APA Acute Pain Guidelines Richard Howard Great Ormond Street Hospital London

APA Acute Pain Guidelines

Richard Howard

Great Ormond Street Hospital

London

APA Guidelines

Commissioned evidence-based guidance using SIGN protocol

• Acute Pain Management• Perioperative Fluid Management• PONV• Airway Management• Others…

Clinical Practice Guidelines

• availability of research evidence alone will not change clinical practice

• need way of appraising evidence, implementing change and translating evidence into practice

why guidelines?

• Evidence-based medicine

• Review published guidelines

• APA acute pain guideline

Guidelines in Paediatric Acute Pain Practice

• Evidence-based medicine: SIGN




Evidence-Based Medicine

Integration of best research evidence with clinical expertise and patient values

• 1992 Gordon Guyatt: McMaster University, Canada• Clear, systematic, rigourous, methodologies

• Books, Journals, CD’s, Websites• http://www.cebm.utoronto.ca/• http://www.jr2.ox.ac.uk/Bandolier/index.html

















Evidence-based medicine and clinical decision-making

What is an (evidence-based) clinical guideline?

Clinical guidelines are systematically developed statements,which assist in decision making about appropriate healthcare for specific clinical conditions.

Their aim: to improve the treatment of a particular

condition; to reduce variations in medical practice and thereby improve the quality of patient care in clinical practice; and to encourage further research.

Evidence-based guidelines are based on good research evidence of clinical effectiveness. They will form the basis for the standards against which comparative audit will be conducted.

Guideline development• Identifying relevant and answerable clinical questions

• Finding the ‘evidence’

• Appraising the evidence

• Integrating critical appraisal with clinical expertise and patient biology and values

• Statements/ recommendations

• Evaluation and review

SIGN

The Scottish Intercollegiate Guidelines Network was established in 1993 by the medical Royal Colleges to develop evidence based national guidelines for NHS Scotland.

http://www.sign.ac.uk/index.htmlhttp://www.sign.ac.uk/guidelines/fulltext/50/index.html‘Guideline Developers Handbook’

http://www.sign.ac.uk/index.html

http://www.sign.ac.uk/guidelines/fulltext/50/index.html

compare costs andbenefitsof interventions

Maintain and update guidelines

Evaluate change in practice- audit : compliance and effectiveness- side effects / risk-benefit- cost

Disseminate and implement guidelines- ? appropriate and feasible in local practice

Develop and publish evidence-based guidelines or update existing guidelines

Assess evidence- strength and quality- size of effect- relevance for clinical practice

Identify relevant evidence

Develop appropriate question

Guideline protocols

AGREE Collaboration

Appraisal of Guidelines Research and Evaluations

• Assess quality of guidelines

• AGREE instrument

http://www.agreecollaboration.org/

Levels of EvidenceSIGN

I : Systematic review +/- meta-analysis of RCTs

II : One or more well designed RCTs

III: Well designed non-randomised CT; or well designed cohort or case-control studies

IV: Expert opinion / laboratory evidence

Levels of Evidence





Levels of Evidence





Levels of Evidence





Levels of Evidence





Recommendations

A : Systematic reviews +/- meta-analysis of RCTs

B: Well designed RCTs or extrapolated from SR

C: Well designed non-randomised CT; or well designed cohort or case-control studies

D: Expert opinion / laboratory evidence

Recommendations





Recommendations





Recommendations





Recommendations





Good Practice Points

Recommended best practice based on the clinical experience of the guideline development group

GRADEGrading of Recommendations

Assessment Development and Evaluation

• International working party since 2002

• Propose ‘New’ system of grading of

recommendations

• Based on Strong or Weak evidence

• http://www.gradeworkinggroup.org/index.htm

Recommendations









Clinical Practice Guidelinesthe ideal …

from EVIDENCE to PRACTICE: – based on high level evidence– to assist clinicians and consumers to make

appropriate health care decisions– prepared by national body with extensive

consultation– information published and widely available– regularly reviewed and updated

Published guidelines (7)

• Recognition and Assessment of Acute Pain in Children. RCN UK 1999

• Acute Pain Management. Scientific Evidence.

NHMRC Australia 2005(adults and children)

• Guideline Statement: Management of Procedure-related Pain in Neonates, Children and Adolescents. RACP 2005





Content6 sections

– Introduction– Quick reference guide– Pain Assessment– Procedural Pain– Postoperative Pain– Review of Analgesia

4 appendicestechnical report, implementation, audit, cost implications, research,data extraction tables

Development Process

• Committee

• Clinical questions

• Searches

• Evaluation

• Recommendations

• Consultation and Peer Review

• Publication

Committee

• Anaesthesia• Pain medicine• Paediatrics• Paediatric nursing• Paediatric surgery• Patient representative

Expert advisors: EBM, Psychology

Clinical questions

Procedure specific

• Postoperative pain

• Acute procedural pain

Clinical question

‘What is the evidence for efficacy of

different analgesic strategies for each

procedure?’

Procedures

• 40 Surgical procedures

• 12 Medical procedures– 5 Neonatal– 7 infants and older children

Searches

• Search 1996-2006 (1200 articles)

– 483 articles included in total

– 43 pain assessment

– 120 procedural pain

– 310 postoperative pain

Recommendations

• 83 Recommendations– Grade A 32%– Grade B 13%– Grade C 43%– Grade D 10%

• 27 Good Practice Points

Procedure layout

• Introduction

• Good practice points

• Recommendations

• Summary of evidence

• Evidence table

Timetable

• Complete draft April 2007

• Consultation period May 2007

• Review August 2007

• Publication October 2007

Timetable

• Complete draft July 2007

• Consultation period September 2007

• Review January 2008

• Publication May 2008

Procedural Pain in the Neonate

• Breast feeding mothers should be encouraged to breast feed during the procedure, if feasible, as this helps reduce the response to pain: Grade A{Carbajal, 2003#168}{Shah, 2006 #41}

• Sucrose or other sweet solutions can be used to reduce the response to pain: Grade A {Skogsdal Y, 1997 #129{Ogawa S, 2005 #126}{Ling JM, 2005 #123}{Bauer K, 2004 #99{Carbajal, 2003 #168}{Gradin M, 2004 #113}{Carbajal, 2002 #13}{Bellieni CV, 2002 #100}

• Allowing an infant to suck during the procedure reduces the response to pain: Grade A {Carbajal R, 1999 #103}{Shah, 2006 #41}{Bellieni CV, 2002 #100} : this may be less effective in very preterm infants {Carbajal, 2002 #13}

• Tactile stimulation such as holding or stroking the infant can be used to reduce the pain response: Grade B Bellieni CV, 2002 #100}

Blood sampling in neonate

• Venepuncture is to be preferred over heelstick as it is less painful: Grade A {Ogawa S, 2005 #126}{Shah V, 2004 #128}{Logan, 1999 #125}

• Topical local anaesthetics alone are insufficient for heel stick pain: Grade A {Taddio, 1998 #167}

• Topical local anaesthetics should be used for venepuncture pain: Grade A

• {Jain A, 2000 #115}{Taddio, 1998 #167}{Gradin M, 2002 #114}{Taddio A, 2006 #91}

• Morphine alone is insufficient for heel stick pain: Grade B {Carbajal-Ricardo, 2005 #104}

Tonsillectomy

• A combination of individually titrated intraoperative opioids and regularly administered perioperative mild analgesics (NSAID and/or paracetamol) is required for management of tonsillectomy pain: Grade A {Hamunen, 2005 #19}[1++]

• Local anaesthesia injection in the tonsillar fossa may improve pain scores, reduce time to first oral intake, and reduce the incidence of referred ear pain following tonsillectomy: Grade B {Naja, 2005 #141}[1-]{Giannoni, 2001 #12}[1-]{Somdas, 2004 #35}[2+]{Kaygusuz, 2003 #142}[2+]

• Implementation of standardised protocols including intraoperative opioid ± anti-emetic, perioperative NSAID (diclofenac or ibuprofen) and paracetamol are associated with good pain relief and low rates of PONV: Grade C. {Ewah, 2006 #27}[2+]{White, 2005 #31}[2-]

Postoperative Paingood practice points

• Providers of postoperative care should be aware of the general principles of good pain management, including knowledge of assessment techniques, which are appropriate for developmental age and setting.

• Postoperative analgesia should be appropriate to developmental age, surgical procedure and setting in order to provide safe, sufficiently potent and flexible pain relief with a low incidence of side effects.

Implementation and Audit

Implementation algorithm– Identify implementation lead– Assess current practice– Does it comply with recommendations?

E.g. is developmentally appropriate pain assessment in use?

– Identify barriers to implementation

E.g. is staff training adequate, are resources available

– Plan– Audit

Research implications

• Many studies poorly designed

• Wide variations in drugs and regimens

• Very few comparisons between standard techniques

• Some procedures little or no data e.g. pyloromyotomy

• Cost-effectiveness not studied

• Few data on (serious) adverse effects

The future

• Planned update 2 years post publication

• Feedback from members

• Closer collaboration with other groups?

• More procedures included?

• Non-professional accessibility?

• Funding?

Availability

Online supplement

APA London 2008

?APA website

? Purchase

[email protected]

Best Evidence in Paediatric Acute Pain?

NH&MRC Acute Pain Management Guideline

1999

•Level I & II– adult 67%– paediatric 8%

•Level III & IV– adult 33%– paediatric 92%

Second Edition 2005

Key Messages : Level I• increase <20 to >100

Paediatric citations• Level I & II 50% (8%)

Is there sufficient evidence to guide paediatric acute pain management?

Best Evidence in Paediatric Acute Pain?

NH&MRC Acute Pain Management Guideline

1999

•Level I & II– adult 67%– paediatric 8%

•Level III & IV– adult 33%– paediatric 92%

Guideline development

• Identifying relevant and answerable clinical questions




• Evaluating our effectiveness and efficiency













APA 2008

‘Good Practice in Postoperative and Procedural Pain Management’

• Procedure based • Systematic literature searches 1996-2006• Data extraction and grading of studies• Evaluation of evidence• Formulation of recommendations

Documents

APA Acute Pain Guidelines Richard Howard Great Ormond Street Hospital London