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1.   INTRODUCTION

1.1.   Effective treatment of acute pain is a fundamental component of quality patient care.

1.2.   Education and practical experience in acute pain management are essential components of training programs for Fellowships of ANZCA and FPMANZCA.

2.   PRINCIPLES OF ACUTE PAIN MANAGEMENT

2.1.   Adverse physiological and psychological effects may result from unrelieved severe acute pain.

2.2.   Effective treatment of postoperative pain may reduce the incidence of postoperative morbidity and facilitate earlier discharge from hospital.

2.3.   Preventive treatment of postoperative pain may reduce the incidence of chronic pain.

2.4.   Effective management of acute pain requires tailoring of treatment regimens to the individual patient.

2.5.   Effective management of acute pain depends on close liaison with and education and training of all staff, and involvement and education of the patient and their carers.

2.6.   Effective management of acute pain depends on formal protocols and guidelines covering acute pain management which are relevant to each institution; and formal quality assurance programs to regularly evaluate the effectiveness of acute pain management.

2.7.   The following groups of patients have special needs that require particular attention:

2.7.1.   Children.

2.7.2.   Pregnant patients.

2.7.3.   Elderly patients.

2.7.4.   Aboriginal and Torres Strait Islander People.

2.7.5.   Māori.

2.7.6.   Other ethnic groups and non-English speaking people.

2.7.7.   Patients with obstructive sleep apnoea.

2.7.8.   Patients with concurrent hepatic or renal disease.

2.7.9.   Opioid-tolerant patients.

2.7.10.   Patients with a substance abuse disorder.

2.7.11.   Patients with cognitive behavioural and/or sensory impairments.

3.   EDUCATION

3.1.   Education regarding acute pain management should be part of the medical undergraduate core curriculum. Knowledge should be supplemented at the postgraduate level for all medical and other staff.

3.2.   Nursing staff have a key role in the management of acute pain. Appropriate ongoing education and accreditation of relevant nursing staff are essential.

3.3.   Patient attitudes and beliefs have been shown to modify pain perceptions and analgesic requirements, and patient and carer education can therefore positively influence the outcome of acute pain management.

3.3.1.   A discussion regarding analgesia, its role in recovery and rehabilitation, and options available (pharmacological and non-pharmacological), is an essential component of an acute pain management consultation.

3.3.2.   Availability of appropriate reading material will enhance patient and carer understanding and expectations of available pharmacological and non-pharmacological therapies.

4.   ASSESSMENT OF ANALGESIC EFFICACY AND ADVERSE EFFECTS

4.1.   Tailoring of treatment regimens to the individual patient requires that regular assessments of adequacy of analgesia and any adverse effects of analgesic drugs or techniques are performed and documented.

4.2.   Proper assessment and control of pain requires patient involvement, and measurement using self-reporting techniques, and frequent assessment and reassessment of pain intensity and effect of any intervention.

4.3.   Pain should be assessed both at rest and during activity. In addition to patient comfort, pain relief should be assessed with respect to adequate function including physical therapy requirements and mobilisation.

4.4.   Unexpected levels of pain, or pain that suddenly increases, may signal the development of a new medical, surgical or psychiatric diagnosis.

4.5.   All side effects and significant complications should be recorded, as should treatment changes resulting from these issues.

5.   PHARMACOLOGICAL THERAPIES

5.1.   Drugs that may be used include opioids, non-steroidal anti-inflammatory drugs and local anaesthetics, as well as adjuvant agents such as antidepressants, anticonvulsants and membrane stabilisers. Other drugs may be required for the treatment of any analgesia-related side effects; or other symptoms. The selection of appropriate drugs and routes and techniques for their administration should follow an evidence-based approach.

5.2.   In order to obtain the best therapeutic effect while minimising side effects, many analgesic drugs require careful titration and individualisation of dose regimens.

5.3.   Multimodal analgesia (i.e. the concurrent use of different classes of analgesics) improves the effectiveness of acute pain management.

5.4.   Drug administration can be by oral, subcutaneous, intramuscular, intravenous, epidural, intrathecal, inhalational, rectal, transdermal or transmucosal routes.

5.5.   Some specialised analgesia delivery techniques require greater medical and nursing knowledge and expertise, as well as some complex equipment and the use of established protocols and guidelines. The anaesthetist initiating these forms of analgesia may delegate the management of the techniques to another medical practitioner or registered nurse or to a pain service, provided that these personnel have received appropriate training and provided the anaesthetist is satisfied with the competence of the person(s) to whom management has been delegated. Such techniques include:

5.5.1.   Patient-controlled analgesia

5.5.2.   Epidural and intrathecal analgesia

5.5.3.   Other regional analgesic procedures

5.5.4.   Continuous infusions of opioids, local anaesthetics, ketamine and other drugs

6.   NON-PHARMACOLOGICAL THERAPIES

6.1.   Non-pharmacological therapies must be considered as complementary to pharmacological therapies.

6.2.   Psychological interventions, acupuncture, TENS and physical therapy may be effective in some acute pain settings.

7.   ACUTE PAIN SERVICES

7.1.   A multidisciplinary approach to the management of acute pain, such as with an acute pain service, can lead to improved pain relief, patient outcomes and reduced incidence of side effects.

7.2.   Such an approach is recommended for all patients, especially those with complex medical or psychological pathology.

7.3.   Features of such a service should include:

7.3.1.   Staffing by medical personnel, particularly anaesthetists and nurses with special expertise in acute pain management.

7.3.2.   Close liaison with physiotherapists, psychologists, pharmacists and other paramedical personnel.

7.3.3.   Close collaboration with surgical and other specialties involved in the patient’s overall acute perioperative care.

7.3.4.   Development of specific policies, protocols and guidelines for treatment and monitoring.

7.3.5.   Review of all patients under the care of the service at least once daily, and liaison with appropriate medical and nursing staff.

7.3.6.   Provision of a consultation service for patients with acute or acute-on-chronic pain problems.

7.3.7.   Provision of an after-hours service with appropriate consultant involvement.

7.3.8.   Involvement with management plans for analgesia after discharge, where appropriate.

7.3.9.   Research.

7.3.10.   Education of medical, nursing and other staff and students.

8.   QUALITY ASSURANCE

8.1.   Regular audits of acute pain management should be instituted to assess continuing effectiveness of any treatment and incidence of side effects and adverse effects.

8.2.   It is recommended that a record is made of patient demographics, analgesic drugs, techniques used, pain reports and any adverse effects that occur (see 4.5. above).

Reference

Acute Pain Management: Scientific Evidence, Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, Melbourne, ANZCA. 2005.

COLLEGE PROFESSIONAL DOCUMENTS

College Professional Documents are progressively being coded as follows:

TE Training and Educational

EX Examinations

PS Professional Standards

T Technical

POLICY - defined as 'a course of action adopted and pursued by the College'. These are matters coming within the authority and control of the College.

RECOMMENDATIONS - defined as 'advisable courses of action'.

GUIDELINES - defined as 'a document offering advice'. These may be clinical (in which case they will eventually be evidence-based), or non-clinical.

STATEMENTS - defined as 'a communication setting out information'.

This document is intended to apply wherever anaesthesia is administered.

This document has been prepared having regard to general circumstances, and it is the responsibility of the practitioner to have express regard to the particular circumstances of each case, and the application of this document in each case.

Professional documents are reviewed from time to time, and it is the responsibility of the practitioner to ensure that the practitioner has obtained the current version. Professional documents have been prepared having regard to the information available at the time of their preparation, and the practitioner should therefore have regard to any information, research or material which may have been published or become available subsequently.

Whilst the College endeavours to ensure that professional documents are as current as possible at the time of their preparation, it takes no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.

Promulgated: 2000

Reviewed: 2005

Date of current document: Feb 2007

© This document is copyright and cannot be reproduced in whole or in part without prior permission.

College Website: http://www.anzca.edu.au/