Acute Pain

Effective pain management is fundamental to the quality of care and currently the majority of patients do not have good pain control after surgery. We believe that good control of pain also speeds recovery, but there is still no compelling evidence that this is so. Pain is a common reason for patients to seek healthcare and be admitted to hospitals. According to the National Center for Health Statistics, 46 million Americans undergo inpatient surgical procedures each year and experience acute surgical pain. In 2006, pain was a frequent “chief complaint” for adults who presented to emergency departments (EDs), and pain severity was reported as moderate to severe by 45% of patients in the ED.

Acute pain is “the normal, predicted physiologic response to an adverse chemical, thermal, or mechanical stimulus … associated with surgery, trauma, or acute illness.” Acute pain results from activation of the pain receptors (nociceptors) at the site of tissue damage. Acute pain is healthy pain due to nociceptive or inflammatory pathways (see mechanisms of inflammatory pain and Cells molecules and mechanisms). This type of pain generally accompanies surgery, traumatic injury, tissue damage, and inflammatory processes. Acute pain plays the vital role of providing a warning signal that something is wrong and in need of further examination. Acute pain is typically self-limited and resolves over days to weeks, but it can persist for 3 months or longer as healing occurs. Acute pain can activate the sympathetic branch of the autonomic nervous system and produce such responses as hypertension, tachycardia, diaphoresis, shallow respiration, restlessness, facial grimacing, guarding behavior, pallor, and pupil dilation. Although pain in response to tissue damage is a normal phenomenon, it may be associated with significant, unnecessary physical, psychological, and emotional distress. Inadequate relief of acute pain can contribute to hypercoagulability and impaired immunity, leading to such complications as venous thromboembolic disease and infections. Inadequately controlled acute pain can be a factor in the development of chronic pain, extended hospital stay, readmission, and patient dissatisfaction.

Such organizations as the American Society for Pain Management Nursing (ASPMN), the American Pain Society (APS), the American Society of Anesthesiologists (ASA), and the American Society of PeriAnesthesia Nurses (ASPAN) have attempted to improve the quality of pain management in the United States through formulation and publication of pain-related position statements and clinical practice guidelines. Accreditation agencies, such as the Joint Commission, have developed standards for the assessment and management of pain. Despite recognition of the widespread prevalence of pain and increased efforts to promote effective pain management, numerous studies document that pain remains inconsistently and inadequately addressed.

There has been attempts at introducing Pain as the 5th vital sign following: heart rate; blood pressure; respiratory rate; temperature. However application of measuring pain levels routinely has not led to improved pain control or prognosis. In a national telephone survey about postoperative pain, 59% of patients reported concern about experiencing postoperative pain and 80% of patients rated acute pain as moderate to severe in the first hours to days following surgery.

Poor pain management in surgical settings is known to be associated with slower recovery, greater morbidity, longer lengths of stay, lower patient satisfaction, and higher costs of care, suggesting that optimal pain care in these settings is of utmost importance in promoting acute illness management, recovery, and adaptation. VA/DoD Clinical Practice Guidelines have been developed for the management of acute post-operative pain, although the basis for many of the recommendations was by expert consensus rather than empirical evidence.

The prevalence of pain on the inpatient medical ward is lower than that of a surgical service, but is still substantial. In one hospital survey, 43% of medical ward patients experienced pain, and 12% reported unbearable pain. There are currently no pain-relevant performance measures in place that can support efforts to enhance pain care in these settings, and research on pain management in nonsurgical, nonmalignant acute pain is sparse.

Acute pain management will vary dependent upon several factors;

  • Patient demographics
  • Type of surgery
  • Site of pain
  • Patient health

It must be acknowledged that even seemingly innocuous over the counter (OTC) analgesics have risks and side effects. In 2010 in the US, 16,665 people died from opioid-related overdoses. That is a four-fold increase from 1999 when only 4,030 such deaths occurred. And the number of opioid prescriptions written has doubled from 109 million in 1998 to 219 million in 2011.)

This is a comprehensive plan for acute pain management.

Acute dental pain or post surgical pain (see also acute orofacial pain lecture, dental pain) is best managed by either removing the cause for pain (non-vital tooth pulp, poor prognosis tooth, foreign body) with appropriate post surgical pain management, for evidence see Paper evidence for analgesic PDF and Summary paper Hargreaves summit.

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