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KEY POINTS

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KEY POINTS

  1. Analgesia, as distinct from hypnosis, is a vital and integral component of anesthesia.

  2. Anesthesiologists must plan for the continuum of intra- and postoperative pain.

  3. The principles of “opioid sparing” or “multimodal analgesia” are central to the goal of early recovery after surgery.

  4. Patient-controlled analgesia (PCA) has greatly facilitated acute pain management at both provider and institutional levels.

  5. Epidural analgesia continues to play an important role in the treatment of pain after major intraabdominal and thoracic surgery, although the benefit versus risk should be reexamined in an era of potent thrombosis prophylaxis and multimodal analgesia.

  6. Regional nerve blocks and catheters remain important adjuncts for orthopedic and extremity surgeries.

  7. Chronic opioid use and tolerance remain challenges during acute pain treatment.

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INTRODUCTION

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THE ROLE OF THE ACUTE PAIN SERVICE

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The idea of the acute pain service arose during the 1980s when “walking” epidurals made epidural analgesia suddenly more feasible for postoperative patients and when the microchips made patient-controlled analgesia (PCA) pumps small enough to have wide applicability. Initially, pain services ran both these modalities, developed treatment protocols, and taught nurses and others how to manage these new therapies. Soon, surgeons and nurses became familiar with the use of PCA, so they, at least for routine cases, largely came to manage this component of postoperative management. Epidurals and continuous nerve blocks remain the province of anesthesiologists, and a key function of the acute pain service is to manage these postoperative catheters. The acute pain service is also available to help with complex cases, notably cases that cannot be managed using routine measures. Naturally, each institution will structure its pain service differently, according to institutional and local factors. Smaller hospitals and ambulatory facilities may not have a service as such.

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Acute pain services are usually staffed by a mixture of attending physicians (sometimes trained in pain control and commonly anesthesiologists), nurses, physician assistants, pain fellows, and anesthesia residents. The acute pain service rotation is a valuable component of residency training because this is likely the only point during training that anesthesia residents have the opportunity to follow patients postoperatively in continuity. The allocation of roles on the service will depend to a large extent on factors such as reimbursement, hospital policies, the relationship between anesthesia and surgery, and the expectations and support of both the hospital and the department of surgery. For example, funding for nursing on the service varies according to institution, and the provision of nonbillable services, such as daily follow-up of PCA, may be feasible only if nurses are available and funded. Unfortunately, as pain management becomes increasingly challenging because of rising numbers of opioid-tolerant patients, increasing complexities of surgery and hospital throughput expectations, reimbursement often fails to cover the realistic costs of ideal pain management.

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PAIN MANAGEMENT AND QUALITY ASSURANCE

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Pain management has become an important metric by which ...

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