Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints.Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data.This revision includes data published since the “Practice Guidelines for Acute Pain Management in the Perioperative Setting” were adopted by the American Society of Anesthesiologists (ASA) in 1994; it also includes data and recommendations for a wider range of management techniques than was previously addressed. The approaches to identification and retrieval of pertinent literature, as well as its synthesis, reflect the continuous evolution in the field of practice guideline development since 1994.For these Guidelines, acute pain in the perioperative setting is defined as pain that is present in a surgical patient because of preexisting disease, the surgical procedure (with associated drains, chest or nasogastric tubes, or complications), or a combination of disease-related and procedure-related sources.The purpose of these Guidelines is to (1) facilitate the safety and effectiveness of acute pain management in the perioperative setting; (2) reduce the risk of adverse outcomes; (3) maintain the patient’s functional abilities, as well as physical and psychological well-being; and (4) enhance the quality of life for patients with acute pain during the perioperative period. Adverse outcomes that may result from the undertreatment of perioperative pain include (but are not limited to) thromboembolic and pulmonary complications, additional time spent in an intensive care unit or hospital, hospital readmission for further pain management, needless suffering, impairment of health-related quality of life, and development of chronic pain. Adverse outcomes associated with the management of perioperative pain include (but are not limited to) respiratory depression, brain or other neurologic injury, sedation, circulatory depression, nausea, vomiting, pruritus, urinary retention, impairment of bowel function, and sleep disruption. Health-related quality of life includes (but is not limited to) physical, emotional, social, and spiritual well-being.These Guidelines focus on acute pain management in the perioperative setting for adult (including geriatric) and pediatric patients undergoing either inpatient or outpatient surgery. Modalities for perioperative pain management addressed in these Guidelines require a higher level of professional expertise and organizational structure than “as needed” intramuscular or intravenous injections of opioid analgesics. These Guidelines are not intended as an exhaustive compendium of specific techniques.Patients with severe or concurrent medical illness such as sickle cell crisis, pancreatitis, or acute pain related to cancer or cancer treatment may also benefit from aggressive pain control. Labor pain is another condition of interest to anesthesiologists. However, the complex interactions of concurrent medical therapies and physiologic alterations make it impractical to address pain management for these populations within the context of this document.While patients undergoing painful procedures may benefit from the appropriate use of anxiolytics and sedatives in combination with analgesics and local anesthetics when indicated, these Guidelines do not specifically address the use of anxiolysis or sedation during such procedures.These Guidelines are intended for use by anesthesiologists and individuals who deliver care under the supervision of anesthesiologists. The Guidelines may also serve as a resource for other physicians and healthcare professionals who manage perioperative pain. In addition, these Guidelines are intended for use by policymakers to promote effective and patient-centered care.Anesthesiologists bring an exceptional level of interest and expertise to the area of perioperative pain management. Anesthesiologists are uniquely qualified and positioned to provide leadership in integrating pain management within perioperative care. In this leadership role, anesthesiologists improve quality of care by developing and directing institution-wide, interdisciplinary perioperative analgesia programs.The ASA appointed a Task Force of nine members to (1) review the published evidence, (2) obtain the opinions of anesthesiologists selected by the Task Force as consultants, and (3) build consensus within the community of practitioners likely to be affected by the Guidelines. The Task Force included anesthesiologists in both private and academic practices from various geographic areas of the United States, and consulting methodologists from the ASA Committee on Practice Parameters.These Guidelines update the 1995 publication of Practice Guidelines for Acute Pain Management in the Perioperative Setting .*The Task Force revised the earlier Guidelines by reviewing and evaluating original published research studies retrieved from multiple sources. The draft document was made available for review on the ASA Web site, and input was invited via e-mail announcement to all ASA members. All submitted comments were considered by the Task Force in preparing the final draft.Preparation of these Guidelines followed a rigorous methodologic process (Appendix). To convey the findings in a concise fashion, these Guidelines employ several descriptive terms that are easier to understand than the technical terms used in the actual analyses.When sufficient numbers of studies are available for evaluation, the following terms describe the strength of the findings.Supportive: Meta-analyses of a sufficient number of adequately designed studies indicate a statistically significant relationship (P < 0.01) between a clinical intervention and a clinical outcome.Suggestive: Information from case reports and descriptive studies permits inference of a relationship between an intervention and an outcome. This type of qualitative information does not permit a statistical assessment of significance.Equivocal: Qualitative data are not adequate to permit inference of a relationship between an intervention and an outcome and (1) there is insufficient quantitative information, or (2) aggregated comparative studies have found no significant differences among groups or conditions.The lack of scientific evidence in the literature is described by the following terms.Silent: No identified studies address the relationship of interest.Insufficient: There are too few published studies to investigate a relationship between an intervention and an outcome.Inadequate: The available studies cannot be used to assess the relationship between an intervention and an outcome. These studies either do not meet the criteria for content as defined in the “Focus” of these Guidelines, or they do not permit a clear causal interpretation of findings because of methodologic concerns.Institutional policies and procedures include (but are not limited to) (1) education and training for healthcare providers, (2) monitoring of patient outcomes, (3) documentation of monitoring activities, (4) monitoring of outcomes at an institutional level, (5) 24-h availability of anesthesiologists providing perioperative pain management, and (6) use of a dedicated Acute Pain Service. The literature suggests that education and training for health-care providers is associated with decreased pain intensity. The published evidence is insufficient to evaluate the effects of monitoring, documentation at either the individual patient level or institutional level, and the efficacy of the 24-h availability of anesthesiologists. Although randomized comparative literature was not found, pre–post studies support the efficacy of an Acute Pain Service for reducing pain and suggest that adverse effects are also decreased.The Task Force agrees that education, training, and experience contribute to improved quality of care. The Task Force views patient and family education in planning for and participating in preoperative pain control as important to the patient’s comfort and well-being. The Task Force supports 24-h availability of anesthesiologists for perioperative pain management to provide this comfort and safety. The Task Force recognizes that “analgesic gaps” are common during the transition from epidural or patient-controlled analgesia (PCA) to oral analgesic therapy, and believes that the quality improvement activities of a dedicated Acute Pain Service may reduce such gaps and enhance patient comfort. The Task Force supports the implementation of institutional policies and procedures as a logical part of interdisciplinary perioperative pain management, and recognizes their importance for institutional accreditation. Other professionals that play an important role in perioperative pain management include surgeons, nurses, pharmacists, and physical therapists.Anesthesiologists offering perioperative analgesia services should provide, in collaboration with other healthcare professionals as appropriate, ongoing education and training to ensure that hospital personnel are knowledgeable and skilled with regard to the effective and safe use of the available treatment options within the institution. Educational content should range from basic bedside pain assessment to sophisticated pain management techniques (e.g. , epidural analgesia, patient controlled analgesia, and various regional anesthesia techniques) and nonpharmacologic techniques (e.g. , relaxation, imagery, hypnotic methods). For optimal pain management, ongoing education and training are essential for new personnel, to maintain skills, and whenever therapeutic approaches are modified.Anesthesiologists and other healthcare providers should use standardized, validated instruments to facilitate the regular evaluation and documentation of pain intensity, the effects of pain therapy, and side effects caused by the therapy.Analgesic techniques involve risk for adverse effects that may require prompt medical evaluation. Anesthesiologists responsible for perioperative analgesia should be available at all times to consult with ward nurses, surgeons, or other involved physicians, and should assist in evaluating patients who are experiencing problems with any aspect of perioperative pain relief.Anesthesiologists providing perioperative analgesia services should do so within the framework of an Acute Pain Service, and participate in developing standardized institutional policies and procedures. An integrated approach to perioperative pain management that minimizes analgesic gaps includes ordering, administering, and transitioning therapies, and transferring responsibility for perioperative pain therapy, as well as outcomes assessment and continuous quality improvement.Preoperative patient evaluation and planning is integral to perioperative pain management. Proactive individualized planning is an anticipatory strategy for postoperative analgesia that integrates pain management into the perioperative care of patients. Patient factors to consider in formulating a plan include type of surgery, expected severity of postoperative pain, underlying medical conditions (e.g. , presence of respiratory or cardiac disease, allergies), the risk-benefit ratio for the available techniques, and a patient’s preferences or previous experience with pain. Although the literature is silent regarding the value of a preoperative directed pain history, a directed physical examination, or consultations with other healthcare providers, the Task Force points out the obvious value of these activities.A directed pain history, a directed physical examination, and a pain control plan should be included in the anesthetic preoperative evaluation.Preoperative patient preparation includes (1) adjustment or continuation of medications whose sudden cessation may provoke a withdrawal syndrome, (2) treatment(s) to reduce preexisting pain and anxiety, (3) premedication(s) prior to surgery as part of a multimodal analgesic pain management program, and (4) patient and family education (including behavioral pain control techniques).There is insufficient literature to evaluate the impact of preoperative adjustment or continuation of medications whose sudden cessation may provoke an abstinence syndrome. Similarly, there is insufficient literature to evaluate the efficacy of the preoperative initiation of treatment(s) either to reduce preexisting pain, or as part of a multimodal analgesic pain management program. The literature supports patient education for reducing anxiety and decreasing time to discharge. The literature is equivocal regarding the impact of patient education on the direct reduction of patients’ pain, but indicates that lower total dosages of analgesics are used by patients receiving preoperative education.The Task Force supports patient and family education and participation in perioperative pain control for promoting patient comfort and well-being.Patient preparation for perioperative pain management should include appropriate adjustments or continuation of medications to avert an abstinence syndrome, treatment of preexistent pain, or preoperative initiation of therapy for postoperative pain management.Anesthesiologists offering perioperative analgesia services should provide, in collaboration with others as appropriate, patient and family education regarding their important roles in achieving comfort, reporting pain, and in proper use of the recommended analgesic methods. Common misconceptions that overestimate the risk of adverse effects and addiction should be dispelled. Patient education for optimal use of PCA and other sophisticated methods, such as patient-controlled epidural analgesia (PCEA), might include discussion of these analgesic methods at the time of the preanesthetic evaluation, brochures, and videotapes to educate patients about therapeutic options, and discussion at the bedside during postoperative visits. Such education may also include instruction in behavioral modalities for control of pain and anxiety.The literature supports the efficacy and safety of three techniques used by anesthesiologists for perioperative pain control: (1) epidural or intrathecal opioid analgesia; (2) PCA with systemic opioids; and (3) regional analgesic techniques, including but not limited to intercostal blocks, plexus blocks, and local anesthetic infiltration of incisions. The literature indicates that adverse effects are no more frequent with these three analgesic techniques than with other less effective techniques. The Task Force supports the use of epidural, PCA, and regional techniques by anesthesiologists when appropriate and feasible.The literature supports the efficacy of epidural morphine and fentanyl for perioperative analgesia but is insufficient to characterize the spectrum of risks and benefits associated with the use of other specific opioids (e.g. , hydromorphone, sufentanil) given by these routes. Pruritus and urinary retention occur more frequently when morphine is given by these routes when compared to systemic administration. Epidural morphine provides more effective pain relief than intramuscular morphine. Similarly, epidural fentanyl provides more effective postoperative analgesia than intravenous fentanyl. The literature is insufficient to evaluate the effect of epidural techniques administered at different times (e.g. , preincisional, postincisional or postoperative).When compared with intramuscular techniques, the literature supports the efficacy of PCA for postoperative pain management. The literature is equivocal regarding the efficacy of PCA techniques when compared to nurse or staff-administered intravenous analgesia. In addition, the literature is equivocal regarding the comparative efficacy of patient-controlled epidural analgesia (PCEA) and intravenous PCA techniques. When background opioid infusions are included with PCA techniques, patients report better analgesia and higher morphine consumption without increased incidence of nausea, vomiting, pruritus or sedation. Although higher morphine consumption during PCA with continuous background infusion might predispose patients to respiratory depression, the literature is insufficient to reveal this adverse effect.The literature supports the analgesic efficacy of peripheral nerve blocks (e.g. , intercostal, ilioinguinal, penile, interpleural or plexus). The literature also supports postincisional infiltration with local anesthetics for postoperative analgesia. However, the literature is equivocal regarding the analgesic benefits of preincisional infiltration. The literature suggests that intraatricular analgesia with opioids, local anesthetics or combinations of the two provides analgesic benefit.Anesthesiologists who manage perioperative pain should therapeutic options such as epidural or intrathecal opioids, systemic opioid PCA, and regional techniques, the risks and benefits for the individual These modalities should be used in to intramuscular opioids “as The therapy selected should reflect the individual as well as the for safe application of the in practice This includes the to and adverse effects that initiation of should be when continuous infusion modalities are as may contribute to adverse literature supports the of two analgesic that by different via a for providing analgesic efficacy with or adverse include epidural opioids administered in combination with epidural local anesthetics or and intravenous opioids in combination with or adverse effects with of a occur it is given or in combination with other medications (e.g. , opioids may nausea, vomiting, pruritus or urinary retention, and local anesthetics may The literature is insufficient to evaluate the postoperative analgesic effects of oral opioids with (e.g. , (e.g. , or when compared with oral opioids The Task Force believes that or a effect for administered literature suggests that two routes of when compared with a may be more effective in providing perioperative analgesia. include (1) epidural or intrathecal opioid analgesia with or analgesics epidural opioids or (2) intravenous opioids with oral or intravenous The literature is insufficient to evaluate the efficacy of pain management with or pain management when compared to pain management anesthesiologists should employ multimodal pain management all patients should an of or In addition, regional with local anesthetics should be should be administered to efficacy the risk of adverse The of and of therapy should be patient groups are at risk for pain and require additional analgesic Patient populations at risk include (1) pediatric (2) and (3) or or other patients who may have The Task Force believes that and the pain experience and to analgesic In addition, the Task Force believes that patient and access to treatment as well as pain assessment by healthcare Task Force believes that optimal care for and (including to the of pain. This specific patient differences in their experience and of pain and suffering, and their to analgesic in both the and hospital may have regarding the importance of analgesia as well as its risks and In the of a clear of pain or obvious pain may that pain is not and methods for providing analgesia are in pediatric patients for of respiratory of pain is in and of and may as as the surgical of injections intramuscular or other routes of the of analgesia prior to injections may not this literature suggests that a of techniques are effective in providing analgesia in pediatric patients. are the as for (e.g. , are more used in The Task Force believes that it is important for to that pediatric patients require to ensure optimal perioperative and pain management is to the undertreatment of pain in Perioperative care for undergoing painful procedures or surgery appropriate pain assessment and therapy should on and and should involve a multimodal techniques, important in the of pain, should be whenever and local anesthetics are all important of appropriate analgesic for painful procedures. analgesic medications are with it is that appropriate monitoring be during the procedure and patients may from conditions such as or cancer that more likely to surgery. The Task Force believes that pain is and individuals may be more to the effects of such The physical, social, emotional, and associated with have an impact on perioperative pain management. These patients may have different than adult patients in pain and appropriate the analgesic and local anesthetics are and and frequently literature suggests that techniques effective in also benefit patients without an in adverse The literature also suggests that perioperative analgesics are in lower dosages to than to The Task Force believes the for lower perioperative analgesic in the are undertreatment of pain in is assessment and therapy should be integrated into the perioperative care of patients. Pain assessment appropriate to a patient’s should be and evaluation and may be to that regarding pain. Anesthesiologists should that patients might than patients to pain and analgesic because of is to ensure adequate treatment adverse effects such as in this who are other medications (including and who are (e.g. , or who have (e.g. , or present to perioperative pain management. The Task Force believes that techniques that reduce dosages to provide effective analgesia (e.g. , regional analgesia and multimodal may be for such patients. modalities and techniques such as PCA that on of analgesics are less for the The literature is insufficient to evaluate the application of pain assessment methods or pain management techniques specific to these should that patients who are or have may require additional to ensure optimal perioperative pain management. Anesthesiologists should consider a therapeutic of an analgesic in patients with and or when other than pain have scientific assessment of these Guidelines was on evidence or regarding between clinical and The below were to assess their relationship to a of outcomes related to the management of acute pain in the perioperative evidence was from aggregated research literature, and from open and other activities (e.g. , For of literature clinical studies were identified via and of the The a from The a from than were a total of that addressed related to the evidence review of the studies not provide direct evidence, and were total of direct result for was by a literature outcome as either a a or The were to obtain a assessment for prior to to evidence studies with and statistical information sufficient for These were (1) acute pain (2) patient and family education, (3) epidural or intrathecal opioids, (4) intravenous PCA or continuous (5) intravenous PCA (6) epidural PCA intravenous PCA, intravenous PCA with background infusion of opioids no background intercostal or interpleural blocks, plexus and other blocks, infiltration of epidural opioids with local anesthetics epidural opioids, epidural opioids with local anesthetics epidural local epidural opioids with epidural opioids, intravenous opioids with intravenous opioids, and intravenous opioids with intravenous or were for continuous outcome and were for outcome were as (1) The on of the from the and (2) the providing of the studies by of the by the of the An procedure on the for was used with outcome An level was at < for of the studies were to among the were considered when significant was To control for a value was No for studies was and no for research were are in To be considered findings of with when both of data are In the of both the and with other to be considered findings of among Task Force members and two methodologists was by a for were as (1) type of to (2) type of to (3) evidence to and (4) literature for to (1) (2) type of (3) (4) literature These of findings of the literature were by the opinions of Task Force members opinions from a of including and comments from of the draft document on the ASA Web In addition, opinions from open forum and other used in the original Guidelines were and