++
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.
++
++
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 pain ...