Running head POSTOPERATIVE PAIN .docx

Running head: POSTOPERATIVE PAIN
1
POSTOPERATIVE PAIN
3
Postoperative Pain after Reconstructive Surgery
Carla S. Garcia
Nicole Wertheim College of Nursing and Health Sciences
Author Note
Carla S. Garcia, Nicole Wertheim College of Nursing and
Health Sciences, Florida International University
Correspondence concerning this article should be addressed
to Carla Garcia, Nicole Wertheim College of Nursing and
Health Sciences, Florida International University, Miami, FL
33199. Contact: [email protected]
Abstract
Postoperative pain is common for most patients who have
undergone reconstructive surgery after a burn. The American
Society of Pain (ASP) has devised methods of dealing with
postoperative pain since most patients report the incident and
only half of them were reported to have recovered from it. The
use of local anesthetic-based peripheral regional analgesic
technique is an efficient way of reducing postoperative pain, as
well as the multi-modal approach for pain management, which
has been used for patients after a forty-eight-hour post operative
period. The American Society of Regional Anesthesia (ASRA)
has approved these methods, and through research, has prepared
organizational plans that assist surgical and outpatients with

postoperative pain management. Measures such as preoperative
education, preoperative pain management and pharmacological
and non-pharmacological modalities have been recommended.
Evidence shows that multi-modal methods of dealing with
postoperative pain have been used for most of the cases. This
paper will explore the evidence of postoperative pain
management after burn reconstruction surgery and include the
comparison between the uses of local anesthetic to the use of
multi-modal methods in dealing with postoperative pain. In
adition, the paper will look at the use of these postoperative
methods both in the United States of America (USA) and other
countries, and how these methods impact patient outcome.
Keywords: Evidence-Based, Research, Nursing Research,
Postoperative, Patient Response.
Significance and Background
Burn reconstruction is a common experience for patients both in
the USA and other countries in the world. Postoperative pain is
expected after a burn reconstruction, hence the incorporation of
methods such as the use of local anesthesia and multi-modal
techniques in dealing with pain are recommended. The inquiry
is whether the use of local anesthetics is more effective than the
multi-modal method in dealing with postoperative pain in adult
patients recovering from reconstructive surgery within a forthy-
eight-hour time frame.
During a study composed of members of the ASP with help from
the American Society of Anesthesiologists (ASA), they
assembled in a meeting where members with expertise in
anesthesia or pain medicine were put in a research panel
(Fuzaylov & Kelly, 2015). The panel’s objective was to review
the evidence presented to them and recommend on ways of
managing postoperative pain. The target audience of the study
were clinicians who managed chronic pain, acute surgical pain,
dental pain, and traumatic pain. Over 858 studies were included

in the research making it a very effective research (Fuzaylov &
Kelly, 2015).
Purpose
The pain experienced after the surgical procedure can be
managed in different ways. One way is through the
subcutaneous infusion of local anesthetics. Skin burns are
accompanied by a burning sensation that can be very irritating
to the victim. This method of subcutaneous infusion of local
anesthetic admission reduces that unpleasant burning feeling.
For adolescents, the anaesthetic is administered in different
dosage for those of 13-18 years, adults 19-44 years and adults
between 45-64 years to both male and female (Poulsen, 2019).
The anesthetic is administered in small amounts over the course
of healing and the use of multi-modal techniques is not
required.
Most countries especially the developing ones do not have
adequate clinical equipment to perform multi-modal methods of
dealing with postoperative pain. In some countries, skin
reconstruction procedures are not available to burn victims,
thus, most people are forced to remain with healing scars. The
lack of resources has been the down side of many countries
without the necessary equipment (Poulsen, 2019). Victims are
left with no choice but to receive local anesthesia and wait for
the pruritic burns to resolve in time.
The administration of local anesthesia is introduced depending
on the patients consent. A multi-modal approach of dealing with
postoperative pain is widely practiced in the USA since most
clinicians are assigned to the task of reducing pain after surgery
(Poulsen, 2019). Therapeutic exercise and constant skin
stretches are recommended by the ASP in the postoperative
period for pain control.
Study #1: Nursing Research Study in the USA

The APS and the ASA have joined hands to handle the research
being done in the USA (Poulsen, 2019). Preoperative education
and preoperative pain management planning has been one key
recommendation of these societies. Clinicians are advised to
brief the family and the patient on the surgical procedure to be
performed and how the postoperative pain experience will be
managed. The method of checking is based on tracking patient’s
response to postoperative pain treatment and change the
treatment plan if the need arises (Poulsen, 2019). Cognitive
behavioral modalities are recommended by the societies in order
to access the patient’s response to surgery and ascertain whether
they are still in their right set of mind. The panel neither
recommends nor stops the use of other therapeutic method to
control pain such as acupuncture and massage therapy (Poulsen,
2019). The choice is left entirely to the clinician assigned the
task of managing the patient’s postoperative pain.
The use of systematic pharmacological therapies have also been
recommended by the societies. The use of oral methods over the
intravenous administration of opioids for patients after surgery
are highly recommended to those who can receive the drugs
orally (Chou & Gordon, 2016). The intramuscular route should
be avoided at all costs since patients are not very stable after
surgery and the injection can become lethal to them, especially
within burn victims. The use of gabapentin and pregabalin is
recommended among multi-modal analgesia.
For adults, intravenous ketamine should be used as a form of
multi-modal analgesia but it is not a strict recommendation
since research evidence was based on moderate quality evidence
(Poulsen, 2019). Therefore, in the USA, nursing research has
been spearheaded by medical societies that have made it easier
to be able to apply both the local anesthetic methods and the
multi-modal technics in an effective manner. Medical societies
have shaped down the nursing sector and all clinicians are

subjected to a study session where they learn how to manage
postoperative pain. In addition, specific clinicians in health
centers are given the task of evaluating the outcomes.
Study #2: Nursing Research Study Non-USA
The nursing research modality in foreign countries is totally
different from that of the USA. The differences are brought
about by different government policies that are used to control
the medical space. The policies in different countries enable the
study to be carried out in a very fast and effective manner.
While some other counties lack the necessary resources in order
to make the research a success (Cooney, 2016). Time has shown
that research needs to be taken seriously with the result being
studied on a daily basis and ensuring that patients are the sole
beneficiaries of the programs.
For example, in a study of burned victims conducted in Ukraine,
the results obtained were different since clinic resources were
limited and patients were numerous. Therefore, clinicians had to
administer small dosages of medicication to a total of 109
patients present and then observe the results. A group of 64
patients received the standard postoperative drug of metamizole
1g or ketorolac 3%-30mg by the nursing staff (Chou & Gordon,
2016). The other 45 patients received a different type of dosage
and then the researchers had to wait and observe the patients.
From the presented case, it is clear that the hospital in which
the study was being performed had inadequate resources; Thus,
researchers were forced to maintain spare supplies for future
use to avoid depletion (Fuzaylov & Kelly, 2015). Organizational
structure, policies and procedures have been laid down by
societies on the placement of surgery platforms for safe and
effective delivery of postoperative pain control (Chou &
Gordon, 2016). For example, surgical rooms should be full of
clinicians that have specialized in pain management. Facilities
in which neuraxial analgesia and continuous peripheral blocks

are conducted have procedures for safe delivery and trained
individuals to manage those procedures.
Study #3: Postoperative pain management: clinical practice
guidelines. Journal of Paranesthesia Nursing.
Postoperative pain has been reported by patients with 80% of
them reporting on acute pain and 75% of them reporting on
moderate pain (Cooney, 2016). Lack of proper pain control can
lead to decreased function, impaired recovery and reduced
quality of life. Many organizations have published guidelines on
how to use methods to control patient’s postoperative pain.
These organizations comprise of American Society of Pain
Management, American Society of Perinesthesia and the ASA.
The ASA published its first guideline in 2012 (Cooney, 2016).
In addition, the APS in parftenrship with the ASA and the
ASRA published other effective methods of dealing with
postoperative pain. The guidelines in these publications
included the preoperative education, planning for preoperative
pain management, organizational policies and procedures of
dealing with postoperative pain and the transition to outpatient
care.
A study was carried out to determine the nursing practice
implications of care to patients with postoperative pain. The
study was composed of 23 multi-disciplinary experts that came
from different departments including: surgery, gynecology,
primary care, physical therapy, nursing, anesthesia, hospital
medicine and psychology (Cooney, 2016). The panel chosen to
carry out the study was tasked with reviewing the evidence
based on postoperative pain management. The panel was in
charge of formulating conclusions and giving recommendations
for effective, safe and evidence-based postoperative pain
management for patients. The study was composed of over 107
systematic reviews and 858 primary studies that were evidence-
based on the final report (Cooney, 2016). Reviewers from the
Oregon Health Sciences ranked the strengths of the reports

using the methods from the grading recommendation assessment
and they found that using both the pharmacological methods and
multi-modal methods all worked in reducing postoperative pain.
Therefore, the combination of these methods was found to be
the best way of treating the post-surgical pain.
Study #4: Music as a Postoperative Pain Management
Intervention
The most common reported effect after surgical intervention is
pain, and opioid therapy has been used to treat it. The use of
opioids has been extensive because of its immediate effects in
the central nervous system, ease of administration and multiple
delivery forms. Nevertheless, it has been reported by the US
Department of Health and Human Services that opioid’s side
effects are detrimental (Poulsen, 2019). These side effects
include opioid use disorder and even opioid related deaths;
Hence, causing the medical community to reconsider the
approach to pain management. Between the years 2016 and
2017, the United States Drug Enforcement Agency started
restricting companies on producing opioid drugs. While in 2018
the commission from the organization of drug enforcement
raised new standards which focused on improving pain
management and implemented measures to improve opioid
safety (Poulsen, 2019). In the new standards established, multi-
modal therapies have been proposed. Citation here?
Ironically, one of the non-pharmacological methods for pain
control, is the therapeutic use of music to reduce post-operative
pain. Music has been discovered to reduce post-surgical pain in
recent years. It is also a good method for nurses and patients
since it requires no provider orders. A study utilized Positron
Emission Tomography (PET) scan and functional magnetic
resonance imaging (fMRI) to reveal that music arouses the
caudate and nucleus acumens parts of the brain (Poulsen, 2019).
These regions of the brain are responsible for the release of
dopamine, inducing an euphoric state, producing pleasure that
significantly reduces pain. Further research on a number of
patients gave positive results that made music an alternative

method of reducing postoperative pain.(source?) Therefore,
music can be used as a multi-modal method of reducing post-
surgical pain and can also be used in preoperative nursing
practice.
Conclusion
Neither the local anesthetic analgesic techniques nor the multi-
modal techniques can be dismissed. Both techniques target the
same issue from different approaches to relieve postoperative
pain. Pain manifests differently from person to person, and
recovery is based on the person’s overall health, age, and
comorbidities. For instance, a person who smokes chronicly, or
has a long standing use of ilicit drugs may have more difficulty
recovering after surgery as opposed to a person who has
maintained a healthy life style and has no significant
comorbidities.
The comparison between the local anesthetic-based peripheral
regional analgesic techniques, with the use of a multi-modal
approach for pain management alone differs in countries
depending on the resources available (Cooney, 2016). The USA
has shown to be better equipped with societies such as the APS
managing the nursing sector and making sure that the required
research is conducted properly.
Postoperative pain has been reported to persist for years in
some patients. The nursing research team and any governmental
policy that is aimed at helping research through funding, should
prioritize this matter and establish evidence based guidelines,
and create innovative methods to help patients who are
experiencing postoperative surgical pain. A relief to the
suffering of this patients should be provided, and the most
accurate results come from research. Based on the presented
review of studies, the use of local anesthetic-based peripheral
regional analgesic techniques, and the use of multi-modal
approaches should both be considered to provide fast and
effective pain relief in recovering surgical patients.

References
Chou, R., Gordon, D. B. (2016). Management of Postoperative
Pain: a clinical practice guideline from the American pain
society, the American Society of Regional Anesthesia and Pain
Medicine, and the American Society of Anesthesiologists'
committee on regional anesthesia, executive committee, and
administrative council. The Journal of Pain.
Cooney, M. F. (2016). Postoperative pain management: clinical
practice guidelines. Journal of Perianesthesia Nursing.
Fuzaylov, G., Kelly, T. L. (2015). Post-operative pain control
for burn reconstructive surgery in a resource-restricted country
with subcutaneous infusion of local anesthetics through a soaker
catheter to the surgical site: Preliminary results. Burns.
Poulsen, M. J. (2019). Music as a Postoperative Pain
Management Intervention. Journal of PeriAnesthesia Nursing.
Running head: POSTOPERATIVE PAIN
1
POSTOPERATIVE PAIN
3
Postoperative Pain
Name
Institution
Abstract
Postoperative pain is common for most of patients who have
undergone reconstructive surgery after a burn. The American
Society of Pain (ASP) has devised methods of dealing with this
problem since most patients report the incident and only half of
them were reported to have recovered from post-operative pain.

The problem is a real challenge for the medical professionals
and the medical society’s device ways of dealing with the issue
on every occasion. The use of local anesthetic-based peripheral
regional analgesic technique is one way of dealing with the pain
and the multi-modal approach for pain management is another
technique that has been used for patients after a forty eight hour
period post operation. The techniques are also different in the
USA and other countries. The American society of regional
anesthesia (ASRA) has approved these methods and through
research has come up with the organizational plans that assist
outpatients with postoperative pain management. Measures such
as preoperative education, preoperative pain management and
pharmacological and non-pharmacological modalities have been
recommended. Evidence shows that multi-modal methods of
dealing with postoperative pain have been used for most of the
cases. This paper will explore the evidence of postoperative
pain management after burn reconstruction surgery and include
the comparison between the uses of local anesthetic to the use
of multi-modal methods in dealing with postoperative pain. In
adition, the paper will look at the use of these postoperative
methods both in the USA and other countries and how these
methods impact patient outcome.
Keywords: Evidence-Based, Research, Nursing Research,
Postoperative, Patient Response.
Significance and background
Burn reconstruction is a common experience for patients both in
the USA and other countries in the world. Postoperative pain is
expected after a burn reconstruction hence the incorporation of
methods such as the use of local anesthesia and multi-modal
techniques in dealing with pain is recommended. The
interrogant is whether the use of local anesthetic is more
effective than the multi-modal method in dealing with
postoperative pain in adult patients recovering from

reconstructive surgery within a forthy eight hour time frame.
A research done on the same was composed of members of the
American Society of Pain (ASP) with the help from the
American Society of Anesthesiologists (ASA). They assembled
in a meeting where the members with expertise in anesthesia or
pain medicine were put in a research panel (Fuzaylov & Kelly,
2015). The panel’s objective was to review the evidence
presented to them and recommend on ways of managing
postoperative pain. The target audience of the study were
clinicians who managed chronic pain, acute surgical pain,
dental pain, and even traumatic pain (Fuzaylov & Kelly, 2015).
Over 858 studies were included in the research making it a very
effective research. Therefore, post operative pain mangement
has been reviewed by the nursing department over time making
it easier to compare the different postoperative pain techniques
and delivering a good report on the same.
Purpose
Postoperative pain can be a problem for burn victims especially
the ones who have already been on the surgical table. Over the
years, burns were observed as a deformation of the skin but
today with technology advancement, it has become easier to
reconstruct and reverse the burn process. The pain experienced
after the surgical procedure can be managed in different ways.
One way is through the subcutaneous infusion of local
anesthetics. The infusion is done using a sacker that penetrates
the skin to the lower layer and the drug is given at that juncture.
Skin burns are accompanied by a burning sensation that can be
very irritating to the victim. This method of anesthetic
admission reduces that unpleasant burning feeling.
Local anasthetics have been used in other countries to treat the
burn reconstructed patient and it usually works differently
depending on the age of the patient. For adolescents, the
anaesthetic is administered in different dosage for those of 13-
18 years, adults 19-44 years and adults between 45-64 years to

both male and female (Poulsen, 2019). The anesthetic is
administered in small amounts over the course of the healing
and no use of multi-modal techniques is required.
Most countries especially the developing ones do not have
adequate clinical equipment to perform multi-modal methods of
dealing with postoperative pain. In some countries, skin
reconstruction procedures are not available to burn victims,
thus, most people are forced to remain with healing scars. The
lack of resources has been the down side of many countries
without the necessary equipment (Poulsen, 2019). Victims are
left with no choice but to receive local anesthesia and wait for
the pruritic burns to resolve in time.
In the United States, the methods for treating postoperative pain
are different since the American Society of pain (ASP)
establishes guidelines concerning this issue. Continuous use of
the infusion of local anesthetics is done in order to provide
analgesia following a skin harvest from the thigh which is used
in the burn reconstruction process. The administration of local
anesthesia is introduced depending on the patients consent. A
multi-modal approach of dealing with postoperative pain is
widely practiced in the USA since most clinicians are assigned
to the task of reducing pain after surgery (Poulsen, 2019).
Therapeutic exercise and constant skin stretches are
recommended by the ASP in the postoperative period for pain
control. Therefore, there is an obvious difference between the
practices in the USA and other countries on how they handle
burn victims.
Study #1: Nursing research Study in the USA
Research is the key to many issues affecting the nursing field
and postoperative pain for burn victims is one area that can be
used for research. The American Pain Society (APS) and the
American Society of Anesthesiologists (ASA) have joined hands

and handle the research being done in the USA (Poulsen, 2019).
Preoperative education and preoperative pain management
planning has been one key recommendation of these societies.
Clinicians are advised to brief the family and the patient on the
surgical procedure to be performed and how the postoperative
pain experience will be managed. Medication is administered to
provide pain relief and to make sure it is reduced as much as
possible.
The method of checking is based on tracking patient’s response
to postoperative pain treatment and change the treatment plan if
the need arises (Poulsen, 2019). General principles regarding
the use of multi-modal therapies is recommended and the
clinicians are advised to use nonpharmacological
interventions for the treatment of postoperative pain. Cognitive
behavioral modalities are recommended by the societies in order
to access the patient’s response to surgery and ascertain whether
they are still in their right set of mind. The panel neither
recommends nor stops the use of other therapeutic method to
control pain such as acupuncture and massage therapy (Poulsen,
2019). The choice is left entirely to the clinician assigned the
task of managing the patient’s postoperative pain.
The use of systematic pharmacological therapies have also been
recommended by the societies. The use of oral methods over the
intravenous administration of opioids for patients after surgery
are highly recommended to those who can receive the drugs
orally. The intramuscular route should be avoided at all costs
since patients are not very stable after surgery and the injection
can become lethal to them, especially within burn victims. The
use of gabapentin and pregabalin is recommended among multi-
modal analgesia.
For adults, intravenous ketamine should be used as a form of
multi-modal analgesia but it is not a strict recommendation
since research evidence was based on moderate quality evidence

(Poulsen, 2019). Therefore, in the USA, nursing research has
been spearheaded by medical societies that have made it easier
to be able to apply both the local anesthetic methods and the
multi-modal technics in an effective manner. Medical societies
have shaped down the nursing sector and all clinicians are
subjected to a study session where they learn how to manage
postoperative pain. In addition, specific clinicians in health
centers are given the task of evaluating the outcomes.
Study #2: Nursing Research Study Non-USA
The nursing research modality in foreign countries is totally
different from that of the USA. The differences are brought
about by different government policies that are used to control
the medical space. The policies in different countries enable the
study to be carried out in a very fast and effective manner.
While some other counties lack the necessary resources in order
to make the research a success (Cooney, 2016). Time has shown
that research needs to be taken seriously with the result being
studied on a daily basis and ensuring that patients are the sole
beneficiaries of the programs.
For example, in a study of burned victims conducted in Ukraine,
the results obtained were different since clinic resources were
limited and patients were numerous. Therefore, clinicians had to
administer small dosages of medicication to a total of 109
patients present and then observe the results. A group of 64
patients received the standard postoperative drug of metamizole
1g or ketorolac 3%-30mg by the nursing staff (Chou & Gordon,
2016). The other 45 patients received a different type of dosage
and then the researchers had to wait and observe the patients.
From the presented case, it is clear that the hospital in which
the study was being performed had inadequate resources; Thus,
researchers were forced to maintain spare supplies for future
use to avoid depletion. Hence, there is a clear cut difference
between researchers in international communities in countries

that have underfunded medical budgets, or in countries where
there is scarcely any tools for research. Burn patients in such
countries face many difficulties in utilizing what is available to
them. Nevertheless, some countries do have the resources, for
instance England, wich is part of the European nations,
competing with the USA in terms of delivering research
including nursing professionals. Life has never been easy for
such counties since they have societies that keep pushing the
delivery of better health care to its people.
Organizational structure, policies and procedures have been laid
down by societies on the placement of surgery platforms for
safe and effective delivery of postoperative pain control (Chou
& Gordon, 2016). For example, surgical rooms should be full of
clinicians that have specialized in pain management. Facilities
in which neuraxial analgesia and continuous peripheral blocks
are conducted have procedures for safe delivery and trained
individuals to manage those procedures.
In England, clinicians consider the surgical local anesthetic
based on topical pharmacological therapies due to their location
and constant weather change in the region. Therefore, pain
reduction after an operation also considers the weather at the
time and prevent any medication that can endanger the patient.
Therefore, the difference is there for cases in and out of the
USA. Though the approach and goals are the same, the
execution of duties change depending on the region. Countries
that are able to compete with the USA have been reviewing
their nursing profession and making sure their research is as
good as any other. Hence, research in the nursing sector is
beneficial to many postoperative cases and the morale for
research should be encouraged.
Conclusion
Neither the local anesthetic analgesic techniques nor the multi-

modal techniques can be dismissed. Both techniques target the
same issue from different approaches to relieve postoperative
pain. Over the years, patients have required innovative methods
of controlling pain. Pain manifests differently from person to
person, and recovery is based on the person’s overall health,
age, and comorbidities. For instance, a person who smokes
chronicly, or has a long standing use of ilicit drugs may have
more difficulty recovering after surgery as opposed to a person
who has maintained a healthy life style and has no significant
comorbidities.
The comparison between the local anesthetic-based peripheral
regional analgesic techniques, with the use of a multi-modal
approach for pain management alone differs in countries
depending on the resources available. For multi-modal
approaches a country needs to provide the necessary resources
in order for them to be applied. For local aesthetics to be used
the process needs to be funded. The USA has shown to be better
equipped with societies such as the APS managing the nursing
sector and making sure that the required research is conducted
properly.
Changes that relate to these question of comparison include the
research process. The research is sometime equipped with
moderately researched evidence. At least, the conserved parties
should try and have very strong recommended research as the
only option when it comes with dealing with postoperative pain.
Therefore, the research should be define and there should not be
any second guessing on the final recommendations of the
research.
Another factor, would be to provide the guidelines of the
practice to nurses or other clinicians and make sure they follow
those steps for the safety of the patient. In addition, there
should be a clear understanding of which multi-modal therapies
to use and the medical societies should not be skeptical with use
of therapies such as acupuncture.

Postoperative pain has been reported to persist for years in
some patients. The nursing research team and any governmental
policy that is aimed at helping research through funding, should
prioritize this matter and establish evidence based guidelines,
and create innovative methods to help patients who are
experiencing postoperative surgical pain. A relief to the
suffering of this patients should be provided, and the most
accurate results come from research. Based on the presented
review of studies, the use of local anesthetic-based peripheral
regional analgesic techniques, and the use of multi-modal
approaches should both be considered to provide fast and
effective pain relief in recovering surgical patients.
References
Chou, R., Gordon, D. B. (2016). Management of Postoperative
Pain: a clinical practice guideline from the American pain
society, the American Society of Regional Anesthesia and Pain
Medicine, and the American Society of Anesthesiologists'
committee on regional anesthesia, executive committee, and
administrative council. The Journal of Pain.
Cooney, M. F. (2016). Postoperative pain management: clinical
practice guidelines. Journal of Perianesthesia Nursing.
Fuzaylov, G., Kelly, T. L. (2015). Post-operative pain control
for burn reconstructive surgery in a resource-restricted country
with subcutaneous infusion of local anesthetics through a soaker
catheter to the surgical site: Preliminary results. Burns.
Poulsen, M. J. (2019). Music as a Postoperative Pain
Management Intervention. Journal of PeriAnesthesia Nursing.
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International Journal of Nursing Studies 49 (2012) 65–71
A R
Artic
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Rece
Acce
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Guid
Pain
Post
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Tel.:
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002
doi:
stoperative pain assessment based on numeric ratings is not the
same
r patients and professionals: A cross-sectional study
queline F.M. van Dijk a,*, Albert J.M. van Wijck a, Teus H.
Kappen a, Linda M. Peelen a,b,
r J. Kalkman a, Marieke J. Schuurmans c
iversity Medical Centre Utrecht, Department of Perioperative
Care and Emergency Medicine, The Netherlands
iversity Medical Centre Utrecht, Julius Centre for Health
Sciences and Primary Care, The Netherlands
iversity Medical Centre Utrecht, Department of Nursing
Science, The Netherlands
What is already known about the topic?
ain assessment is the foundation of pain management
hen a patient is experiencing postoperative pain. A
frequent and thorough assessment of patients’ pain by
registered nurses provides information to achieve
optimal pain relief.
� Clinical guidelines are developed for postoperative pain
management based on the patient’s pain score. In these
guidelines different cut-off points are used to treat the

pain.
What this paper adds
� Patients and professionals do interpret the numeric
rating scores for postoperative pain differently.
T I C L E I N F O
le history:
ived 27 December 2010
ived in revised form 7 July 2011
pted 16 July 2011
ords:
lgesics
eline
measurement
operative pain
A B S T R A C T
Background: Numeric pain scores have become important in
clinical practice to assess
postoperative pain and to help develop guidelines for treating
pain. Professionals need the
patients’ pain scores to administer analgesic medication.

However, do professionals
interpret the pain scores in line with the actual perception of
pain by the patients?
Objective: The study aim was to assess which Numerical Rating
Scale (NRS) pain score was
considered bearable on a Verbal Rating Scale (VRS) by patients
and professionals.
Methods: This prospective study examined the relationship
between the Numerical Rating
Scale and a Verbal Rating Scale. The patients (n = 10,434) rated
their pain the day after
surgery on the 11-point NRS (0 = no pain and 10 = worst
imaginable pain) and a VRS
comprising five descriptors: ‘‘no pain’’; ‘‘little pain’’; ‘‘painful
but bearable’’; ‘‘considerable
pain’’; and ‘‘terrible pain’’. The first three categories together
(‘‘no pain’’, ‘‘little pain’’ and
‘‘painful but bearable’’) were considered ‘‘bearable’’ and the
last two categories (‘‘considerable
pain’’ and ‘‘terrible pain’’) were deemed as ‘‘unbearable’’ pain.
The professionals (n = 303)
were asked to relate the numbers of the NRS to the words of the
VRS.
Results: Most patients considered NRS 4–6 as ‘‘bearable’’ pain.

Among professionals,
anesthesiologists, Post Anaesthesia Care nurses, and ward
nurses interpreted NRS scores in
the same way as the patients. Only the Acute Pain Nurses
interpreted the scores
differently; they considered NRS of 5 and higher to be not
bearable.
Conclusions: Some care providers and patients differ in their
interpretation of the
postoperative NRS scores. A risk of overtreatment might arise
when health care providers
rigidly follow guidelines that prescribe strong analgesics for
pain scores above 3 or 4
without probing the patient’s preference for pharmacological
treatment.
� 2011 Elsevier Ltd. All rights reserved.
Corresponding author at: University Medical Centre Utrecht,
Pain
ic L02.502, Department of Perioperative Care and Emergency
icine, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
+31 88 75 56163; fax: +31 88 75 55511.
E-mail address: [email protected]
queline F.M. van Dijk).

Contents lists available at ScienceDirect
International Journal of Nursing Studies
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J.F.M. van Dijk et al. / International Journal of Nursing Studies
49 (2012) 65–7166
� The findings suggest a potential risk of overtreatment if
the pain is assessed by the Numeric Rating Scale (NRS)
only.
1. Introduction
According to the American Pain Society guidelines (APS,
1995) for pain management, postoperative pain should be
assessed regularly and documented carefully. The inten-
sity of pain should be evaluated and recorded at intervals
depending on the severity of pain and the clinical situation.
Pain assessment and management is a significant part of
nursing care and the pain is mostly assessed through
verbal communication with the patient. The Numeric
Rating Scale (NRS) is frequently used for this purpose: the
patient is asked to score the pain on an 11 point scale,
where 0 indicates no pain and 10 indicates the worst
imaginable pain. The NRS is considered a valid and reliable

pain assessment tool (Breivik et al., 2000; DeLoach et al.,
1998; Good et al., 2001).
The patient’s NRS score is a leading indicator in the
postoperative pain treatment. Many guidelines for pain
management recommend prescription of analgesics on the
basis of the patients’ NRS pain score (APS, 1995; Gordon
et al., 2005; VMS, 2009). However, the NRS threshold for
prescribing analgesics varies: some guidelines for acute
and cancer pain chose an NRS cut-off >4 (APS, 1995;
Gordon et al., 2005) while at least in one other, also for
acute and cancer pain, an NRS cut-off >3 is the criterion for
administering analgesics (VMS, 2009). Furthermore, in
clinical practice not all patients with an NRS pain score
above the treatment threshold are willing to accept the
analgesic treatment offered mostly because they still
consider the pain as ‘‘bearable’’. This suggests that
professionals and patients might perceive the necessity
for pain treatment differently. If so, health care providers
who strictly follow current guidelines could be at risk of
overtreating some patients.
The aim of the study was to investigate how post-
operative NRS pain scores of the patients relate to the
presence of ‘‘bearable’’ versus ‘‘unbearable’’ pain. In a
prospective study, the postoperative NRS pain scores were
compared with the same patients’ adjectival descriptions
of pain on a Verbal Rating Scale (VRS). The agreement
between patients and professionals on the relationship
between the NRS and VRS was then studied on the basis of
comparisons between the two scales. We hypothesized
that patients and professionals might differ in their
interpretation of NRS scores.
2. Methods

2.1. Study design
We describe a cross-sectional study of a large sample of
patients admitted for elective surgery. The current study
was part of a large cluster-randomized study, implement-
ing a prediction rule for improving the treatment of
postoperative nausea and vomiting. In this study, 23,000
in- and out-patients participated. The study was approved
by the institutional Ethics Committee of the University
Medical Centre in Utrecht. It was not necessary to obtain
informed consent from the patients because pain mea-
surement is part of clinical care. Informed and voluntary
consent of the health care professionals was assumed by
return of a completed questionnaire.
2.2. Subjects
Between March 16th, 2006 and December 21st, 2007, all
adult patients scheduled for elective surgery at the
University Medical Centre of Utrecht were recruited. The
following patients were excluded: those who were trans-
ferred directly to an intensive care unit; who needed
postoperative ventilatory support; who had complications
followed by a second operation; who did not understand the
verbal questions of the research nurse; or who underwent
ambulatory surgery. All patients received a written bro-
chure preoperatively giving information about postopera-
tive pain measurement and treatment, in accordance with
the protocol of the hospital’s Acute Pain Service.
Furthermore, we conducted a national survey in which
303 professionals participated: anesthesiologists, Acute
Pain Nurses, nurses working on the Post Anaesthesia Care
Unit (PACU), student PACU-nurses and ward nurses. The
health professionals were a convenience sample. During

one week in May, 2008 the PACU nurses and nurses on the
surgical wards of the UMC Utrecht were visited and invited
to participate in the study. In addition, the nurses in
training in the UMC Utrecht for PACU-nurse and working
in different hospitals in the Netherlands were invited to
participate. The anesthesiologists were randomly selected
from a national anaesthesia congress. The Acute Pain
Nurses, registered as members of the Dutch association for
pain nurses in 2008, were approached by email. All health
professionals were personally informed and invited to
participate by the pain nurse who was not involved in
patient care.
2.3. Data collection
Trained research nurses who were not involved in the
postoperative care asked the patients about their pain at
rest on the day after surgery. The 11 point NRS was used,
where 0 indicates no pain and 10 the worst pain
imaginable. The VRS used in this study gives five
expressions on a scale of increasing burden: ‘‘no pain’’
(VRS 0), ‘‘little pain’’ (VRS 1), ‘‘painful but bearable’’ (VRS
2),
‘‘considerable pain’’ (VRS 3) and ‘‘terrible pain’’ (VRS 4). The
first three categories together (‘‘no pain’’, ‘‘little pain’’ and
‘painful but bearable’) were considered ‘bearable’ and the
last two categories together (‘considerable pain’ and
‘terrible pain’) were deemed as ‘unbearable’ pain. Further-
more, information concerning gender, age, surgical pro-
cedure and type of anaesthesia was gathered. The
professionals were invited to relate the NRS to the VRS;
they received a hand-delivered questionnaire with the five
descriptions constituting the aforementioned VRS and
were asked to relate the numbers 0–10 of the NRS to these
words. The questionnaires were hand-collected when once
completed. No demographic data from the health profes-

sionals were collected.
2.4.
com
exp
foll
tive
Cor
Spe
for
Wh
Sen
‘un
VRS
we
(RO
NR
val
exa
pat
bet
did
ana
ver
con
tha
3. R
3.1.
in
elig

und
inc
obt
one
ma
sco
unc
Tab
Dem
Ag
Ge
Ty
Ty
ENT
Valu
49 (2012) 65–71 67
Statistical analyses
Data were analyzed using descriptive statistics on
plete cases. Results for continuous variables were
ressed as mean (SD) or as median for variables
owing normal and non-normal distributions, respec-
ly. Categorical data were expressed as frequencies.
relations between NRS and VRS were calculated by the
arman rank correlation coefficient. Statistical testing

non-normally distributed variables used the Mann–
itney test, and for categorical values the x2 test.
sitivity and specificity of the NRS in detecting
bearable’ pain were calculated using cut-off points
�2 (bearable pain) and VRS >2 (unbearable pain) and
re represented by a Receiver Operator Characteristic
C) curve. To analyze the relationship between VRS and
S scores, we used the modal score (the most frequent
ue) of the numbers of the NRS per VRS category and
mined whether this relationship differed between
ients and professionals. To be able to detect differences
ween males and females and different age groups we
subgroup analyses for gender and age. Statistical
lyses were performed using SPSS Statistical Software,
sion 15.0 (SPSS Inc., Chicago, IL). The results were
sidered statistically significant if the p-values were less
n 0.05.
esults
Patients
The demographic and perioperative data are presented
Table 1. Data from 10,576 surgical inpatients were
ible for the current study; the other 12,424 patients
erwent ambulatory surgery or did not meet the
lusion criteria. An NRS and VRS pain score pair was
ained 24 h after surgery from 10,434 patients. Data on
or both scales were incomplete for 142 patients,
inly because they were too sick to determine the pain
re; failed to understand; were confused; or were
ooperative.

Fig. 1 shows the distribution of the NRS scores of actual
pain at rest 24 h after the operation. The median NRS score
was 2. Twenty-four percent of the patients scored an NRS
>4; this is the threshold value for pain treatment
according to various guidelines (APS, 1995; Gordon
et al., 2005). In general, women reported higher pain
scores than men (median 3 versus 2, respectively;
p < 0.001). Older patients (aged 65 and older) reported
lower pain scores than younger patients (median 2 versus
3; p < 0.001) (Table 2).
Fig. 2 shows the distribution of the VRS scores of actual
pain at rest 24 h after surgery. Both the median and the
mode of the VRS scores were 1 (little pain). In total, 22.7% of
the patients reported ‘no pain’ (VRS 0), 38.9% reported ‘little
pain’ (VRS 1), 29.4% reported ‘painful but bearable’ (VRS 2),
8.3% reported ‘considerable pain’ (VRS 3) and 0.7% reported
‘terrible pain’ (VRS 4). Women consistently reported more
severe pain scores than men (p < 0.001). Older patients
reported less severe pain scores than younger patients
(p < 0.001) (Table 3).
3.2. Professionals
One hundred and forty anesthesiologists participated
(response rate 100%), along with 50 Acute Pain Nurses
(response rate 94%); 33 PACU nurses (response rate 100%);
16 nurses in training for PACU-nurse (response rate 100%);
and 67 nurses on the ward (response rate 100%).
le 1
ographic and perioperative data (n = 10,434 patients).
e, mean � SD (range) 52 � 17 (18–98)

nder, n (%)
Female 5348 (51)
Male 5086 (49)
pe of surgery, n (%)
General 2097 (20)
ENT/faciomaxillary 1988 (19)
Orthopedic 1058 (10)
Neurosurgery 974 (9)
Urology 965 (9)
Gynecologic 868 (8)
Plastic surgery 838 (8)
Vascular surgery 676 (6)
Eye surgery 593 (6)
Cardiothoracic 226 (2)
Other 151 (1)
pe of anaesthesia, n (%)
General 9182 (88)
Locoregional 1252 (12)

NRS
109876543210
Pe
rc
en
t
20%
15%
10%
5%
0%
Fig. 1. Pain scores on the Numeric Rating Scale 24 h after
surgery in
percentages.
Table 2
Differences in NRS pain scores.
Median pain score p-Value
Gender (n)
Male (5086) 2 <0.001a
Female (5348) 3

Age (n)
�65 years (7760) 2 <0.001a
<65 years (2674) 3
: ear, nose and throat surgery.
es are numbers (%). a Mann–Whitney test.
49 (2012) 65–7168
3.3. The relation of the NRS to the VRS
The VRS and NRS scores of the patients were
significantly correlated (Spearman correlation coefficient
r = 0.84, p < 0.001). Twenty-four percent of the post-
operative patients reported an NRS pain score >4, while
9% reported ‘considerable’ or ‘terrible pain’ on the VRS. The
patients associated NRS 0 with VRS ‘no pain’; NRS 1–3 with
VRS ‘little pain’; NRS 4–5 with VRS ‘painful but bearable’;
NRS 6–8 with VRS ‘considerable pain’; and NRS 9–10 with
VRS ‘terrible pain’.
As different guidelines show various NRS cut-off points
to determine the need for treatment with analgesics, the
sensitivity and specificity of the NRS scores and VRS
‘bearable’ and ‘unbearable’ were calculated for different
NRS cut-off points. Fig. 3 shows an ROC curve depicting the
sensitivity and 1 � specificity for these cut-off points.
Using an NRS cut-off point of 4, 17% of the patients
considered NRS >4 to be ‘bearable’ pain (1 � specificity)
and 5% considered it as ‘unbearable’ pain (1 � sensitivity).
So using an NRS cut-off value >4 for analgesic adminis-
tration, 17% of the patients would be incorrectly classified

as having unbearable pain, possibly resulting in over-
treatment, while 5% would be undertreated. With a cut-off
point of NRS >3, 30% of the patients would be overtreated
and 3% would be undertreated.
Fig. 4 shows the distribution of the relationship
between the NRS and VRS according to the patients and
the professionals. The PACU and ward nurses interpreted
the NRS and VRS scores in the same way: NRS 0 equated
with VRS ‘no pain’; NRS 1-3 with VRS ‘little pain’; NRS 4–5
with VRS ‘painful but bearable’; NRS 6–8 with VRS
‘considerable pain’; and NRS 9–10 with VRS ‘terrible pain’.
The anesthesiologists interpreted NRS 1 as ‘no pain’ but
their other ratings were identical to those of the PACU and
ward nurses. The Acute Pain Nurses interpreted the scores
differently: NRS 1–2 ‘little pain’; 3–4 ‘painful but bearable’;
5–7 ‘considerable pain’; and 8–10 ‘terrible pain’. The
distribution of the NRS scores over the VRS categories
given by the Acute Pain Nurse was shifted to the left in
comparison with those of the other professionals and
patients, because they assigned lower NRS scores to the
VRS categories.
4. Discussion
The present study distinguishes ‘bearable’ from
‘unbearable’ postoperative pain and analyzes the relation-
ship between NRS and VRS scores as assessed by post-
operative patients and professionals. We found that most
patients (65%) with NRS 4–6 considered their pain
bearable. Among the professionals, the anesthesiologists,
PACU and ward nurses interpreted the NRS scores in the
same way as the patients. Only the Acute Pain Nurses
interpreted the scores differently.

In previous studies, different descriptions of pain have
frequently been used: no; mild; moderate; and severe
pain. In a recent study on pain after orthopedic surgery, the
patients related NRS 1–3 to mild; 4–5 to moderate; and 6–
10 to severe pain (Dihle et al., 2006). After coronary artery
bypass grafting, NRS 1–3 was related to mild; 4–6 to
moderate; and 7–10 to severe pain (Mendoza et al., 2004).
These studies show that in postoperative pain the upper
boundary for mild pain is NRS 3 and for moderate pain NRS
5 or 6. These results are comparable to the findings of the
VRS
terrible painconsiderable
pain
pain but
bearable
little painno pain
Pe
rc
en
t
40%
30%
20%
10%
0%

Fig. 2. Pain scores on the Verbal Rating Scale 24 h after surgery
in
percentages.
1 - Specificity
1,00,80,60,40,20,0
Se
ns
iti
vi
ty
1,0
0,8
0,6
0,4
0,2
0,0
NRS 4
NRS 5
NRS 6
NRS 3

NRS 2
NRS 7
Fig. 3. ROC curve of bearable pain (VRS �2) and unbearable
pain (VRS >2)
with the different NRS cut-off points for 10,434 patients.
Table 3
Differences in VRS pain scores.
Considerable and terrible pain p-Value
Gender (n)
Male (5086) 7.6% <0.001a
Female (5348) 10.3%
Age (n)
�65 years (7760) 8.0% <0.001a
<65 years (2674) 9.4%
a Chi-square test.
cur
the
dist
pre
pat
gui
Dol

sev
(Jam
200
wh
Fig.
prof
Care
VRS
49 (2012) 65–71 69
rent study. However, instead of moderate pain we used
term ‘painful but bearable’. For severe pain we
inguished ‘considerable’ and ‘terrible pain’. Several
vious studies have demonstrated that postoperative
ients suffer moderate to severe pain despite the use of
delines (Apfelbaum et al., 2003; Chung and Lui, 2003;
in et al., 2002) and that nurses often underestimate the
erity of postoperative pain of the patients in their care
ison et al., 1997; Taylor et al., 2003; Zelman et al.,
3). It is, however, uncertain to what extent the patients
o indicate ‘moderate’ pain really suffer. In the current
study most patients with NRS 4–6 considered their pain as
bearable. This relates with other studies where the patients
were satisfied with their postoperative pain relief although
they still had moderate pain (Apfelbaum et al., 2003;
Jamison et al., 1997; Hawkins, 1997). It is possible that
most patients experienced moderate but ‘bearable’ pain
and that the nurses did not underestimate the patients’

pain.
Most patients with NRS 4–6 considered their pain
bearable. Possible reasons are that patients do not under-
stand the NRS pain scores or refuse pain therapy because of
side effects or fear for addiction (Wilder-Smith and
Schuler, 1992). It is unknown why some patients bear
acute pain to some degree and why others do not. Nurses
should not only ask the patient about the pain score and
follow the guidelines rigidly but also communicate with
the patient about the pain and pain therapy (McDonald
et al., 2000). The numerical pain ratings are only one
dimension of the patient’s subjective experience of pain
(Hanks, 2008) and adequate pain relief cannot be reliably
achieved using opioid analgesics without a high risk of
adverse effects (White and Kehlet, 2007).
The results of the current study indicate that the
patients and the professionals have a different view of the
range of numerical ratings that indicate ‘bearable’ or
‘unbearable’ pain.
In particular, Acute Pain Nurses tended to over-
estimate the severity of pain as perceived by the patient
when interpreting NRS scores. Of all health care
professionals, the nurses operate most closely to the
patient in postoperative care and they can make
independent medication decisions for pain relief. The
results of this study suggest that the PACU and ward
nurses were best informed about what the patients
consider as ‘bearable’ pain. In contrast, the Acute Pain
Nurses evaluated the pain scores differently from the
patients; they more often overestimate the intensity of
pain. In most hospitals the Acute Pain Nurse is the
coordinator of the Acute Pain Service and responsible for
the in-service education of health care professionals.

Although he/she often daily checks up on the patients
with Patient Controlled Analgesia or epidural analgesia,
the Acute Pain Nurse is not as close to the patient as the
ward and PACU nurses are. Another possible explanation
of the observed differences is that the Acute Pain Nurses
are typically aware of the results of several former
studies which have repeatedly demonstrated under-
assessment and undertreatment of postoperative pain
(Idvall et al., 2005; Sloman et al., 2005; Zalon, 1993).
What does ‘moderate’ pain or an NRS 5 or 6 mean for the
patient in order to decide on the need for opioid
administration? In the present study, many patients
who reported an NRS of 5 or 6 considered their condition
to be ‘painful but bearable’. A patient who indicates that his/
her pain is ‘bearable’ might not necessarily want to receive
additional analgesic medication, even though all guide-
lines suggest starting treatment on the basis of these NRS
scores. Although we did not ask the patient if he/she would
need treatment for his pain, and we did not measure the
administered amount of analgesics, the data imply a
potential risk of overtreatment when health care providers
4. The relations made of the NRS with the VRS by patients and
essionals: Anesthesiologists, Acute Pain Nurses, Post
Anaesthesia
Unit nurses and ward nurses. Spearman correlation coefficient
NRS–
r = 0.84, p < 0.001.

49 (2012) 65–7170
follow the postoperative pain guidelines to the letter.
Because a number of studies have demonstrated poor
control of the postoperative pain (Apfelbaum et al., 2003;
Chung and Lui, 2003; Dolin et al., 2002) the Joint
Commission on Accreditation of Health Care Organizations
defined new standards for pain management in their
standards manual (Philips, 2000). In addition, the Amer-
ican Pain Society and the Dutch VMS recently provided
recommendations for improving the quality of acute and
cancer pain management (Gordon et al., 2005; VMS, 2009).
In these recommendations increasing emphasis is placed
on reducing the patients’ pain scores, which entails
increased analgesic usage. Decreasing the intensity of
pain is a laudable objective and one of the pillars of health
care. In postoperative pain management, both under-
treatment and overtreatment are undesirable. Unrelieved
pain has adverse psychological and physiological con-
sequences e.g., more complications and prolonged hospital
stay (Watt-Watson et al., 1999). On the other hand,
improved pain control should not jeopardize patient safety
(Taylor et al., 2003). Unnecessary use of analgesics,
especially opioids, increases the patient’s discomfort
because of the side effects, such as nausea, vomiting and
pruritus. Unnecessary opioid administration also increases
the probability of sedation and potentially dangerous
respiratory depression (Cashman and Dolin, 2004; Taylor
et al., 2005). An increase of opioid oversedation is reported
after the implementation of the new standards of the Joint
Commission (Vila et al., 2005). Therefore, to balance the
risks of overtreatment and undertreatment in this range of
numerical pain scores, the health care provider might
simply add the following question: ‘‘would you like to have
an analgesic?’’ In addition, the patients’ level of conscious-
ness should be assessed when patients receive (additional)
opioids.

4.1. Limitations
The present study is subject to a number of limitations.
We measured the postoperative pain scores of the patient
in rest. These pain scores can be different of the pain scores
at movement. Nevertheless, the purpose of the study was
to examine what numeric ratings were bearable to the
patient. The health care professionals participated in this
study were a convenience sample and no demographic
data were collected. Regarding their level of experience,
however, given the fact that all professionals working in
the shift in which the data were collected participated, the
sample was representative. Another potential source of
error is the order in which the two pain scores were asked.
All patients first indicated the severity of their pain on the
VRS and then on the NRS. We chose this order because we
anticipated that patients might try to ‘convert back’ to an
adjective in the VRS once they had given an NRS score
(which requires mental conversion from a subjective
feeling to a number). Although in theory it can make a
difference whether NRS or VRS is asked first, a recent study
reported that error rates were not related to the order of
presentation of the scales (Gagliese et al., 2005).
The data we used for this study were part of a larger
treatment of postoperative nausea and vomiting (PONV).
We are aware of the relationship between PONV and pain.
In the larger study, the anesthesiologists were more
focused on PONV and possibly prescribed less analgesia.
However, we assume that there was no interference from
the PONV study, because we studied two scales for
expressing the severity of pain, and not the severity of
the pain itself. This assumption was verified by repeating
our analyses with data from the control group of the PONV

study only; this yielded similar results.
5. Conclusions
By combining data from a large sample of surgical
patients with a national survey of health care workers, a
lack of agreement is found between the patients and the
Acute Pain Nurses on what constitutes ‘bearable’ pain in
relation to the reported NRS scores. The Acute Pain Nurses
tended to overestimate the severity of pain when the
patients reported intermediate NRS scores, whereas most
patients considered NRS 4–6 to be ‘bearable’ pain. These
findings suggest a potential risk of overtreatment, if the
pain is assessed by the NRS only and treatment decisions
are based solely on a patient’s NRS response. Specifically
asking a patient whether the pain is bearable and he/she
would like to receive additional analgesics might circum-
vent this problem.
Conflict of interest. None of the authors has any potential
conflicting interest in this study.
Funding. This study is supported by ZonMW (Clinical Trial nr.
NCT00293618), the Netherlands Organization for Health
Research and Development. The study is supported by the
Division of Perioperative Care and Emergency Medicine,
University Medical Centre Utrecht, The Netherlands.
Ethical approval. The study was approved by the institutional
Ethics Committee of the University Medical Centre in

Utrecht.
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Postoperative pain assessment based on numeric ratings is not
the same for patients and professionals: A cross-sectional
studyIntroductionMethodsStudy designSubjectsData
collectionStatistical analysesResultsPatientsProfessionalsThe
relation of the NRS to the
VRSDiscussionLimitationsConclusionsReferences
PAIN MANAGEMENT
Postoperative Pain Management: Clinical
Practice Guidelines
Maureen F. Cooney, DNP, FNP-BC
OVER THE PAST 2 decades, there has been an
increased emphasis on the need for effective
management of acute pain. The focus on pain man-
agement was sharpened when the Joint Commis-
sion on Accreditation of Healthcare Organizations

integrated the requirement for pain assessment
and management into their standards in 2000.
1
Acute postoperative pain, however, continues to
be inadequately controlled. Among patients who
have had surgical procedures, 80% experience
postoperative pain and 75% or more of them report
pain that is at a moderate, severe, or extreme level.
2
Inadequately treated acute pain is associated with
the risk for the development of persistent postsur-
gical pain.
3,4
Poor pain control has significant
physiological consequences that can ultimately
result in impaired recovery, decreased function,
and reduced quality of life.
2,5
In recent years, the number and types of pharma-
cologic, interventional, and nonpharmacological

options to treat acute postoperative pain have
expanded. Many professional organizations,
including the American Society of PeriAnesthesia
Nurses and American Society for Pain Management
Nursing have published guidelines and other doc-
uments related to the management of acute pain.
The American Society of Anesthesiologists (ASA)
published guidelines for perioperative pain man-
agement in 2012.
6
In 2016, the American Pain So-
ciety (APS), with input from the ASA, and review
and approval by the American Society of Regional
Anesthesia and Pain Medicine, published guide-
lines for the management of postoperative pain.
Maureen F. Cooney, DNP, FNP-BC, is a Nurse Practitioner,
Pain Management, Westchester Medical Center, Valhalla, NY.
Conflict of interest: None to report.
Address correspondence to Maureen F. Cooney, Westchester
Medical Center, Pain Management, Rm 2108 Macy Pavilion,
100 Woods Rd, Valhalla, NY 10595; e-mail address:

[email protected]
� 2016 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
http://dx.doi.org/10.1016/j.jopan.2016.08.001
Journal of PeriAnesthesia Nursing, Vol 31, No 5 (October),
2016: pp 445-451
These guidelines are somewhat unique because,
in addition to recommendations for pharmacolog-
ical and nonpharmacological pain interventions,
they include recommendations for preoperative
education, perioperative pain management plan-
ning, organizational policies and procedures, and
transition to outpatient care.
7
This article summa-
rizes the development of the guidelines and high-
lights key recommendations with nursing
practice implications for the care of patients with
acute postsurgical pain.
Methodology for Guideline Development
AguidelinepanelwasselectedbytheAPS,withinput

from the ASA, and consisted of 23 multidisciplinary
experts representing specialists from fields that
included anesthesia, pain management, surgery, hos-
pital medicine, nursing, obstetrics and gynecology,
psychology, primary care, and physical therapy.
The panel was charged with the tasks of reviewing
the evidence related to postoperative pain manage-
ment and formulating recommendations for
evidence-based, effective, safer postsurgical pain
management for adults and children.
7
The Oregon
Evidence-Based Practice Center conducted an evi-
dence review that included literature searches
through December 2015.
7,8
Upon completion of
the literature search, there were 107 systematic
reviews and an additional 858 primary studies in
the final evidence report.
8

The quality of randomized
trials was assessed using criteria adapted by the Co-
chrane Back Review Group.
7,8
Two reviewers
from the Oregon Health Sciences Evidence center
independently reviewed and ranked the strength
(strong or weak) and quality of the evidence (high,
moderate, or low) using methods adapted from
the Grading of Recommendations Assessment,
Development, and Evaluation Working Group
and the Agency for Healthcare Research and
Quality (AHRQ) Methods Guide for Effectiveness
and Comparative Effectiveness Reviews.
7,8
A
strong recommendation indicates the reviewers’
assessment that the potential benefits of following
the recommendation clearly outweigh potential
445

Delta:1_given name
http://crossmark.crossref.org/dialog/?doi=10.1016/j.jopan.2016.
08.001&domain=pdf
446 MAUREEN F. COONEY
harms and burdens. A weak recommendation
indicates the reviewers’ assessment that benefits of
following the recommendation outweigh the
potential harms and burdens, but the benefits to
harms or burdens balance is smaller or evidence is
weaker.
7
The grade of the quality of evidence
(high, moderate, low) reflects the confidence level
ofthereviewersthattheevidencereflectsthetrueef-
fect and the likelihood that further research would
change the confidence in the estimate of effect.
8
The grading of evidence and recommendations is
further detailed in the published guidelines.
Following the evidence review, the guideline panel

drafted recommendations and engaged in a multi-
stage Delphi process to rank and revise the series
of the draft recommendation statements.
7
Unani-
mous or near-unanimous consensus was achieved
for all recommendations.
7
Subsequently, 20 external
peer reviewers provided additional comments on
the draft guidelines, which underwent an additional
revision and panel approval process.
7
The finalized
guidelines were approved by the APS Board of Direc-
tors; the ASA’s Committee on Regional Anesthesia,
Executive Committee, and Administrative Council;
and the American Society of Regional Anesthesia
Board of Directors in 2015 and published in early
2016.
7
Key Recommendations

Preoperative Education and Perioperative
Pain Management Planning
The panel recommends:
1. Clinicians should provide patient- and
family-centered, individually tailored edu-
cation to the patient (and/or responsible
caregiver), including information on treat-
ment options for management of postoper-
ative pain, and document the plan and
goals for postoperative pain management
(strong recommendation, low-quality evi-
dence).
2. Parents (or other adult caregivers) of chil-
dren who undergo surgery receive instruc-
tion in developmentally appropriate
methods for assessing pain and counseling
on appropriate administration of analgesics
and modalities (strong recommendation,
low-quality evidence).
3. Clinicians conduct a preoperative evaluation

including assessment of medical and psychi-
atric comorbidities, concomitant medica-
tions, history of chronic pain, substance
abuse, and previous postoperative treatment
regimes and responses, to guide the periop-
erative pain management plan (strong
recommendation, low-quality evidence).
4. Clinicians adjust the pain management plan
on the basis of adequacy of pain relief and
presence of adverse events (strong recom-
mendation, low-quality evidence).
Methods of Assessment
5. Clinicians use a validated pain assessment
tool to track responses to postoperative
pain treatments and adjust treatment plans
accordingly (strong recommendation, low-
quality evidence).
General Principles Regarding the Use of
Multimodal Therapies

6. Clinicians offer multimodal analgesia or the
use of a variety of analgesic medications
and techniques combined with nonpharma-
cological interventions for the treatment of
postoperative pain in children and adults
(strong recommendation, high-quality evi-
dence).
Use of Physical Modalities
7. Clinicians consider transcutaneous electri-
cal nerve stimulation (TENS) as an adjunct
to other postoperative pain treatments
(weak recommendation, moderate-quality
evidence).
The panel:
8. Neither recommends nor discourages
acupuncture, massage, or cold therapy as ad-
juncts to other postoperative pain treat-
ments (insufficient evidence).

PAIN MANAGEMENT 447
Use of Cognitive Behavioral Modalities
9. Clinicians consider the use of cognitive
behavioral modalities in adults as part of a
multimodal approach (weak recommenda-
tion, moderate-quality evidence).
Use of Systemic Pharmacological Therapies
10. Oral over intravenous (IV) administration
of opioids for postoperative analgesia in pa-
tients who can use the oral route (strong
recommendation, moderate-quality evi-
dence).
11. Clinicians avoid using the intramuscular
route for the administration of analgesics
for management of postoperative pain
(strong recommendation, moderate-
quality evidence).

12. IV patient-controlled analgesia (PCA) use
for postoperative systemic analgesia when
the parenteral route is needed (strong
dence).
13. Against routine use of basal infusion of
opioids with IV PCA in opioid-na€ıve
adults (strong recommendation, moderate-
quality evidence).
14. Clinicians provide appropriate monitoring
of sedation, respiratory status, and other
adverse events in patients who receive sys-
temic opioids for postoperative analgesia
dence).
15. Clinicians provide adults and children with
acetaminophen and/or nonsteroidal anti-
inflammatory drugs (NSAIDs) as part of
multimodal analgesia for management of

postoperative pain in patients without con-
traindications (strong recommendation,
high-quality evidence).
16. Clinicians consider giving a preoperative
dose of oral celecoxib in adult patients
without contraindications (strong recom-
mendation, moderate-quality evidence).
17. Clinicians consider use of gabapentin
or pregabalin as a component of multi-
modal analgesia (strong recommendation,
moderate-quality evidence).
18. Clinicians consider IV ketamine as a
component of multimodal analgesia in
adults (weak recommendation, moderate-
quality evidence).
19. Clinicians consider IV lidocaine infusions
in adults who undergo open and laparo-
scopic abdominal surgery who do not
have contraindications (weak recommen-
dation, moderate-quality evidence).

Use of Local and/or Topical
Pharmacological Therapies
20. Clinicians consider surgical site-specific
local anesthetic infiltration for surgical pro-
cedures with evidence indicating efficacy
evidence).
21. Clinicians use topical local anesthetics in
combination with nerve blocks before
circumcision (strong recommendation,
The panel does not recommend:
22. Intrapleural analgesia with local anes-
thetics for pain control after thoracic sur-
gery (strong recommendation, moderate-
quality evidence).
Use of Peripheral Regional Anesthesia
23. Clinicians consider surgical site-specific pe-
ripheral regional anesthetic techniques in

adults and children for procedures with ev-
idence indicating efficacy (strong recom-
mendation, high-quality evidence).
24. Clinicians use continuous, local anesthetic-
based peripheral regional analgesic tech-
niques when the need for analgesia is
likely to exceed the duration of effect of a
single injection (strong recommendation,
25. Clinicians consider the addition of cloni-
dine as an adjuvant for prolongation of anal-
gesia with a single-injection peripheral
neural blockade (weak recommendation,
Use of Neuraxial Therapies
26. Clinicians offer neuraxial analgesia for ma-

jor thoracic and abdominal procedures,
particularly in patients at risk for cardiac
complications, pulmonary complications,
or prolonged ileus (strong recommenda-
tion, high-quality evidence).
27. Clinicians avoid the neuraxial administra-
tion of magnesium, benzodiazepines,
neostigmine, tramadol, and ketamine in
the treatment of postoperative pain (strong
dence).
of patients who have received neuraxial in-
terventions for perioperative analgesia
dence).
Organizational Structure, Policies, and
Procedures
29. Facilities in which surgery is performed

have an organizational structure in place
to develop and refine policies and proced-
ures for safe and effective delivery of
postoperative pain control (strong recom-
provide clinicians with access to consulta-
tion with a pain specialist for patients
with inadequately controlled postopera-
tive pain or at risk of inadequately
controlled postoperative pain (eg, opioid
tolerant, history of substance abuse)
dence).
31. Facilities in which neuraxial analgesia and
continuous peripheral blocks are per-
formed have policies and procedures to
support their safe delivery and trained in-
dividuals to manage these procedures

dence).
Transitioning to Outpatient Care
32. Clinicians provide education to all patients
(adults and children) and primary care-
givers on the pain treatment plan including
tapering of analgesics after hospital
discharge (strong recommendation, low-
quality evidence).
Perianesthesia Nursing
Recommendations
Awareness of the content in the APS Guidelines in
the Management of Postoperative Pain
7
is impor-
tant for nurses working in perianesthesia settings.
A complete review of the article, along with a
focused examination of recommendations specific
to their roles, will provide valuable information.
Recommendations related to preoperative educa-
tion, pain assessment, multimodal therapies, use

of physical and cognitive behavioral modalities,
use of systemic, local, and/or topical pharmacolog-
ical therapies, use of peripheral regional anes-
thesia and neuraxial therapies, and outpatient
care transitions have particular applicability to
the nurse in a direct care provider role. Some
specific content applicable to the practice of the
perianesthesia nurse is addressed in the following
paragraphs.
The guideline development panel members
recommend preoperative education and perioper-
ative pain management planning, and cite studies
which show that educational programs individu-
ally designed for surgical patients with specific
medical, developmental, psychological, or social
needs have been found to reduce opioid consump-
tion, preoperative anxiety, requests for sedating
medications, and postoperative lengths of stay.
7

There is no strong evidence to support the use of
one educational intervention over another or the
timing and content of interventions. However, it
is recommended that content includes specific in-
formation related to analgesic use before surgery
(continuation, discontinuation, or changes) to
avoid withdrawal syndrome (such as is possible
with opioids, benzodiazepines, gabapentin, and
baclofen), prevent surgical complications (eg,
aspirin and hemorrhage), and improve postopera-
tive pain control (eg, routine use of nonopioid
PAIN MANAGEMENT 449
analgesics).
7
Preoperative education related to the
use of pain assessment tools, realistic pain goals,
and how and when to report pain is advised. It is
important to address specific pain-related expecta-
tions and misconceptions, and inform patients
about the effects and possible adverse effects of

postoperative pain interventions. If patients will
be using postoperative devices and modalities
(eg, IV PCA), they/significant others should be in-
structed in the use of the modalities preopera-
tively. The pain management plan should be
developed preoperatively through shared
decision-making with the patient/parent/signifi-
cant other, based on an assessment of the individ-
ual patient’s history, condition, needs, and risks.
The panel identifies the importance of an assess-
ment of substance use and abuse (opioids, benzo-
diazepines, cocaine, alcohol and other substances
that may affect pain management) to guide devel-
opment of the postoperative pain management
plan. The role of the perianesthesia nurse in assess-
ing pain and patient responses to analgesic inter-
ventions is critical in assuring the re-evaluation
and adjustment of the pain management plan.
The panel emphasizes the importance of the use of

validated instruments to assess pain.
7
Patient self-
report, not behaviors or vital signs, is the primary
basis of pain assessment. Behaviors and the input
from caregivers are used to assess pain when the
patient cannot self-report. Pain should be assessed
during rest and activity. There are no clear recom-
mendations as to the optimal timing and frequency
of assessment, but after analgesic administration,
reassessment should occur by the time the medica-
tion reaches peak effect (15 to 30 minutes after
parenteral analgesics and 1 to 2 hours after oral
agents).
7
The use of multimodal analgesia, including phar-
macological and nonpharmacological interven-
tions, is recommended in the management of
postoperative pain. It is noted that a number of
different combinations of pharmacological and

nonpharmacological approaches are possible and
may vary depending on the type of surgery, patient
condition, and preferences.
7
Within the guide-
lines, there are some specific recommendations
for the particular multimodal approach based on
the type of surgical procedure. The use of TENS,
inexpensive, small, portable devices that deliver
a small low-voltage electrical impulse through
electrodes on the skin has been shown to reduce
pain through the descending inhibitory pain path-
ways which activate opioid receptors.
7
The panel
cites studies that have demonstrated reductions
in postoperative analgesic requirements. In most
cases, TENS electrodes were applied near the sur-
gical incision. There is insufficient evidence to
recommend the use of acupuncture. Other phys-
ical modalities such as acupressure, massage,
cold therapy, immobilization, and bracing are

generally safe, but there is a lack of evidence to
recommend their use. As components of a multi-
modal plan, cognitive behavioral therapies such
as hypnosis, guided imagery, music, and relaxation
methods have shown some positive effects on
postoperative pain, anxiety, or analgesic use, but
few studies of these modalities have been conduct-
ed with children.
7
Multimodal pharmacological approaches are rec-
ommended. Oral opioids, when possible, are
preferred over IV administration as there is no
strong evidence to show that IV therapy provides
superior relief of pain.
7
The use of short-acting opi-
oids, administered around the clock in the immedi-
ate postoperative period, is recommended.
7
Except if used preoperatively, long-acting opioids
should not be used for postoperative pain manage-

ment. Intramuscular injections should be avoided
as they do not provide reliable effects and show
no superiority over other routes.
7
The guidelines
support the use of IV PCA, without the use of a
basal infusion, when IV opioids are needed as IV
PCA has been shown to provide greater effective-
ness and patient satisfaction.
7
To reduce the risk
of opioid-related adverse events, the panel re-
commends close monitoring of sedation level
and respiratory status, especially in the hours
immediately after surgery or with dose changes.
7
There is no clear recommendation for the use of
pulse oximetry, capnography, or other monitoring
methods due to a lack of evidence.
7
Identification
of patients at increased risk for opioid-related

adverse events is advised, and interventions to
minimize risks, including dose adjustments, are
recommended.
7
Nonopioids are recommended as components of a
multimodal analgesic plan.
7
The panel cites evi-
dence that shows that acetaminophen and NSAIDs
reduce pain and opioid requirements in postsur-
gical patients. NSAIDs are associated with risks,
including gastrointestinal bleeding, anastomotic
leakage in colorectal surgery, and cardiovascular
events and renal dysfunction, which must be
considered and may contraindicate their use in
some postsurgical patients.
7
NSAIDs and cele-
coxib are contraindicated for perioperative pain

management in patients undergoing coronary ar-
tery bypass grafting.
7
Perianesthesia nurses may
be aware of the reluctance of some orthopaedic
surgeons to use NSAIDs for their patients due to
concerns of bone nonunion after certain surgical
procedures, but the panel notes that there is insuf-
ficient evidence to recommend against the use of
NSAIDs for orthopaedic fractures and spinal fusion
and identifies the need for informed decision-
making and consideration of alternatives by the
surgeon and the patient.
7
Celecoxib, in doses of
200 to 400 mg administered 30 to 60 minutes pre-
operatively to adults is recommended for postsur-
gical pain and opioid requirement reducing
benefits.
7
The panel cites evidence that doses of
gabapentin (600 or 1,200 mg) or pregabalin (150

or 300 mg) administered 1 to 2 hours preopera-
tively to adults are effective components of a multi-
modal plan, and postoperative dosing has shown
effectiveness in some trials.
7
Additional multimodal pharmacological interven-
tions that perianesthesia nurses may be less
familiar with are also recommended in the guide-
lines. Although the panel is unable to identify suf-
ficient evidence for optimal dosing of IV ketamine,
it recommends a preoperative bolus of 0.5 mg/kg
followed by an infusion of 10 mcg/kg/minute intra-
operatively, and a lower dosage postoperative infu-
sion as a multimodal analgesic component for
adult surgical patients to reduce postoperative
pain, analgesic use, and possibly the risk of persis-
tent postsurgical pain.
7
Evidence is cited to sup-
port the use of IV lidocaine infusions in adults

undergoing open and laparoscopic abdominal sur-
geries as this intervention is associated with
shorter duration of ileus and improved analgesia.
7
The panel recommends an initial bolus dose of
1.5 mg/kg followed by an infusion of 2 mg/kg/
hour during surgery; insufficient evidence is cited
to recommend postoperative use.
7
Site-specific peripheral regional local anesthetic in-
jections, and in some cases, continuous infusions
are supported in the guidelines. Neuraxial
(epidural or spinal) analgesia is recommended for
the management of major thoracic, abdominal, ce-
sarean section, hip, and lower extremity sur-
geries.
7
The neuraxial approach may reduce risks
of postoperative mortality, venous thromboembo-
lism, myocardial, infarction, pneumonia, respira-
tory depression, and may decrease duration of an
ileus.

7
The panel notes that epidural analgesia
has the advantage over spinal analgesia as an
epidural can be used as a continuous infusion
with or without PCA and can be used to deliver
local anesthetics. Epidural clonidine is sometimes
used with local anesthetics to improve postopera-
tive pain, but evidence is lacking and it may be
associated with increased hypotension.
7
Perianes-
thesia nurses need to be competent in the assess-
ment of patients who have received peripheral
regional anesthesia and neuraxial anesthetics/anal-
gesics and must be aware of the signs, symptoms,
and emergency management of any complications,
including local anesthetic toxicity. Some orthopae-
dic surgeries are associated with an increased risk
for compartment syndrome, and signs and symp-
toms may be diminished or masked with regional

and neuraxial techniques. When opioids are used
in spinal or epidural analgesia, patients must be
monitored for opioid-related adverse outcomes.
In addition, patients who have received neuraxial
analgesia are at risk for spinal cord compression.
Perianesthesia nurses must be educated about
these potential complications and prepared to
implement appropriate emergency measures.
Perianesthesia nurses have significant roles in
assuring appropriate transitions of patient care.
The panel recommends that all patients and/or
caregivers receive a coordinated approach to
discharge planning and discharge teaching from
all involved disciplines (surgeons, nurses, thera-
pists, pharmacists). It is necessary to provide in-
structions in the safe and appropriate use of
pain medications and side effect management.
Discharge teaching should include warnings about
the life-threatening risks of concomitant use of

alcohol and other central nervous system depres-
sants when opioids are used. Teaching should also
include an individualized plan for opioid weaning
and discontinuation and safe storage and disposal
of opioids and other medications.
7
Clear evidence
to guide the method for postsurgical opioid wean-
ing is not available, but the panel notes that severe
postoperative pain usually diminishes rapidly in the
first few days after surgery. For minor surgeries,
PAIN MANAGEMENT 451
pain may be controlled with nonopioid analgesics
or a very limited opioid supply after discharge. In
patients with more involved surgeries, a longer
course of postoperative analgesics, including opi-
oids, may be needed. If used for more than 1 to
2 weeks, a gradual opioid reduction is suggested
to prevent withdrawal, with dose reductions by
20% to 25% of the discharge dose every 1 to 2 days.

7
Conclusion
The above statements constitute key recommen-
dations contained in the APS Postoperative Pain
Guidelines. In addition, the guidelines include
elaboration on each of the recommendations, a
list of interventions for the management of postop-
erative pain in patients receiving long-term opioid
therapy, a table of options for components of a
multimodal analgesic surgery-specific approach,
and a summary table of interventions for manage-
ment of postoperative pain. Perianesthesia nurses
may find it helpful to review the guidelines to
inform various aspects of their clinical practice.
It is important to note that clinical practice guide-
lines are general statements that do not dictate
practice, but provide guidance for practice based
on the evidence available at the time they are writ-
ten. They do not apply to all patients, as individual

patients and clinical scenarios may not be appro-
priate for implementation of the recommenda-
tions, but require patient-specific approaches
based on assessment and consideration of individ-
ual patient needs and resources. In examining each
recommendation, it is important to note that
despite a comprehensive review of the literature,
only 4 of the 32 recommendations have a high-
quality evidence rating.
7,8
High-quality evidence was only found to support
the use of multimodal analgesia, including the
use of acetaminophen and NSAIDs, site-specific
peripheral regional anesthetic techniques, and
neuraxial analgesia with opioids and local anes-
thetics for thoracic and abdominal procedures.
7,8
Although there are 28 other recommendations,
they are rated with moderate- or low-quality evi-
dence because the panel identified significant

research gaps in the evidence review.
7,8
However, despite the lack of high-quality evi-
dence, these recommendations reflect the panel’s
near-unanimous consensus on all the recommen-
dations.
7
The task of developing evidence-based
guidelines presents challenges; There are limita-
tions in the ability to gather and synthesize all
high-quality studies that are available related to
an area as broad as postoperative pain, and even
as available evidence is analyzed and recommen-
dations are developed, additional studies are
completed and newer evidence surfaces.
8
This
further highlights the necessity of individualizing
patient care and using informed clinical judgment
over strict adherence to recommendations con-
tained in the guidelines. It also demonstrates the
significant need for additional research to address

the gaps in evidence related to the management
of postoperative pain.
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http://refhub.elsevier.com/S1089-9472(16)30282-
9/sref8Postoperative Pain Management: Clinical Practice
GuidelinesMethodology for Guideline DevelopmentKey
RecommendationsPreoperative Education and Perioperative
Pain Management PlanningMethods of AssessmentGeneral
Principles Regarding the Use of Multimodal TherapiesUse of
Physical ModalitiesUse of Cognitive Behavioral ModalitiesUse
of Systemic Pharmacological TherapiesUse of Local and/or
Topical Pharmacological TherapiesUse of Peripheral Regional
AnesthesiaUse of Neuraxial TherapiesOrganizational Structure,
Policies, and ProceduresTransitioning to Outpatient
CarePerianesthesia Nursing
RecommendationsConclusionReferences
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same
r patients and professionals: A cross-sectional study
queline F.M. van Dijk a,*, Albert J.M. van Wijck a, Teus H.
Kappen a, Linda M. Peelen a,b,
r J. Kalkman a, Marieke J. Schuurmans c
iversity Medical Centre Utrecht, Department of Perioperative

Care and Emergency Medicine, The Netherlands
iversity Medical Centre Utrecht, Julius Centre for Health
Sciences and Primary Care, The Netherlands
iversity Medical Centre Utrecht, Department of Nursing
Science, The Netherlands
What is already known about the topic?
ain assessment is the foundation of pain management
hen a patient is experiencing postoperative pain. A
frequent and thorough assessment of patients’ pain by
registered nurses provides information to achieve
optimal pain relief.
� Clinical guidelines are developed for postoperative pain
management based on the patient’s pain score. In these
guidelines different cut-off points are used to treat the
pain.
What this paper adds
� Patients and professionals do interpret the numeric
rating scores for postoperative pain differently.
T I C L E I N F O
le history:
ived 27 December 2010
ived in revised form 7 July 2011
pted 16 July 2011

ords:
lgesics
eline
measurement
operative pain
A B S T R A C T
Background: Numeric pain scores have become important in
clinical practice to assess
postoperative pain and to help develop guidelines for treating
pain. Professionals need the
patients’ pain scores to administer analgesic medication.
However, do professionals
interpret the pain scores in line with the actual perception of
pain by the patients?
Objective: The study aim was to assess which Numerical Rating
Scale (NRS) pain score was
considered bearable on a Verbal Rating Scale (VRS) by patients
and professionals.
Methods: This prospective study examined the relationship
between the Numerical Rating
Scale and a Verbal Rating Scale. The patients (n = 10,434) rated
their pain the day after

surgery on the 11-point NRS (0 = no pain and 10 = worst
imaginable pain) and a VRS
comprising five descriptors: ‘‘no pain’’; ‘‘little pain’’; ‘‘painful
but bearable’’; ‘‘considerable
pain’’; and ‘‘terrible pain’’. The first three categories together
(‘‘no pain’’, ‘‘little pain’’ and
‘‘painful but bearable’’) were considered ‘‘bearable’’ and the
last two categories (‘‘considerable
pain’’ and ‘‘terrible pain’’) were deemed as ‘‘unbearable’’ pain.
The professionals (n = 303)
were asked to relate the numbers of the NRS to the words of the
VRS.
Results: Most patients considered NRS 4–6 as ‘‘bearable’’ pain.
Among professionals,
anesthesiologists, Post Anaesthesia Care nurses, and ward
nurses interpreted NRS scores in
the same way as the patients. Only the Acute Pain Nurses
interpreted the scores
differently; they considered NRS of 5 and higher to be not
bearable.
Conclusions: Some care providers and patients differ in their
interpretation of the
postoperative NRS scores. A risk of overtreatment might arise
when health care providers

rigidly follow guidelines that prescribe strong analgesics for
pain scores above 3 or 4
without probing the patient’s preference for pharmacological
treatment.
� 2011 Elsevier Ltd. All rights reserved.
Corresponding author at: University Medical Centre Utrecht,
Pain
ic L02.502, Department of Perioperative Care and Emergency
icine, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
+31 88 75 56163; fax: +31 88 75 55511.
E-mail address: [email protected]
queline F.M. van Dijk).
Contents lists available at ScienceDirect
International Journal of Nursing Studies
journal homepage: www.elsevier.com/ijns
0-7489/$ – see front matter � 2011 Elsevier Ltd. All rights
reserved.
10.1016/j.ijnurstu.2011.07.009
http://www.sciencedirect.com/science/journal/00207489

49 (2012) 65–7166
� The findings suggest a potential risk of overtreatment if
the pain is assessed by the Numeric Rating Scale (NRS)
only.
1. Introduction
According to the American Pain Society guidelines (APS,
1995) for pain management, postoperative pain should be
assessed regularly and documented carefully. The inten-
sity of pain should be evaluated and recorded at intervals
depending on the severity of pain and the clinical situation.
Pain assessment and management is a significant part of
nursing care and the pain is mostly assessed through
verbal communication with the patient. The Numeric
Rating Scale (NRS) is frequently used for this purpose: the
patient is asked to score the pain on an 11 point scale,
where 0 indicates no pain and 10 indicates the worst
imaginable pain. The NRS is considered a valid and reliable
pain assessment tool (Breivik et al., 2000; DeLoach et al.,
1998; Good et al., 2001).
The patient’s NRS score is a leading indicator in the
postoperative pain treatment. Many guidelines for pain
management recommend prescription of analgesics on the
basis of the patients’ NRS pain score (APS, 1995; Gordon
et al., 2005; VMS, 2009). However, the NRS threshold for
prescribing analgesics varies: some guidelines for acute
and cancer pain chose an NRS cut-off >4 (APS, 1995;
Gordon et al., 2005) while at least in one other, also for
acute and cancer pain, an NRS cut-off >3 is the criterion for
administering analgesics (VMS, 2009). Furthermore, in
clinical practice not all patients with an NRS pain score
above the treatment threshold are willing to accept the
analgesic treatment offered mostly because they still

consider the pain as ‘‘bearable’’. This suggests that
professionals and patients might perceive the necessity
for pain treatment differently. If so, health care providers
who strictly follow current guidelines could be at risk of
overtreating some patients.
The aim of the study was to investigate how post-
operative NRS pain scores of the patients relate to the
presence of ‘‘bearable’’ versus ‘‘unbearable’’ pain. In a
prospective study, the postoperative NRS pain scores were
compared with the same patients’ adjectival descriptions
of pain on a Verbal Rating Scale (VRS). The agreement
between patients and professionals on the relationship
between the NRS and VRS was then studied on the basis of
comparisons between the two scales. We hypothesized
that patients and professionals might differ in their
interpretation of NRS scores.
2. Methods
2.1. Study design
We describe a cross-sectional study of a large sample of
patients admitted for elective surgery. The current study
was part of a large cluster-randomized study, implement-
ing a prediction rule for improving the treatment of
postoperative nausea and vomiting. In this study, 23,000
in- and out-patients participated. The study was approved
by the institutional Ethics Committee of the University
Medical Centre in Utrecht. It was not necessary to obtain
informed consent from the patients because pain mea-
surement is part of clinical care. Informed and voluntary
consent of the health care professionals was assumed by
return of a completed questionnaire.

2.2. Subjects
Between March 16th, 2006 and December 21st, 2007, all
adult patients scheduled for elective surgery at the
University Medical Centre of Utrecht were recruited. The
following patients were excluded: those who were trans-
ferred directly to an intensive care unit; who needed
postoperative ventilatory support; who had complications
followed by a second operation; who did not understand the
verbal questions of the research nurse; or who underwent
ambulatory surgery. All patients received a written bro-
chure preoperatively giving information about postopera-
tive pain measurement and treatment, in accordance with
the protocol of the hospital’s Acute Pain Service.
Furthermore, we conducted a national survey in which
303 professionals participated: anesthesiologists, Acute
Pain Nurses, nurses working on the Post Anaesthesia Care
Unit (PACU), student PACU-nurses and ward nurses. The
health professionals were a convenience sample. During
one week in May, 2008 the PACU nurses and nurses on the
surgical wards of the UMC Utrecht were visited and invited
to participate in the study. In addition, the nurses in
training in the UMC Utrecht for PACU-nurse and working
in different hospitals in the Netherlands were invited to
participate. The anesthesiologists were randomly selected
from a national anaesthesia congress. The Acute Pain
Nurses, registered as members of the Dutch association for
pain nurses in 2008, were approached by email. All health
professionals were personally informed and invited to
participate by the pain nurse who was not involved in
patient care.
2.3. Data collection
Trained research nurses who were not involved in the

postoperative care asked the patients about their pain at
rest on the day after surgery. The 11 point NRS was used,
where 0 indicates no pain and 10 the worst pain
imaginable. The VRS used in this study gives five
expressions on a scale of increasing burden: ‘‘no pain’’
(VRS 0), ‘‘little pain’’ (VRS 1), ‘‘painful but bearable’’ (VRS
2),
‘‘considerable pain’’ (VRS 3) and ‘‘terrible pain’’ (VRS 4). The
first three categories together (‘‘no pain’’, ‘‘little pain’’ and
‘painful but bearable’) were considered ‘bearable’ and the
last two categories together (‘considerable pain’ and
‘terrible pain’) were deemed as ‘unbearable’ pain. Further-
more, information concerning gender, age, surgical pro-
cedure and type of anaesthesia was gathered. The
professionals were invited to relate the NRS to the VRS;
they received a hand-delivered questionnaire with the five
descriptions constituting the aforementioned VRS and
were asked to relate the numbers 0–10 of the NRS to these
words. The questionnaires were hand-collected when once
completed. No demographic data from the health profes-
sionals were collected.
2.4.
com
exp
foll
tive
Cor
Spe
for
Wh
Sen
‘un

VRS
we
(RO
NR
val
exa
pat
bet
did
ana
ver
con
tha
3. R
3.1.
in
elig
und
inc
obt
one
ma
sco
unc
Tab
Dem
Ag
Ge

Ty
Ty
ENT
Valu
49 (2012) 65–71 67
Statistical analyses
Data were analyzed using descriptive statistics on
plete cases. Results for continuous variables were
ressed as mean (SD) or as median for variables
owing normal and non-normal distributions, respec-
ly. Categorical data were expressed as frequencies.
relations between NRS and VRS were calculated by the
arman rank correlation coefficient. Statistical testing
non-normally distributed variables used the Mann–
itney test, and for categorical values the x2 test.
sitivity and specificity of the NRS in detecting
bearable’ pain were calculated using cut-off points
�2 (bearable pain) and VRS >2 (unbearable pain) and
re represented by a Receiver Operator Characteristic
C) curve. To analyze the relationship between VRS and
S scores, we used the modal score (the most frequent
ue) of the numbers of the NRS per VRS category and
mined whether this relationship differed between
ients and professionals. To be able to detect differences
ween males and females and different age groups we
subgroup analyses for gender and age. Statistical
lyses were performed using SPSS Statistical Software,

sion 15.0 (SPSS Inc., Chicago, IL). The results were
sidered statistically significant if the p-values were less
n 0.05.
esults
Patients
The demographic and perioperative data are presented
Table 1. Data from 10,576 surgical inpatients were
ible for the current study; the other 12,424 patients
erwent ambulatory surgery or did not meet the
lusion criteria. An NRS and VRS pain score pair was
ained 24 h after surgery from 10,434 patients. Data on
or both scales were incomplete for 142 patients,
inly because they were too sick to determine the pain
re; failed to understand; were confused; or were
ooperative.
Fig. 1 shows the distribution of the NRS scores of actual
pain at rest 24 h after the operation. The median NRS score
was 2. Twenty-four percent of the patients scored an NRS
>4; this is the threshold value for pain treatment
according to various guidelines (APS, 1995; Gordon
et al., 2005). In general, women reported higher pain
scores than men (median 3 versus 2, respectively;
p < 0.001). Older patients (aged 65 and older) reported
lower pain scores than younger patients (median 2 versus
3; p < 0.001) (Table 2).
Fig. 2 shows the distribution of the VRS scores of actual
pain at rest 24 h after surgery. Both the median and the
mode of the VRS scores were 1 (little pain). In total, 22.7% of
the patients reported ‘no pain’ (VRS 0), 38.9% reported ‘little

pain’ (VRS 1), 29.4% reported ‘painful but bearable’ (VRS 2),
8.3% reported ‘considerable pain’ (VRS 3) and 0.7% reported
‘terrible pain’ (VRS 4). Women consistently reported more
severe pain scores than men (p < 0.001). Older patients
reported less severe pain scores than younger patients
(p < 0.001) (Table 3).
3.2. Professionals
One hundred and forty anesthesiologists participated
(response rate 100%), along with 50 Acute Pain Nurses
(response rate 94%); 33 PACU nurses (response rate 100%);
16 nurses in training for PACU-nurse (response rate 100%);
and 67 nurses on the ward (response rate 100%).
le 1
ographic and perioperative data (n = 10,434 patients).
e, mean � SD (range) 52 � 17 (18–98)
nder, n (%)
Female 5348 (51)
Male 5086 (49)
pe of surgery, n (%)
General 2097 (20)
ENT/faciomaxillary 1988 (19)
Orthopedic 1058 (10)
Neurosurgery 974 (9)

Urology 965 (9)
Gynecologic 868 (8)
Plastic surgery 838 (8)
Vascular surgery 676 (6)
Eye surgery 593 (6)
Cardiothoracic 226 (2)
Other 151 (1)
pe of anaesthesia, n (%)
General 9182 (88)
Locoregional 1252 (12)
NRS
109876543210
Pe
rc
en
t
20%
15%
10%
5%

0%
Fig. 1. Pain scores on the Numeric Rating Scale 24 h after
surgery in
percentages.
Table 2
Differences in NRS pain scores.
Median pain score p-Value
Gender (n)
Male (5086) 2 <0.001a
Female (5348) 3
Age (n)
�65 years (7760) 2 <0.001a
<65 years (2674) 3
: ear, nose and throat surgery.
es are numbers (%). a Mann–Whitney test.
49 (2012) 65–7168
3.3. The relation of the NRS to the VRS
The VRS and NRS scores of the patients were

significantly correlated (Spearman correlation coefficient
r = 0.84, p < 0.001). Twenty-four percent of the post-
operative patients reported an NRS pain score >4, while
9% reported ‘considerable’ or ‘terrible pain’ on the VRS. The
patients associated NRS 0 with VRS ‘no pain’; NRS 1–3 with
VRS ‘little pain’; NRS 4–5 with VRS ‘painful but bearable’;
NRS 6–8 with VRS ‘considerable pain’; and NRS 9–10 with
VRS ‘terrible pain’.
As different guidelines show various NRS cut-off points
to determine the need for treatment with analgesics, the
sensitivity and specificity of the NRS scores and VRS
‘bearable’ and ‘unbearable’ were calculated for different
NRS cut-off points. Fig. 3 shows an ROC curve depicting the
sensitivity and 1 � specificity for these cut-off points.
Using an NRS cut-off point of 4, 17% of the patients
considered NRS >4 to be ‘bearable’ pain (1 � specificity)
and 5% considered it as ‘unbearable’ pain (1 � sensitivity).
So using an NRS cut-off value >4 for analgesic adminis-
tration, 17% of the patients would be incorrectly classified
as having unbearable pain, possibly resulting in over-
treatment, while 5% would be undertreated. With a cut-off
point of NRS >3, 30% of the patients would be overtreated
and 3% would be undertreated.
Fig. 4 shows the distribution of the relationship
between the NRS and VRS according to the patients and
the professionals. The PACU and ward nurses interpreted
the NRS and VRS scores in the same way: NRS 0 equated
with VRS ‘no pain’; NRS 1-3 with VRS ‘little pain’; NRS 4–5
with VRS ‘painful but bearable’; NRS 6–8 with VRS
‘considerable pain’; and NRS 9–10 with VRS ‘terrible pain’.
The anesthesiologists interpreted NRS 1 as ‘no pain’ but
their other ratings were identical to those of the PACU and
ward nurses. The Acute Pain Nurses interpreted the scores

differently: NRS 1–2 ‘little pain’; 3–4 ‘painful but bearable’;
5–7 ‘considerable pain’; and 8–10 ‘terrible pain’. The
distribution of the NRS scores over the VRS categories
given by the Acute Pain Nurse was shifted to the left in
comparison with those of the other professionals and
patients, because they assigned lower NRS scores to the
VRS categories.
4. Discussion
The present study distinguishes ‘bearable’ from
‘unbearable’ postoperative pain and analyzes the relation-
ship between NRS and VRS scores as assessed by post-
operative patients and professionals. We found that most
patients (65%) with NRS 4–6 considered their pain
bearable. Among the professionals, the anesthesiologists,
PACU and ward nurses interpreted the NRS scores in the
same way as the patients. Only the Acute Pain Nurses
interpreted the scores differently.
In previous studies, different descriptions of pain have
frequently been used: no; mild; moderate; and severe
pain. In a recent study on pain after orthopedic surgery, the
patients related NRS 1–3 to mild; 4–5 to moderate; and 6–
10 to severe pain (Dihle et al., 2006). After coronary artery
bypass grafting, NRS 1–3 was related to mild; 4–6 to
moderate; and 7–10 to severe pain (Mendoza et al., 2004).
These studies show that in postoperative pain the upper
boundary for mild pain is NRS 3 and for moderate pain NRS
5 or 6. These results are comparable to the findings of the
VRS
terrible painconsiderable
pain

pain but
bearable
little painno pain
Pe
rc
en
t
40%
30%
20%
10%
0%
Fig. 2. Pain scores on the Verbal Rating Scale 24 h after surgery
in
percentages.
1 - Specificity
1,00,80,60,40,20,0
Se
ns
iti
vi
ty

1,0
0,8
0,6
0,4
0,2
0,0
NRS 4
NRS 5
NRS 6
NRS 3
NRS 2
NRS 7
Fig. 3. ROC curve of bearable pain (VRS �2) and unbearable
pain (VRS >2)
with the different NRS cut-off points for 10,434 patients.
Table 3
Differences in VRS pain scores.
Considerable and terrible pain p-Value
Gender (n)

Male (5086) 7.6% <0.001a
Female (5348) 10.3%
Age (n)
�65 years (7760) 8.0% <0.001a
<65 years (2674) 9.4%
a Chi-square test.
cur
the
dist
pre
pat
gui
Dol
sev
(Jam
200
wh
Fig.
prof
Care
VRS
49 (2012) 65–71 69
rent study. However, instead of moderate pain we used

term ‘painful but bearable’. For severe pain we
inguished ‘considerable’ and ‘terrible pain’. Several
vious studies have demonstrated that postoperative
ients suffer moderate to severe pain despite the use of
delines (Apfelbaum et al., 2003; Chung and Lui, 2003;
in et al., 2002) and that nurses often underestimate the
erity of postoperative pain of the patients in their care
ison et al., 1997; Taylor et al., 2003; Zelman et al.,
3). It is, however, uncertain to what extent the patients
o indicate ‘moderate’ pain really suffer. In the current
study most patients with NRS 4–6 considered their pain as
bearable. This relates with other studies where the patients
were satisfied with their postoperative pain relief although
they still had moderate pain (Apfelbaum et al., 2003;
Jamison et al., 1997; Hawkins, 1997). It is possible that
most patients experienced moderate but ‘bearable’ pain
and that the nurses did not underestimate the patients’
pain.
Most patients with NRS 4–6 considered their pain
bearable. Possible reasons are that patients do not under-
stand the NRS pain scores or refuse pain therapy because of
side effects or fear for addiction (Wilder-Smith and
Schuler, 1992). It is unknown why some patients bear
acute pain to some degree and why others do not. Nurses
should not only ask the patient about the pain score and
follow the guidelines rigidly but also communicate with
the patient about the pain and pain therapy (McDonald
et al., 2000). The numerical pain ratings are only one
dimension of the patient’s subjective experience of pain
(Hanks, 2008) and adequate pain relief cannot be reliably
achieved using opioid analgesics without a high risk of
adverse effects (White and Kehlet, 2007).

The results of the current study indicate that the
patients and the professionals have a different view of the
range of numerical ratings that indicate ‘bearable’ or
‘unbearable’ pain.
In particular, Acute Pain Nurses tended to over-
estimate the severity of pain as perceived by the patient
when interpreting NRS scores. Of all health care
professionals, the nurses operate most closely to the
patient in postoperative care and they can make
independent medication decisions for pain relief. The
results of this study suggest that the PACU and ward
nurses were best informed about what the patients
consider as ‘bearable’ pain. In contrast, the Acute Pain
Nurses evaluated the pain scores differently from the
patients; they more often overestimate the intensity of
pain. In most hospitals the Acute Pain Nurse is the
coordinator of the Acute Pain Service and responsible for
the in-service education of health care professionals.
Although he/she often daily checks up on the patients
with Patient Controlled Analgesia or epidural analgesia,
the Acute Pain Nurse is not as close to the patient as the
ward and PACU nurses are. Another possible explanation
of the observed differences is that the Acute Pain Nurses
are typically aware of the results of several former
studies which have repeatedly demonstrated under-
assessment and undertreatment of postoperative pain
(Idvall et al., 2005; Sloman et al., 2005; Zalon, 1993).
What does ‘moderate’ pain or an NRS 5 or 6 mean for the
patient in order to decide on the need for opioid
administration? In the present study, many patients
who reported an NRS of 5 or 6 considered their condition
to be ‘painful but bearable’. A patient who indicates that his/
her pain is ‘bearable’ might not necessarily want to receive

additional analgesic medication, even though all guide-
lines suggest starting treatment on the basis of these NRS
scores. Although we did not ask the patient if he/she would
need treatment for his pain, and we did not measure the
administered amount of analgesics, the data imply a
potential risk of overtreatment when health care providers
4. The relations made of the NRS with the VRS by patients and
essionals: Anesthesiologists, Acute Pain Nurses, Post
Anaesthesia
Unit nurses and ward nurses. Spearman correlation coefficient
NRS–
r = 0.84, p < 0.001.
49 (2012) 65–7170
follow the postoperative pain guidelines to the letter.
Because a number of studies have demonstrated poor
control of the postoperative pain (Apfelbaum et al., 2003;
Chung and Lui, 2003; Dolin et al., 2002) the Joint
Commission on Accreditation of Health Care Organizations
defined new standards for pain management in their
standards manual (Philips, 2000). In addition, the Amer-
ican Pain Society and the Dutch VMS recently provided
recommendations for improving the quality of acute and
cancer pain management (Gordon et al., 2005; VMS, 2009).
In these recommendations increasing emphasis is placed
on reducing the patients’ pain scores, which entails
increased analgesic usage. Decreasing the intensity of
pain is a laudable objective and one of the pillars of health
care. In postoperative pain management, both under-

treatment and overtreatment are undesirable. Unrelieved
pain has adverse psychological and physiological con-
sequences e.g., more complications and prolonged hospital
stay (Watt-Watson et al., 1999). On the other hand,
improved pain control should not jeopardize patient safety
(Taylor et al., 2003). Unnecessary use of analgesics,
especially opioids, increases the patient’s discomfort
because of the side effects, such as nausea, vomiting and
pruritus. Unnecessary opioid administration also increases
the probability of sedation and potentially dangerous
respiratory depression (Cashman and Dolin, 2004; Taylor
et al., 2005). An increase of opioid oversedation is reported
after the implementation of the new standards of the Joint
Commission (Vila et al., 2005). Therefore, to balance the
risks of overtreatment and undertreatment in this range of
numerical pain scores, the health care provider might
simply add the following question: ‘‘would you like to have
an analgesic?’’ In addition, the patients’ level of conscious-
ness should be assessed when patients receive (additional)
opioids.
4.1. Limitations
The present study is subject to a number of limitations.
We measured the postoperative pain scores of the patient
in rest. These pain scores can be different of the pain scores
at movement. Nevertheless, the purpose of the study was
to examine what numeric ratings were bearable to the
patient. The health care professionals participated in this
study were a convenience sample and no demographic
data were collected. Regarding their level of experience,
however, given the fact that all professionals working in
the shift in which the data were collected participated, the
sample was representative. Another potential source of
error is the order in which the two pain scores were asked.
All patients first indicated the severity of their pain on the

VRS and then on the NRS. We chose this order because we
anticipated that patients might try to ‘convert back’ to an
adjective in the VRS once they had given an NRS score
(which requires mental conversion from a subjective
feeling to a number). Although in theory it can make a
difference whether NRS or VRS is asked first, a recent study
reported that error rates were not related to the order of
presentation of the scales (Gagliese et al., 2005).
The data we used for this study were part of a larger
treatment of postoperative nausea and vomiting (PONV).
We are aware of the relationship between PONV and pain.
In the larger study, the anesthesiologists were more
focused on PONV and possibly prescribed less analgesia.
However, we assume that there was no interference from
the PONV study, because we studied two scales for
expressing the severity of pain, and not the severity of
the pain itself. This assumption was verified by repeating
our analyses with data from the control group of the PONV
study only; this yielded similar results.
5. Conclusions
By combining data from a large sample of surgical
patients with a national survey of health care workers, a
lack of agreement is found between the patients and the
Acute Pain Nurses on what constitutes ‘bearable’ pain in
relation to the reported NRS scores. The Acute Pain Nurses
tended to overestimate the severity of pain when the
patients reported intermediate NRS scores, whereas most
patients considered NRS 4–6 to be ‘bearable’ pain. These
findings suggest a potential risk of overtreatment, if the
pain is assessed by the NRS only and treatment decisions
are based solely on a patient’s NRS response. Specifically
asking a patient whether the pain is bearable and he/she

would like to receive additional analgesics might circum-
vent this problem.
Conflict of interest. None of the authors has any potential
conflicting interest in this study.
Funding. This study is supported by ZonMW (Clinical Trial nr.
NCT00293618), the Netherlands Organization for Health
Research and Development. The study is supported by the
Division of Perioperative Care and Emergency Medicine,
University Medical Centre Utrecht, The Netherlands.
Ethical approval. The study was approved by the institutional
Ethics Committee of the University Medical Centre in
Utrecht.
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Postoperative pain assessment based on numeric ratings is not
the same for patients and professionals: A cross-sectional

studyIntroductionMethodsStudy designSubjectsData
collectionStatistical analysesResultsPatientsProfessionalsThe
relation of the NRS to the
VRSDiscussionLimitationsConclusionsReferences
PAIN MANAGEMENT
Postoperative Pain Management: Clinical
Practice Guidelines
Maureen F. Cooney, DNP, FNP-BC
OVER THE PAST 2 decades, there has been an
increased emphasis on the need for effective
management of acute pain. The focus on pain man-
agement was sharpened when the Joint Commis-
sion on Accreditation of Healthcare Organizations
integrated the requirement for pain assessment
and management into their standards in 2000.1
Acute postoperative pain, however, continues to
be inadequately controlled. Among patients who
have had surgical procedures, 80% experience
postoperative pain and 75% ormore of them report
pain that is at a moderate, severe, or extreme level.2
Inadequately treated acute pain is associated with

the risk for the development of persistent postsur-
gical pain.3,4 Poor pain control has significant
physiological consequences that can ultimately
result in impaired recovery, decreased function,
and reduced quality of life.2,5
In recent years, the number and types of pharma-
cologic, interventional, and nonpharmacological
options to treat acute postoperative pain have
expanded. Many professional organizations,
including the American Society of PeriAnesthesia
Nurses and American Society for Pain Management
Nursing have published guidelines and other doc-
uments related to the management of acute pain.
The American Society of Anesthesiologists (ASA)
published guidelines for perioperative pain man-
agement in 2012.6 In 2016, the American Pain So-
ciety (APS), with input from the ASA, and review
and approval by the American Society of Regional
Anesthesia and Pain Medicine, published guide-

lines for the management of postoperative pain.
Maureen F. Cooney, DNP, FNP-BC, is a Nurse Practitioner,
Pain Management, Westchester Medical Center, Valhalla, NY.
Conflict of interest: None to report.
Address correspondence to Maureen F. Cooney, Westchester
Medical Center, Pain Management, Rm 2108 Macy Pavilion,
100 Woods Rd, Valhalla, NY 10595; e-mail address:
[email protected]
� 2016 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
Journal of PeriAnesthesia Nursing, Vol 31, No 5 (October),
2016: pp 445-451
These guidelines are somewhat unique because,
in addition to recommendations for pharmacolog-
ical and nonpharmacological pain interventions,
they include recommendations for preoperative
education, perioperative pain management plan-
ning, organizational policies and procedures, and
transition to outpatient care.7 This article summa-
rizes the development of the guidelines and high-

lights key recommendations with nursing
practice implications for the care of patients with
acute postsurgical pain.
Methodology for Guideline Development
Aguidelinepanelwas selectedby theAPS,with input
from the ASA, and consisted of 23 multidisciplinary
experts representing specialists from fields that
included anesthesia, painmanagement, surgery, hos-
pital medicine, nursing, obstetrics and gynecology,
psychology, primary care, and physical therapy.
The panel was charged with the tasks of reviewing
the evidence related to postoperative pain manage-
ment and formulating recommendations for
evidence-based, effective, safer postsurgical pain
management for adults and children.7 The Oregon
Evidence-Based Practice Center conducted an evi-
dence review that included literature searches
through December 2015.7,8 Upon completion of
the literature search, there were 107 systematic

reviews and an additional 858 primary studies in
the final evidence report.8 The quality of randomized
trials was assessed using criteria adapted by the Co-
chrane Back Review Group.7,8 Two reviewers
from the Oregon Health Sciences Evidence center
independently reviewed and ranked the strength
(strong or weak) and quality of the evidence (high,
moderate, or low) using methods adapted from
the Grading of Recommendations Assessment,
Development, and Evaluation Working Group
and the Agency for Healthcare Research and
Quality (AHRQ) Methods Guide for Effectiveness
and Comparative Effectiveness Reviews.7,8 A
strong recommendation indicates the reviewers’
assessment that the potential benefits of following
the recommendation clearly outweigh potential
445
Delta:1_given name
http://crossmark.crossref.org/dialog/?doi=10.1016/j.jopan.2016.
08.001&domain=pdf

harms and burdens. A weak recommendation
indicates the reviewers’ assessment that benefits of
following the recommendation outweigh the
potential harms and burdens, but the benefits to
harms or burdens balance is smaller or evidence is
weaker.7 The grade of the quality of evidence
(high, moderate, low) reflects the confidence level
of the reviewers that theevidence reflects the trueef-
fect and the likelihood that further research would
change the confidence in the estimate of effect.8
The grading of evidence and recommendations is
further detailed in the published guidelines.
Following the evidence review, the guideline panel
drafted recommendations and engaged in a multi-
stage Delphi process to rank and revise the series
of the draft recommendation statements.7 Unani-
mous or near-unanimous consensus was achieved
for all recommendations.7 Subsequently, 20 external

peer reviewers provided additional comments on
the draft guidelines, which underwent an additional
revision and panel approval process.7 The finalized
guidelineswere approved by the APSBoard ofDirec-
tors; the ASA’s Committee on Regional Anesthesia,
Executive Committee, and Administrative Council;
and the American Society of Regional Anesthesia
Board of Directors in 2015 and published in early
2016.7
Key Recommendations
Preoperative Education and Perioperative
Pain Management Planning
1. Clinicians should provide patient- and
family-centered, individually tailored edu-
cation to the patient (and/or responsible
caregiver), including information on treat-
ment options for management of postoper-
ative pain, and document the plan and
goals for postoperative pain management

dence).
2. Parents (or other adult caregivers) of chil-
dren who undergo surgery receive instruc-
tion in developmentally appropriate
methods for assessing pain and counseling
on appropriate administration of analgesics
and modalities (strong recommendation,
3. Clinicians conduct a preoperative evaluation
including assessment of medical and psychi-
atric comorbidities, concomitant medica-
tions, history of chronic pain, substance
abuse, and previous postoperative treatment
regimes and responses, to guide the periop-
erative pain management plan (strong
4. Clinicians adjust the pain management plan
on the basis of adequacy of pain relief and

presence of adverse events (strong recom-
5. Clinicians use a validated pain assessment
tool to track responses to postoperative
pain treatments and adjust treatment plans
accordingly (strong recommendation, low-
quality evidence).
6. Clinicians offer multimodal analgesia or the
use of a variety of analgesic medications
and techniques combined with nonpharma-
cological interventions for the treatment of
postoperative pain in children and adults
(strong recommendation, high-quality evi-
dence).

7. Clinicians consider transcutaneous electri-
cal nerve stimulation (TENS) as an adjunct
to other postoperative pain treatments
evidence).
The panel:
8. Neither recommends nor discourages
acupuncture, massage, or cold therapy as ad-
juncts to other postoperative pain treat-
ments (insufficient evidence).
PAIN MANAGEMENT 447
Use of Cognitive Behavioral Modalities
9. Clinicians consider the use of cognitive
behavioral modalities in adults as part of a
multimodal approach (weak recommenda-
Use of Systemic Pharmacological Therapies

10. Oral over intravenous (IV) administration
of opioids for postoperative analgesia in pa-
tients who can use the oral route (strong
dence).
11. Clinicians avoid using the intramuscular
route for the administration of analgesics
for management of postoperative pain
(strong recommendation, moderate-
quality evidence).
12. IV patient-controlled analgesia (PCA) use
for postoperative systemic analgesia when
the parenteral route is needed (strong
dence).
13. Against routine use of basal infusion of
opioids with IV PCA in opioid-na€ıve
adults (strong recommendation, moderate-
quality evidence).

of sedation, respiratory status, and other
adverse events in patients who receive sys-
temic opioids for postoperative analgesia
dence).
15. Clinicians provide adults and children with
acetaminophen and/or nonsteroidal anti-
inflammatory drugs (NSAIDs) as part of
multimodal analgesia for management of
postoperative pain in patients without con-
traindications (strong recommendation,
high-quality evidence).
16. Clinicians consider giving a preoperative
dose of oral celecoxib in adult patients
without contraindications (strong recom-
17. Clinicians consider use of gabapentin
or pregabalin as a component of multi-
modal analgesia (strong recommendation,

18. Clinicians consider IV ketamine as a
component of multimodal analgesia in
adults (weak recommendation, moderate-
quality evidence).
19. Clinicians consider IV lidocaine infusions
in adults who undergo open and laparo-
scopic abdominal surgery who do not
have contraindications (weak recommen-
20. Clinicians consider surgical site-specific
local anesthetic infiltration for surgical pro-
cedures with evidence indicating efficacy
evidence).
21. Clinicians use topical local anesthetics in
combination with nerve blocks before

circumcision (strong recommendation,
The panel does not recommend:
22. Intrapleural analgesia with local anes-
thetics for pain control after thoracic sur-
gery (strong recommendation, moderate-
quality evidence).
23. Clinicians consider surgical site-specific pe-
ripheral regional anesthetic techniques in
adults and children for procedures with ev-
idence indicating efficacy (strong recom-
mendation, high-quality evidence).
24. Clinicians use continuous, local anesthetic-
based peripheral regional analgesic tech-
niques when the need for analgesia is
likely to exceed the duration of effect of a
single injection (strong recommendation,

25. Clinicians consider the addition of cloni-
dine as an adjuvant for prolongation of anal-
gesia with a single-injection peripheral
26. Clinicians offer neuraxial analgesia for ma-
jor thoracic and abdominal procedures,
particularly in patients at risk for cardiac
complications, pulmonary complications,
or prolonged ileus (strong recommenda-
27. Clinicians avoid the neuraxial administra-
tion of magnesium, benzodiazepines,
neostigmine, tramadol, and ketamine in
the treatment of postoperative pain (strong

dence).
of patients who have received neuraxial in-
terventions for perioperative analgesia
dence).
Procedures
have an organizational structure in place
to develop and refine policies and proced-
ures for safe and effective delivery of
postoperative pain control (strong recom-
provide clinicians with access to consulta-
tion with a pain specialist for patients
with inadequately controlled postopera-

tive pain or at risk of inadequately
controlled postoperative pain (eg, opioid
tolerant, history of substance abuse)
dence).
31. Facilities in which neuraxial analgesia and
continuous peripheral blocks are per-
formed have policies and procedures to
support their safe delivery and trained in-
dividuals to manage these procedures
dence).
32. Clinicians provide education to all patients
(adults and children) and primary care-
givers on the pain treatment plan including
tapering of analgesics after hospital
discharge (strong recommendation, low-
quality evidence).

Perianesthesia Nursing
Recommendations
Awareness of the content in the APS Guidelines in
the Management of Postoperative Pain7 is impor-
tant for nurses working in perianesthesia settings.
A complete review of the article, along with a
focused examination of recommendations specific
to their roles, will provide valuable information.
Recommendations related to preoperative educa-
tion, pain assessment, multimodal therapies, use
of physical and cognitive behavioral modalities,
use of systemic, local, and/or topical pharmacolog-
ical therapies, use of peripheral regional anes-
thesia and neuraxial therapies, and outpatient
care transitions have particular applicability to
the nurse in a direct care provider role. Some
specific content applicable to the practice of the
perianesthesia nurse is addressed in the following
paragraphs.
The guideline development panel members

recommend preoperative education and perioper-
ative pain management planning, and cite studies
which show that educational programs individu-
ally designed for surgical patients with specific
medical, developmental, psychological, or social
needs have been found to reduce opioid consump-
tion, preoperative anxiety, requests for sedating
medications, and postoperative lengths of stay.7
There is no strong evidence to support the use of
one educational intervention over another or the
timing and content of interventions. However, it
is recommended that content includes specific in-
formation related to analgesic use before surgery
(continuation, discontinuation, or changes) to
avoid withdrawal syndrome (such as is possible
with opioids, benzodiazepines, gabapentin, and
baclofen), prevent surgical complications (eg,
aspirin and hemorrhage), and improve postopera-
tive pain control (eg, routine use of nonopioid

PAIN MANAGEMENT 449
analgesics).7 Preoperative education related to the
use of pain assessment tools, realistic pain goals,
and how and when to report pain is advised. It is
important to address specific pain-related expecta-
tions and misconceptions, and inform patients
about the effects and possible adverse effects of
postoperative pain interventions. If patients will
be using postoperative devices and modalities
(eg, IV PCA), they/significant others should be in-
structed in the use of the modalities preopera-
tively. The pain management plan should be
developed preoperatively through shared
decision-making with the patient/parent/signifi-
cant other, based on an assessment of the individ-
ual patient’s history, condition, needs, and risks.
The panel identifies the importance of an assess-
ment of substance use and abuse (opioids, benzo-
diazepines, cocaine, alcohol and other substances

that may affect pain management) to guide devel-
opment of the postoperative pain management
plan. The role of the perianesthesia nurse in assess-
ing pain and patient responses to analgesic inter-
ventions is critical in assuring the re-evaluation
and adjustment of the pain management plan.
The panel emphasizes the importance of the use of
validated instruments to assess pain.7 Patient self-
report, not behaviors or vital signs, is the primary
basis of pain assessment. Behaviors and the input
from caregivers are used to assess pain when the
patient cannot self-report. Pain should be assessed
during rest and activity. There are no clear recom-
mendations as to the optimal timing and frequency
of assessment, but after analgesic administration,
reassessment should occur by the time the medica-
tion reaches peak effect (15 to 30 minutes after
parenteral analgesics and 1 to 2 hours after oral
agents).7

The use of multimodal analgesia, including phar-
macological and nonpharmacological interven-
tions, is recommended in the management of
postoperative pain. It is noted that a number of
different combinations of pharmacological and
nonpharmacological approaches are possible and
may vary depending on the type of surgery, patient
condition, and preferences.7 Within the guide-
lines, there are some specific recommendations
for the particular multimodal approach based on
the type of surgical procedure. The use of TENS,
inexpensive, small, portable devices that deliver
a small low-voltage electrical impulse through
electrodes on the skin has been shown to reduce
pain through the descending inhibitory pain path-
ways which activate opioid receptors.7 The panel
cites studies that have demonstrated reductions
in postoperative analgesic requirements. In most
cases, TENS electrodes were applied near the sur-
gical incision. There is insufficient evidence to

recommend the use of acupuncture. Other phys-
ical modalities such as acupressure, massage,
cold therapy, immobilization, and bracing are
generally safe, but there is a lack of evidence to
recommend their use. As components of a multi-
modal plan, cognitive behavioral therapies such
as hypnosis, guided imagery, music, and relaxation
methods have shown some positive effects on
postoperative pain, anxiety, or analgesic use, but
few studies of these modalities have been conduct-
ed with children.7
Multimodal pharmacological approaches are rec-
ommended. Oral opioids, when possible, are
preferred over IV administration as there is no
strong evidence to show that IV therapy provides
superior relief of pain.7 The use of short-acting opi-
oids, administered around the clock in the immedi-
ate postoperative period, is recommended.7
Except if used preoperatively, long-acting opioids

should not be used for postoperative pain manage-
ment. Intramuscular injections should be avoided
as they do not provide reliable effects and show
no superiority over other routes.7 The guidelines
support the use of IV PCA, without the use of a
basal infusion, when IV opioids are needed as IV
PCA has been shown to provide greater effective-
ness and patient satisfaction.7 To reduce the risk
of opioid-related adverse events, the panel re-
commends close monitoring of sedation level
and respiratory status, especially in the hours
immediately after surgery or with dose changes.7
There is no clear recommendation for the use of
pulse oximetry, capnography, or other monitoring
methods due to a lack of evidence.7 Identification
of patients at increased risk for opioid-related
adverse events is advised, and interventions to
minimize risks, including dose adjustments, are
recommended.7

Nonopioids are recommended as components of a
multimodal analgesic plan.7 The panel cites evi-
dence that shows that acetaminophen and NSAIDs
reduce pain and opioid requirements in postsur-
gical patients. NSAIDs are associated with risks,
including gastrointestinal bleeding, anastomotic
leakage in colorectal surgery, and cardiovascular
events and renal dysfunction, which must be
considered and may contraindicate their use in
some postsurgical patients.7 NSAIDs and cele-
coxib are contraindicated for perioperative pain
management in patients undergoing coronary ar-
tery bypass grafting.7 Perianesthesia nurses may
be aware of the reluctance of some orthopaedic
surgeons to use NSAIDs for their patients due to
concerns of bone nonunion after certain surgical
procedures, but the panel notes that there is insuf-

ficient evidence to recommend against the use of
NSAIDs for orthopaedic fractures and spinal fusion
and identifies the need for informed decision-
making and consideration of alternatives by the
surgeon and the patient.7 Celecoxib, in doses of
200 to 400 mg administered 30 to 60 minutes pre-
operatively to adults is recommended for postsur-
gical pain and opioid requirement reducing
benefits.7 The panel cites evidence that doses of
gabapentin (600 or 1,200 mg) or pregabalin (150
or 300 mg) administered 1 to 2 hours preopera-
tively to adults are effective components of a multi-
modal plan, and postoperative dosing has shown
effectiveness in some trials.7
Additional multimodal pharmacological interven-
tions that perianesthesia nurses may be less
familiar with are also recommended in the guide-
lines. Although the panel is unable to identify suf-
ficient evidence for optimal dosing of IV ketamine,
it recommends a preoperative bolus of 0.5 mg/kg

followed by an infusion of 10mcg/kg/minute intra-
operatively, and a lower dosage postoperative infu-
sion as a multimodal analgesic component for
adult surgical patients to reduce postoperative
pain, analgesic use, and possibly the risk of persis-
tent postsurgical pain.7 Evidence is cited to sup-
port the use of IV lidocaine infusions in adults
undergoing open and laparoscopic abdominal sur-
geries as this intervention is associated with
shorter duration of ileus and improved analgesia.7
The panel recommends an initial bolus dose of
1.5 mg/kg followed by an infusion of 2 mg/kg/
hour during surgery; insufficient evidence is cited
to recommend postoperative use.7
Site-specific peripheral regional local anesthetic in-
jections, and in some cases, continuous infusions
are supported in the guidelines. Neuraxial
(epidural or spinal) analgesia is recommended for
the management of major thoracic, abdominal, ce-

sarean section, hip, and lower extremity sur-
geries.7 The neuraxial approach may reduce risks
of postoperative mortality, venous thromboembo-
lism, myocardial, infarction, pneumonia, respira-
tory depression, and may decrease duration of an
ileus.7 The panel notes that epidural analgesia
has the advantage over spinal analgesia as an
epidural can be used as a continuous infusion
with or without PCA and can be used to deliver
local anesthetics. Epidural clonidine is sometimes
used with local anesthetics to improve postopera-
tive pain, but evidence is lacking and it may be
associated with increased hypotension.7 Perianes-
thesia nurses need to be competent in the assess-
ment of patients who have received peripheral
regional anesthesia and neuraxial anesthetics/anal-
gesics and must be aware of the signs, symptoms,
and emergencymanagement of any complications,
including local anesthetic toxicity. Some orthopae-

dic surgeries are associated with an increased risk
for compartment syndrome, and signs and symp-
toms may be diminished or masked with regional
and neuraxial techniques. When opioids are used
in spinal or epidural analgesia, patients must be
monitored for opioid-related adverse outcomes.
In addition, patients who have received neuraxial
analgesia are at risk for spinal cord compression.
Perianesthesia nurses must be educated about
these potential complications and prepared to
implement appropriate emergency measures.
Perianesthesia nurses have significant roles in
assuring appropriate transitions of patient care.
The panel recommends that all patients and/or
caregivers receive a coordinated approach to
discharge planning and discharge teaching from
all involved disciplines (surgeons, nurses, thera-
pists, pharmacists). It is necessary to provide in-
structions in the safe and appropriate use of
pain medications and side effect management.

Discharge teaching should include warnings about
the life-threatening risks of concomitant use of
alcohol and other central nervous system depres-
sants when opioids are used. Teaching should also
include an individualized plan for opioid weaning
and discontinuation and safe storage and disposal
of opioids and other medications.7 Clear evidence
to guide the method for postsurgical opioid wean-
ing is not available, but the panel notes that severe
postoperative pain usually diminishes rapidly in the
first few days after surgery. For minor surgeries,
PAIN MANAGEMENT 451
pain may be controlled with nonopioid analgesics
or a very limited opioid supply after discharge. In
patients with more involved surgeries, a longer
course of postoperative analgesics, including opi-
oids, may be needed. If used for more than 1 to
2 weeks, a gradual opioid reduction is suggested

to prevent withdrawal, with dose reductions by
20% to 25% of the discharge dose every 1 to 2 days.7
Conclusion
The above statements constitute key recommen-
dations contained in the APS Postoperative Pain
Guidelines. In addition, the guidelines include
elaboration on each of the recommendations, a
list of interventions for the management of postop-
erative pain in patients receiving long-term opioid
therapy, a table of options for components of a
multimodal analgesic surgery-specific approach,
and a summary table of interventions for manage-
ment of postoperative pain. Perianesthesia nurses
may find it helpful to review the guidelines to
inform various aspects of their clinical practice.
It is important to note that clinical practice guide-
lines are general statements that do not dictate
practice, but provide guidance for practice based
on the evidence available at the time they are writ-

ten. They do not apply to all patients, as individual
patients and clinical scenarios may not be appro-
priate for implementation of the recommenda-
tions, but require patient-specific approaches
based on assessment and consideration of individ-
ual patient needs and resources. In examining each
recommendation, it is important to note that
despite a comprehensive review of the literature,
only 4 of the 32 recommendations have a high-
quality evidence rating.7,8
High-quality evidence was only found to support
the use of multimodal analgesia, including the
use of acetaminophen and NSAIDs, site-specific
peripheral regional anesthetic techniques, and
neuraxial analgesia with opioids and local anes-
thetics for thoracic and abdominal procedures.7,8
Although there are 28 other recommendations,
they are rated with moderate- or low-quality evi-
dence because the panel identified significant

research gaps in the evidence review.7,8
However, despite the lack of high-quality evi-
dence, these recommendations reflect the panel’s
near-unanimous consensus on all the recommen-
dations.7 The task of developing evidence-based
guidelines presents challenges; There are limita-
tions in the ability to gather and synthesize all
high-quality studies that are available related to
an area as broad as postoperative pain, and even
as available evidence is analyzed and recommen-
dations are developed, additional studies are
completed and newer evidence surfaces.8 This
further highlights the necessity of individualizing
patient care and using informed clinical judgment
over strict adherence to recommendations con-
tained in the guidelines. It also demonstrates the
significant need for additional research to address
the gaps in evidence related to the management
of postoperative pain.
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esthesiologists’ Committee on Regional Anesthesia, Executive
Committee, and Administrative Council. J Pain. 2016;17:
131-157.
8. Gordon DB, de Leon-Casasola OA, Wu CL, Sluka KA,
Brennan TJ, Chou R. Research gaps in practice guidelines for
acute postoperative pain management in adults: Findings
from a review of the evidence for an American Pain Society
clin-
ical practice guideline. J Pain. 2016;17:158-166.

9/sref8Postoperative Pain Management: Clinical Practice
GuidelinesMethodology for Guideline DevelopmentKey
RecommendationsPreoperative Education and Perioperative
Pain Management PlanningMethods of AssessmentGeneral
Principles Regarding the Use of Multimodal TherapiesUse of
Physical ModalitiesUse of Cognitive Behavioral ModalitiesUse

of Systemic Pharmacological TherapiesUse of Local and/or
Topical Pharmacological TherapiesUse of Peripheral Regional
AnesthesiaUse of Neuraxial TherapiesOrganizational Structure,
Policies, and ProceduresTransitioning to Outpatient
CarePerianesthesia Nursing
RecommendationsConclusionReferences
The Journal of Pain, Vol 17, No 2 (February), 2016: pp 131-157
Available online at www.jpain.org and www.sciencedirect.com
Guidelines on the Management of Postoperative Pain
Management of Postoperative Pain: A Clinical Practice
Guideline
From the American Pain Society, the American Society of
Regional
Anesthesia and Pain Medicine, and the American Society of
Anesthesiologists’ Committee on Regional Anesthesia,
Executive
Committee, and Administrative Council
Roger Chou,* Debra B. Gordon,y Oscar A. de Leon-Casasola,z
Jack M. Rosenberg,x
Stephen Bickler,{ Tim Brennan,k Todd Carter,** Carla L.
Cassidy,yy Eva Hall Chittenden,zz
Ernest Degenhardt,xx Scott Griffith,{{ Renee Manworren,kk
Bill McCarberg,***
Robert Montgomery,yyy Jamie Murphy,zzz Melissa F.
Perkal,xxx Santhanam Suresh,{{{

Kathleen Sluka,kkk Scott Strassels,**** Richard Thirlby,yyyy
Eugene Viscusi,zzzz
Gary A. Walco,xxxx Lisa Warner,{{{{ Steven J. Weisman,kkkk
and Christopher L. Wuzzz
*Departments of Medicine, and Medical Informatics and
Clinical Epidemiology, Oregon Health and Science University,
Pacific Northwest Evidence Based Practice Center, Portland,
Oregon.
yDepartment of Anesthesiology and Pain Medicine, University
of Washington, Seattle, Washington.
zDepartment of Anesthesiology and Pain Medicine, Roswell
Park Cancer Institute and University at Buffalo School of
Medicine and Biomedical Sciences, Buffalo, New York.
xVeterans Integrated Service Network, Department of Veterans
Affairs and Departments of Physical Medicine and
Rehabilitation and Anesthesiology, University of Michigan, Ann
Arbor, Michigan.
{Pediatric Surgery, University of California, San Diego, San
Diego, California.
kDepartment of Anesthesia, University of Iowa Hospitals and
Clinics, Iowa City, Iowa.
**Department of Anesthesia, University of Cincinnati,
Cincinnati, Ohio.
yyDepartment of Veterans Affairs, Veterans Health
Administration, Washington, DC.
zzDepartment of Palliative Care, Massachusetts General
Hospital, Boston, Massachusetts.
xxQuality Management Division, United States Army Medical
Command, San Antonio, Texas.
{{Critical Care Medicine, Walter Reed Army Medical Center,
Bethesda, Maryland.
kkDepartment of Pediatrics, University of Connecticut School
of Medicine, Mansfield, Connecticut.

***American Academy of Pain Medicine, San Diego,
California.
yyyDepartment of Anesthesiology, University of Colorado,
Denver, Denver, Colorado.
zzzDepartment of Anesthesiology and Critical Care Medicine,
Johns Hopkins University, Baltimore, Maryland.
xxxDepartment of Surgery, Veterans Affairs Medical Center,
West Haven, Connecticut.
{{{Department of Pediatric Anesthesia, Children’s Hospital of
Chicago, Chicago, Illinois.
kkkDepartment of Physical Therapy and Rehabilitation,
University of Iowa, Iowa City, Iowa.
****College of Pharmacy, University of Texas at Austin,
Austin, Texas.
yyyyBariatric Weight Loss Surgery Center, Virginia Mason
Medical Center, Seattle, Washington.
zzzzDepartment of Anesthesiology, Thomas Jefferson
University, Philadelphia, Pennsylvania.
xxxxDepartment of Anesthesiology and Pain Medicine, Seattle
Children’s Hospital, Seattle, Washington.
{{{{Department of Veteran Affairs, Phoenix, Arizona.
kkkkDepartment of Anesthesiology, Children’s Hospital of
Wisconsin, Wauwatosa, Wisconsin.
Received October 28, 2015; Revised December 11, 2015;
Accepted
December 14, 2015.
Funding for this guideline was provided by the American Pain
Society.
The guideline was submitted for approval by the partnering
organiza-
tions, but the content of the guideline is the sole responsibility
of the au-
thors and panel members.
All panelists were required to disclose conflicts of interest
within the pre-
ceding 5 years at all face-to-face meetings and before

submission of the
guideline for publication, and to recuse themselves from votes
if a
conflict was present. Conflicts of interest of the authors and
panel
members are listed in Supplementary Appendix 1.
Supplementary data accompanying this article are available
online at
www.jpain.org and www.sciencedirect.com.
Address reprint requests to Roger Chou, MD, 3181 SW Sam
Jackson Park
Road, Mail code BICC, Portland, OR 97239. E-mail:
[email protected]
1526-5900/$36.00
ª 2016 by the American Pain Society
http://dx.doi.org/10.1016/j.jpain.2015.12.008
131
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http://www.jpain.org
http://www.sciencedirect.com
http://www.jpain.org
http://www.sciencedirect.com
M
132 The Journal of Pain Management of Postoperative Pain
Abstract: Most patients who undergo surgical procedures
experience acute postoperative pain, but ev-
idence suggests that less than half report adequate postoperative
pain relief. Many preoperative, intra-
operative, and postoperative interventions and management
strategies are available for reducing and
managing postoperative pain. The American Pain Society, with
input from the American Society of Anes-
thesiologists, commissioned an interdisciplinary expert panel to
develop a clinical practice guideline to
promote evidence-based, effective, and safer postoperative pain

management in children and adults.
The guideline was subsequently approved by the American
Society for Regional Anesthesia. As part of
the guideline development process, a systematic review was
commissioned on various aspects related
to various interventions and management strategies for
postoperative pain. After a review of the evi-
dence, the expert panel formulated recommendations that
addressed various aspects of postoperative
pain management, including preoperative education,
perioperative pain management planning, use of
different pharmacological and nonpharmacological modalities,
organizational policies, and transition
tooutpatient care. The recommendations are based on the
underlying premise that optimalmanagement
begins in the preoperative period with an assessment of the
patient and development of a plan of care
tailored to the individual and the surgical procedure involved.
The panel found that evidence supports
the use of multimodal regimens in many situations, although the
exact components of effective multi-
modal care will vary depending on the patient, setting, and
surgical procedure. Although these guide-
lines are based on a systematic review of the evidence on

management of postoperative pain, the
panel identified numerous research gaps. Of 32
recommendations, 4 were assessed as being supported
by high-quality evidence, and 11 (in the areas of patient
education and perioperative planning, patient
assessment, organizational structures and policies, and
transitioning to outpatient care) were made on
the basis of low-quality evidence.
Perspective: This guideline, on the basis of a systematic review
of the evidence on postoperative pain
management, provides recommendations developed by a
multidisciplinary expert panel. Safe and effec-
tivepostoperativepain management should beonthebasisofaplan
ofcaretailoredtothe individualand
the surgical procedure involved, and multimodal regimens are
recommended in many situations.
ª 2016 by the American Pain Society
Key words: Postoperative pain management, clinical practice
guidelines, analgesia, education, multi-
modal therapy, patient assessment, regional analgesia, neuraxial
analgesia.
ore than 80% of patients who undergo surgical
procedures experience acute postoperative
pain and approximately 75% of those with post-
operative pain report the severity as moderate, severe, or
extreme.12,96 Evidence suggests that less than half of

patients who undergo surgery report adequate
postoperative pain relief.12 Inadequately controlled
pain negatively affects quality of life, function, and func-
tional recovery, the risk of post-surgical complications,
and the risk of persistent postsurgical pain.165
Many preoperative, intraoperative, and postoperative
interventions and management strategies are available
and continue to evolve for reducing and managing post-
operative pain. The American Pain Society (APS), with
input from the American Society of Anesthesiologists
(ASA), commissioned a guideline on management of post-
operative pain to promote evidence-based, effective, and
safer postoperative pain management in children and
adults, addressing areas that include preoperative educa-
tion, perioperative pain management planning, use of
different pharmacological and nonpharmacological mo-
dalities, organizational policies and procedures, and tran-
sition to outpatient care. The ASA published a practice
guideline for acute painmanagement inthe perioperative
setting in 20126; the APS has not previously published
guidelines on management of postoperative pain. After
completion, the guideline was also reviewed for approval
by the American Society of Regional Anesthesia and Pain
Medicine.
Methods
Panel Composition
The APS, with input from the ASA, convened a panel of
23 members with expertise in anesthesia and/or pain
medicine, surgery, obstetrics and gynecology, pediatrics,
hospital medicine, nursing, primary care, physical
therapy, and psychology to review the evidence and
formulate recommendations on management of
postoperative pain (see Supplementary Appendix 1 for

a list of panel members). Three cochairs (D.B.G. [selected
by the APS], O.d.L.-C. [selected by the ASA], and J.M.R.)
were selected to lead the panel, which also included
the APS Director of Clinical Guidelines Development
(R.C.).
Target Audience and Scope
The intent of the guideline is to provide evidence-
based recommendations for management of postopera-
tive pain. The target audience is all clinicians who
manage postoperative pain. Management of chronic
pain, acute nonsurgical pain, dental pain, trauma pain,
and periprocedural (nonsurgical) pain are outside the
scope of this guideline.
Evidence Review
This guideline is informed by an evidence review con-
ducted at the Oregon Evidence-Based Practice Center
Chou et al The Journal of Pain 133
and commissioned by APS.51 With the Oregon Evidence-
Based Practice Center, the panel developed the key ques-
tions, scope, and inclusion criteria used to guide the evi-
dence review. Literature searches were conducted
through November 2012. The full search strategy,
including the search terms and databases searches, is
available in the evidence review. Investigators reviewed
6556 abstracts from searches for systematic reviews and
primary studies from multiple electronic databases,
reference lists of relevant articles, and suggestions from
expert reviewers. A total of 107 systematic reviews and
858 primary studies (not included in previously published

systematic reviews) were included in the evidence
report.51 Updated searches were conducted through
December 2015. New evidence was reviewed and judged
to be consistent with the recommendations in this guide-
line, which was updated with new citations as relevant.
Grading of the Evidence and
Recommendations
The panel used methods adapted from the Grading of
Recommendations Assessment, Development, and Eval-
uation Working Group to rate the recommendations
included in this guideline.118 Each recommendation
received a separate grade for the strength of the recom-
mendation (strong or weak) and for the quality of evi-
dence (high, moderate, or poor) (Supplementary
Appendix 2). In general, a strong recommendation is
on the basis of the panel’s assessment that the potential
benefits of following the recommendation clearly
outweigh potential harms and burdens. In light of the
available evidence, most clinicians and patients would
choose to follow a strong recommendation. A weak
recommendation is on the basis of the panel’s assessment
that benefits of following the recommendation
outweigh potential harms and burdens, but the balance
of benefits to harms or burdens is smaller or evidence is
weaker. Decisions to follow a weak recommendation
could vary depending on specific clinical circumstances
or patient preferences and values. For grading the qual-
ity of a body of evidence that supports a recommenda-
tion, we considered the type, number, size, and quality
of studies; strength of associations or effects; and consis-
tency of results among studies.118
Guideline Development Process
The guideline panel met in person in August 2009 and

January 2011. At the first meeting, the panel developed
the scope and key questions used to guide the systematic
evidence review. At the second meeting, the panel re-
viewed the results of the evidence review and drafted
initial potential recommendation statements. After the
second meeting, additional draft recommendation state-
ments were proposed. The panelists then participated in
a multistage Delphi process, in which each draft recom-
mendation was ranked and revised. At each stage of
the Delphi process, the lowest-ranked recommendations
were eliminated. A two-thirds majority was required for
a recommendation to be approved, although unanimous
or near-unanimous consensus was achieved for all rec-
ommendations. Persons who had conflicts of interest
were recused from voting on recommendations poten-
tially affected by the conflicts. After finalization of the
recommendations, the guideline was written by panel
subgroups and drafts distributed to the panel for feed-
back and revisions. More than 20 external peer reviewers
were solicited for additional comments on the draft
guideline. After another round of revisions and panel
approval, the guideline was submitted to the APS and
ASA for approval. The guideline was approved by the
APS Board of Directors in April 2015 and by the ASA’s
Committee on Regional Anesthesia, Executive Commit-
tee, and Administrative Council in October 2015. It was
also approved by the American Society of Regional Anes-
thesia Board of Directors in August 2015.
The APS intends to update this guideline and the evi-
dence report used to develop it by 2021, or earlier if crit-
ical new evidence becomes available. Recommendations
that do not specifically state that they are for adults or
children are general recommendations across age
groups.

Recommendations
Preoperative Education and
Perioperative Pain Management
Planning
Recommendation 1
� The panel recommends that clinicians provide pa-
tient and family-centered, individually tailored edu-
cation to the patient (and/or responsible caregiver),
including information on treatment options for
management of postoperative pain, and document
the plan and goals for postoperative pain manage-
ment (strong recommendation, low-quality evi-
dence).
Individually tailored programs of education and sup-
port for patients with more intensive needs (eg, due to
medical or psychological comorbidities or social factors)
who undergo surgery are associated with beneficial ef-
fects including reduced postoperative opioid consump-
tion,73,172 less preoperative anxiety,9,42,57,69 fewer
requests for sedative medications,172 and reduced length
of stay after surgery.15,57,73,308 Although studies of
patients without more intensive needs did not clearly
show beneficial clinical effects of preoperative
educational interventions, the panel believes such
interventions remain of value for helping to inform
patients regarding perioperative treatment options
and to engage them in the decision-making process.
Educational interventions can range from single epi-
sodes of face-to-face instruction or provision of written
materials, videos, audiotapes, or Web-based educational
information to more intensive, multicomponent preop-
erative interventions including individualized and super-

vised exercise, education, and telephone calls. There is
insufficient evidence to determine the comparative
effectiveness of different educational interventions or
to recommend specific interventions, but the diversity
of clinical situations, patient needs, and patient prefer-
ences support the need for an individualized approach.
Such an individualized approach to preoperative educa-
tion includes provision of information that is ‘‘age-
appropriate, geared to the person’s and family’s level
of comprehension and general health literacy, cultural
and linguistic competency, and supported by timely op-
portunities to ask questions and receive authoritative
and useful answers.’’56
Although the optimal timing and content of preoper-
ative education is uncertain, the panel suggests that
preoperative education routinely include information
regarding indicated changes in use of analgesics before
surgery (eg, discontinuation of aspirin for procedures
in which hemorrhage would present high risks or in pa-
tients at high risk of hemorrhage) and continuation of
medications (eg, opioids, benzodiazepines, gabapenti-
noids, or baclofen) to avoid a withdrawal syndrome,
unless there is a specific plan to taper. Although use of
opioids before surgery is associated with greater postop-
erative analgesic requirements,221 there is insufficient
evidence to recommend routinely decreasing opioid
doses or discontinuing opioids before surgery. Patients
receiving long-term opioid therapy before surgery might
benefit from routine use of nonopioid adjuvant
medications that might reduce postoperative opioids
requirements (see Recommendation 30). Education or

counseling should also include information about how
pain is reported and assessed (including use of pain
assessment tools), when to report pain, individualized
options for perioperative pain management (in many
cases including a multimodal pharmacologic and non-
pharmacologic approach), and realistic goals for pain
control. When certain cognitive modalities are planned,
preoperative training of patients can enhance effective-
ness (see Recommendation 9). Education should also aim
to correct any underlying misperceptions about pain and
analgesics (eg, beliefs that pain after surgery does not
warrant treatment, that health care providers will only
respond to extreme expressions of pain, that opioids
are always required for postoperative pain, or that
opioid use inevitably leads to addiction).56 Pregnant
women who undergo surgery should be informed about
potential effects of treatment options on the fetus and
newborn, including effects of in utero and breastfeeding
exposure to opioids or other medications for manage-
ment of postoperative pain.148
Recommendation 2
� The panel recommends that the parents (or other
adult caregivers) of children who undergo surgery
receive instruction in developmentally-appropriate
methods for assessing pain as well as counseling on
appropriate administration of analgesics and mo-
dalities (strong recommendation, low-quality evi-
dence).
The panel recommends that clinicians provide devel-
opmentally appropriate information to children and
their parents, to better inform and engage them in
care. Research showing effectiveness of preoperative
child or parental educational interventions on postoper-

ative clinical outcomes in children who undergo surgery
is limited.46,143,258 However, preoperative education
might help address parental barriers to appropriate
management of postoperative pediatric pain, such as
uncertainty regarding how to evaluate pain and
reluctance to use pain medication because of fears of
addiction, although more research is needed to
understand optimal methods of preoperative parental
education.159,160 Reduction of parental anxiety
regarding postoperative pain might be associated with
decreased reports of pain and pain behaviors in
children, perhaps mediated in part by changes in how
analgesics are administered by the parents.121 Suggested
components of education include parental preparation
for what to expect regarding the child’s postoperative
course and information on how to help children cope
with perioperative pain.143,200
Studies on the accuracy and usefulness of parents’
assessment of children’s pain are mixed. Although
some studies indicate better correlation between parent
and child pain ratings than those of health care providers
and children, other studies indicate that parents
frequently under- or overestimate their child’s postsur-
gical pain.49,121,143,159,264 Therefore, although the panel
recommends that parents receive education on
methods for assessing postoperative pain in children,
there is insufficient evidence to recommend a specific
method. Better validation of pain assessment tools for
parents to assess their children’s pain and evaluations
of the usefulness of explicit written instructions to
supplement verbal discharge directions would help to
better inform optimal methods for providing
postdischarge pain management in children.88,160
Recommendation 3

� The panel recommends that clinicians conduct a pre-
operative evaluation including assessment of medi-
cal and psychiatric comorbidities, concomitant
medications, history of chronic pain, substance
abuse, and previous postoperative treatment regi-
mens and responses, to guide the perioperative
pain management plan (strong recommendation,
Clinicians should perform a thorough history and phys-
ical examination to develop an individually tailored pain
management plan through a shared decision-making
approach. The pain management plan should be on
the basis of evidence regarding effective interventions
for the specific surgery or surgical site in question, modi-
fied by factors unique to the patient, including previous
experiences with surgery and postoperative treatment,
medication allergies and intolerances, cognitive status,
comorbidities, preferences for treatment, and treatment
goals. Research in other areas of pain and health care in-
dicates that patients engaged in collaborative care
including shared decision-making with their providers
experience better health outcomes.70,133
Although no study has specifically evaluated the use-
fulness of individual components of the preoperative
history and physical, an assessment of past and current
history of pain (including the use of, response to, and
preferences regarding analgesics), and presence of med-
ical comorbidities (eg, bleeding disorders or previous spi-
nal surgery are relative contraindications to the use of

epidural or spinal techniques) and psychiatric comorbid-
ities (eg, anxiety, depression, and maladaptive coping
behaviors such as catastrophizing) are critical for devel-
oping an appropriate postoperative pain management
plan. It is also important to assess for a history of physical
dependence or tolerance to opioids and previous or cur-
rent substance use disorder because their presence might
be associated with increased opioid requirements and
delayed recovery in the postoperative period,221 and to
assess for risk factors for opioid misuse, which might
affect medication choices, follow-up, monitoring, and
tapering protocols. In addition to use of opioids, the his-
tory should also attempt to identify in a nonjudgmental
manner use and abuse of benzodiazepines, cocaine,
alcohol, and other psychoactive substances that might
affect pain management.
Recommendation 4
� The panel recommends that clinicians adjust the
pain management plan on the basis of adequacy
of pain relief and presence of adverse events (strong
Provision of optimal pain management requires
ongoing reassessments to determine the adequacy of
pain relief, detect adverse events early, and help monitor
progress toward functional goals. Clinicians should be
prepared to adjust the pain management plan postoper-
atively when pain relief is inadequate or to address or
avert adverse events. For example, some patients might
develop respiratory depression requiring rapid reduction
of opioids and close monitoring, or other measures de-
pending on the urgency of the situation. Individual dif-
ferences in response to analgesics and other
interventions are well recognized and support an individ-

ualized and flexible approach to pain management.5,108
Table 1. Examples of Validated Pain Intensity
Assessment Scales
NAME OF SCALE RATING SYSTEM
NRSs Six-point NRS (NRS 0-5)207
Eleven-point NRS (NRS 0-10)24,25,53,95
Twenty-one point NRS (NRS 0-20)50,131,281
VRS Four-point VRS53
Seven-point Graphic Rating Scale24,25
Six-point Present Pain Inventory
(PPI)94,95,157,201,223
Visual Analogue
Scales
Commonly rated 0 to 10 cm or 0 to 100 mm.
Pain Thermometer Combines a visual thermometer with
verbal descriptions of pain130,131
Faces Rating Scales Faces Pain Scale-
Revised31,53,83,93,131,157,273,281
Wong-Baker FACES pain rating scale309,314

Oucher scale27,29
Abbreviations: NRS, Numeric Rating Scale; VRS, Verbal Rating
Scale.
Recommendation 5
� The panel recommends that clinicians use a vali-
dated pain assessment tool to track responses to
postoperative pain treatments and adjust treatment
plans accordingly (strong recommendation, low-
quality evidence).
Pain assessment and reassessment are required to pro-
vide optimal postoperative pain care. Pain assessment
helps determine whether pain management is adequate,
whether analgesic or analgesic dose changes are
required, whether changes in the postoperative pain
management plan or additional interventions are war-
ranted, and in the case of difficult to manage pain
whether specialty consultation or other measures are
needed. Because pain is inherently subjective, patient
self-report is the primary basis of all pain assess-
ments.5,293 For patients who cannot adequately report
their pain because of cognitive deficits, sedation,
developmental stage, or other factors, clinicians might
need to use behavioral assessment tools and solicit
input from caregivers to assess pain.129 In all cases, clini-
cians should not rely solely on ‘‘objective’’ measures such
as pain-related behaviors or vital signs in lieu of patient
self-report to determine the presence of or intensity of
pain because such measures are neither valid nor reli-
able. At similar levels of pain, pain behaviors might
vary markedly between individuals. Therefore, although
assessments of pain behaviors might supplement infor-

mation from self-reported pain, it is important to inter-
pret behavioral observations cautiously.
A number of pain assessment tools have been vali-
dated for accuracy in detecting the presence of and
quantifying the severity of pain, and have been tested
for intrapatient and inter-rater reliability (Table 1).28,30,
41,43,45,100,131,137,140,185,195,197,202,224,225,234,254,27
6,280,295,
297,309 Validated pain assessment tools use different
methods to measure pain, including visual analogue
scales, numeric or verbal rating scales, symbols, and
others. The panel recommends that clinicians use a
validated pain assessment tool, although there is
inadequate evidence on the effects of different pain
assessment tools on postoperative pain outcomes to
guide recommendations on which specific tools to use.
Therefore, the selection of a particular pain assessment
tool should be on the basis of factors such as
developmental status, cognitive status, level of
consciousness, educational level, and cultural and
language differences. In children, the Pediatric
Initiative on Methods, Measurement, and Pain
Assessment in Clinical Trials group suggests the use of
the Face, Legs, Arms, Cry, Consolability and Parents
Post-operative Pain Measure for assessing acute pain in
preverbal and nonverbal children298 on the basis of the
reliability, validity, and ease of use. Tools that have
been developed for use in the intensive care unit setting
include the Behavioral Pain Scale and the Critical-Care
Pain Observation Tool.3,98
Table 2. Suggested Elements of Postoperative Pain Assessment

ELEMENT QUESTIONS USED FOR ASSESSMENT
1. Onset and pattern When did the pain start? How often does it
occur? Has its intensity changed?
2. Location Where is the pain? Is it local to the incisional site,
referred, or elsewhere?
3. Quality of pain What does the pain feel like?
4. Intensity How severe is the pain? (See Table 1)
5. Aggravating and relieving
factors
What makes the pain better or worse?
6. Previous treatment What types of treatment have been
effective or ineffective in the past to relieve the pain?
7. Effect How does the pain affect physical function, emotional
distress, and sleep?
8. Barriers to pain assessment What factors might affect
accuracy or reliability of pain assessments128 (eg, cultural or
language barriers,
cognitive barriers, misconceptions about interventions)?
Pain assessment involves more than just quantifying
the intensity of pain. High pain intensity ratings or behav-
ioral scale scores that do not respond to usual care should
be investigated to determine whether the pain might be

due to a new medical issue or surgical complication and
the potential role of opioid tolerance and psychological
distress. Assessment should determine what interven-
tions have been effective for the pain, how the pain af-
fects function, the type of pain (eg, neuropathic,
visceral, somatic, muscle spasms), and whether there are
barriers to effective pain management, such as cultural
or language differences, cognitive deficits, or patient mis-
conceptions about pain management (Table 2). In addi-
tion, it is not sufficient to assess pain only at rest. Pain
that is relatively well controlled at rest can be severe dur-
ing movement or with specific activities that cause
increased pain (eg, swallowing after tonsillectomy),
with important implications for symptom management
and recovery. The panel suggests that clinicians assess
pain at rest and with activities, as the latter is often
more severe and difficult to control than pain at
rest.110,270 Presence of pain with activity has important
implications for use of additional interventions and
discharge planning. For example, pain that is well
controlled at rest but severe with movement can have
major effects on a patient’s ability to participate in
postsurgical rehabilitation and return to normal
function, and pain with swallowing after tonsillectomy
could increase risk for dehydration. Assessments for
other clinical issues such as sedation, delirium, and
nausea or other side effects related to interventions are
also important to help guide decisions regarding
adjustment of the postoperative pain management plan.
There is insufficient evidence to guide firm recom-
mendations on optimal timing or frequency of patient
reassessments in the postoperative setting. The timing
of assessments after administration of an intervention
should be informed by the time to achieve peak ef-
fects, which is typically 15 to 30 minutes after paren-

teral drug therapy or 1 to 2 hours after
administration of an oral analgesic. With nonpharma-
cologic interventions, pain relief often occurs during
or immediately after their application. The optimal fre-
quency of reassessment is likely to depend on a num-
ber of factors, including the type of surgical
procedure, the adequacy of initial pain relief, the pres-
ence of side effects, presence of comorbidities, and
changes in clinical status. Reassessments might be per-
formed less frequently for patients with more stable
pain (eg, patients who have exhibited good pain con-
trol without side effects after 24 hours of stable ther-
apy). Pain reassessments might be useful at the time
of nursing shift changes or with new caregivers to
establish a baseline and promote continuity of care,
although evidence showing that routine reassessment
of pain at nursing shift changes is associated with
improved clinical outcomes is not available.
Recommendation 6
� The panel recommends that clinicians offer multi-
modal analgesia, or the use of a variety of analgesic
medications and techniques combined with non-
pharmacological interventions, for the treatment
of postoperative pain in children and adults (strong
recommendation, high-quality evidence).
Multimodal analgesia, defined as the use of a variety
of analgesic medication and techniques that target
different mechanisms of action in the peripheral and/or
central nervous system (which might also be combined
with nonpharmacological interventions) might have ad-
ditive or synergistic effects and more effective pain relief

compared with single-modality interventions. For
example, clinicians might offer local anesthetic-based
regional (peripheral and neuraxial) analgesic techniques
in combination with systemic opioids and other analge-
sics as part of a multimodal approach to perioperative
pain. Because of the availability of effective nonopioid
analgesics and nonpharmacologic therapies for postop-
erative pain management, the panel suggests that clini-
cians routinely incorporate around the clock nonopioid
analgesics and nonpharmacologic therapies into multi-
modal analgesia regimens. Systemic opioids might not
be required in all patients. One study suggests that it
should be avoided when not needed, because limited ev-
idence suggests that perioperative opioid therapy might
be associated with increased likelihood of long-term
opioid use, with its attendant risks.4
Randomized trials76,194 have shown that multimodal
analgesia involving simultaneous use of combinations of
several medications acting at different receptors or 1 or
more medications administered through different
techniques (eg, systemically and neuraxially) is
associated with superior pain relief and decreased
opioid consumption compared with use of a single
medication administered through 1 technique, even
after excluding trials that were retracted because of
scientific fraud or were not retracted but authored by
an investigator who admitted to fraud in other
work.238,260 The addition of nonpharmacological
interventions might result in additional effects
consistent with the biopsychosocial model of pain. For
any given situation, a number of potential multimodal

combinations are possible, and different multimodal
regimens might be appropriate, depending on the
specific surgery, individual clinical factors, and patient
preferences. Subsequent sections of this guideline
provide more specific recommendations on the different
components of multimodal analgesia. In general, the
use of local anesthetic-based regional anesthesia tech-
niques for surgical procedures of the extremities,
abdomen, and thorax is encouraged, because of the mul-
tiple trials that showed their effectiveness in combination
with systemic analgesics (see Recommendation 23). Selec-
tion of multimodal therapies is a challenge because for
each surgical procedure, many potential multimodal ther-
apy combinations are possible, but relatively few have
been evaluated in rigorous trials. On the basis of the avail-
able evidence and panel consensus, the options for com-
ponents of multimodal therapy for several commonly
performed surgeries are summarized in Table 3.
Techniques not typically used together are intra-
articular, peripheral regional, and neuraxial techniques.
When using multimodal analgesia, clinicians should be
aware of the different side effect profile for each anal-
gesic medication or technique used, and provide appro-
priate monitoring to identify and manage adverse
events. Studies varied in showing whether multimodal
approaches were associated with a decreased risk of
adverse events than single-modality approaches, de-
pending in part on the specific regimens and compari-
sons evaluated.194
Recommendations 7 and 8
� The panel recommends that clinicians consider
transcutaneous electrical nerve stimulation (TENS)

as an adjunct to other postoperative pain treat-
ments (weak recommendation, moderate-quality
evidence).
� The panel can neither recommend nor discourage
acupuncture, massage, or cold therapy as adjuncts
to other postoperative pain treatments (insufficient
evidence).
Physical modalities include transcutaneous TENS,
acupuncture and related interventions, massage, cold
therapy (with and without compression), localized
heat, warm insufflation, continuous passive motion,
and immobilization or bracing. Although these therapies
are generally considered to be safe, evidence on their
effectiveness as adjunctive therapies as part of a multi-
modal approach to perioperative pain management
varies substantially.
TENS are small portable devices that deliver low-
voltage electrical currents through the skin. TENS is
thought to activate endogenous descending inhibitory
pathways activating opioid receptors to produce
reduced central excitability and reduce pain through
stimulatory effects on large diameter afferent fibers.266
A fair-quality systematic review of >20 randomized trials
found use of TENS associated with approximately 25%
less postoperative analgesic use compared with no
TENS.32 Therefore, the panel recommends clinicians
consider use of TENS as an adjunct to other postoperative
pain management treatments. There is insufficient evi-
dence to recommend specific TENS regimens, although
effects appear stronger in trials in which TENS was
applied using optimal predefined parameters for the
stimulation.23,102,122,132,151,179,267,300 Studies of TENS

most commonly evaluated its effectiveness when
applied near the surgical incision area, although in
some studies TENS was applied to acupoints away from
the incision, with similar effects.
Acupuncture involves the placement of needles into the
body at defined acupuncture points. Related interven-
tions that also involve stimulation of defined acupuncture
points include acupressure (pressure rather than needles
applied to acupuncture points), auricular acupuncture
(acupuncture applied at the ear), electroacupuncture
(electric current applied to needles placed at acupuncture
points on the body), and others. Evidence on the effec-
tiveness of needle acupuncture to the body for postoper-
ative pain in adults is mixed, with some trials showing no
beneficial effects on postoperative pain or analgesic use
compared with sham acupuncture or analgesic
use.65,111,116,170,284,301 Evidence on acupressure,85 auric-
ular acupuncture,291,292,313 and electroacupuncture in
adults,180,190,262,310 and needle acupuncture in
children302,316 is limited and does not clearly show
beneficial effects in management of postoperative pain.
Evidence on massage was limited, and also did not
clearly demonstrate benefits for postoperative
pain.91,124,141,203,230,271
Although other physical modalities are generally
considered to be safe, lack of demonstrated effectiveness
preclude recommendations supporting their use. Costs
for equipment and care provider time should be consid-
ered in relationship to the low probability of patient
benefit before initiating these therapies as adjuvants to
other multimodal postoperative pain treatments.
Cold therapy refers to the superficial application of cold
to the surface of the skin, with or without compression

and with or without a mechanical recirculating device to
maintain cold temperatures. Localized cold therapy has
commonly been used in acute pain, including postopera-
tive pain, with potential benefits at the site of injury
thought to be related to reductions in tissue temperature,
resulting in reduced edema and local analgesia. Trials of
cold therapy were inconsistent and frequently found no
Table 3. Options for Components of Multimodal Therapy for
Commonly Performed Surgeries
TYPE OF SURGERY SYSTEMIC PHARMACOLOGIC
THERAPY
LOCAL, INTRA-ARTICULAR OR TOPICAL
TECHNIQUES* REGIONAL ANESTHETIC TECHNIQUES*
NEURAXIAL ANESTHETIC TECHNIQUES*
NONPHARMACOLOGIC THERAPIESy
Thoracotomy Opioidsz
NSAIDsx and/or acetaminophen
Gabapentin or pregabalinx
i.v. ketamine{
Paravertebral block Epidural with local anesthetic (with
or without opioid), or intrathecal
opioid
Cognitive modalities
TENS

Open laparotomy Opioidsz
i.v. ketamine{
i.v. lidocaine
Local anesthetic at incision
i.v. lidocaine infusion
Transversus abdominis plane block Epidural with local
anesthetic (with
opioid
TENS
Total hip replacement Opioidsz
i.v. ketamine{
Intra-articular local anesthetic and/
or opioid
Site-specific regional anesthetic
technique with local anesthetic
Epidural with local anesthetic (with

opioid
TENS
Total knee replacement Opioidsz
i.v. ketamine{
Intra-articular local anesthetic and/
or opioid
Site-specific regional anesthetic
technique with local anesthetic
opioid
TENS
Spinal fusion Opioidsz
Acetaminopheny
i.v. ketamine{

Local anesthetic at incision Epidural with local anesthetic (with
opioid
TENS
Cesarean section Opioidsz
Local anesthetic at incision Transversus abdominal plane block
opioid
TENS
CABG Opioidsz
Acetaminophen
i.v. ketamine{
TENS
Abbreviation: CABG, coronary artery bypass grafting.

NOTE. Blank cells indicate techniques generally not used for
the procedure in question.
*Intra-articular, peripheral regional, and neuraxial techniques
typically not used together.
yUse as adjunctive treatments.
zUse i.v. PCA when parenteral route needed for more than a few
hours and patients have adequate cognitive function to
understand the device and safety limitations.
xMay be administered preoperatively.
{On the basis of panel consensus, primarily consider for use in
opioid-tolerant or otherwise complex patients.
1
3
8
T
h
e
Jo
u
rn
a
l
o
f
P
a
in
M
a
n
a

g
e
m
e
n
t
o
f
P
o
sto
p
e
ra
tive
P
a
in
differences compared with no cold therapy in postopera-
tive pain or analgesic use.8,20,26,38,54,
61,67,72,87,101,125,136,168,169,176,214,236,253,255,269,299,
306,311 Si-
milarly, there is no clear evidence of beneficial effects
from immobilization, bracing,312 or continuous passive
motion.55,235,299 Evidence on warm insufflation of the
abdominal cavity251 was limited and insufficient to guide
recommendations.
Use of Cognitive–Behavioral Modalities
Recommendation 9

� The panel recommends that clinicians consider the
use of cognitive–behavioral modalities in adults as
part of a multimodal approach (weak recommenda-
A number of cognitive–behavioral modalities have
been evaluated as adjunctive treatments in patients
who undergo surgery. These include guided imag-
ery11,58,119,174,186,229,286,287 and other relaxation
methods,44,60,86,89,106,107,119,204,229,256,304,305,308
hypnosis,16,
79,80,112,123,152,206,277 and intraoperative suggestions33,
34,36,82,150,181,196 (which involve positive suggestions to
patients, usually under anesthesia, about the patient’s
ability to manage and cope with postoperative pain and
recovery from surgery). Music has been evaluated as a
part of multicomponent relaxation interventions, or as a
separate intervention.71,106,107,126,145,174,192,210,211,241,
259,263,282,285,319 Cognitive–behavioral modalities can be
provided to patients by a variety of practitioners,
including psychologists, psychotherapists, nurses,
physicians, social workers, and child life specialists.
Most studies of cognitive–behavioral modalities
showed some positive effects on postoperative pain,
analgesic use, or anxiety, with inconsistent or unclear ef-
fects on duration of hospitalization. In general, cogni-
tive–behavioral modalities are noninvasive, and do not
appear to be associated with significant harm. Although
studies of cognitive–behavioral modalities have primar-
ily been conducted in adults, a small number of studies
of guided imagery and music have been conducted in
children.142,156,171,187,188 Results have been inconsistent
in terms of showing benefit on outcomes related to
postoperative pain, with studies reporting limited

detail on how interventions addressed specific
developmental considerations in children.
The panel recommends that clinicians consider the use
of cognitive–behavioral modalities as part of a multi-
modal approach in adults. There is insufficient evidence
to recommend one specific cognitive–behavioral modality
over another, or to recommend specific techniques. Some
of these techniques, such as guided imagery and some
relaxation methods, appear to require patient engage-
ment in preoperative training for optimal results. A num-
ber of relaxation methods are available and it is uncertain
which method is most effective, or whether the relaxation
intervention is more effective if started before rather than
after surgery. There is insufficient evidence to recommend
for or against cognitive–behavioral modalities in children.
When considering use of cognitive–behavioral modalities,
clinicians should discuss their use with patients and fam-
ilies as part of an overall perioperative management plan.
Use of Systemic Pharmacological
Therapies
Recommendation 10
� The panel recommends oral over intravenous (i.v.)
administration of opioids for postoperative anal-
gesia in patients who can use the oral route (strong
recommendation, moderate quality evidence).
Most evidence suggests that i.v. administration of opi-
oids is not superior for postoperative analgesia
compared with oral administration.245,268 Therefore,
oral administration of opioids is generally preferred for
management of postoperative pain in patients who
can use the oral route. Postoperative pain is often
continuous initially and often requires round-the-clock

dosing during the first 24 hours. Long-acting oral opioids
are generally not recommended or labeled for use in the
immediate postoperative period289 because of the need
to titrate doses and the lack of evidence showing superi-
ority over short-acting oral opioids, with the possible
exception of patients who receive long-acting opioids
before surgery.
Preoperative administration of opioids is not recom-
mended as an intervention to decrease postoperative
pain and/or opioid consumption, because studies show
no clear benefit from this practice.215 Clinicians should
counsel patients to continue regularly prescribed opioids
during the preoperative period unless there is a plan to
taper or discontinue opioids.
Recommendation 11
� The panel recommends that clinicians avoid using
the intramuscular route for the administration of
analgesics for management of postoperative pain
(strong recommendation, moderate-quality evi-
dence).
The use of the intramuscular route for the administra-
tion of analgesics for management of postoperative pain
is discouraged because intramuscular administration can
cause significant pain and is associated with unreliable
absorption, resulting in inconsistent postoperative anal-
gesia. The intramuscular route also has no clearly shown
advantages over other routes (eg, oral, i.v., rectal, or
topical) of medication administration.268,283
Recommendation 12
� The panel recommends that i.v. patient-controlled
analgesia (PCA) be used for postoperative systemic
analgesia when the parenteral route is needed

dence).
When postoperative parenteral administration of an-
algesics is necessary in hospitalized patients because of
ileus, aspiration risk, or after surgical procedures that
affect the ability to take medications orally or enterally,
the panel recommends the use of i.v. PCA. Patients
appropriate for i.v. PCA are those who will require anal-
gesia for more than a few hours and have adequate
cognitive function to understand the device and its
safety limitations. Research indicates that developmen-
tally appropriate children as young as 6 years are able
to use i.v. PCA appropriately.246,252 On the basis of
evidence showing greater effectiveness and patient
satisfaction,139 i.v. PCA is recommended over health
care provider–initiated intermittent bolus dosing of opi-
oids in adults. Administration by proxy should be
avoided in adults, particularly when patients are
sleeping, although limited evidence suggests that it can
be done safely in children.10,205 I.v. boluses of opioids
might be considered in the immediate (first several
hours) postoperative period for more rapid pain relief
and analgesic titration, and in patients with
postoperative sedation who are closely monitored.215
Recommendation 13
� The panel recommends against routine basal infu-
sion of opioids with i.v. PCA in opioid-naive adults
dence).

In patients who receive i.v. PCA, the panel does not
recommend the routine use of basal infusion of opioids
in opioid-naive patients, because most evidence shows
no improved analgesia compared with PCA without a
basal infusion.115,219,220,248 In addition, basal infusion
of opioids is associated with an increased risk of nausea
and vomiting, and in some studies with increased risk
of respiratory depression in adults.99 Evidence on the
utility of basal infusion of opioids in opioid-tolerant pa-
tients who use PCA is lacking, but there might be a stron-
ger rationale for its use because of the potential for
underdosing and uncontrolled pain, as well as opioid
withdrawal, particularly in patients who received long-
term opioid therapy before surgery. There is insufficient
evidence to guide recommendations on use of basal
infusion of opioids in children, although some evidence
suggests that a low basal rate can be used safely.317
Recommendation 14
� The panel recommends that clinicians provide
appropriate monitoring of sedation, respiratory sta-
tus, and other adverse events in patients who receive
systemic opioids for postoperative analgesia (strong
Because of the risk of excess sedation and respiratory
depression, patients who receive systemic opioids for
postoperative analgesia should be monitored closely in
the initial hours after surgery or subsequent dose
changes.149 Such monitoring should include assessments
of alertness and signs or symptoms of hypoventilation or
hypoxia. Although pulse oximetry is frequently used to
monitor respiratory status in the postoperative period, it
is unclear whether pulse oximetry is superior to nurse

observation of respiratory rate and mental status, because
randomized trials show no clear effect on clinical out-
comes226 and pulse oximetry has low sensitivity for hypo-
ventilation when supplemental oxygen is being
administered. Limited evidence suggests that capnogra-
phy might be more sensitive than pulse oximetry in iden-
tifying respiratory depression in patients receiving
supplemental oxygen.193 However, there is insufficient ev-
idence to guide firm recommendations on the use of cap-
nography or other more sophisticated methods for
monitoring. Risk factors for respiratory depression include
a history of obstructive or central sleep apnea178,182 and
use of other central nervous system depressant
medications.149 In patients with excess sedation or signs
of respiratory depression, clinicians should be prepared
to change or reduce the opioid medication, support respi-
ratory effort, and administer opioid antagonists when
necessary. Clinicians should also assess for other common
side effects associated with opioids, such as postoperative
nausea and vomiting and opioid-induced constipation,
which might be dose-limiting or require dose reductions
if unresponsive to bowel regimens.
Recommendation 15
� The panel recommends that clinicians provide adults
and children with acetaminophen and/or nonste-
roidal anti-inflammatory drugs (NSAIDs) as part of
multimodal analgesia for management of postoper-
ative pain in patients without contraindications
(strong recommendation, high-quality evidence).
Acetaminophen and NSAIDs have been evaluated as
part of multimodal analgesia in patients also receiving
opioids for management of postoperative pain. Most
studies show use of acetaminophen or NSAIDs in

conjunction with opioids is associated with less postoper-
ative pain or opioid consumption than opioids
alone.17,63,103,114,127,166,199 In addition, acetaminophen
and NSAIDs have different mechanisms of action and
research indicates that the combination of
acetaminophen with NSAIDs might be more effective
than either drug alone.216 Most research indicates no
clear differences between i.v. versus oral administration
of acetaminophen or NSAIDs in reducing postoperative
pain,39,228,283 although onset of action might be faster
with i.v. administration. NSAIDs are associated with
increased risk of gastrointestinal bleeding and
ulceration, cardiovascular events, and renal dysfunction
that should be considered when selecting therapy;
gastrointestinal risks are thought to be lower with the
cyclooxygenase 2-selective NSAID celecoxib. Although
animal studies suggest a link between bone nonunion
after orthopedic surgeries and NSAID use, high-quality
evidence on the effect of NSAIDs on nonunion rates after
orthopedic surgical procedures is not available.
Although some observational data suggest a possible as-
sociation between high-dose NSAID use and nonunion in
spinal fusion,68,177 the association was not statistically
significant in an analysis restricted to higher-quality
studies,68 and was not observed in children.274 Observa-
tional studies suggest that NSAID use might be associ-
ated with increased risk of anastomotic leakage after
colorectal surgery.109,247,250 The panel found
insufficient evidence to recommend against use of
NSAIDs in patients who undergo surgery for orthopedic
fractures, spinal fusion, or colorectal surgery, but
acknowledges the uncertainty about potential harms

and that decisions be made after discussions with the
surgeon, the patient, and consideration of alternatives.
NSAIDs are contraindicated for management of
perioperative pain in patients who undergo coronary
artery bypass graft surgery because of an increased risk
of cardiovascular events.290
Recommendation 16
� The panel recommends that clinicians consider giv-
ing a preoperative dose of oral celecoxib in adult
patients without contraindications (strong recom-
The panel recommends that clinicians consider use of
preoperative celecoxib in patients who undergo major
surgery. Celecoxib is associated with reduced opioid re-
quirements after surgery, and some studies reported
lower postoperative pain scores.74,138,146,161,239,275,303
The most common doses of celecoxib in the trials were
200 to 400 mg, administered 30 minutes to 1 hour
preoperatively. Celecoxib is contraindicated in patients
who undergo coronary artery bypass graft surgery,
because of an increased risk of cardiovascular events.290
The panel found insufficient evidence to recommend a
preoperative dose of nonselective NSAIDs. No trial
compared benefits or harms of nonselective NSAIDs
versus celecoxib or placebo in patients who underwent
nondental surgical procedures.
Recommendation 17
� The panel recommends that clinicians consider use
of gabapentin or pregabalin as a component of

multimodal analgesia (strong recommendation,
The panel recommends use of gabapentin or pregaba-
lin as part of a multimodal regimen in patients who un-
dergo surgery. Both medications are associated with
reduced opioid requirements after major or minor surgi-
cal procedures, and some studies reported lower postop-
erative pain scores.2,48,92,105,147,153,191,217,272,318 Both
medications appear effective when administered as a
preoperative dose (typical doses evaluated in trials
were 600 or 1200 mg of gabapentin or 150 or 300 mg
of pregabalin, administered 1–2 hours preoperatively),
although some trials also found regimens that included
postoperative dosing to be effective (typically
gabapentin 600 mg as a single or in multiple doses and
pregabalin 150 or 300 mg after 12 hours). The panel
found insufficient evidence to determine optimal
gabapentin and pregabalin doses; although higher
doses might be more effective, they might also be
associated with more sedation. Both drugs are only
available in oral form, potentially limiting their use in
the immediate postoperative period. The panel
suggests that clinicians consider a preoperative dose of
gabapentin or pregabalin, particularly in patients who
undergo major surgery or other surgeries associated
with substantial pain, or as part of multimodal therapy
for highly opioid-tolerant patients. Potential adverse ef-
fects include dizziness and sedation that has not been
linked to respiratory depression; dose reductions are rec-
ommended in patients with impaired renal function.
Although evidence on effectiveness of gabapentin or
pregabalin in children is limited, some randomized trials
found beneficial effects of preoperative gabapentin on
postoperative pain and opioid use.7,249

Recommendation 18
� The panel recommends that clinicians consider i.v.
ketamine as a component of multimodal analgesia
in adults (weak recommendation, moderate-
quality evidence).
I.v. ketamine has been evaluated as a part of multi-
modal analgesia. In adults and children, studies found
i.v. ketamine infusions were associated with decreased
postoperative pain medication use compared with pla-
cebo, and in some studies with decreased postoperative
pain scores.1,22,59,75,173,213 I.v. ketamine was also
associated with decreased risk of persistent postsurgical
pain.198 In the trials, ketamine was administered preop-
eratively, intraoperatively, and/or postoperatively, at
widely varying doses (ranging from boluses of .15–
2 mg/kg before incision and at closure, with or without
infusions ranging from .12 mg/kg/h [2 mg/kg/min] to
2 mg/kg/h). There was insufficient evidence to determine
the optimal method for dosing ketamine, but the panel
suggests using a preoperative bolus of .5 mg/kg followed
by an infusion at 10 mg/kg/min intraoperatively, with or
without a postoperative infusion at a lower dosage.183
Ketamine was associated with increased risk of hallucina-
tions and nightmares. Clinicians who administer keta-
mine should be familiar with its use and adverse
effects, and the panel suggests that ketamine be
reserved for major surgeries. Some situations in which
ketamine might be particularly useful include manage-
ment of highly opioid-tolerant patients183 and patients
who have difficulty tolerating opioids.
Recommendation 19

� The panel recommends that clinicians consider i.v.
lidocaine infusions in adults who undergo open
and laparoscopic abdominal surgery who do not
have contraindications (weak recommendation,
I.v. lidocaine has been evaluated as a part of multimodal
analgesia. In patients who underwent open or laparo-
scopic abdominal surgical procedures, studies showed
perioperative or intraoperative i.v. lidocaine infusions
were associated with shorter duration of ileus and better
quality of analgesia compared with placebo.189,296 In the
trials, lidocaine was typically administered as a bolus
(100–150 mg or 1.5–2.0 mg/kg) followed by an infusion
of 2 to 3 mg/kg/h through the end of surgery. The panel
found insufficient evidence to determine optimal dosing
of lidocaine, but on the basis of clinical experience
suggest an induction dose of 1.5 mg/kg followed by
2 mg/kg/h intraoperatively.66,84 Continuation of lidocaine
in the postoperative period has not been well studied.
Recommendation 20
� The panel recommends that clinicians consider surgi-
cal site–specific local anesthetic infiltration for surgi-
cal procedures with evidence indicating efficacy
(weak recommendation, moderate-quality evi-
dence).

The use of subcutaneous and/or intraarticular infiltra-
tion of long-acting local anesthetics at the surgical site
has been shown to be effective as a component of multi-
modal analgesia in several surgical procedures, including
total knee replacement, arthroscopic knee surgeries, ce-
sarean section, laparotomy, and hemorrhoid sur-
gery,19,21,35,40,47,77,81,117,164,167,218,265 although some
studies showed no benefit. Because evidence is
somewhat mixed and because of the availability of
alternative methods of postoperative analgesia, the
panel does not recommend routine use of local
anesthetic infiltration. Rather, use of local anesthetic
infiltration should be on the basis of evidence showing
benefit for the surgical procedure in question.
Clinicians should be knowledgeable regarding specific
local anesthetic infiltration techniques (including the
use of extended-release formulations of local anesthetics
such as liposomal bupivacaine),62 which vary depending
on the surgical procedure. In addition, although data are
limited, continuous intra-articular bupivacaine in pa-
tients who undergo shoulder surgery might be associ-
ated with chondrolysis,104,113,237 suggesting caution
when considering this technique.
Recommendation 21
� The panel recommends that clinicians use topical
local anesthetics in combination with nerve blocks
before circumcision (strong recommendation,
In infants who undergo circumcision, evidence indi-
cates effectiveness of topical anesthetics in combination
with penile nerve block. Although studies indicate effec-
tiveness of eutectic mixture of local anesthetics for this
procedure, eutectic mixture of local anesthetics is associ-

ated with risk of methemoglobinemia in infants younger
than 3 months of age, with excessive applications, or
when using other drugs associated with methemoglobi-
nemia.175,278,279,288
Recommendation 22
� The panel does not recommend intrapleural
analgesia with local anesthetics for pain control
after thoracic surgery (strong recommendation,
Intrapleural analgesia with local anesthetics after
thoracic surgery is not associated with clear beneficial ef-
fects on postoperative pain, although results of studies
were somewhat inconsistent.154 In addition, this tech-
nique might be associated with potential toxicity
because of the high systemic absorption of local anes-
thetics from the intrapleural space. If intrapleural anal-
gesia with local anesthetics is used, it should be as part
of a multimodal approach with close monitoring for po-
tential toxicity.64
Recommendation 23
� The panel recommends that clinicians consider surgi-
cal site–specific peripheral regional anesthetic tech-
niques in adults and children for procedures with
evidence indicating efficacy (strong recommenda-
The use of peripheral regional anesthetic techniques
have been shown to be effective as a component of
multimodal analgesia for management of postoperative
pain associated with a number of surgical procedures,

including thoracotomy,154,155 lower extremity joint
surgery,97,158,162,184,227,242,257,261,307,315 shoulder
surgery,242 cesarean section,19 hemorrhoid surgery,209
and circumcision.14,135,163 Clinicians should consider use
of surgical site–specific peripheral regional analgesic
techniques in adults and children as part of multimodal
analgesia, particularly in patients who undergo lower
extremity and upper extremity surgical procedures.
Clinicians should be familiar with the specific regional
anesthetic techniques used, including use of ultrasound
guidance, as well as the potential for motor blockade
and risk of falls. Clinicians should also be aware of case
reports of critical failures involving elastomeric pumps
resulting in early delivery or complete emptying of the
pump, in some cases resulting in death. Unlike
electronic pumps, elastomeric pumps do not have
alarms; if used, they require staff and patient and/or
caregiver monitoring for pump failure and education
regarding the signs and symptoms and emergency
management of local anesthetic toxicity.
Recommendation 24
� The panel recommends that clinicians use contin-
uous, local anesthetic–based peripheral regional
analgesic techniques when the need for analgesia
is likely to exceed the duration of effect of a single
injection (strong recommendation, moderate-
quality evidence).
Although single injection and continuous peripheral
regional analgesic techniques are effective for postoper-
ative analgesia in patients who undergo a number of sur-
gical procedures,222,242 the use of continuous rather than
single-injection peripheral techniques is preferred when

the duration of postoperative pain is likely to be more
prolonged, because of the limited duration of analgesia
expected with a single injection.
Recommendation 25
� The panel recommends that clinicians consider the
addition of clonidine as an adjuvant for prolonga-
tion of analgesia with a single-injection peripheral
For single-injection peripheral neural blockade with a
local anesthetic, the combination of adjuvant agents
administered as part of the injection might prolong the
duration of analgesia and potentially reduce the need
for a continuous infusion. In such circumstances, clini-
cians might consider the use of clonidine as an adjuvant
agent in persons who receive a single-injection periph-
eral neural blockade. However, potential side effects
must be weighed against any possible gains related to
prolongation of analgesia. For instance, a meta-anal-
ysis78,231 indicated that the addition of clonidine
prolongs the duration of a single-injection peripheral
neural blockade by approximately 2 hours, but is also
associated with increased risk of hypotension, syncope,
and sedation.
Recommendation 26
� The panel recommends that clinicians offer neurax-
ial analgesia for major thoracic and abdominal pro-

cedures, particularly in patients at risk for cardiac
complications, pulmonary complications, or pro-
longed ileus (strong recommendation, high-quality
evidence).
Epidural analgesia with local anesthetics (with or
without opioids) or spinal analgesia (intrathecal opioid)
in adults and children is associated with lower postoper-
ative pain scores or decreased rescue analgesic use
compared with placebo injections or systemic opioid
analgesia in patients who underwent a variety of sur-
geries.154,212 Epidural or spinal analgesia might be
associated with a decreased risk of postoperative
mortality, venous thromboembolism, myocardial
infarction, pneumonia, and respiratory depression, and
decreased duration of ileus versus systemic analgesia,
although such benefits were primarily observed in
older trials that might have used outdated systemic
analgesia techniques.18,232,233,243 Therefore, clinicians
should routinely consider use of epidural or spinal
analgesia for management of postoperative pain in
patients who undergo major thoracic and abdominal
procedures, cesarean section, and hip and lower
extremity surgeries, particularly in patients at risk for
cardiac complications, pulmonary complications, or
prolonged ileus. A potential advantage of epidural
analgesia is that it can be performed as a continuous
infusion or as PCA with local anesthetics, whereas
spinal analgesia is limited to a single dose of opioids.
The coadministration of epidural clonidine with local
anesthetics might be associated with improved
analgesia in the postoperative period compared with
epidural local anesthetic alone, but there is insufficient
evidence to recommend its routine use and it is
associated with increased risk of hypotension.90

Recommendation 27
� The panel recommends that clinicians avoid the neu-
raxial administration of magnesium, benzodiaze-
pines, neostigmine, tramadol, and ketamine in the
treatment of postoperative pain (strong recommen-
Evidence on the effectiveness of adjuvant medications
administered using the epidural or spinal route with
local anesthetics (with or without opioids) is limited.90
Neuraxial administration of magnesium, benzodiaze-
pines, neostigmine, tramadol, and ketamine in the treat-
ment of postoperative pain is not recommended because
of no clear benefit and insufficient evidence to deter-
mine safety.13,52,208,294 In addition, most of these
medications are not available in a preservative-free
formulation.90
Recommendation 28
� The panel recommends that clinicians provide
appropriate monitoring of patients who have
received neuraxial interventions for perioperative
analgesia (strong recommendation, low-quality evi-
dence).
Although neuraxial analgesia is associated with a
decreased risk of perioperative mortality and pulmonary
and cardiac complications compared with systemic opi-
oids, adverse effects including respiratory depression,
hypotension, and motor weakness from spinal cord
compression (due to infection or hematoma) can
occur.154 In patients with hip and lower extremity sur-
geries, neuraxial analgesia might mask symptoms of

compartment syndrome. Therefore, clinicians should
monitor patients who have received neuraxial interven-
tions for these adverse effects and be prepared to treat
with dose reductions, removal of catheters, opioid an-
tagonists, decompression surgery for cord-impinging
epidural hematoma or abscess, antibiotics, or other mea-
sures as needed.
Procedures
Recommendation 29
� The panel recommends that facilities in which surgery
isperformedhaveanorganizationalstructureinplace
to develop and refine policies and processes for safe
and effective delivery of postoperative pain control
(strong recommendation, low-quality evidence).
Facilities in which surgery is performed should have an
organizational structure to oversee the development, im-
plementation, and evaluation of policies and practices to
assure safe, evidence-based, and effective postoperative
pain control. Whether through an existing quality
improvement committee or a designated pain manage-
ment team, the process should ideally be interdisci-
plinary. Findings in other areas of health care highlight
the critical role of administrative and physician leadership
including those most integrally involved in perioperative
pain management for the success of such efforts.37
Measurement-driven models of care through outcomes
assessment might be useful to guide quality improve-
ment efforts in postoperative pain control. Although
the specific measurement tools and methodology might
vary, outcomes management should drive refinement of

policies and processes and health systems are encouraged
to standardize and use valid and reliable measures.
Recommendation 30
� The panel recommends that facilities in which sur-
gery is performed provide clinicians with access to
consultation with a pain specialist for patients with
inadequately controlled postoperative pain or at
high risk of inadequately controlled postoperative
pain (eg, opioid-tolerant, history of substance abuse)
(strong recommendation, low-quality evidence).
Management of postoperative pain can be a chal-
lenge, and require advanced assessment and manage-
ment skills available from pain specialists. In some
cases, postoperative pain might be inadequately
controlled despite the use of standard multimodal in-
terventions. Consultation or referral to a pain
specialist might be necessary to assist in the manage-
ment of such patients, to assist with diagnosis, inter-
ventional treatment, or management of comorbid
conditions. Facilities in which surgery is performed
should ensure that access to such expertise is readily
available when needed.
Consultative expertise might also be required in pa-
tients with opioid tolerance, particularly in those with
a history of substance abuse or addiction.120,144,244
Adequate pain treatment should not be withheld from
patients with active or previous opioid addiction
because of fears of worsening addiction or

precipitation of relapse. In addition to the ethical
requirement to address postoperative pain, poorly
treated pain can be a trigger for relapse. Successful
treatment of such individuals might include measures
to prevent relapse and require the involvement of a
specialist trained in the assessment and management
of chemical dependency and addiction disorders. The
clinical problems of underlying chronic pain, persistent
acute pain, and addiction are each complex entities
with biological, psychosocial, and functional
components.134 An interdisciplinary approach using
pharmacologic and nonpharmacologic interventions
might be required to achieve successful postoperative
outcomes and should be considered as part of the peri-
operative management plan in these patients (Table 4).
Table 4. Management of Postoperative Pain in Pat
� Conduct preoperative evaluation to determine preoperative
opioid use a
� Provide education regarding use of opioids before surgery
� Recognize that postoperative opioid requirements will
typically be great
� Consider pain specialty consultation (and in some cases
behavioral and/or
cases
� Consider nonpharmacological interventions
� Transcutaneous electrical nerve stimulation
� Cognitive–behavioral therapies
� Consider nonopioid systemic medications
� Gabapentin or pregabalin
� Ketamine
� Consider local anesthetic-based peripheral regional and
neuraxial local a

� Consider PCA with basal infusion of opioids for difficult to
manage pain
� Provide education and instructions on tapering opioids to
target dose af
Recommendation 31
� The panel recommends that facilities in which neu-
raxial analgesia and continuous peripheral blocks
are performed have policies and procedures to sup-
port their safe delivery and trained individuals to
manage these procedures (strong recommendation,
Providers managing regional or neuraxial techniques
should have the commensurate education, training,
oversight, and experience to assure safe and effective
therapy. Facilities that provide regional or neuraxial
techniques should have clearly defined policies and pro-
cedures in place for appropriate patient monitoring and
competency based training and education for staff
involved in caring for these patients. This should include
clear and reliable means for hospital and nursing staff to
reach the specialists managing these techniques.
Recommendation 32
� The panel recommends that clinicians provide edu-
cation to all patients (adult and children) and pri-
mary caregivers on the pain treatment plan
including tapering of analgesics after hospital
discharge (strong recommendation, low-quality evi-
dence).
Research on methods and outcomes of discharge plan-
ning and follow-up are scarce and insufficient to provide

strong guidance on optimal methods.240 Nonetheless,
anecdotal reports and clinical experience suggest the
need for appropriate discharge teaching and coordina-
tion of transition to the medical home as part of the post-
operative pain management plan. A coordinated
approach to discharge instruction is important, including
advice from prescribers, nurses, physiotherapists, and
pharmacists. Clarity should be established about with
whom and when to follow-up for questions and transi-
tion of care back to the primary provider.
Patients should be counseled on how to take pain
medications safely and to manage side effects to opti-
mize pain control and recovery with return to usual activ-
ities. This might be particularly important for the
ients Receiving Long-Term Opioid Therapy
nd doses
er and that pain might be more difficult to control
addiction consultation) for pain that is difficult to manage and
complex
nalgesic techniques
with appropriate monitoring
ter discharge
Table 5. Summary of Interventions for Management of
Postoperative Pain
INTERVENTION SUGGESTED USE COMMENTS
CONTRAINDICATIONS AND CAUTIONS
Nonpharmacologic therapies

Transcutaneous electrical nerve
stimulation
Consider as an adjunct to other postoperative pain
management treatments
Typically applied at incision site Pacemaker or implanted
defibrillator, lymphedema,
broken skin
Cognitive modalities Consider as an adjunct to other
postoperative pain
management treatments
Includes guided imagery and other relaxation
methods, hypnosis, intraoperative suggestions, and
music
Might require preoperative education and patient
training for optimal results
None, caution in patients with history of psychosis
Systemic pharmacologic therapies
Acetaminophen and NSAIDs Use as component of multimodal
analgesia No clear difference between i.v. and oral

administration
Reduces use of postoperative opioids
Celecoxib usually dosed at 200 to 400 mg
30 minutes to 1 hour preoperatively and then
200 mg b.i.d. postoperatively
Acetaminophen usually dosed at 500 to 1000 mg
p.o. or i.v. every 6 hours
Some observational evidence of association
between high-dose NSAIDs and nonunion in spinal
fusion and surgery for fractures, and between
NSAID use and anastomotic leak in intestinal
surgery.
NSAIDs contraindicated in patients who undergo
coronary artery bypass surgery.
Acetaminophen: hepatotoxicity
NSAIDs: gastrointestinal bleeding and ulceration,
cardiovascular events, renal dysfunction
Oral opioids Use as component of multimodal analgesia Oral is
the preferred route for patients who can take

oral medications
Respiratory depression, potential for addiction and
abuse, sedation, nausea and vomiting, constipation
Patient controlled i.v. analgesia
with opioids
Use when the parenteral route is needed for
postoperative systemic analgesia for more than a
few hours
Avoid basal infusion of opioids in opioid naive adults See oral
opioids
Gabapentin and pregabalin Consider as a component of
multimodal analgesia,
primarily studied in patients who underwent major
surgery, opioid-sparing
Gabapentin doses vary; in trials usually dosed at 600 to
1200 mg 1 to 2 hours preoperatively, 600 mg
postoperatively (single or multiple doses)
Pregabalin doses vary; in trials usually dosed at 100
or 300 mg preoperatively, or 150 or 300 mg

preoperatively followed by the same dose 12 hours
later
Higher doses might be more effective, but might
also be associated with increased sedation
Dizziness, sedation; reduced dose with renal
dysfunction
C
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1
4
5
Table 5. Continued
INTERVENTION SUGGESTED USE COMMENTS
CONTRAINDICATIONS AND CAUTIONS
Ketamine i.v. Consider as a component of multimodal analgesia,
in
patients who undergo major surgery, opioid-
sparing
Dosing varies widely, consider preoperative bolus of
.5 mg/kg followed by an infusion at 10 mg/kg/min
intraoperatively, with or without a postoperative
infusion at a lower dose
Limited evidence for use in children
Patients with history of psychosis.
Hallucinations, nightmares, dissociative symptoms
Lidocaine i.v. Consider as a component of multimodal analgesia
in
patients who undergo open and laparoscopic

abdominal surgery
Dosing varies, consider induction dose of 1.5 mg/kg
followed by 2 mg/kg/h intraoperatively
Conduction block
Dizziness, seizures, bradycardia
Local, intra-articular, and topical
therapies
Local anesthetic infiltration Use local anesthetic infiltration at
incision site for
surgical procedures for which there is evidence
showing benefit (examples: cesarean section,
laparotomy, and hemorrhoid surgery)
local anesthetic infiltration techniques
See Lidocaine i.v. above; also local pain, infection,
bleeding
Intra-articular local anesthetic
and/or opioid

Use intra-articular injections for surgical procedures
for which there is evidence of benefit (examples:
hip, knee, and shoulder surgery)
intra-articular injection techniques.
Caution with use of continuous intra-articular
bupivacaine in shoulder surgery because of
association with chondrolysis
See Lidocaine i.v. and Oral opioids; also local pain,
infection, bleeding; potential chondrolysis with
intra-articular shoulder injections
Topical local anesthetics Use in combination with penile nerve
block in infants
undergoing circumcision
4% Liposomal lidocaine or eutectic mixture of local
anesthetics, lidocaine and procaine
See Lidocaine i.v.; also local pain, infection, bleeding,
rash
Peripheral regional and neuraxial

analgesic therapies
Peripheral regional anesthetic
techniques
Use as part of multimodal analgesia for surgical
procedures for which there is evidence of benefit
(examples: thoracotomy, lower or upper extremity
surgery, hemorrhoid surgery, circumcision)
Clinicians should be familiar with specific regional
anesthetic techniques
Use continuous over single injection techniques
when longer duration of analgesia is required
See Lidocaine; also potential for falls
Neuraxial analgesia (epidural with
local anesthetic [with or without
opioids] or intrathecal opioid)
Use for major thoracic, abdominal, cesarean section,
and lower extremity surgery
No clear difference between continuous infusion with

epidural catheter versus single dose of intrathecal
morphine
See Lidocaine and Oral opioids; also motor weakness
and risk of falls
Abbreviations: b.i.d., twice per day; p.o., orally.
NOTE. Table data are not listed in order of preference or
strength of evidence. The choice of treatments must be made on
the basis of comprehensive patient assessment and the available
evidence with consideration of multiple factors
including individual risk factors for adverse events,
comorbidities, cost, patient response; combinations of
medications and techniques are often indicated. Doses are for
typical adults.
1
4
6
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growing number of outpatient surgical patients. Pa-
tients and families should be informed that the use of
other central nervous depressants (including alcohol) or
illicit drugs in combination with opioids can result in acci-
dental overdose and death. Discharge teaching should

include a discussion of the plan for reduction and discon-
tinuation of opioids as the acute pain resolves, as well as
appropriate disposal of unused supplies of opioids and
other medications. There is insufficient evidence to
guide firm recommendation on how to wean patients
with postoperative pain off of opioids. Although severe
pain after surgery tends to diminish rapidly in the first
few days, postoperative pain can persist for months,
highlighting the need for an individualized approach.
For some minor surgeries, it might be appropriate to
discharge patients with use of acetaminophen or NSAIDs
or a very limited supply of opioids before the transition
to acetaminophen or NSAIDs. In general, patients not
receiving long-term opioid therapy before surgery and
treated with opioids for more than 1 to 2 weeks should
be instructed to gradually reduce the opioid dose to pre-
vent signs and symptoms of severe withdrawal. Dose re-
ductions of approximately 20–25% of the discharge dose
every day or two can be tolerated by most patients when
pain is improving. Patients chronically prescribed opioids
before surgery should be instructed on how to taper
their opioid to their target maintenance dose.
Conclusions
After a review of the evidence, an expert panel
convened by the APS, with input from the ASA, devel-
oped recommendations to promote effective manage-
ment of postoperative pain; the recommendations
were subsequently approved by the APS, the American
Society of Regional Anesthesia and Pain Medicine, and
the ASA Committee on Regional Anesthesia, Executive
Committee, and Administrative Council. The recommen-
dations are on the basis of the underlying premise that
optimal management begins in the preoperative period
and is on the basis of an assessment of the patient and

development of a plan of care tailored to the individual
and the surgical procedure involved, with follow-up as-
sessments and adjustments as needed. The panel found
that evidence supports the use of multimodal regimens
in many situations, although the exact components of
effective multimodal care will vary depending on the pa-
tient, setting, and surgical procedure. Suggested uses for
various interventions for management of postoperative
pain are summarized in Table 5.
Although these guidelines are based on a systematic
review of the evidence on management of postoperative
pain, the panel identified numerous research gaps. Of
32 recommendations, the panel rated only 4 as sup-
ported by high-quality evidence, and 11 recommenda-
tions were on the basis of low-quality evidence.
Nonetheless, the panel came to near-unanimous
consensus on almost all of its recommendations.
Research is urgently needed on optimal methods for
managing patients who receive opioids before surgery,
effectiveness of opioid-sparing multimodal regimens,
optimal methods of pain assessment and monitoring,
and a number of areas related to management of periop-
erative pain in infants and children. There is also an ur-
gent need to fund and conduct research on practice
gaps regarding use of evidence-based interventions for
management of postoperative pain.
Note
Clinical practice guidelines are ‘‘guides’’ only and
might not apply to all patients and all clinical situations.
As part of a shared decision-making approach, it might
be appropriate for the clinician to inform a patient
that a particular recommendation might not be appli-
cable, after considering all circumstances pertinent to
that individual. This guideline was approved by the

ASA Committee on Regional Anesthesia, Executive Com-
mittee, and Administrative Council in October 2015. It
has not been approved by ASA’s House of Delegates or
Board of Directors and does not represent an official or
approved statement or policy of the ASA.
Acknowledgments
The authors thank Leelee K. Thames, Tracy Dana, and
Miranda Pappas for reviewing literature and data
abstraction, and Miranda Pappas for administrative sup-
port.
Supplementary Data
Supplementary data related to this article can be
found online at http://dx.doi.org/10.1016/j.jpain.2015.
12.008.
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http://www.healthquality.va.gov/guidelines/Pain/pop/pop_sum.p
df
http://www.healthquality.va.gov/guidelines/Pain/pop/pop_sum.p
df

5/sref319Management of Postoperative Pain: A Clinical Practice
Guideline From the American Pain Society, the American
Society of Reg ...MethodsPanel CompositionTarget Audience
and ScopeEvidence ReviewGrading of the Evidence and
RecommendationsGuideline Development
ProcessRecommendationsPreoperative Education and
Perioperative Pain Management PlanningRecommendation
1Recommendation 2Recommendation 3Recommendation
4Methods of AssessmentRecommendation 5General Principles
Regarding the Use of Multimodal TherapiesRecommendation
6Use of Physical ModalitiesRecommendations 7 and 8Use of
Cognitive–Behavioral ModalitiesRecommendation 9Use of
Systemic Pharmacological TherapiesRecommendation

19Use of Local and/or Topical Pharmacological
TherapiesRecommendation 20Recommendation
21Recommendation 22Use of Peripheral Regional
AnesthesiaRecommendation 23Recommendation
24Recommendation 25Use of Neuraxial
TherapiesRecommendation 26Recommendation
27Recommendation 28Organizational Structure, Policies, and
ProceduresRecommendation 29Recommendation
30Recommendation 31Transitioning to Outpatient
CareRecommendation
32ConclusionsNoteAcknowledgmentsSupplementary
DataReferences
Running head: DIFFERENCES FOUND IN GLOBAL HEALTH
1
Differences between Quality Improvement (QI), Evidence-
Based Practice (EBP),
and Original Research Evidence in Global Health
Carla S. Garcia
Nicole Wertheim College of Nursing and Health Sciences
Author Note
Carla S. Garcia, Nicole Wertheim College of Nursing and
Health Sciences, Florida
International University
Correspondence concerning this article should be addressed
to Carla Garcia, Nicole

Wertheim College of Nursing and Health Sciences, Florida
International University, Miami, FL
33199. Contact: [email protected]
DIFFERENCES FOUND IN GLOBAL HEALTH
2
Abstract
Care can be improved using different forms of scientific
inquiry. Either at the clinical practice
level, using scientific knowledge as guidance to clinical
decision making; utilizing a more formal
and systematic approach, applying quality improvement, and
evidence-based practice; or
participating in original nursing research. Clinical nurses, nurse
practitioners, researchers, and
the whole healthcare team should participate in activities that
aim to a better practice, facilitating
positive patient outcomes. Such activities work independently
but are interrelated, since they aim
for a common result which is the best possible practices that
yield to successful patient outcomes
in a holistic manner. In this paper a brief review of the
definitions of Quality Improvement (QI),

Evidence Based Practice (EBP), and Research Evidence are
presented as well as their differences
and similarities.
Keywords: Evidence-based, practice, quality, improvement,
original, nursing research,
client care, patient outcomes, scientific base, clinical expertise.
3
Significance and Background
Issues in clinical practice such as the high rate of Catheter
Associated Urinary Tract
Infections (CAUTIs), postoperative Deep Vein Thrombosis
(DVT), development of pressure
ulcers and/or atelectasis on immobilized patients, etc., should
awaken a spirit of inquiry in all
healthcare personnel, especially nurses. In the article
“Clarifying the Conundrum: Evidence-
Based Practice, Quality Improvement, or Research?” by Eileen
J. Carter, Kari Mastro, Courtney
Vose, Reynaldo Rivera and Elaine L. Larson, nurses’ dynamic
participation in clinical

scholarship is required to strengthen the nursing career and
improve patient care (Carter et al.,
2017, p.267). Nurses play a critical role in patient care and are
consistently applying clinical
judgement to meet clients’ needs in a holistic way; Therefore,
nurses’ input is fundamental for
the development of QI, EBP, and original research. These terms
serve the same purpose: better
patient care and cost-efficient practices. They do possess some
differences; however, they are
interrelated not independent (Carter et al., 2017, p.267).
Quality Improvement
A definition from the U.S. Department of Health and Human
Services (2011) stipulates
that quality improvement entails organized and ongoing
activities that lead to measurable
development in healthcare services and the health status of
targeted health communities (as cited
in Connelly, 2018, p.125). Monitoring and improving quality
care are ongoing processes that all
healthcare professionals, including nurses, should participate in.
The intend of quality
improvement is to offer the best possible care to patients,
therefore, improving healthcare

outcomes. Unlike large research studies, quality improvement
work targets smaller populations
utilizing data for a specific organization, such as patients of a
certain healthcare facility or
agency. According to the Quality and Safety Education for
Nurses (QSEN), nurses are expected
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(2017),
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you verify the address
4
to utilize data to trace results of care activities and use
enhancement techniques to design and test

changes to constantly improve the quality and safety of
healthcare systems (as cited in Connelly,
2018, p.125).
One example of quality improvement could be the application of
an ground-breaking
statewide quality improvement initiative in Colorado. The
Colorado Stroke Alliance (CSA)
demonstrated a tremendous improvement in stroke care through
statewide quality endeavors
containing advising, data reporting, and nursing participation
(Smith et al., 2009, p.112). One of
the quality improvement outcomes was reported by participating
CSA hospitals, indicating that
when using the American Heart Association’s (AHA) Get With
the Guideline's Stroke Patient
Management tool (GWTG-Stroke), in grouping with their
hospital’s comprehensive quality
efforts, developments in performance can be perceived.
Participating hospitals in the Colorado
Stroke Registry have registered nurses as stroke program
managers and/or data coordinators
(Smith et al., 2009, p.112). This suggests that nursing
involvement is fundamental for the success
of quality improvement programs.

Evidence Based Practice
Evidence Based Practice is a method of utilizing established
evidence (research and
quality improvement), resolution, and nursing proficiency to
lead the conveyance of holistic
patient care (Boswell & Cannon, 2018). The examination of a
vast compilation of research
studies concludes that EBP enhances the quality and safety of
healthcare, increases better health
results, diminishes geographic disparities in care, and decreases
expenses (Mazurek, 2016). EBP
is viewed as an analytic approach to clinical decision making,
that encompasses the most
efficient and current evidence, clinical proficiency, clinical
assessment, and consideration of
patient predilections and values within a context of caring
(Boswell & Cannon, 2018). In the
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EBP
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QI - be consistent
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5
United States, EBP is vital in meeting the Triple Aim in
healthcare, which involves the
enhancement of patient experience in care, the improvement of
health populations, and a
decrease of the per capita cost of healthcare (Mazurek, 2016).
A key aspect in the development of EBP is to follow seven
important steps which lead to
a successful search, implementation, and evaluation of the EBP
process. Starting with posing the
problem that is negatively affecting patient care (step 0);
formulating the clinical question using
the Patient or Population, Intervention or Interest area,
Comparison intervention or group,
Outcome, and Time format (PICOT) (Step 1); conducting an
evidence search to answer the
clinical question (Step 2); followed by a quick critical appraisal
of a few studies (Step 3);
incorporating the evidence with clinical competence and client
predilections and values (Step 4),
employing and assessing change in practice (Step 5); and lastly,
consolidating change in practice,
and disseminating the outcomes (Step 6) (Mazurek, Fineout-
Overholt, Stillwell, Williamson,

2010, p.51-53).
Original Research Evidence
When clinical or practice situations are not supported by strong
evidence that can lead to
a standard, original nursing research comes into play. Original
research utilizes statistical
methods to calculate the combination of variables that could
yield to better patient care outcomes
(Baker et al., 2014, p.196). Following the scientific method, all
research starts by formulating a
hypothesis. In original research, a relationship is hypothesized
between variables; nevertheless,
their correlation is unknown. The objective of nursing research
is to determine the connection
between these variables and the significance of it. For instance,
the need to provide a successful
suicidal risk screening tool in the emergency department can be
addressed by performing
research leading to the implementation of a tool that works
efficiently in providing a thorough
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Melnyk

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suicidal risk assessment. In this case, a relationship between
certain patient criteria (subjective
and objective), and the risk for suicide can be found (Baker et
al., 2014, p.197).
There are two basic groups that encompass the methods used for
directing nursing
research: quantitative and qualitative research. In quantitative
research, data is collected
objectively in an ordered, systematic, controlled manner so that
the results can be applied to

other circumstances and/or populations (Boswell & Cannon,
2018). Quantitative research utilizes
statistical analysis to validate a hypothesized association among
two variables; it includes use of
mathematical models and expresses the connection between
variables in a numerical form. On
the other hand, qualitative research generally focuses for an in-
depth discernment of the
experiences of others (as cited in Boswell & Cannon, 2018).
The researcher reproduces the
socially built nature of reality, the association amid the research
and the subject of the research,
and the situational aspects that outline inquiry (Boswell &
Cannon, 2018). Groups of qualitative
research comprise phenomenology, grounded theory,
ethnography, and case studies. Types of
data gathering include semi-structured and structured
interviews, and observation. The results are
then summarized to describe the phenomenon (Baker et al.,
2014, p.197).
Discussion
Acknowledging the differences between the three concepts
previously presented, allows

nurses to develop a spirit of inquiry. The appropriate
application and implementation of theses
methodologies maximizes favorable outcomes (Baker et al,
2014, p.195). For example, QI
projects would be suitable when determining whether the
appropriate standards of care are
practiced in a specific clinical setting. The purpose of QI
projects is to regulate the execution and
establishment of standards while monitoring the department’s
continuous process (Baker et al,
2014, p.195). EBP is used when enough research is available to
guide the development of a
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clinical or practice standard, but the research has not been fully
adopted in the practice
environment. For instance, EBP can be useful to explore
enhanced screening for domestic
violence in an Emergency Department (ED). There is available
research on the topic, and its
implementation if of significant importance in the ED setting,
but still there is some learning to
do when it comes to its practice in this area (Baker et al, 2014,
p.196). Lastly, research
incorporates activities aimed to the exploration of new findings.

An example of research would
be a study done by Provonost et al., in which a set of evidence-
based strategies such as hand
hygiene before central line insertion, and use of optimal
catheter insertion site, were used to
prevent central line infections. The incorporation of these
initiatives decreased the rate of central
line infections and has been implemented nationally with great
success. In this scenario, the work
of researchers established new findings by determining the
influence of a new intervention on
rates of central line infection, leading to higher quality care and
outcomes (as cited in Carter et
al., 2017, p.267).
Conclusion
Today’s healthcare environment demands the application of
several methodologies in
order to offer high quality care. The application of these
methodologies is to be carried out by
members of the healthcare team, particularly nurses. Nurses’
clinical judgement, knowledge of
standard practices in the healthcare setting, and their research
inquiry are essential qualities for

QI, EBP, and research. The definition of these activities is not
completely clear, and therefore
could be subject to interpretation. For this reason, they may be
viewed as separate entities rather
than being interrelated. Quality Improvement aims to reach an
improved clinical practice in
healthcare. In order to do so, it compares the current
performance through data analysis to meet
the desired standard. The EBP process starts with an inquiry;
the inquiry is converted into a well
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then cite the studies
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formulated question that facilitates research; a few works of
research on the topic are selected
and examined; followed by the integration of clinical
experience and patient preference; and
finally, the evaluation of outcomes in practice, and
dissemination of the established change.
Original Research Evidence presents a more scientific approach,
it basically aims to find a
correlation between two hypothesized variables. It utilizes
quantitative measurement and
qualitative measurement; the latter focusing on the association
between the research and the
subject of the research, and the situational aspects that outline
inquiry. Even though noticeable
differences exist, QI, EBP and research aim to a sole purpose:
better patient outcomes in clinical

practice.
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9
References
Baker, K. M., Clark, P. R., Henderson, D., Wolf, L. A., Carman,
M. J., Manton, A., & Zavotsky,
K. E. (2014). Identifying the Differences Between Quality
Improvement, Evidence-based
Practice, and Original Research. JEN: Journal of Emergency
Nursing, 40(2), 195–197.
https://doi.org/10.1016/j.jen.2013.12.016
Boswell, C., & Cannon, S. (2020). Introduction to nursing
research: Incorporating evidence-
based practice. Burlington, MA: Jones & Bartlett Learning.
Carter, E. J., Mastro, K., Vose, C., Rivera, R., & Larson, E. L.
(2017). Clarifying the
Conundrum. JONA: The Journal of Nursing Administration,
47(5), 266-270.
doi:10.1097/nna.0000000000000477

Connelly, L. M. (2018). Overview of Quality Improvement.
MEDSURG Nursing, 27(2), 125–
126. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=rzh&A
N=129092748&site=ehos
t-live&scope=site
Mazurek Melnyk, B., Gallagher-Ford, L., & Fineout-Overholt,
E. (2016). Improving healthcare
quality, patient outcomes, and costs with evidence-based
practice. Reflections on Nursing
Leadership, 42(3), 1–8. Retrieved from
N=119422530&site=ehos
t-live&scope=site
Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., &
Williamson, K. M. (2010). Evidence-
Based Practice: Step by Step: The Seven Steps of Evidence-
Based Practice. AJN,
American Journal of Nursing, 110(1), 51-53.
doi:10.1097/01.naj.0000366056.06605.d2
https://doi.org/10.1016/j.jen.2013.12.016
N=129092748&site=ehost-live&scope=site

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Smith D, Murphy P, Phillips M, Paulsen M, Vislosky FM, Wide
M, & Santos P. (2009). The
implementation of an innovative statewide quality improvement
initiative. Journal of
Neuroscience Nursing, 41(2), 106-114. Retrieved from
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AN=105501203&site=eh
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