Chapter 72: Organization of an Acute Pain Management Service Incorporating Regional Anesthesia Techniques

INTRODUCTION

Acute pain management is constantly evolving, especially 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 led 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 that were ordered “as needed.”

To provide more consistent analgesia, intravenous patient-controlled analgesia (IV-PCA) was introduced in the 1980s, leading to the development of specialized pain management teams, most often under the direction of anesthesiologists. The additional advancement intrathecal opioids and epidural analgesia for postoperative pain management heralded the first pain service in the United States.¹ In Europe, Narinder Rawal promoted 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

In recent years, regional anesthesia has gained popularity because if its contribution to postoperative pain management. Single-injection and continuous peripheral neural blockade are increasingly practiced in both the inpatient and outpatient settings. This provides another key component of multimodal therapy, in which pain is targeted with a variety of techniques and medication classes.⁴ However, effective application of these techniques requires adequate expertise, surveillance, and organization.

A dedicated acute pain management team is the pivotal component in managing these procedures and techniques to optimize pain control. The primary goals of the team are to offer a wide variety of services, provide a high level of patient surveillance, and integrate these services into the overall hospital setting. Optimal analgesia requires judicious dose adjustments to maximize the benefits and minimize the side effects of therapy. This can only occur if the patient is adequately monitored.

The American Society of Anesthesiologists (ASA) Task Force first established practice guidelines for acute pain management in 1995.⁵ The most recent revision was in 2012; please refer to this document for details.⁶ The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established standards (Table 72–1) for pain management in January 2001 that are still practiced today.⁷ These standards provided an impetus for hospitals to have an institutionwide 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 2012 highlighted the importance of multidisciplinary collaboration among anesthesiologists, surgeons, nurses, pharmacists, and other members of the healthcare team.