as options for pain management (conditional recommendation based on very low certainty in the evidence about effects). 2. For adults who have SCD-related chronic pain with no identifiable cause beyond SCD, the ASH guideline panel suggests tricyclic antidepressants (TCAs; e.g., amitriptyline) as an option for pain management (conditional recommendation based on very low certainty in the evidence about effects). 3. For adults who have SCD-related chronic pain with no identifiable cause beyond SCD, the ASH guideline panel suggests gabapentinoids (e.g., pregabalin) as options for pain management (conditional recommendation based on very low certainty in the evidence about effects). Chronic opioid therapy for chronic pain in SCD Care Question : Should COT vs no COT or periodic opioid therapy be used in patients with SCD who have chronic pain? Guidelines on the management of postoperative pain This guideline is considered the most referenced in the clinical care of postoperative pain in adults and children. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and the development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. The following guidelines are the recommendations as they relate to the theme of this course. Preoperative education and perioperative pain management planning 1. The panel recommends that clinicians provide patient and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for the management of postoperative pain, and document the plan and goals for postoperative pain management. 2. The panel recommends that the parents (or other adult caregivers) of children who undergo surgery receive instruction in developmentally appropriate methods for assessing pain as well as counseling on the appropriate administration of analgesics and modalities. 3. The panel recommends that clinicians conduct a preoperative evaluation including an assessment of medical and psychiatric comorbidities, concomitant medications, history of chronic pain, substance abuse, and previous postoperative treatment regimens and responses, to guide the perioperative pain management plan. 4. The panel recommends that clinicians adjust the pain management plan based on the adequacy of pain relief and the presence of adverse events. 5. The panel recommends that clinicians use a validated pain assessment tool to track responses to postoperative pain treatments and adjust treatment plans accordingly. Use of multimodal therapies in postoperative pain care 1. The panel recommends that clinicians offer multimodal analgesia, or the use of a variety of
1. For adults and children with SCD and emerging and/ or recently developed chronic pain, the ASH guideline panel suggests against the initiation of COT unless pain is refractory to multiple other treatment modalities (conditional recommendation based on very low certainty in the evidence about effects). 2. For adults and children with chronic pain from SCD who are receiving COT, are functioning well, and have perceived benefits, the ASH guideline panel suggests shared decision-making for the continuation of COT (conditional recommendation based on very low certainty in the evidence about effects). 3. For adults and children with chronic pain from SCD who are receiving COT, are functioning poorly, or are at high risk for aberrant opioid use or toxicity, the ASH guideline panel suggests against the continuation of COT (conditional recommendation based on very low certainty in the evidence about effects). analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults. Use of physical modalities 1. The panel recommends that clinicians consider transcutaneous electrical nerve stimulation (TENS) as an adjunct to other postoperative pain treatments. 2. The panel can neither recommend nor discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments. Use of systemic pharmacological therapies 1. The panel recommends oral over intravenous (i.v.) administration of opioids for postoperative analgesia in patients who can use the oral route. 2. The panel recommends that clinicians avoid using the intramuscular route for the administration of analgesics for the management of postoperative pain. 3. The panel recommends that i.v. patient-controlled analgesia (PCA) be used for postoperative systemic analgesia when the parenteral route is needed. 4. The panel recommends against routine basal infusion of opioids with i.v. PCA in opioid-naive adults. 5. The panel recommends that clinicians provide appropriate monitoring of sedation, respiratory status, and other adverse events in patients who receive systemic opioids for postoperative analgesia. 6. The panel recommends that clinicians provide adults and children with acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for the management of postoperative pain in patients without contraindications. 7. The panel recommends that clinicians consider giving a preoperative dose of oral celecoxib to adult patients without contraindications. Clinicians should also consider the use of gabapentin or pregabalin as a component of multimodal analgesia. 8. The panel recommends that clinicians consider i.v. ketamine as a component of multimodal analgesia in adults. Clinicians should also consider i.v. lidocaine infusions in adults who undergo open and laparoscopic abdominal surgery who do not have contraindications. Use of local and/or topical pharmacological therapies 1. The panel recommends that clinicians consider surgical site–specific local anesthetic infiltration for surgical procedures with evidence indicating efficacy. 2. The panel recommends that clinicians use topical local anesthetics in combination with nerve blocks before circumcision.
Book Code: PYCA2725
Page 154
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