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VHA/Dod CLINICAL PRACTICE GUIDELINE for the MANAGEMENT of POSTOPERATIVE PAIN

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VHA/Dod CLINICAL PRACTICE GUIDELINE for the MANAGEMENT of POSTOPERATIVE PAIN VHA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF POSTOPERATIVE PAIN Veterans Health Administration Department of Defense Prepared by: THE MANAGEMENT OF POSTOPERATIVE PAIN Working Group with support from: The Office of Performance and Quality, VHA, Washington, DC & Quality Management Directorate, United States Army MEDCOM VERSION 1.2 JULY 2001/ UPDATE MAY 2002 VHA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF POSTOPERATIVE PAIN TABLE OF CONTENTS Version 1.2 Version 1.2 VHA/DoD Clinical Practice Guideline for the Management of Postoperative Pain TABLE OF CONTENTS INTRODUCTION A. ALGORITHM & ANNOTATIONS • Preoperative Pain Management.....................................................................................................1 • Postoperative Pain Management ...................................................................................................2 B. PAIN ASSESSMENT C. SITE-SPECIFIC PAIN MANAGEMENT • Summary Table: Site-Specific Pain Management Interventions ................................................1 • Head and Neck Surgery..................................................................................................................3 - Ophthalmic Surgery - Craniotomies Surgery - Radical Neck Surgery - Oral-maxillofacial • Thorax (Non-cardiac) Surgery.......................................................................................................9 - Thoracotomy - Mastectomy - Thoracoscopy • Thorax (Cardiac) Surgery............................................................................................................16 - Coronary Artery Bypass Graft (CABG) - Minimally Invasive Direct Coronary Artery Bypass (MID-CAB) • Upper Abdominal Surgery ...........................................................................................................19 - Laparotomy - Laparoscopic Cholecystectomy - Nephrectomy • Lower Abdominal and Pelvis Surgery.........................................................................................26 - Hysterectomy - Radical Retropubic Prostatectomy - Inguinal Hernia • Back/Spinal Surgery .....................................................................................................................30 - Laminectomy - Spinal Fusion • Surgery of Extremities/Vascular Surgery...................................................................................33 - Total Hip Replacement - Total Knee Replacement - Knee Arthroscopy and Arthroscopic Joint Repair - Amputation - Shoulder – Open Rotator Cuff Repair or Arthroscopic Sub-Acromial Decompression - Vascular Surgery Table of Contents Page 1 Version 1.2 VHA/DoD Clinical Practice Guideline for the Management of Postoperative Pain D. OPTIONS FOR POSTOPERATIVE PAIN MANAGEMENT NON-PHARMACOLOGIC MANAGEMENT • Cognitive Modalities .......................................................................................................................1 - Distraction, Relaxation, and Biofeedback - Hypnosis • Physical Modalities..........................................................................................................................5 - Transcutaneous Electrical Nerve Stimulation (TENS) - Cold - Heat - Exercise - Positioning - Immobilization/Rest - Massage - Accupuncture PHARMACOLOGIC MANAGEMENT • Routes of Administration................................................................................................................2 • Pharmacologic Management..........................................................................................................9 - OPIOIDS....................................................................................................................................9 Summary Table – Site Specific Pain Management Interventions - Opioids Table OP1 – OPIOIDS: Mechanism of Action, Contraindications, Other Considerations Table OP2 – OPIOIDS: Dosing and Pharmacokinetics Table OP2.5 – OPIOIDS: Dosage Formulations Table OP3 – OPIOIDS: Drug Interactions Table OP4 – OPIOIDS: Equianalgesic Dosing Table OP5 – OPIODS: Dosage Formulations - Acetaminophen and NSAIDs...................................................................................................49 Summary Table – Site Specific Pain Management Interventions - NSAIDs Table NS1 – NSAIDs: Mechanism of Action, Contraindications, Other Considerations Table NS2 – NSAIDs: Dosing and Pharmacokinetics Table NS3 – NSAIDs: Drug Interactions - Local Anesthetics.....................................................................................................................62 Summary Table – Site Specific Pain Management Interventions– Local Anesthetics Table LA1 – Local Anesthetics: Mechanism of Action, Contraindications, Other considerations Table LA2 – Local Anesthetics: Pharmacologic, Pharmacokinetic, and Clinical Characteristics Table LA3 – Local Anesthetics: Adverse Effects Table of Contents Page 2 Version 1.2 VHA/DoD Clinical Practice Guideline for the Management of Postoperative Pain - Glucocorticoids........................................................................................................................72 Summary Table GC1 – Comparison of glucocorticoid agents in order of increasing potency and duration. Table GC2 – Dosing and routes of administration of glucocorticoids with postoperative analgesic efficacy Table GC3 – Dosing and administration of glucocorticoids fpr [pstoperative and e[idural morphine-related nausea or vomiting E. EDUCATION FOR PAIN MANAGEMENT • General Preoperative Education....................................................................................................1 • Discharge Education .......................................................................................................................5 • The Pain Trajectory Relative to The Operative Procedure.......................................................12 F. APPENDICES • APPENDIX A: Guideline Development Process ..........................................................................1 • APPENDIX B: Participant List .....................................................................................................1 • APPENDIX C: Bibliography..........................................................................................................1 Table of Contents Page 3 VHA/DoD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF POSTOPERATIVE PAIN INTRODUCTION Version 1.2 Version 1.2 VHA/DoD Clinical Practice Guideline for the Management of Postoperative Pain Postoperative Pain Management Acute postoperative pain is a significant issue for surgical patients in the Veterans Health Administration (VHA) health care system, the Department of Defense (DoD) health care system, and in the nation at large. In 2000, more than 360,000, combined inpatient and outpatient, surgical procedures were performed in the VHA (VHA Patient Care Services, 2001), and approximately 475,000 procedures were done in the DoD system (TRICARE, 2001). Effective pain management is associated with patient satisfaction, earlier mobilization, shortened hospital stay, and reduced costs (AHCPR, 1992). Despite these benefits, there are substantial numbers of patients who suffer from postoperative pain. To address this problem, the Agency for Health Care Policy and Research (AHCPR) Acute Pain Management Clinical Practice Guideline (CPG) was released in 1992. The VHA added pain as a fifth vital sign as of October 2000 (VHA, 2000). Since then, therapeutic advances, outcome studies, and the publication of the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) Pain Management Standard for 2001 have refined the practice of pain management, (2001). It is therefore essential that the VHA and DoD develop a systematic approach to pain management that assures that pain is recognized and treated promptly and effectively. This guideline is part of a system-wide approach to pain management that is designed to reduce pain and suffering for patients experiencing acute and chronic pain. Alleviation of pain and suffering, especially when it occurs as a consequence of treatment, is a priority for all health professionals. The subjective nature of the pain experience requires flexibility, compassion, and understanding on the part of the health care practitioner. This acute postoperative pain guideline was written from a specific procedural perspective and is intended as a tool to enhance the practitioner’s clinical skills by presenting therapeutic options with supporting information. It does not dictate one approach, but provides principles and guidance to effective, safe, and timely pain management. As a web-based guideline, it can be used in a variety of ways—providing information on algorithms, assessment, special needs, interventions, and planning for pain management at the chosen level of detail. In addition, as improvements in pain management are realized, they can be rapidly disseminated. Surgical procedures inevitably produce tissue trauma and release potent mediators of inflammation and pain (NHMRC, 1999). New treatment techniques and drugs, and the increased attention to pain management in general, have led to opportunities to improve the care of patients with pain. The VHA/DoD Guideline for the Management of Postoperative Pain is intended to improve the quality of care and facilitate the management of patients with postoperative pain. The guideline focuses on the assessment, diagnosis, treatment, management, and follow-up of these patients. Goals of the Guideline The VHA/DoD Clinical Practice Guideline for the Management
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