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 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.
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. 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. 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. 2. The panel cannot recommend a specific cryotherapy delivery modality or protocol. 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.
Guideline on the Management of Pain in Acute Musculoskeletal Injury Designed by the Orthopedic Trauma Association Musculoskeletal Pain Task Force, this guideline defines orthopedic best practices
Book Code: PYFL4024
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