Running head POSTOPERATIVE PAIN .docx

1. Running head: POSTOPERATIVE PAIN 1 POSTOPERATIVE PAIN 3 Postoperative Pain after Reconstructive Surgery Carla S. Garcia Nicole Wertheim College of Nursing and Health Sciences Author Note Carla S. Garcia, Nicole Wertheim College of Nursing and Health Sciences, Florida International University Correspondence concerning this article should be addressed to Carla Garcia, Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL 33199. Contact: [email protected] Abstract Postoperative pain is common for most patients who have undergone reconstructive surgery after a burn. The American Society of Pain (ASP) has devised methods of dealing with postoperative pain since most patients report the incident and only half of them were reported to have recovered from it. The use of local anesthetic-based peripheral regional analgesic technique is an efficient way of reducing postoperative pain, as well as the multi-modal approach for pain management, which has been used for patients after a forty-eight-hour post operative period. The American Society of Regional Anesthesia (ASRA) has approved these methods, and through research, has prepared organizational plans that assist surgical and outpatients with

2. postoperative pain management. Measures such as preoperative education, preoperative pain management and pharmacological and non-pharmacological modalities have been recommended. Evidence shows that multi-modal methods of dealing with postoperative pain have been used for most of the cases. This paper will explore the evidence of postoperative pain management after burn reconstruction surgery and include the comparison between the uses of local anesthetic to the use of multi-modal methods in dealing with postoperative pain. In adition, the paper will look at the use of these postoperative methods both in the United States of America (USA) and other countries, and how these methods impact patient outcome. Keywords: Evidence-Based, Research, Nursing Research, Postoperative, Patient Response. Significance and Background Burn reconstruction is a common experience for patients both in the USA and other countries in the world. Postoperative pain is expected after a burn reconstruction, hence the incorporation of methods such as the use of local anesthesia and multi-modal techniques in dealing with pain are recommended. The inquiry is whether the use of local anesthetics is more effective than the multi-modal method in dealing with postoperative pain in adult patients recovering from reconstructive surgery within a forthy- eight-hour time frame. During a study composed of members of the ASP with help from the American Society of Anesthesiologists (ASA), they assembled in a meeting where members with expertise in anesthesia or pain medicine were put in a research panel (Fuzaylov & Kelly, 2015). The panel’s objective was to review the evidence presented to them and recommend on ways of managing postoperative pain. The target audience of the study were clinicians who managed chronic pain, acute surgical pain, dental pain, and traumatic pain. Over 858 studies were included

3. in the research making it a very effective research (Fuzaylov & Kelly, 2015). Purpose The pain experienced after the surgical procedure can be managed in different ways. One way is through the subcutaneous infusion of local anesthetics. Skin burns are accompanied by a burning sensation that can be very irritating to the victim. This method of subcutaneous infusion of local anesthetic admission reduces that unpleasant burning feeling. For adolescents, the anaesthetic is administered in different dosage for those of 13-18 years, adults 19-44 years and adults between 45-64 years to both male and female (Poulsen, 2019). The anesthetic is administered in small amounts over the course of healing and the use of multi-modal techniques is not required. Most countries especially the developing ones do not have adequate clinical equipment to perform multi-modal methods of dealing with postoperative pain. In some countries, skin reconstruction procedures are not available to burn victims, thus, most people are forced to remain with healing scars. The lack of resources has been the down side of many countries without the necessary equipment (Poulsen, 2019). Victims are left with no choice but to receive local anesthesia and wait for the pruritic burns to resolve in time. The administration of local anesthesia is introduced depending on the patients consent. A multi-modal approach of dealing with postoperative pain is widely practiced in the USA since most clinicians are assigned to the task of reducing pain after surgery (Poulsen, 2019). Therapeutic exercise and constant skin stretches are recommended by the ASP in the postoperative period for pain control. Study #1: Nursing Research Study in the USA

4. The APS and the ASA have joined hands to handle the research being done in the USA (Poulsen, 2019). Preoperative education and preoperative pain management planning has been one key recommendation of these societies. Clinicians are advised to brief the family and the patient on the surgical procedure to be performed and how the postoperative pain experience will be managed. The method of checking is based on tracking patient’s response to postoperative pain treatment and change the treatment plan if the need arises (Poulsen, 2019). Cognitive behavioral modalities are recommended by the societies in order to access the patient’s response to surgery and ascertain whether they are still in their right set of mind. The panel neither recommends nor stops the use of other therapeutic method to control pain such as acupuncture and massage therapy (Poulsen, 2019). The choice is left entirely to the clinician assigned the task of managing the patient’s postoperative pain. The use of systematic pharmacological therapies have also been recommended by the societies. The use of oral methods over the intravenous administration of opioids for patients after surgery are highly recommended to those who can receive the drugs orally (Chou & Gordon, 2016). The intramuscular route should be avoided at all costs since patients are not very stable after surgery and the injection can become lethal to them, especially within burn victims. The use of gabapentin and pregabalin is recommended among multi-modal analgesia. For adults, intravenous ketamine should be used as a form of multi-modal analgesia but it is not a strict recommendation since research evidence was based on moderate quality evidence (Poulsen, 2019). Therefore, in the USA, nursing research has been spearheaded by medical societies that have made it easier to be able to apply both the local anesthetic methods and the multi-modal technics in an effective manner. Medical societies have shaped down the nursing sector and all clinicians are

5. subjected to a study session where they learn how to manage postoperative pain. In addition, specific clinicians in health centers are given the task of evaluating the outcomes. Study #2: Nursing Research Study Non-USA The nursing research modality in foreign countries is totally different from that of the USA. The differences are brought about by different government policies that are used to control the medical space. The policies in different countries enable the study to be carried out in a very fast and effective manner. While some other counties lack the necessary resources in order to make the research a success (Cooney, 2016). Time has shown that research needs to be taken seriously with the result being studied on a daily basis and ensuring that patients are the sole beneficiaries of the programs. For example, in a study of burned victims conducted in Ukraine, the results obtained were different since clinic resources were limited and patients were numerous. Therefore, clinicians had to administer small dosages of medicication to a total of 109 patients present and then observe the results. A group of 64 patients received the standard postoperative drug of metamizole 1g or ketorolac 3%-30mg by the nursing staff (Chou & Gordon, 2016). The other 45 patients received a different type of dosage and then the researchers had to wait and observe the patients. From the presented case, it is clear that the hospital in which the study was being performed had inadequate resources; Thus, researchers were forced to maintain spare supplies for future use to avoid depletion (Fuzaylov & Kelly, 2015). Organizational structure, policies and procedures have been laid down by societies on the placement of surgery platforms for safe and effective delivery of postoperative pain control (Chou & Gordon, 2016). For example, surgical rooms should be full of clinicians that have specialized in pain management. Facilities in which neuraxial analgesia and continuous peripheral blocks

6. are conducted have procedures for safe delivery and trained individuals to manage those procedures. Study #3: Postoperative pain management: clinical practice guidelines. Journal of Paranesthesia Nursing. Postoperative pain has been reported by patients with 80% of them reporting on acute pain and 75% of them reporting on moderate pain (Cooney, 2016). Lack of proper pain control can lead to decreased function, impaired recovery and reduced quality of life. Many organizations have published guidelines on how to use methods to control patient’s postoperative pain. These organizations comprise of American Society of Pain Management, American Society of Perinesthesia and the ASA. The ASA published its first guideline in 2012 (Cooney, 2016). In addition, the APS in parftenrship with the ASA and the ASRA published other effective methods of dealing with postoperative pain. The guidelines in these publications included the preoperative education, planning for preoperative pain management, organizational policies and procedures of dealing with postoperative pain and the transition to outpatient care. A study was carried out to determine the nursing practice implications of care to patients with postoperative pain. The study was composed of 23 multi-disciplinary experts that came from different departments including: surgery, gynecology, primary care, physical therapy, nursing, anesthesia, hospital medicine and psychology (Cooney, 2016). The panel chosen to carry out the study was tasked with reviewing the evidence based on postoperative pain management. The panel was in charge of formulating conclusions and giving recommendations for effective, safe and evidence-based postoperative pain management for patients. The study was composed of over 107 systematic reviews and 858 primary studies that were evidence- based on the final report (Cooney, 2016). Reviewers from the Oregon Health Sciences ranked the strengths of the reports

7. using the methods from the grading recommendation assessment and they found that using both the pharmacological methods and multi-modal methods all worked in reducing postoperative pain. Therefore, the combination of these methods was found to be the best way of treating the post-surgical pain. Study #4: Music as a Postoperative Pain Management Intervention The most common reported effect after surgical intervention is pain, and opioid therapy has been used to treat it. The use of opioids has been extensive because of its immediate effects in the central nervous system, ease of administration and multiple delivery forms. Nevertheless, it has been reported by the US Department of Health and Human Services that opioid’s side effects are detrimental (Poulsen, 2019). These side effects include opioid use disorder and even opioid related deaths; Hence, causing the medical community to reconsider the approach to pain management. Between the years 2016 and 2017, the United States Drug Enforcement Agency started restricting companies on producing opioid drugs. While in 2018 the commission from the organization of drug enforcement raised new standards which focused on improving pain management and implemented measures to improve opioid safety (Poulsen, 2019). In the new standards established, multi- modal therapies have been proposed. Citation here? Ironically, one of the non-pharmacological methods for pain control, is the therapeutic use of music to reduce post-operative pain. Music has been discovered to reduce post-surgical pain in recent years. It is also a good method for nurses and patients since it requires no provider orders. A study utilized Positron Emission Tomography (PET) scan and functional magnetic resonance imaging (fMRI) to reveal that music arouses the caudate and nucleus acumens parts of the brain (Poulsen, 2019). These regions of the brain are responsible for the release of dopamine, inducing an euphoric state, producing pleasure that significantly reduces pain. Further research on a number of patients gave positive results that made music an alternative

8. method of reducing postoperative pain.(source?) Therefore, music can be used as a multi-modal method of reducing postsurgical pain and can also be used in preoperative nursing practice. Conclusion Neither the local anesthetic analgesic techniques nor the multi- modal techniques can be dismissed. Both techniques target the same issue from different approaches to relieve postoperative pain. Pain manifests differently from person to person, and recovery is based on the person’s overall health, age, and comorbidities. For instance, a person who smokes chronicly, or has a long standing use of ilicit drugs may have more difficulty recovering after surgery as opposed to a person who has maintained a healthy life style and has no significant comorbidities. The comparison between the local anesthetic-based peripheral regional analgesic techniques, with the use of a multi-modal approach for pain management alone differs in countries depending on the resources available (Cooney, 2016). The USA has shown to be better equipped with societies such as the APS managing the nursing sector and making sure that the required research is conducted properly. Postoperative pain has been reported to persist for years in some patients. The nursing research team and any governmental policy that is aimed at helping research through funding, should prioritize this matter and establish evidence based guidelines, and create innovative methods to help patients who are experiencing postoperative surgical pain. A relief to the suffering of this patients should be provided, and the most accurate results come from research. Based on the presented review of studies, the use of local anesthetic-based peripheral regional analgesic techniques, and the use of multi-modal approaches should both be considered to provide fast and effective pain relief in recovering surgical patients.

9. References Chou, R., Gordon, D. B. (2016). Management of Postoperative Pain: a clinical practice guideline from the American pain society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' committee on regional anesthesia, executive committee, and administrative council. The Journal of Pain. Cooney, M. F. (2016). Postoperative pain management: clinical practice guidelines. Journal of Perianesthesia Nursing. Fuzaylov, G., Kelly, T. L. (2015). Post-operative pain control for burn reconstructive surgery in a resource-restricted country with subcutaneous infusion of local anesthetics through a soaker catheter to the surgical site: Preliminary results. Burns. Poulsen, M. J. (2019). Music as a Postoperative Pain Management Intervention. Journal of PeriAnesthesia Nursing. Running head: POSTOPERATIVE PAIN 1 POSTOPERATIVE PAIN 3 Postoperative Pain Name Institution Abstract Postoperative pain is common for most of patients who have undergone reconstructive surgery after a burn. The American Society of Pain (ASP) has devised methods of dealing with this problem since most patients report the incident and only half of them were reported to have recovered from post-operative pain.

10. The problem is a real challenge for the medical professionals and the medical society’s device ways of dealing with the issue on every occasion. The use of local anesthetic-based peripheral regional analgesic technique is one way of dealing with the pain and the multi-modal approach for pain management is another technique that has been used for patients after a forty eight hour period post operation. The techniques are also different in the USA and other countries. The American society of regional anesthesia (ASRA) has approved these methods and through research has come up with the organizational plans that assist outpatients with postoperative pain management. Measures such as preoperative education, preoperative pain management and pharmacological and non-pharmacological modalities have been recommended. Evidence shows that multi-modal methods of dealing with postoperative pain have been used for most of the cases. This paper will explore the evidence of postoperative pain management after burn reconstruction surgery and include the comparison between the uses of local anesthetic to the use of multi-modal methods in dealing with postoperative pain. In adition, the paper will look at the use of these postoperative methods both in the USA and other countries and how these methods impact patient outcome. Keywords: Evidence-Based, Research, Nursing Research, Postoperative, Patient Response. Significance and background Burn reconstruction is a common experience for patients both in the USA and other countries in the world. Postoperative pain is expected after a burn reconstruction hence the incorporation of methods such as the use of local anesthesia and multi-modal techniques in dealing with pain is recommended. The interrogant is whether the use of local anesthetic is more effective than the multi-modal method in dealing with postoperative pain in adult patients recovering from

11. reconstructive surgery within a forthy eight hour time frame. A research done on the same was composed of members of the American Society of Pain (ASP) with the help from the American Society of Anesthesiologists (ASA). They assembled in a meeting where the members with expertise in anesthesia or pain medicine were put in a research panel (Fuzaylov & Kelly, 2015). The panel’s objective was to review the evidence presented to them and recommend on ways of managing postoperative pain. The target audience of the study were clinicians who managed chronic pain, acute surgical pain, dental pain, and even traumatic pain (Fuzaylov & Kelly, 2015). Over 858 studies were included in the research making it a very effective research. Therefore, post operative pain mangement has been reviewed by the nursing department over time making it easier to compare the different postoperative pain techniques and delivering a good report on the same. Purpose Postoperative pain can be a problem for burn victims especially the ones who have already been on the surgical table. Over the years, burns were observed as a deformation of the skin but today with technology advancement, it has become easier to reconstruct and reverse the burn process. The pain experienced after the surgical procedure can be managed in different ways. One way is through the subcutaneous infusion of local anesthetics. The infusion is done using a sacker that penetrates the skin to the lower layer and the drug is given at that juncture. Skin burns are accompanied by a burning sensation that can be very irritating to the victim. This method of anesthetic admission reduces that unpleasant burning feeling. Local anasthetics have been used in other countries to treat the burn reconstructed patient and it usually works differently depending on the age of the patient. For adolescents, the anaesthetic is administered in different dosage for those of 13- 18 years, adults 19-44 years and adults between 45-64 years to

12. both male and female (Poulsen, 2019). The anesthetic is administered in small amounts over the course of the healing and no use of multi-modal techniques is required. Most countries especially the developing ones do not have adequate clinical equipment to perform multi-modal methods of dealing with postoperative pain. In some countries, skin reconstruction procedures are not available to burn victims, thus, most people are forced to remain with healing scars. The lack of resources has been the down side of many countries without the necessary equipment (Poulsen, 2019). Victims are left with no choice but to receive local anesthesia and wait for the pruritic burns to resolve in time. In the United States, the methods for treating postoperative pain are different since the American Society of pain (ASP) establishes guidelines concerning this issue. Continuous use of the infusion of local anesthetics is done in order to provide analgesia following a skin harvest from the thigh which is used in the burn reconstruction process. The administration of local anesthesia is introduced depending on the patients consent. A multi-modal approach of dealing with postoperative pain is widely practiced in the USA since most clinicians are assigned to the task of reducing pain after surgery (Poulsen, 2019). Therapeutic exercise and constant skin stretches are recommended by the ASP in the postoperative period for pain control. Therefore, there is an obvious difference between the practices in the USA and other countries on how they handle burn victims. Study #1: Nursing research Study in the USA Research is the key to many issues affecting the nursing field and postoperative pain for burn victims is one area that can be used for research. The American Pain Society (APS) and the American Society of Anesthesiologists (ASA) have joined hands

13. and handle the research being done in the USA (Poulsen, 2019). Preoperative education and preoperative pain management planning has been one key recommendation of these societies. Clinicians are advised to brief the family and the patient on the surgical procedure to be performed and how the postoperative pain experience will be managed. Medication is administered to provide pain relief and to make sure it is reduced as much as possible. The method of checking is based on tracking patient’s response to postoperative pain treatment and change the treatment plan if the need arises (Poulsen, 2019). General principles regarding the use of multi-modal therapies is recommended and the clinicians are advised to use nonpharmacological interventions for the treatment of postoperative pain. Cognitive behavioral modalities are recommended by the societies in order to access the patient’s response to surgery and ascertain whether they are still in their right set of mind. The panel neither recommends nor stops the use of other therapeutic method to control pain such as acupuncture and massage therapy (Poulsen, 2019). The choice is left entirely to the clinician assigned the task of managing the patient’s postoperative pain. The use of systematic pharmacological therapies have also been recommended by the societies. The use of oral methods over the intravenous administration of opioids for patients after surgery are highly recommended to those who can receive the drugs orally. The intramuscular route should be avoided at all costs since patients are not very stable after surgery and the injection can become lethal to them, especially within burn victims. The use of gabapentin and pregabalin is recommended among multi- modal analgesia. For adults, intravenous ketamine should be used as a form of multi-modal analgesia but it is not a strict recommendation since research evidence was based on moderate quality evidence

14. (Poulsen, 2019). Therefore, in the USA, nursing research has been spearheaded by medical societies that have made it easier to be able to apply both the local anesthetic methods and the multi-modal technics in an effective manner. Medical societies have shaped down the nursing sector and all clinicians are subjected to a study session where they learn how to manage postoperative pain. In addition, specific clinicians in health centers are given the task of evaluating the outcomes. Study #2: Nursing Research Study Non-USA The nursing research modality in foreign countries is totally different from that of the USA. The differences are brought about by different government policies that are used to control the medical space. The policies in different countries enable the study to be carried out in a very fast and effective manner. While some other counties lack the necessary resources in order to make the research a success (Cooney, 2016). Time has shown that research needs to be taken seriously with the result being studied on a daily basis and ensuring that patients are the sole beneficiaries of the programs. For example, in a study of burned victims conducted in Ukraine, the results obtained were different since clinic resources were limited and patients were numerous. Therefore, clinicians had to administer small dosages of medicication to a total of 109 patients present and then observe the results. A group of 64 patients received the standard postoperative drug of metamizole 1g or ketorolac 3%-30mg by the nursing staff (Chou & Gordon, 2016). The other 45 patients received a different type of dosage and then the researchers had to wait and observe the patients. From the presented case, it is clear that the hospital in which the study was being performed had inadequate resources; Thus, researchers were forced to maintain spare supplies for future use to avoid depletion. Hence, there is a clear cut difference between researchers in international communities in countries

15. that have underfunded medical budgets, or in countries where there is scarcely any tools for research. Burn patients in such countries face many difficulties in utilizing what is available to them. Nevertheless, some countries do have the resources, for instance England, wich is part of the European nations, competing with the USA in terms of delivering research including nursing professionals. Life has never been easy for such counties since they have societies that keep pushing the delivery of better health care to its people. Organizational structure, policies and procedures have been laid down by societies on the placement of surgery platforms for safe and effective delivery of postoperative pain control (Chou & Gordon, 2016). For example, surgical rooms should be full of clinicians that have specialized in pain management. Facilities in which neuraxial analgesia and continuous peripheral blocks are conducted have procedures for safe delivery and trained individuals to manage those procedures. In England, clinicians consider the surgical local anesthetic based on topical pharmacological therapies due to their location and constant weather change in the region. Therefore, pain reduction after an operation also considers the weather at the time and prevent any medication that can endanger the patient. Therefore, the difference is there for cases in and out of the USA. Though the approach and goals are the same, the execution of duties change depending on the region. Countries that are able to compete with the USA have been reviewing their nursing profession and making sure their research is as good as any other. Hence, research in the nursing sector is beneficial to many postoperative cases and the morale for research should be encouraged. Conclusion Neither the local anesthetic analgesic techniques nor the multi-

16. modal techniques can be dismissed. Both techniques target the same issue from different approaches to relieve postoperative pain. Over the years, patients have required innovative methods of controlling pain. Pain manifests differently from person to person, and recovery is based on the person’s overall health, age, and comorbidities. For instance, a person who smokes chronicly, or has a long standing use of ilicit drugs may have more difficulty recovering after surgery as opposed to a person who has maintained a healthy life style and has no significant comorbidities. The comparison between the local anesthetic-based peripheral regional analgesic techniques, with the use of a multi-modal approach for pain management alone differs in countries depending on the resources available. For multi-modal approaches a country needs to provide the necessary resources in order for them to be applied. For local aesthetics to be used the process needs to be funded. The USA has shown to be better equipped with societies such as the APS managing the nursing sector and making sure that the required research is conducted properly. Changes that relate to these question of comparison include the research process. The research is sometime equipped with moderately researched evidence. At least, the conserved parties should try and have very strong recommended research as the only option when it comes with dealing with postoperative pain. Therefore, the research should be define and there should not be any second guessing on the final recommendations of the research. Another factor, would be to provide the guidelines of the practice to nurses or other clinicians and make sure they follow those steps for the safety of the patient. In addition, there should be a clear understanding of which multi-modal therapies to use and the medical societies should not be skeptical with use of therapies such as acupuncture.

17. Postoperative pain has been reported to persist for years in some patients. The nursing research team and any governmental policy that is aimed at helping research through funding, should prioritize this matter and establish evidence based guidelines, and create innovative methods to help patients who are experiencing postoperative surgical pain. A relief to the suffering of this patients should be provided, and the most accurate results come from research. Based on the presented review of studies, the use of local anesthetic-based peripheral regional analgesic techniques, and the use of multi-modal approaches should both be considered to provide fast and effective pain relief in recovering surgical patients. References Chou, R., Gordon, D. B. (2016). Management of Postoperative Pain: a clinical practice guideline from the American pain society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' committee on regional anesthesia, executive committee, and administrative council. The Journal of Pain. Cooney, M. F. (2016). Postoperative pain management: clinical practice guidelines. Journal of Perianesthesia Nursing. Fuzaylov, G., Kelly, T. L. (2015). Post-operative pain control for burn reconstructive surgery in a resource-restricted country with subcutaneous infusion of local anesthetics through a soaker catheter to the surgical site: Preliminary results. Burns. Poulsen, M. J. (2019). Music as a Postoperative Pain Management Intervention. Journal of PeriAnesthesia Nursing. Po fo Jac

18. Co a Un b Un c Un � P w International Journal of Nursing Studies 49 (2012) 65–71 A R Artic Rece Rece Acce Keyw Ana Guid Pain Post * Clin Med

19. Tel.: (Jac 002 doi: stoperative pain assessment based on numeric ratings is not the same r patients and professionals: A cross-sectional study queline F.M. van Dijk a,*, Albert J.M. van Wijck a, Teus H. Kappen a, Linda M. Peelen a,b, r J. Kalkman a, Marieke J. Schuurmans c iversity Medical Centre Utrecht, Department of Perioperative Care and Emergency Medicine, The Netherlands iversity Medical Centre Utrecht, Julius Centre for Health Sciences and Primary Care, The Netherlands iversity Medical Centre Utrecht, Department of Nursing Science, The Netherlands What is already known about the topic? ain assessment is the foundation of pain management hen a patient is experiencing postoperative pain. A frequent and thorough assessment of patients’ pain by registered nurses provides information to achieve optimal pain relief. � Clinical guidelines are developed for postoperative pain management based on the patient’s pain score. In these guidelines different cut-off points are used to treat the

20. pain. What this paper adds � Patients and professionals do interpret the numeric rating scores for postoperative pain differently. T I C L E I N F O le history: ived 27 December 2010 ived in revised form 7 July 2011 pted 16 July 2011 ords: lgesics eline measurement operative pain A B S T R A C T Background: Numeric pain scores have become important in clinical practice to assess postoperative pain and to help develop guidelines for treating pain. Professionals need the patients’ pain scores to administer analgesic medication.

21. However, do professionals interpret the pain scores in line with the actual perception of pain by the patients? Objective: The study aim was to assess which Numerical Rating Scale (NRS) pain score was considered bearable on a Verbal Rating Scale (VRS) by patients and professionals. Methods: This prospective study examined the relationship between the Numerical Rating Scale and a Verbal Rating Scale. The patients (n = 10,434) rated their pain the day after surgery on the 11-point NRS (0 = no pain and 10 = worst imaginable pain) and a VRS comprising five descriptors: ‘‘no pain’’; ‘‘little pain’’; ‘‘painful but bearable’’; ‘‘considerable pain’’; and ‘‘terrible pain’’. The first three categories together (‘‘no pain’’, ‘‘little pain’’ and ‘‘painful but bearable’’) were considered ‘‘bearable’’ and the last two categories (‘‘considerable pain’’ and ‘‘terrible pain’’) were deemed as ‘‘unbearable’’ pain. The professionals (n = 303) were asked to relate the numbers of the NRS to the words of the VRS. Results: Most patients considered NRS 4–6 as ‘‘bearable’’ pain.

22. Among professionals, anesthesiologists, Post Anaesthesia Care nurses, and ward nurses interpreted NRS scores in the same way as the patients. Only the Acute Pain Nurses interpreted the scores differently; they considered NRS of 5 and higher to be not bearable. Conclusions: Some care providers and patients differ in their interpretation of the postoperative NRS scores. A risk of overtreatment might arise when health care providers rigidly follow guidelines that prescribe strong analgesics for pain scores above 3 or 4 without probing the patient’s preference for pharmacological treatment. � 2011 Elsevier Ltd. All rights reserved. Corresponding author at: University Medical Centre Utrecht, Pain ic L02.502, Department of Perioperative Care and Emergency icine, P.O. Box 85500, 3508 GA Utrecht, The Netherlands. +31 88 75 56163; fax: +31 88 75 55511. E-mail address: [email protected] queline F.M. van Dijk).

23. Contents lists available at ScienceDirect International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns 0-7489/$ – see front matter � 2011 Elsevier Ltd. All rights reserved. 10.1016/j.ijnurstu.2011.07.009 http://dx.doi.org/10.1016/j.ijnurstu.2011.07.009 mailto:[email protected] http://www.sciencedirect.com/science/journal/00207489 http://dx.doi.org/10.1016/j.ijnurstu.2011.07.009 J.F.M. van Dijk et al. / International Journal of Nursing Studies 49 (2012) 65–7166 � The findings suggest a potential risk of overtreatment if the pain is assessed by the Numeric Rating Scale (NRS) only. 1. Introduction According to the American Pain Society guidelines (APS, 1995) for pain management, postoperative pain should be assessed regularly and documented carefully. The intensity of pain should be evaluated and recorded at intervals depending on the severity of pain and the clinical situation. Pain assessment and management is a significant part of nursing care and the pain is mostly assessed through verbal communication with the patient. The Numeric Rating Scale (NRS) is frequently used for this purpose: the patient is asked to score the pain on an 11 point scale, where 0 indicates no pain and 10 indicates the worst imaginable pain. The NRS is considered a valid and reliable

24. pain assessment tool (Breivik et al., 2000; DeLoach et al., 1998; Good et al., 2001). The patient’s NRS score is a leading indicator in the postoperative pain treatment. Many guidelines for pain management recommend prescription of analgesics on the basis of the patients’ NRS pain score (APS, 1995; Gordon et al., 2005; VMS, 2009). However, the NRS threshold for prescribing analgesics varies: some guidelines for acute and cancer pain chose an NRS cut-off >4 (APS, 1995; Gordon et al., 2005) while at least in one other, also for acute and cancer pain, an NRS cut-off >3 is the criterion for administering analgesics (VMS, 2009). Furthermore, in clinical practice not all patients with an NRS pain score above the treatment threshold are willing to accept the analgesic treatment offered mostly because they still consider the pain as ‘‘bearable’’. This suggests that professionals and patients might perceive the necessity for pain treatment differently. If so, health care providers who strictly follow current guidelines could be at risk of overtreating some patients. The aim of the study was to investigate how postoperative NRS pain scores of the patients relate to the presence of ‘‘bearable’’ versus ‘‘unbearable’’ pain. In a prospective study, the postoperative NRS pain scores were compared with the same patients’ adjectival descriptions of pain on a Verbal Rating Scale (VRS). The agreement between patients and professionals on the relationship between the NRS and VRS was then studied on the basis of comparisons between the two scales. We hypothesized that patients and professionals might differ in their interpretation of NRS scores. 2. Methods

25. 2.1. Study design We describe a cross-sectional study of a large sample of patients admitted for elective surgery. The current study was part of a large cluster-randomized study, implementing a prediction rule for improving the treatment of postoperative nausea and vomiting. In this study, 23,000 in- and out-patients participated. The study was approved by the institutional Ethics Committee of the University Medical Centre in Utrecht. It was not necessary to obtain informed consent from the patients because pain measurement is part of clinical care. Informed and voluntary consent of the health care professionals was assumed by return of a completed questionnaire. 2.2. Subjects Between March 16th, 2006 and December 21st, 2007, all adult patients scheduled for elective surgery at the University Medical Centre of Utrecht were recruited. The following patients were excluded: those who were trans- ferred directly to an intensive care unit; who needed postoperative ventilatory support; who had complications followed by a second operation; who did not understand the verbal questions of the research nurse; or who underwent ambulatory surgery. All patients received a written bro- chure preoperatively giving information about postoperative pain measurement and treatment, in accordance with the protocol of the hospital’s Acute Pain Service. Furthermore, we conducted a national survey in which 303 professionals participated: anesthesiologists, Acute Pain Nurses, nurses working on the Post Anaesthesia Care Unit (PACU), student PACU-nurses and ward nurses. The health professionals were a convenience sample. During

26. one week in May, 2008 the PACU nurses and nurses on the surgical wards of the UMC Utrecht were visited and invited to participate in the study. In addition, the nurses in training in the UMC Utrecht for PACU-nurse and working in different hospitals in the Netherlands were invited to participate. The anesthesiologists were randomly selected from a national anaesthesia congress. The Acute Pain Nurses, registered as members of the Dutch association for pain nurses in 2008, were approached by email. All health professionals were personally informed and invited to participate by the pain nurse who was not involved in patient care. 2.3. Data collection Trained research nurses who were not involved in the postoperative care asked the patients about their pain at rest on the day after surgery. The 11 point NRS was used, where 0 indicates no pain and 10 the worst pain imaginable. The VRS used in this study gives five expressions on a scale of increasing burden: ‘‘no pain’’ (VRS 0), ‘‘little pain’’ (VRS 1), ‘‘painful but bearable’’ (VRS 2), ‘‘considerable pain’’ (VRS 3) and ‘‘terrible pain’’ (VRS 4). The first three categories together (‘‘no pain’’, ‘‘little pain’’ and ‘painful but bearable’) were considered ‘bearable’ and the last two categories together (‘considerable pain’ and ‘terrible pain’) were deemed as ‘unbearable’ pain. Further- more, information concerning gender, age, surgical procedure and type of anaesthesia was gathered. The professionals were invited to relate the NRS to the VRS; they received a hand-delivered questionnaire with the five descriptions constituting the aforementioned VRS and were asked to relate the numbers 0–10 of the NRS to these words. The questionnaires were hand-collected when once completed. No demographic data from the health profes-

27. sionals were collected. 2.4. com exp foll tive Cor Spe for Wh Sen ‘un VRS we (RO NR val exa pat bet did ana ver con tha 3. R 3.1. in elig

28. und inc obt one ma sco unc Tab Dem Ag Ge Ty Ty ENT Valu J.F.M. van Dijk et al. / International Journal of Nursing Studies 49 (2012) 65–71 67 Statistical analyses Data were analyzed using descriptive statistics on plete cases. Results for continuous variables were ressed as mean (SD) or as median for variables owing normal and non-normal distributions, respec- ly. Categorical data were expressed as frequencies. relations between NRS and VRS were calculated by the arman rank correlation coefficient. Statistical testing

29. non-normally distributed variables used the Mann– itney test, and for categorical values the x2 test. sitivity and specificity of the NRS in detecting bearable’ pain were calculated using cut-off points �2 (bearable pain) and VRS >2 (unbearable pain) and re represented by a Receiver Operator Characteristic C) curve. To analyze the relationship between VRS and S scores, we used the modal score (the most frequent ue) of the numbers of the NRS per VRS category and mined whether this relationship differed between ients and professionals. To be able to detect differences ween males and females and different age groups we subgroup analyses for gender and age. Statistical lyses were performed using SPSS Statistical Software, sion 15.0 (SPSS Inc., Chicago, IL). The results were sidered statistically significant if the p-values were less n 0.05. esults Patients The demographic and perioperative data are presented Table 1. Data from 10,576 surgical inpatients were ible for the current study; the other 12,424 patients erwent ambulatory surgery or did not meet the lusion criteria. An NRS and VRS pain score pair was ained 24 h after surgery from 10,434 patients. Data on or both scales were incomplete for 142 patients, inly because they were too sick to determine the pain re; failed to understand; were confused; or were ooperative.

30. Fig. 1 shows the distribution of the NRS scores of actual pain at rest 24 h after the operation. The median NRS score was 2. Twenty-four percent of the patients scored an NRS >4; this is the threshold value for pain treatment according to various guidelines (APS, 1995; Gordon et al., 2005). In general, women reported higher pain scores than men (median 3 versus 2, respectively; p < 0.001). Older patients (aged 65 and older) reported lower pain scores than younger patients (median 2 versus 3; p < 0.001) (Table 2). Fig. 2 shows the distribution of the VRS scores of actual pain at rest 24 h after surgery. Both the median and the mode of the VRS scores were 1 (little pain). In total, 22.7% of the patients reported ‘no pain’ (VRS 0), 38.9% reported ‘little pain’ (VRS 1), 29.4% reported ‘painful but bearable’ (VRS 2), 8.3% reported ‘considerable pain’ (VRS 3) and 0.7% reported ‘terrible pain’ (VRS 4). Women consistently reported more severe pain scores than men (p < 0.001). Older patients reported less severe pain scores than younger patients (p < 0.001) (Table 3). 3.2. Professionals One hundred and forty anesthesiologists participated (response rate 100%), along with 50 Acute Pain Nurses (response rate 94%); 33 PACU nurses (response rate 100%); 16 nurses in training for PACU-nurse (response rate 100%); and 67 nurses on the ward (response rate 100%). le 1 ographic and perioperative data (n = 10,434 patients). e, mean � SD (range) 52 � 17 (18–98)

31. nder, n (%) Female 5348 (51) Male 5086 (49) pe of surgery, n (%) General 2097 (20) ENT/faciomaxillary 1988 (19) Orthopedic 1058 (10) Neurosurgery 974 (9) Urology 965 (9) Gynecologic 868 (8) Plastic surgery 838 (8) Vascular surgery 676 (6) Eye surgery 593 (6) Cardiothoracic 226 (2) Other 151 (1) pe of anaesthesia, n (%) General 9182 (88) Locoregional 1252 (12)

32. NRS 109876543210 Pe rc en t 20% 15% 10% 5% 0% Fig. 1. Pain scores on the Numeric Rating Scale 24 h after surgery in percentages. Table 2 Differences in NRS pain scores. Median pain score p-Value Gender (n) Male (5086) 2 <0.001a Female (5348) 3

33. Age (n) �65 years (7760) 2 <0.001a <65 years (2674) 3 : ear, nose and throat surgery. es are numbers (%). a Mann–Whitney test. J.F.M. van Dijk et al. / International Journal of Nursing Studies 49 (2012) 65–7168 3.3. The relation of the NRS to the VRS The VRS and NRS scores of the patients were significantly correlated (Spearman correlation coefficient r = 0.84, p < 0.001). Twenty-four percent of the postoperative patients reported an NRS pain score >4, while 9% reported ‘considerable’ or ‘terrible pain’ on the VRS. The patients associated NRS 0 with VRS ‘no pain’; NRS 1–3 with VRS ‘little pain’; NRS 4–5 with VRS ‘painful but bearable’; NRS 6–8 with VRS ‘considerable pain’; and NRS 9–10 with VRS ‘terrible pain’. As different guidelines show various NRS cut-off points to determine the need for treatment with analgesics, the sensitivity and specificity of the NRS scores and VRS ‘bearable’ and ‘unbearable’ were calculated for different NRS cut-off points. Fig. 3 shows an ROC curve depicting the sensitivity and 1 � specificity for these cut-off points. Using an NRS cut-off point of 4, 17% of the patients considered NRS >4 to be ‘bearable’ pain (1 � specificity) and 5% considered it as ‘unbearable’ pain (1 � sensitivity). So using an NRS cut-off value >4 for analgesic administration, 17% of the patients would be incorrectly classified

34. as having unbearable pain, possibly resulting in overtreatment, while 5% would be undertreated. With a cut-off point of NRS >3, 30% of the patients would be overtreated and 3% would be undertreated. Fig. 4 shows the distribution of the relationship between the NRS and VRS according to the patients and the professionals. The PACU and ward nurses interpreted the NRS and VRS scores in the same way: NRS 0 equated with VRS ‘no pain’; NRS 1-3 with VRS ‘little pain’; NRS 4–5 with VRS ‘painful but bearable’; NRS 6–8 with VRS ‘considerable pain’; and NRS 9–10 with VRS ‘terrible pain’. The anesthesiologists interpreted NRS 1 as ‘no pain’ but their other ratings were identical to those of the PACU and ward nurses. The Acute Pain Nurses interpreted the scores differently: NRS 1–2 ‘little pain’; 3–4 ‘painful but bearable’; 5–7 ‘considerable pain’; and 8–10 ‘terrible pain’. The distribution of the NRS scores over the VRS categories given by the Acute Pain Nurse was shifted to the left in comparison with those of the other professionals and patients, because they assigned lower NRS scores to the VRS categories. 4. Discussion The present study distinguishes ‘bearable’ from ‘unbearable’ postoperative pain and analyzes the relationship between NRS and VRS scores as assessed by postoperative patients and professionals. We found that most patients (65%) with NRS 4–6 considered their pain bearable. Among the professionals, the anesthesiologists, PACU and ward nurses interpreted the NRS scores in the same way as the patients. Only the Acute Pain Nurses interpreted the scores differently.

35. In previous studies, different descriptions of pain have frequently been used: no; mild; moderate; and severe pain. In a recent study on pain after orthopedic surgery, the patients related NRS 1–3 to mild; 4–5 to moderate; and 6– 10 to severe pain (Dihle et al., 2006). After coronary artery bypass grafting, NRS 1–3 was related to mild; 4–6 to moderate; and 7–10 to severe pain (Mendoza et al., 2004). These studies show that in postoperative pain the upper boundary for mild pain is NRS 3 and for moderate pain NRS 5 or 6. These results are comparable to the findings of the VRS terrible painconsiderable pain pain but bearable little painno pain Pe rc en t 40% 30% 20% 10% 0%

36. Fig. 2. Pain scores on the Verbal Rating Scale 24 h after surgery in percentages. 1 - Specificity 1,00,80,60,40,20,0 Se ns iti vi ty 1,0 0,8 0,6 0,4 0,2 0,0 NRS 4 NRS 5 NRS 6 NRS 3

37. NRS 2 NRS 7 Fig. 3. ROC curve of bearable pain (VRS �2) and unbearable pain (VRS >2) with the different NRS cut-off points for 10,434 patients. Table 3 Differences in VRS pain scores. Considerable and terrible pain p-Value Gender (n) Male (5086) 7.6% <0.001a Female (5348) 10.3% Age (n) �65 years (7760) 8.0% <0.001a <65 years (2674) 9.4% a Chi-square test. cur the dist pre pat gui Dol

38. sev (Jam 200 wh Fig. prof Care VRS J.F.M. van Dijk et al. / International Journal of Nursing Studies 49 (2012) 65–71 69 rent study. However, instead of moderate pain we used term ‘painful but bearable’. For severe pain we inguished ‘considerable’ and ‘terrible pain’. Several vious studies have demonstrated that postoperative ients suffer moderate to severe pain despite the use of delines (Apfelbaum et al., 2003; Chung and Lui, 2003; in et al., 2002) and that nurses often underestimate the erity of postoperative pain of the patients in their care ison et al., 1997; Taylor et al., 2003; Zelman et al., 3). It is, however, uncertain to what extent the patients o indicate ‘moderate’ pain really suffer. In the current study most patients with NRS 4–6 considered their pain as bearable. This relates with other studies where the patients were satisfied with their postoperative pain relief although they still had moderate pain (Apfelbaum et al., 2003; Jamison et al., 1997; Hawkins, 1997). It is possible that most patients experienced moderate but ‘bearable’ pain and that the nurses did not underestimate the patients’

39. pain. Most patients with NRS 4–6 considered their pain bearable. Possible reasons are that patients do not understand the NRS pain scores or refuse pain therapy because of side effects or fear for addiction (Wilder-Smith and Schuler, 1992). It is unknown why some patients bear acute pain to some degree and why others do not. Nurses should not only ask the patient about the pain score and follow the guidelines rigidly but also communicate with the patient about the pain and pain therapy (McDonald et al., 2000). The numerical pain ratings are only one dimension of the patient’s subjective experience of pain (Hanks, 2008) and adequate pain relief cannot be reliably achieved using opioid analgesics without a high risk of adverse effects (White and Kehlet, 2007). The results of the current study indicate that the patients and the professionals have a different view of the range of numerical ratings that indicate ‘bearable’ or ‘unbearable’ pain. In particular, Acute Pain Nurses tended to overestimate the severity of pain as perceived by the patient when interpreting NRS scores. Of all health care professionals, the nurses operate most closely to the patient in postoperative care and they can make independent medication decisions for pain relief. The results of this study suggest that the PACU and ward nurses were best informed about what the patients consider as ‘bearable’ pain. In contrast, the Acute Pain Nurses evaluated the pain scores differently from the patients; they more often overestimate the intensity of pain. In most hospitals the Acute Pain Nurse is the coordinator of the Acute Pain Service and responsible for the in-service education of health care professionals.

40. Although he/she often daily checks up on the patients with Patient Controlled Analgesia or epidural analgesia, the Acute Pain Nurse is not as close to the patient as the ward and PACU nurses are. Another possible explanation of the observed differences is that the Acute Pain Nurses are typically aware of the results of several former studies which have repeatedly demonstrated under- assessment and undertreatment of postoperative pain (Idvall et al., 2005; Sloman et al., 2005; Zalon, 1993). What does ‘moderate’ pain or an NRS 5 or 6 mean for the patient in order to decide on the need for opioid administration? In the present study, many patients who reported an NRS of 5 or 6 considered their condition to be ‘painful but bearable’. A patient who indicates that his/ her pain is ‘bearable’ might not necessarily want to receive additional analgesic medication, even though all guidelines suggest starting treatment on the basis of these NRS scores. Although we did not ask the patient if he/she would need treatment for his pain, and we did not measure the administered amount of analgesics, the data imply a potential risk of overtreatment when health care providers 4. The relations made of the NRS with the VRS by patients and essionals: Anesthesiologists, Acute Pain Nurses, Post Anaesthesia Unit nurses and ward nurses. Spearman correlation coefficient NRS– r = 0.84, p < 0.001. J.F.M. van Dijk et al. / International Journal of Nursing Studies

41. 49 (2012) 65–7170 follow the postoperative pain guidelines to the letter. Because a number of studies have demonstrated poor control of the postoperative pain (Apfelbaum et al., 2003; Chung and Lui, 2003; Dolin et al., 2002) the Joint Commission on Accreditation of Health Care Organizations defined new standards for pain management in their standards manual (Philips, 2000). In addition, the Amer- ican Pain Society and the Dutch VMS recently provided recommendations for improving the quality of acute and cancer pain management (Gordon et al., 2005; VMS, 2009). In these recommendations increasing emphasis is placed on reducing the patients’ pain scores, which entails increased analgesic usage. Decreasing the intensity of pain is a laudable objective and one of the pillars of health care. In postoperative pain management, both undertreatment and overtreatment are undesirable. Unrelieved pain has adverse psychological and physiological consequences e.g., more complications and prolonged hospital stay (Watt-Watson et al., 1999). On the other hand, improved pain control should not jeopardize patient safety (Taylor et al., 2003). Unnecessary use of analgesics, especially opioids, increases the patient’s discomfort because of the side effects, such as nausea, vomiting and pruritus. Unnecessary opioid administration also increases the probability of sedation and potentially dangerous respiratory depression (Cashman and Dolin, 2004; Taylor et al., 2005). An increase of opioid oversedation is reported after the implementation of the new standards of the Joint Commission (Vila et al., 2005). Therefore, to balance the risks of overtreatment and undertreatment in this range of numerical pain scores, the health care provider might simply add the following question: ‘‘would you like to have an analgesic?’’ In addition, the patients’ level of conscious- ness should be assessed when patients receive (additional) opioids.

42. 4.1. Limitations The present study is subject to a number of limitations. We measured the postoperative pain scores of the patient in rest. These pain scores can be different of the pain scores at movement. Nevertheless, the purpose of the study was to examine what numeric ratings were bearable to the patient. The health care professionals participated in this study were a convenience sample and no demographic data were collected. Regarding their level of experience, however, given the fact that all professionals working in the shift in which the data were collected participated, the sample was representative. Another potential source of error is the order in which the two pain scores were asked. All patients first indicated the severity of their pain on the VRS and then on the NRS. We chose this order because we anticipated that patients might try to ‘convert back’ to an adjective in the VRS once they had given an NRS score (which requires mental conversion from a subjective feeling to a number). Although in theory it can make a difference whether NRS or VRS is asked first, a recent study reported that error rates were not related to the order of presentation of the scales (Gagliese et al., 2005). The data we used for this study were part of a larger treatment of postoperative nausea and vomiting (PONV). We are aware of the relationship between PONV and pain. In the larger study, the anesthesiologists were more focused on PONV and possibly prescribed less analgesia. However, we assume that there was no interference from the PONV study, because we studied two scales for expressing the severity of pain, and not the severity of the pain itself. This assumption was verified by repeating our analyses with data from the control group of the PONV

43. study only; this yielded similar results. 5. Conclusions By combining data from a large sample of surgical patients with a national survey of health care workers, a lack of agreement is found between the patients and the Acute Pain Nurses on what constitutes ‘bearable’ pain in relation to the reported NRS scores. The Acute Pain Nurses tended to overestimate the severity of pain when the patients reported intermediate NRS scores, whereas most patients considered NRS 4–6 to be ‘bearable’ pain. These findings suggest a potential risk of overtreatment, if the pain is assessed by the NRS only and treatment decisions are based solely on a patient’s NRS response. Specifically asking a patient whether the pain is bearable and he/she would like to receive additional analgesics might circum- vent this problem. Conflict of interest. None of the authors has any potential conflicting interest in this study. Funding. This study is supported by ZonMW (Clinical Trial nr. NCT00293618), the Netherlands Organization for Health Research and Development. The study is supported by the Division of Perioperative Care and Emergency Medicine, University Medical Centre Utrecht, The Netherlands. Ethical approval. The study was approved by the institutional Ethics Committee of the University Medical Centre in

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49. pain by choice? The influence of patient attitudes and patient education. Pain 50, 257–262. Zalon, M.L., 1993. Nurses’ assessment of postoperative patients’ pain. Pain 54, 329–334. Zelman, D.C., Hoffman, D.L., Seifeldin, R., Dukes, E.M., 2003. Development of a metric for a day of manageable pain control: derivation of pain severity cut-points for low back pain and osteoarthritis. Pain 106, 35–42. Postoperative pain assessment based on numeric ratings is not the same for patients and professionals: A cross-sectional studyIntroductionMethodsStudy designSubjectsData collectionStatistical analysesResultsPatientsProfessionalsThe relation of the NRS to the VRSDiscussionLimitationsConclusionsReferences PAIN MANAGEMENT Postoperative Pain Management: Clinical Practice Guidelines Maureen F. Cooney, DNP, FNP-BC OVER THE PAST 2 decades, there has been an increased emphasis on the need for effective management of acute pain. The focus on pain management was sharpened when the Joint Commis- sion on Accreditation of Healthcare Organizations

50. integrated the requirement for pain assessment and management into their standards in 2000. 1 Acute postoperative pain, however, continues to be inadequately controlled. Among patients who have had surgical procedures, 80% experience postoperative pain and 75% or more of them report pain that is at a moderate, severe, or extreme level. 2 Inadequately treated acute pain is associated with the risk for the development of persistent postsurgical pain. 3,4 Poor pain control has significant physiological consequences that can ultimately result in impaired recovery, decreased function, and reduced quality of life. 2,5 In recent years, the number and types of pharma- cologic, interventional, and nonpharmacological

51. options to treat acute postoperative pain have expanded. Many professional organizations, including the American Society of PeriAnesthesia Nurses and American Society for Pain Management Nursing have published guidelines and other doc- uments related to the management of acute pain. The American Society of Anesthesiologists (ASA) published guidelines for perioperative pain management in 2012. 6 In 2016, the American Pain So- ciety (APS), with input from the ASA, and review and approval by the American Society of Regional Anesthesia and Pain Medicine, published guidelines for the management of postoperative pain. Maureen F. Cooney, DNP, FNP-BC, is a Nurse Practitioner, Pain Management, Westchester Medical Center, Valhalla, NY. Conflict of interest: None to report. Address correspondence to Maureen F. Cooney, Westchester Medical Center, Pain Management, Rm 2108 Macy Pavilion, 100 Woods Rd, Valhalla, NY 10595; e-mail address:

52. [email protected] � 2016 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2016.08.001 Journal of PeriAnesthesia Nursing, Vol 31, No 5 (October), 2016: pp 445-451 These guidelines are somewhat unique because, in addition to recommendations for pharmacological and nonpharmacological pain interventions, they include recommendations for preoperative education, perioperative pain management planning, organizational policies and procedures, and transition to outpatient care. 7 This article summa- rizes the development of the guidelines and highlights key recommendations with nursing practice implications for the care of patients with acute postsurgical pain. Methodology for Guideline Development AguidelinepanelwasselectedbytheAPS,withinput

53. from the ASA, and consisted of 23 multidisciplinary experts representing specialists from fields that included anesthesia, pain management, surgery, hospital medicine, nursing, obstetrics and gynecology, psychology, primary care, and physical therapy. The panel was charged with the tasks of reviewing the evidence related to postoperative pain management and formulating recommendations for evidence-based, effective, safer postsurgical pain management for adults and children. 7 The Oregon Evidence-Based Practice Center conducted an evidence review that included literature searches through December 2015. 7,8 Upon completion of the literature search, there were 107 systematic reviews and an additional 858 primary studies in the final evidence report. 8

54. The quality of randomized trials was assessed using criteria adapted by the Co- chrane Back Review Group. 7,8 Two reviewers from the Oregon Health Sciences Evidence center independently reviewed and ranked the strength (strong or weak) and quality of the evidence (high, moderate, or low) using methods adapted from the Grading of Recommendations Assessment, Development, and Evaluation Working Group and the Agency for Healthcare Research and Quality (AHRQ) Methods Guide for Effectiveness and Comparative Effectiveness Reviews. 7,8 A strong recommendation indicates the reviewers’ assessment that the potential benefits of following the recommendation clearly outweigh potential 445

55. Delta:1_given name mailto:[email protected] http://dx.doi.org/10.1016/j.jopan.2016.08.001 http://crossmark.crossref.org/dialog/?doi=10.1016/j.jopan.2016. 08.001&domain=pdf 446 MAUREEN F. COONEY harms and burdens. A weak recommendation indicates the reviewers’ assessment that benefits of following the recommendation outweigh the potential harms and burdens, but the benefits to harms or burdens balance is smaller or evidence is weaker. 7 The grade of the quality of evidence (high, moderate, low) reflects the confidence level ofthereviewersthattheevidencereflectsthetrueef- fect and the likelihood that further research would change the confidence in the estimate of effect. 8 The grading of evidence and recommendations is further detailed in the published guidelines. Following the evidence review, the guideline panel

56. drafted recommendations and engaged in a multi- stage Delphi process to rank and revise the series of the draft recommendation statements. 7 Unani- mous or near-unanimous consensus was achieved for all recommendations. 7 Subsequently, 20 external peer reviewers provided additional comments on the draft guidelines, which underwent an additional revision and panel approval process. 7 The finalized guidelines were approved by the APS Board of Direc- tors; the ASA’s Committee on Regional Anesthesia, Executive Committee, and Administrative Council; and the American Society of Regional Anesthesia Board of Directors in 2015 and published in early 2016. 7 Key Recommendations

57. Preoperative Education and Perioperative Pain Management Planning The panel recommends: 1. Clinicians should 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). 2. Parents (or other adult caregivers) of children who undergo surgery receive instruc- tion in developmentally appropriate methods for assessing pain and counseling on appropriate administration of analgesics and modalities (strong recommendation, low-quality evidence). 3. Clinicians conduct a preoperative evaluation

58. including assessment of medical and psychi- atric comorbidities, concomitant medications, history of chronic pain, substance abuse, and previous postoperative treatment regimes and responses, to guide the perioperative pain management plan (strong recommendation, low-quality evidence). 4. 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 The panel recommends: 5. 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 The panel recommends:

59. 6. 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 The panel recommends: 7. Clinicians consider transcutaneous electrical nerve stimulation (TENS) as an adjunct to other postoperative pain treatments (weak recommendation, moderate-quality evidence). The panel: 8. Neither recommends nor discourages acupuncture, massage, or cold therapy as ad- juncts to other postoperative pain treatments (insufficient evidence).

60. PAIN MANAGEMENT 447 Use of Cognitive Behavioral Modalities The panel recommends: 9. 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 The panel recommends: 10. Oral over intravenous (IV) administration of opioids for postoperative analgesia in patients who can use the oral route (strong recommendation, moderate-quality evidence). 11. Clinicians avoid using the intramuscular route for the administration of analgesics for management of postoperative pain (strong recommendation, moderate- quality evidence).

61. 12. IV patient-controlled analgesia (PCA) use for postoperative systemic analgesia when the parenteral route is needed (strong recommendation, moderate-quality evidence). 13. Against routine use of basal infusion of opioids with IV PCA in opioid-na€ıve adults (strong recommendation, moderate- quality evidence). 14. 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). 15. Clinicians provide adults and children with acetaminophen and/or nonsteroidal anti- inflammatory drugs (NSAIDs) as part of multimodal analgesia for management of

62. postoperative pain in patients without contraindications (strong recommendation, high-quality evidence). 16. Clinicians consider giving a preoperative dose of oral celecoxib in adult patients without contraindications (strong recommendation, moderate-quality evidence). 17. Clinicians consider use of gabapentin or pregabalin as a component of multi- modal analgesia (strong recommendation, moderate-quality evidence). 18. Clinicians consider IV ketamine as a component of multimodal analgesia in adults (weak recommendation, moderate- quality evidence). 19. Clinicians consider IV lidocaine infusions in adults who undergo open and laparoscopic abdominal surgery who do not have contraindications (weak recommendation, moderate-quality evidence).

63. Use of Local and/or Topical Pharmacological Therapies The panel recommends: 20. Clinicians consider surgical site-specific local anesthetic infiltration for surgical procedures with evidence indicating efficacy (weak recommendation, moderate-quality evidence). 21. Clinicians use topical local anesthetics in combination with nerve blocks before circumcision (strong recommendation, moderate-quality evidence). The panel does not recommend: 22. Intrapleural analgesia with local anesthetics for pain control after thoracic surgery (strong recommendation, moderate- quality evidence). Use of Peripheral Regional Anesthesia The panel recommends: 23. Clinicians consider surgical site-specific peripheral regional anesthetic techniques in

64. adults and children for procedures with evidence indicating efficacy (strong recommendation, high-quality evidence). 24. 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). 25. Clinicians consider the addition of clonidine as an adjuvant for prolongation of analgesia with a single-injection peripheral 448 MAUREEN F. COONEY neural blockade (weak recommendation, moderate-quality evidence). Use of Neuraxial Therapies The panel recommends: 26. Clinicians offer neuraxial analgesia for ma-

65. jor thoracic and abdominal procedures, particularly in patients at risk for cardiac complications, pulmonary complications, or prolonged ileus (strong recommendation, high-quality evidence). 27. Clinicians avoid the neuraxial administration of magnesium, benzodiazepines, neostigmine, tramadol, and ketamine in the treatment of postoperative pain (strong recommendation, moderate-quality evidence). 28. Clinicians provide appropriate monitoring of patients who have received neuraxial interventions for perioperative analgesia (strong recommendation, low-quality evidence). Organizational Structure, Policies, and Procedures The panel recommends: 29. Facilities in which surgery is performed

66. have an organizational structure in place to develop and refine policies and procedures for safe and effective delivery of postoperative pain control (strong recommendation, low-quality evidence). 30. Facilities in which surgery is performed provide clinicians with access to consulta- tion with a pain specialist for patients with inadequately controlled postoperative pain or at risk of inadequately controlled postoperative pain (eg, opioid tolerant, history of substance abuse) (strong recommendation, low-quality evidence). 31. 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

67. (strong recommendation, low-quality evidence). Transitioning to Outpatient Care The panel recommends: 32. Clinicians provide education to all patients (adults and children) and primary caregivers on the pain treatment plan including tapering of analgesics after hospital discharge (strong recommendation, low- quality evidence). Perianesthesia Nursing Recommendations Awareness of the content in the APS Guidelines in the Management of Postoperative Pain 7 is important for nurses working in perianesthesia settings. A complete review of the article, along with a focused examination of recommendations specific to their roles, will provide valuable information. Recommendations related to preoperative education, pain assessment, multimodal therapies, use

68. of physical and cognitive behavioral modalities, use of systemic, local, and/or topical pharmacological therapies, use of peripheral regional anesthesia and neuraxial therapies, and outpatient care transitions have particular applicability to the nurse in a direct care provider role. Some specific content applicable to the practice of the perianesthesia nurse is addressed in the following paragraphs. The guideline development panel members recommend preoperative education and perioperative pain management planning, and cite studies which show that educational programs individually designed for surgical patients with specific medical, developmental, psychological, or social needs have been found to reduce opioid consump- tion, preoperative anxiety, requests for sedating medications, and postoperative lengths of stay. 7

69. There is no strong evidence to support the use of one educational intervention over another or the timing and content of interventions. However, it is recommended that content includes specific information related to analgesic use before surgery (continuation, discontinuation, or changes) to avoid withdrawal syndrome (such as is possible with opioids, benzodiazepines, gabapentin, and baclofen), prevent surgical complications (eg, aspirin and hemorrhage), and improve postoperative pain control (eg, routine use of nonopioid PAIN MANAGEMENT 449 analgesics). 7 Preoperative education related to the use of pain assessment tools, realistic pain goals, and how and when to report pain is advised. It is important to address specific pain-related expecta- tions and misconceptions, and inform patients about the effects and possible adverse effects of

70. postoperative pain interventions. If patients will be using postoperative devices and modalities (eg, IV PCA), they/significant others should be in- structed in the use of the modalities preoperatively. The pain management plan should be developed preoperatively through shared decision-making with the patient/parent/significant other, based on an assessment of the individual patient’s history, condition, needs, and risks. The panel identifies the importance of an assessment of substance use and abuse (opioids, benzodiazepines, cocaine, alcohol and other substances that may affect pain management) to guide development of the postoperative pain management plan. The role of the perianesthesia nurse in assessing pain and patient responses to analgesic interventions is critical in assuring the re-evaluation and adjustment of the pain management plan. The panel emphasizes the importance of the use of

71. validated instruments to assess pain. 7 Patient self- report, not behaviors or vital signs, is the primary basis of pain assessment. Behaviors and the input from caregivers are used to assess pain when the patient cannot self-report. Pain should be assessed during rest and activity. There are no clear recommendations as to the optimal timing and frequency of assessment, but after analgesic administration, reassessment should occur by the time the medication reaches peak effect (15 to 30 minutes after parenteral analgesics and 1 to 2 hours after oral agents). 7 The use of multimodal analgesia, including pharmacological and nonpharmacological interventions, is recommended in the management of postoperative pain. It is noted that a number of different combinations of pharmacological and

72. nonpharmacological approaches are possible and may vary depending on the type of surgery, patient condition, and preferences. 7 Within the guidelines, there are some specific recommendations for the particular multimodal approach based on the type of surgical procedure. The use of TENS, inexpensive, small, portable devices that deliver a small low-voltage electrical impulse through electrodes on the skin has been shown to reduce pain through the descending inhibitory pain path- ways which activate opioid receptors. 7 The panel cites studies that have demonstrated reductions in postoperative analgesic requirements. In most cases, TENS electrodes were applied near the surgical incision. There is insufficient evidence to recommend the use of acupuncture. Other physical modalities such as acupressure, massage, cold therapy, immobilization, and bracing are

73. generally safe, but there is a lack of evidence to recommend their use. As components of a multi- modal plan, cognitive behavioral therapies such as hypnosis, guided imagery, music, and relaxation methods have shown some positive effects on postoperative pain, anxiety, or analgesic use, but few studies of these modalities have been conducted with children. 7 Multimodal pharmacological approaches are recommended. Oral opioids, when possible, are preferred over IV administration as there is no strong evidence to show that IV therapy provides superior relief of pain. 7 The use of short-acting opioids, administered around the clock in the immediate postoperative period, is recommended. 7 Except if used preoperatively, long-acting opioids should not be used for postoperative pain manage-

74. ment. Intramuscular injections should be avoided as they do not provide reliable effects and show no superiority over other routes. 7 The guidelines support the use of IV PCA, without the use of a basal infusion, when IV opioids are needed as IV PCA has been shown to provide greater effectiveness and patient satisfaction. 7 To reduce the risk of opioid-related adverse events, the panel recommends close monitoring of sedation level and respiratory status, especially in the hours immediately after surgery or with dose changes. 7 There is no clear recommendation for the use of pulse oximetry, capnography, or other monitoring methods due to a lack of evidence. 7 Identification of patients at increased risk for opioid-related

75. adverse events is advised, and interventions to minimize risks, including dose adjustments, are recommended. 7 Nonopioids are recommended as components of a multimodal analgesic plan. 7 The panel cites evidence that shows that acetaminophen and NSAIDs reduce pain and opioid requirements in postsurgical patients. NSAIDs are associated with risks, 450 MAUREEN F. COONEY including gastrointestinal bleeding, anastomotic leakage in colorectal surgery, and cardiovascular events and renal dysfunction, which must be considered and may contraindicate their use in some postsurgical patients. 7 NSAIDs and celecoxib are contraindicated for perioperative pain

76. management in patients undergoing coronary artery bypass grafting. 7 Perianesthesia nurses may be aware of the reluctance of some orthopaedic surgeons to use NSAIDs for their patients due to concerns of bone nonunion after certain surgical procedures, but the panel notes that there is insufficient evidence to recommend against the use of NSAIDs for orthopaedic fractures and spinal fusion and identifies the need for informed decision- making and consideration of alternatives by the surgeon and the patient. 7 Celecoxib, in doses of 200 to 400 mg administered 30 to 60 minutes preoperatively to adults is recommended for postsurgical pain and opioid requirement reducing benefits. 7 The panel cites evidence that doses of gabapentin (600 or 1,200 mg) or pregabalin (150

77. or 300 mg) administered 1 to 2 hours preoperatively to adults are effective components of a multi- modal plan, and postoperative dosing has shown effectiveness in some trials. 7 Additional multimodal pharmacological interventions that perianesthesia nurses may be less familiar with are also recommended in the guidelines. Although the panel is unable to identify suf- ficient evidence for optimal dosing of IV ketamine, it recommends a preoperative bolus of 0.5 mg/kg followed by an infusion of 10 mcg/kg/minute intra- operatively, and a lower dosage postoperative infusion as a multimodal analgesic component for adult surgical patients to reduce postoperative pain, analgesic use, and possibly the risk of persistent postsurgical pain. 7 Evidence is cited to support the use of IV lidocaine infusions in adults

78. undergoing open and laparoscopic abdominal surgeries as this intervention is associated with shorter duration of ileus and improved analgesia. 7 The panel recommends an initial bolus dose of 1.5 mg/kg followed by an infusion of 2 mg/kg/ hour during surgery; insufficient evidence is cited to recommend postoperative use. 7 Site-specific peripheral regional local anesthetic injections, and in some cases, continuous infusions are supported in the guidelines. Neuraxial (epidural or spinal) analgesia is recommended for the management of major thoracic, abdominal, ce- sarean section, hip, and lower extremity surgeries. 7 The neuraxial approach may reduce risks of postoperative mortality, venous thromboembo- lism, myocardial, infarction, pneumonia, respiratory depression, and may decrease duration of an ileus.

79. 7 The panel notes that epidural analgesia has the advantage over spinal analgesia as an epidural can be used as a continuous infusion with or without PCA and can be used to deliver local anesthetics. Epidural clonidine is sometimes used with local anesthetics to improve postoperative pain, but evidence is lacking and it may be associated with increased hypotension. 7 Perianes- thesia nurses need to be competent in the assessment of patients who have received peripheral regional anesthesia and neuraxial anesthetics/analgesics and must be aware of the signs, symptoms, and emergency management of any complications, including local anesthetic toxicity. Some orthopaedic surgeries are associated with an increased risk for compartment syndrome, and signs and symptoms may be diminished or masked with regional

80. and neuraxial techniques. When opioids are used in spinal or epidural analgesia, patients must be monitored for opioid-related adverse outcomes. In addition, patients who have received neuraxial analgesia are at risk for spinal cord compression. Perianesthesia nurses must be educated about these potential complications and prepared to implement appropriate emergency measures. Perianesthesia nurses have significant roles in assuring appropriate transitions of patient care. The panel recommends that all patients and/or caregivers receive a coordinated approach to discharge planning and discharge teaching from all involved disciplines (surgeons, nurses, thera- pists, pharmacists). It is necessary to provide in- structions in the safe and appropriate use of pain medications and side effect management. Discharge teaching should include warnings about the life-threatening risks of concomitant use of

81. alcohol and other central nervous system depres- sants when opioids are used. Teaching should also include an individualized plan for opioid weaning and discontinuation and safe storage and disposal of opioids and other medications. 7 Clear evidence to guide the method for postsurgical opioid weaning is not available, but the panel notes that severe postoperative pain usually diminishes rapidly in the first few days after surgery. For minor surgeries, PAIN MANAGEMENT 451 pain may be controlled with nonopioid analgesics or a very limited opioid supply after discharge. In patients with more involved surgeries, a longer course of postoperative analgesics, including opioids, may be needed. If used for more than 1 to 2 weeks, a gradual opioid reduction is suggested to prevent withdrawal, with dose reductions by 20% to 25% of the discharge dose every 1 to 2 days.

82. 7 Conclusion The above statements constitute key recommendations contained in the APS Postoperative Pain Guidelines. In addition, the guidelines include elaboration on each of the recommendations, a list of interventions for the management of postoperative pain in patients receiving long-term opioid therapy, a table of options for components of a multimodal analgesic surgery-specific approach, and a summary table of interventions for management of postoperative pain. Perianesthesia nurses may find it helpful to review the guidelines to inform various aspects of their clinical practice. It is important to note that clinical practice guidelines are general statements that do not dictate practice, but provide guidance for practice based on the evidence available at the time they are written. They do not apply to all patients, as individual

83. patients and clinical scenarios may not be appropriate for implementation of the recommendations, but require patient-specific approaches based on assessment and consideration of individual patient needs and resources. In examining each recommendation, it is important to note that despite a comprehensive review of the literature, only 4 of the 32 recommendations have a high- quality evidence rating. 7,8 High-quality evidence was only found to support the use of multimodal analgesia, including the use of acetaminophen and NSAIDs, site-specific peripheral regional anesthetic techniques, and neuraxial analgesia with opioids and local anesthetics for thoracic and abdominal procedures. 7,8 Although there are 28 other recommendations, they are rated with moderate- or low-quality evidence because the panel identified significant

84. research gaps in the evidence review. 7,8 However, despite the lack of high-quality evidence, these recommendations reflect the panel’s near-unanimous consensus on all the recommendations. 7 The task of developing evidence-based guidelines presents challenges; There are limitations in the ability to gather and synthesize all high-quality studies that are available related to an area as broad as postoperative pain, and even as available evidence is analyzed and recommendations are developed, additional studies are completed and newer evidence surfaces. 8 This further highlights the necessity of individualizing patient care and using informed clinical judgment over strict adherence to recommendations contained in the guidelines. It also demonstrates the significant need for additional research to address

85. the gaps in evidence related to the management of postoperative pain. References 1. Berry PH, Dahl JL. The new JCAHO pain standards: Impli- cations for pain management nurses. Pain Manag Nurs. 2000; 1:3-12. 2. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Inci- dence, patient satisfaction, and perceptions of post-surgical pain: Results from a US national survey. Curr Med Res Opin. 2014;30:149-160. 3. Clarke H, Bonin RP, Orser BA, Englesakis M, Wijeysundera DN, Katz J. The prevention of chronic postsurgical pain using gabapentin and pregabalin: A combined systematic review and meta-analysis. Anesth Analg. 2012;115:428- 442. 4. Page MG, Katz J, Romero Escobar EM, et al. Distinguishing problematic from nonproblematic postsurgical pain: A pain tra- jectory analysis after total knee arthroplasty. Pain. 2015;156: 460-468.

86. 5. Argoff CE. Recent management advances in acute postoperative pain. Pain Pract. 2014;14:477-487. 6. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists task force on acute pain management. Anesthesiology. 2012;116:248-273. 7. Chou R, Gordon DB, de Leon-Casasola OA, et al. Manage- ment of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of An- esthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17: 131-157. 8. Gordon DB, de Leon-Casasola OA, Wu CL, Sluka KA, Brennan TJ, Chou R. Research gaps in practice guidelines for acute postoperative pain management in adults: Findings from a review of the evidence for an American Pain Society clin-

87. ical practice guideline. J Pain. 2016;17:158-166. http://refhub.elsevier.com/S1089-9472(16)30282-9/sref1 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref1 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref1 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref2 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref2 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref2 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref2 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref3 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref3 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref3 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref3 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref4 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref4 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref4 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref4 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref5 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref5 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref6 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref6 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref6 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref6 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref6 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref7 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref7 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref7 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref7 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref7 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref7 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref7 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref8 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref8 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref8 http://refhub.elsevier.com/S1089-9472(16)30282-9/sref8

88. http://refhub.elsevier.com/S1089-9472(16)30282- 9/sref8Postoperative Pain Management: Clinical Practice GuidelinesMethodology for Guideline DevelopmentKey RecommendationsPreoperative Education and Perioperative Pain Management PlanningMethods of AssessmentGeneral Principles Regarding the Use of Multimodal TherapiesUse of Physical ModalitiesUse of Cognitive Behavioral ModalitiesUse of Systemic Pharmacological TherapiesUse of Local and/or Topical Pharmacological TherapiesUse of Peripheral Regional AnesthesiaUse of Neuraxial TherapiesOrganizational Structure, Policies, and ProceduresTransitioning to Outpatient CarePerianesthesia Nursing RecommendationsConclusionReferences Po fo Jac Co a Un b Un c Un � P w International Journal of Nursing Studies 49 (2012) 65–71 A R Artic Rece

89. Rece Acce Keyw Ana Guid Pain Post * Clin Med Tel.: (Jac 002 doi: stoperative pain assessment based on numeric ratings is not the same r patients and professionals: A cross-sectional study queline F.M. van Dijk a,*, Albert J.M. van Wijck a, Teus H. Kappen a, Linda M. Peelen a,b, r J. Kalkman a, Marieke J. Schuurmans c iversity Medical Centre Utrecht, Department of Perioperative

90. Care and Emergency Medicine, The Netherlands iversity Medical Centre Utrecht, Julius Centre for Health Sciences and Primary Care, The Netherlands iversity Medical Centre Utrecht, Department of Nursing Science, The Netherlands What is already known about the topic? ain assessment is the foundation of pain management hen a patient is experiencing postoperative pain. A frequent and thorough assessment of patients’ pain by registered nurses provides information to achieve optimal pain relief. � Clinical guidelines are developed for postoperative pain management based on the patient’s pain score. In these guidelines different cut-off points are used to treat the pain. What this paper adds � Patients and professionals do interpret the numeric rating scores for postoperative pain differently. T I C L E I N F O le history: ived 27 December 2010 ived in revised form 7 July 2011 pted 16 July 2011

91. ords: lgesics eline measurement operative pain A B S T R A C T Background: Numeric pain scores have become important in clinical practice to assess postoperative pain and to help develop guidelines for treating pain. Professionals need the patients’ pain scores to administer analgesic medication. However, do professionals interpret the pain scores in line with the actual perception of pain by the patients? Objective: The study aim was to assess which Numerical Rating Scale (NRS) pain score was considered bearable on a Verbal Rating Scale (VRS) by patients and professionals. Methods: This prospective study examined the relationship between the Numerical Rating Scale and a Verbal Rating Scale. The patients (n = 10,434) rated their pain the day after

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