Pain, Acute, Assessment and Management of (Guideline) [ICSI-NQMC-AHRQ]

Pain, Acute, Assessment and Management of (Guideline)

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http://www.icsi.org/pain_acute/pain__acute__assessment_and_management_of__3.html

Scope and Target Population:
This guideline has been developed for patients of all ages (from infant to very elderly) who have acute pain or may be experiencing acute pain in the future (i.e., planned surgery). This guideline excludes patients with acute cancer pain, labor pain and migraine headache, although many of the guideline's recommendations apply to those groups, as well.

Rather than focus on the cause of the pain (a comprehensive list would fill a textbook) or the setting where the pain is treated (inpatient or outpatient), this guideline focuses on effective treatment based on the physiologic mechanisms of pain transmission (e.g., somatic, visceral, neuropathic). Understanding this should allow clinicians to apply this algorithm to almost any kind of acute pain (no matter what the cause) and in any setting.

We acknowledge that assessments of pain in the preverbal, non-English-speaking and cognitively impaired are challenging. As a result, relevant recommendations will be made in order to enhance assessment of an intervention for all patients. The following definitions are assumed:

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Acute pain states can be brief, lasting moments or hours, or they can be persistent, lasting weeks or several months until the disease or injury heals.

Chronic pain, is defined as persistent pain, which can be either continuous or recurrent and of sufficient duration and intensity to adversely affect a patient's well-being, level of function, and quality of life. If a patient's pain has persisted for six weeks (or longer than the anticipated healing time), a thorough evaluation for the cause of the chronic pain is warranted.

Clinical Highlights and Recommendations:

Intensity of pain is assessed prior to initiation of appropriate treatment and continually reassessed throughout duration of treatment.

Determine the mechanism of pain (i.e., somatic, visceral, neuropathic) based on the physical examination and detailed history.

Patients often experience more than one type of pain.

Somatic pain is well localized and may be responsive to acetaminophen, cold packs, corticosteroids, localized anesthetic (topical or infiltrate), NSAIDs, opioids and tactile stimulation.

Visceral pain is more generalized and is most responsive to opioid treatment.

Neuropathic pain may be resistant to opioid therapy and consideration should be given to adjuvant therapy such as tricyclic antidepressants and anticonvulsants.

While the emphasis of this guideline is on pharmacologic therapy, multimodal treatment approaches are important to consider because patient satisfaction is high when non-pharmacologic approaches are provided.

Priority Aims:

Improve the assessment and reassessment of all age patients with acute pain by determining the mechanism and intensity of pain.

Improve the treatment of patients (all ages) with acute pain, to include appropriate selection of pharmacologic and/or non-pharmacologic interventions.

Increase the involvement of patients with acute pain of all ages, or their caregiver, in the management of their pain symptoms.

Additional Background:
Rather than focus on the cause of pain (a comprehensive list would fill a text book) or the setting where the pain is treated (inpatient/outpatient), this guideline focuses on effective treatment based on the physiologic mechanisms of pain transmission (e.g., somatic, visceral, neuropathic). Understanding this should allow clinicians to apply this algorithm to almost any kind of acute pain in any setting (this guideline excludes patients with acute cancer pain, labor pain, and migraine headache). We acknowledge that assessments of pain in the preverbal, non-English speaking and cognitively impaired are challenging. As a result, relevant recommendations have been made in order to enhance assessment of an intervention for all patients.