Use of peripheral regional anesthesia 1. The panel recommends that clinicians consider surgical site–specific peripheral regional anesthetic techniques in adults and children for procedures with evidence indicating efficacy. 2. The panel recommends that clinicians use continuous, local anesthetic–based peripheral regional analgesic techniques when the need for analgesia is likely to exceed the duration of effect of a single injection. Musculoskeletal Pain Task Force, this guideline defines orthopedic best practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. The guideline was submitted to the Orthopedic Trauma Association for review approval in 2018. Subsequently, the first version of this guideline was published in the Journal of Orthopedic Trauma in 2019. The following guideline is the recommendations as it relates to the theme of this course. Cognitive and emotional strategies for pain assessment and management 1. The panel recommends discussing the alleviation of pain, the expected recovery course, and patient experience at all encounters. 2. The panel recommends connecting patients with pain that is greater or more persistent than expected and patients with substantial symptoms of depression, anxiety, or posttraumatic stress or less effective coping strategies (greater catastrophic thinking and lower self- efficacy) to psychosocial interventions and resources. 3. The panel recommends that clinicians consider using anxiety-reducing strategies to increase self-efficacy and promote peace of mind with patients like aromatherapy, music therapy, or cognitive behavioral therapy. Physical strategies 1. The panel recommends the use of transcutaneous electrical stimulation (TENS) as an adjunct to other immediate postinjury or postoperative pain treatments. 2. The panel can neither recommend nor discourage a specific TENS device or protocol. Regimens that incorporate suboptimal frequencies not approaching a “sub-noxious or maximal tolerable/painful” setting lack effective pain modulation and should be avoided. Cryotherapy 1. The panel recommends the use of cryotherapy for acute musculoskeletal injury and the postsurgical orthopedic patient as an adjunct to other postoperative pain treatments. 2. The panel cannot recommend a specific cryotherapy delivery modality or protocol.
3. The panel recommends that clinicians consider the addition of clonidine as an adjuvant for the prolongation of analgesia with a single-injection peripheral neural blockade. Use of cognitive-behavioral modalities 1. The panel recommends that clinicians consider the use of cognitive–behavioral modalities in adults as part of a multimodal approach. Opioid safety and effectiveness 1. The panel endorses that all opioids used for pain carry a risk of misuse. Opioids are also associated with adverse clinical events. Patient comfort and safety must be carefully balanced when prescribing opioids. Because of the potential for misuse of all opioids, the panel recommends that the prescriber should use the lowest effective dose for the shortest period possible. 2. The panel recommends not prescribing benzodiazepines in conjunction with opioids because of the significant risks of inconsistent sedation and the potential for misuse. 3. The panel recommends avoiding long-acting opioids in the acute setting. 4. The panel recommends prescribing precisely. Commonly written prescriptions with ranges of dose and duration can allow tripling of daily dose to levels consistent with adverse events. Multimodal analgesia 1. The panel recommends the use of multimodal analgesia (MMA) as opposed to opioid monotherapy for pain control. 2. The panel recommends the use of periarticular injections as an adjunct to pain management that improves pain control postoperatively. 3. The panel cannot recommend specific MMA regimens at this time without further scientific evidence. MMA should be tailored to patients’ injuries and medical comorbidities. Intraoperatively and the immediate postoperatively period 1. The panel recommends that clinicians consider local or regional block anesthesia during operative treatment of fractures and as part of the postoperative multimodality pain control regimen. 2. The panel recommends that if a block is going to be performed for intraoperative and postoperative pain control, a continuous catheter be considered over a single-shot block to better facilitate postoperative pain control and diminish rebound pain. and NSAIDs are effective drugs at any step of the WHO analgesic ladder, regardless of their intensity and provided that their use is not contraindicated. Nonopioids, such as paracetamol and NSAIDs, must be considered for the management of cancer pain in this setting. They are useful in mild or mild/moderate pain, and there is no evidence to claim that some NSAIDs are more effective or safer than others. At therapeutic doses, all of them present anti-inflammatory, analgesic, and antipyretic properties to a greater or lesser extent. Paracetamol and NSAIDs are effective drugs at any step of the WHO analgesic ladder, regardless of their intensity and provided that their use is not contraindicated.
Guideline on the Management of Pain in Acute Musculoskeletal Injury Designed by the Orthopedic Trauma Association
The Spanish Society of Medical Oncology Clinical Guideline for Cancer Pain Management First designed and published in 2018, this guideline was designed to establish recommendations that can be applied by professionals in their clinical practice to optimize cancer pain management. The following notable guidelines are the recommendations as they relate to the theme of this course. Mild cancer pain
Non-opioids, such as paracetamol and NSAIDs, must be considered for the management of cancer pain in this setting. They are useful in mild or mild/moderate pain, and there is no evidence to claim that some NSAIDs are more effective or safer than others. At therapeutic doses, all of them present anti-inflammatory, analgesic, and antipyretic properties to a greater or lesser extent. Paracetamol
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