Guidelines on the

Management of
Postoperative Pain
Masitah Binti Omar 11.2016.094
Pembimbing: dr. Nur Syamsiani

Kepaniteraan Klinik Ilmu Anestesi

Periode 14 Juli 2017 – 2 September 2017
Fakultas Kedokteran Universitas Kristen Krida Wacana
Jakarta
 The American Pain Society (APS), with input
from the American Society of
Anesthesiologists (ASA), commissioned a
guideline on management of postoperative
pain to promote evidence-based, effective,
and safer postoperative pain management in
children and adults, addressing areas that
include:
• preoperative education,
• perioperative pain management planning,
• use of different pharmacological and
nonpharmacological modalities,
• organizational policies and procedures,
• transition to outpatient care.
 Preoperative Education and
Perioperative Pain Management
Planning
Recommendation 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 management of
postoperative pain, and document the plan and
goals for postoperative pain management
(strong recommendation, low-quality evidence).
Recommendation 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 appropriate administration of
analgesics and modalities (strong
recommendation, low-quality evidence).
Recommendation 3
The panel recommends that clinicians
conduct a preoperative evaluation
including 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
(strong recommendation, low-quality
evidence).
Recommendation 4
The panel recommends that clinicians
adjust the pain management plan on
the basis of adequacy of pain relief
and presence of adverse events (strong
recommendation, low-quality
evidence).
Methods of Assessment
Recommendation 5
The panel recommends that clinicians
use a validated pain assessment tool
to track responses to postoperative
pain treatments and adjust treatment
plans accordingly (strong
recommendation, low quality
evidence).
General Principles Regarding the
Use of Multimodal Therapies
Recommendation 6
The panel recommends that clinicians
offer multimodal analgesia, or the use
of a variety of analgesic medications
and techniques combined with
nonpharmacological interventions, for
the treatment of postoperative pain in
children and adults (strong
recommendation,high-quality
evidence).
 Use of Physical Modalities
Recommendations 7 and 8
The panel recommends that clinicians
consider transcutaneous electrical nerve
stimulation (TENS) as an adjunct to other
postoperative pain treatments (weak
recommendation, moderate-quality
evidence). The panel can neither
recommend nor discourage acupuncture,
massage, or cold therapy as adjuncts to
other postoperative pain treatments
(insufficient evidence).
 Use of Cognitive–Behavioral
Modalities
Recommendation 9
The panel recommends that clinicians
consider the use of cognitive–
behavioral modalities in adults as part
of a multimodal approach (weak
recommendation,moderate-quality
evidence).
 Use of Systemic
Pharmacological Therapies
Recommendation 10
The panel recommends oral over
intravenous (i.v.) administration of
opioids for postoperative analgesia in
patients who can use the oral route
(strong recommendation, moderate
quality evidence).
Recommendation 11
The panel recommends that clinicians avoid
using the intramuscular route for the
administration of analgesics for management
of postoperative pain (strong
recommendation,moderate-quality evidence).
Recommendation 12
The panel recommends that i.v.
patient-controlled analgesia (PCA)
be used for postoperative systemic
analgesia when the parenteral
route is needed (strong
recommendation,moderate-quality
evidence).
Recommendation 13
The panel recommends against
routine basal infusion of opioids
with i.v. PCA in opioid-naive adults
(strong recommendation,
moderate-quality evidence).
Recommendation 14
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
(strong recommendation, low-
quality evidence).
Recommendation 15
The panel recommends that
clinicians provide adults and
children with acetaminophen
and/or nonsteroidal anti-
inflammatory drugs (NSAIDs) as
part of multimodal analgesia for
management of postoperative pain
in patients without
contraindications (strong
recommendation, high-quality
evidence).
Recommendation 16
The panel recommends that
clinicians consider giving a
preoperative dose of oral celecoxib
in adult patients without
contraindications (strong
recommendation, moderate-
quality evidence).
Recommendation 17
The panel recommends that
clinicians consider use of
gabapentin or pregabalin as a
component of multimodal
analgesia (strong recommendation,
moderate-quality evidence).
Recommendation 18
The panel recommends that
clinicians consider i.v. ketamine as
a component of multimodal
analgesia in adults (weak
recommendation, moderate
quality evidence).
Recommendation 19
The panel recommends that
clinicians consider i.v. lidocaine
infusions in adults who undergo
open and laparoscopic abdominal
surgery who do not have
contraindications (weak
recommendation, moderate-
quality evidence).
Use of Local and/or Topical
Pharmacological Therapies
Recommendation 20
The panel recommends that clinicians
consider surgical site–specific local
anesthetic infiltration for surgical
procedures with evidence indicating
efficacy (weak recommendation,
moderate-quality evidence).
Recommendation 21
The panel recommends that
clinicians use topical local
anesthetics in combination with
nerve blocks before circumcision
(strong recommendation,
moderate-quality evidence).
Recommendation 22
The panel does not recommend
intrapleural analgesia with local
anesthetics for pain control after
thoracic surgery (strong
recommendation,moderate-quality
evidence).
Use of Peripheral Regional Anesthesia
Recommendation 23
The panel recommends that clinicians consider
surgical site–specific peripheral regional
anesthetic techniques in adults and children
for procedures with evidence indicating
efficacy (strong recommendation, high-quality
evidence).
Recommendation 24
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 (strong
recommendation, moderate
quality evidence).
Recommendation 25
The panel recommends that
clinicians consider the addition of
clonidine as an adjuvant for
prolongation of analgesia with a
single-injection peripheral neural
blockade (weak recommendation,
moderate-quality evidence).
Use of Neuraxial Therapies
Recommendation 26
The panel recommends that
clinicians offer neuraxial analgesia
for major thoracic and abdominal
procedures, particularly in patients
at risk for cardiac complications,
pulmonary complications, or
prolonged ileus (strong
recommendation, high-quality
evidence).
Recommendation 27
The panel recommends that
clinicians avoid the neuraxial
administration of magnesium,
benzodiazepines, neostigmine,
tramadol, and ketamine in the
treatment of postoperative pain
(strong recommendation,
moderate-quality evidence).
Recommendation 28
The panel recommends that
clinicians provide appropriate
monitoring of patients who have
received neuraxial interventions
for perioperative analgesia (strong
recommendation, low-quality
evidence).
Organizational Structure, Policies,
and Procedures
Recommendation 29
The panel recommends that
facilities in which surgery is
performed have an organizational
structure in place to develop and
refine policies and processes for
safe and effective delivery of
postoperative pain control (strong
recommendation, low-quality
evidence).
Recommendation 30
The panel recommends that facilities in
which surgery is performed provide
clinicians with access to consultation
with a pain specialist for patients with
inadequately controlled postoperative
pain or at high risk of inadequately
controlled postoperative pain (eg,
opioid-tolerant, history of substance
abuse) (strong recommendation, low-
quality evidence).
Recommendation 31
The panel recommends that facilities in
which neuraxial analgesia and
continuous peripheral blocks are
performed have policies and procedures
to support their safe delivery and trained
individuals to manage these procedures
(strong recommendation, low-quality
evidence).
Transitioning to Outpatient Care
Recommendation 32
The panel recommends that clinicians
provide education to all patients (adult
and children) and primary caregivers on
the pain treatment plan including
tapering of analgesics after hospital
discharge (strong recommendation, low-
quality evidence).