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The field of acute pain management has changed substantially in recent years. In the past, acute pain management consisted primarily of opioids given intermittently by intramuscular injection. In addition to pain on injection, this lead to undesirable “analgesic gaps” or periods of inadequate pain control between peak and trough opioid levels. Consequently, patients were often reluctant to request pain medications ordered “as needed.”


To provide more continuous analgesia, intravenous patient controlled analgesia (IVPCA) was introduced in the 1980s, leading to the development of specialized pain management teams, most often under the direction of anesthesiologists. The application of intrathecal opioids and epidural analgesia for postoperative pain management heralded the first pain service in the United States.1 In Europe, Narinder Rawal presented his experience introducing the role of nurses as valued members of the acute pain management team.2 By the early 1990s, 40% of US hospitals had acute pain services.3


The American Society of Anesthesiologists (ASA) Task Force first established practice guidelines for acute pain management in 1995.4 These guidelines were revised in 2004, and the reader is encouraged to review this document.5 The Joint Commission of Accreditation of Healthcare Organizations (JCAHO) established standards (Table 79–1) for pain management in January 2001.6 These standards provided an impetus for hospitals to have an institution-wide commitment for policies and procedures to support effective pain management. This effort promoted the concept of pain as the “fifth vital sign” and established the patient's right to pain management. It also became evident that an effective pain management program can only be achieved with a strong institutional commitment. The revised ASA guidelines of 2004 highlighted the importance of multidisciplinary collaboration among anesthesiologists, surgeons, nurses, pharmacists, and other members of the healthcare team.

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Table 79-1. Key Points from the JCAHO Pain Management Standards 

Early advances on this topic focused on safe application of aggressive techniques utilizing protocols and standing orders with the monitoring available on the ward. However, it is the PCA services that paved the way for the development of true acute pain management services providing on-demand systemic as well as epidural and intrathecal analgesia. The US model focused on physician management; the European model put a greater emphasis on the nursing role.


In recent years, regional anesthesia has gained popularity because if its contribution to postoperative ...

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