Evidence based acute pain management


Chair: Winfried Meissner, Germany
Pain assessment
Winfried Meissner, Germany
Pain assessment is an important element of acute pain management and highly recommended by several guidelines. Traditionally, pain is assessed by asking patients to rate their pain intensity on a numeric (NRS). Pain intensity should be assessed not only in rest but with movement, it should be obtained at least once every 8 hours (but more frequently after surgery), and repeated after pain treatment. However, the use of pain intensity as the main outcome domain in acute pain assessment has been increasingly criticized: because a weak association between pain intensity measurement and improved outcomes, the controversial discussion on the benefits and harms of “pain intensity as the 5th vital sign”, the debatable plausibility of so called “cut-off” values, and the weak relation between pain intensity and function.
Therefore, more and more experts recommend assessing not only pain intensity but the impact of pain on relevant physical functions like mobilization and respiration. This can be done by simple dichotomous questions (“Does pain prevent you from coughing?”) or by rating scales. Likewise, the individual acceptance of pain and desire for more (or less) pain treatment should be assessed.
In patients with cognitive limitations, the verbal rating scale (VRS) is often a meaningful alternative to the NRS. If patients are unable to use self-rating instruments for the assessment of pain, pain has to be assessed by staff. For patients with dementia, the PAINAID scale is widely used. Children under the age of 8 years often have difficulties to use the NRS. For these patients, the Faces Pain Scale-revised (FPS-R) is a validated self-rating instrument to assess pain intensity. Older patients report lower pain intensity scores compared to younger patients. However, this does not necessarily mean that they experience less pain or have less pain-related functional impairment. Therefore, also in older patients pain assessment should focus not only on pain intensity.
Management of postoperative pain
Esther Pogatzki-Zahn, Germany
ERAS: Where do we stand now?
Olle Ljungqvist, Sweden 
Enhanced Recovery After Surgery (ERAS) was initiated in 2001 and is lead by a nonprofit medical society, the ERAS®Society (www.erassociety.org). The Society has developed methodology to produce evidence based perioperative guidelines for a wide range of surgical specialties and operations. When they are put into practice the ERAS principles result in substantial clinical improvements. Complications are reduced by up to 50%, hospital stay shortened from weeks to days, cost for care reduced substantially and recent studies report associations between better compliance to ERAS and survival. While ERAS has been the buzz word in surgery and anesthesia and its principles are spreading around the world and between surgical disciplines the true application of ERAS remains slow. This is manifested by long hospitals stays in most countries. A main reason for this is likely to be lack of audit and control over the details of practice. Many clinicians think they “do ERAS” while in fact they only use some parts of the protocol. Repeatedly it has been shown that the way to success is to secure the inclusion of many elements of care all contributing to the best possible outcome. The challenge for surgery and anesthesia is greater than ever in the light of the backlog of operations caused by COVID19. Still the pandemic showed us all that we are capable to make drastic changes in care when needed. This is the message we need to take with us, since ERAS is more needed than ever.

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