency. However, it should not be assumed that the opioid is always the cause.

    The differential for decrease in mental status, confusion, or delirium is vast. Nausea and vomiting may be related to physiologic causes and other medication side effects, as well as pain medications. The cause should be determined. See Annotation #25, "Side Effect Management."

    Accurate documentation of bowel function should be done by the nurses in the postoperative setting. Constipation could be caused by immobility, all types of medications, metabolism dysfunction, etc., and is best treated from a prevention standpoint rather than after the patient complains. It is usually the belief that prolonged ileus is caused by postoperative opioids. Slowing of bowel function may be due to pain itself. The tendency in the surgical setting is to decrease or stop the opioid if an individual has prolonged ileus. If this is a strong opinion, then efforts need to be continued to control the individual's pain through other means, e.g., local anesthetics or NSAIDs.

    Patient should be given information about possible side effects and other symptoms that should be reported to nurse or provider.

25. Side Effect Management

    Symptom control of drug-induced problems:

    Opioids

    • Nausea and vomiting: consider adding scheduled antiemetics at first, and then transition to as needed dosing.
    • Constipation: start an opioid, start a bowel program with a stimulant. Avoid fiber laxatives as they may cause gas, bloating and cramping.
    • Itching: consider changing the opioid to a different chemical class of opioid. May also use scheduled antihistamines.
    • Myoclonus: consider switching to a different opioid or cautiously use a benzodiazepine to treat the myoclonus.
    • Respiratory depression: In order to reverse respiratory depression due to opioids, mix naloxone 0.4mg with 0.9% sodium chloride 9 ml (total volume = 10 ml). Administer 0.02 mg (0.5 ml) boluses every minute until the respiratory rate increases. This may need to be repeated if the patient is receiving long-acting opioids.

    NSAIDs

    • Gastrointestinal upset: add a proton pump inhibitor.
    • Bleeding problems due to platelet dysfunction: consider changing to an NSAID with no effect on platelet aggregation.

    It is key during patient education to explain pertinent side effects to medications and how to manage. Inform the patient that medications can cause side effects that can be managed or decreased.

26. Follow-Up/Reassess

    Reassessment should be continued at regular intervals, after any intervention, once a sufficient time has elapsed for the treatment to reach peak effect.

    General guideline:

    Parenteral medication -- 30 minutes

    Oral medication -- 60 minutes

    Non-pharmacologic intervention -- 30-60 minutes

    The plan identifies the patient's continuing pain management needs and should be communicated to the patient with regards to appropriate follow-up.

Definitions:

Classes of Research Reports:

1. Primary Reports of New Data Collection:

   Class A:

   • Randomized, controlled trial

   Class B:

   • Cohort study

   Class C:

   • Non-randomized trial with concurrent or historical controls
   • Case-control study
   • Study of sensitivity and specificity of a diagnostic test
   • Population-based descriptive study

   Class D:

   • Cross-sectional study
   • Case series
   • Case report

2. Reports that Synthesize or Reflect upon Collections of Primary Reports:

   Class M:

   • Meta-analysis
   • Systematic review
   • Decision analysis
   • Cost-effectiveness analysis

   Class R:

   • Consensus statement
   • Consensus report
   • Narrative review

   Class X:

   • Medical opinion

Conclusion Grades:

Grade I: The evidence consists of results from studies of strong design for answering the question addressed. The results are both clinically important and consistent with minor exceptions at most. The results are free of any significant doubts about generalizability, bias, and flaws in research design. Studies with negative results have sufficiently large samples to have adequate statistical power.

Grade II: The evidence consists of results from studies of strong design for answering the question addressed, but there is some uncertainty attached to the conclusion because of inconsistencies among the results from the studies or because of minor doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from weaker designs for the question addressed, but the results have been confirmed in separate studies and are consistent with minor exceptions at most.

Grade III: The evidence consists of results from studies of strong design for answering the question addressed, but there is substantial uncertainty attached to the conclusion because of inconsistencies among the results of different studies or because of serious doubts about generalizability, bias, design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from a limited number of studies of weak design for answering the question addressed.

Grade Not Assignable: There is no evidence available that directly supports or refutes the conclusion.

• Assessment of Acute Pain
• Acute Pain Treatment

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

• Assessment and management of acute pain: after 48 hours, the percentage of patients who rate pain greater than 4 (on a 10-point scale) or at an unacceptable level to patient.

ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; e-mail: icsi.info@icsi.org; Web site: www.icsi.org.

ICSI's conflict of interest policy and procedures are available for review on ICSI's website at www.icsi.org.

Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.

• Assessment and management of acute pain. Executive summary. Bloomington (MN): Institute for Clinical Systems Improvement, 2008 Mar. 2 p. Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI)
• ICSI pocket guidelines. May 2007 edition. Bloomington (MN): Institute for Clinical Systems Improvement, 2007.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.