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8. Continuous intravenous infusion of opioids in the general ward setting is associated with
an increased risk of respiratory depression compared with other methods of parenteral
opioid administration (U) (Level IV).
9. Transdermal fentanyl should not be used in the management of acute pain because of
safety concerns and difficulties in short‐term dose adjustments needed for titration;
furthermore, in most countries, it lacks regulatory approval for use in other than opioid‐
tolerant patients (S) (Level IV).
Other than in the treatment of severe acute pain, and providing there are no
contraindications to its use, the oral route is the route of choice for the administration of
most analgesic drugs (U).
Titration of opioids for severe acute pain is best achieved using intermittent intravenous
bolus doses as it allows more rapid titration of effect and avoids the uncertainty of drug SUMMARY
absorption by other routes (U).
Controlled‐release opioid preparations should only be given at set time intervals (U).
Immediate‐release opioids should be used for breakthrough pain and for titration of
controlled‐release opioids (U).
The use of controlled‐release opioid preparations as the sole agents for the early
management of acute pain is discouraged because of difficulties in short‐term dose
adjustments needed for titration (U).
Neither oral transmucosal fentanyl citrate nor fentanyl buccal tablets should be used in
the management of acute pain because of safety concerns and, in most countries, lack of
regulatory approval for use in other than opioid‐tolerant patients (N).
7. PCA, REGIONAL AND OTHER LOCAL ANALGESIA TECHNIQUES
Patient‐controlled analgesia
1. Intravenous opioid PCA provides better analgesia than conventional parenteral opioid
regimens (S) (Level I [Cochrane review]).
2. Opioid administration by intravenous PCA leads to higher opioid consumption (R), a
higher incidence of pruritus (R), and no difference in other opioid‐related adverse effects
(S) or hospital stay (S) compared with traditional methods of intermittent parenteral
opioid administration (Level I [Cochrane review]).
3. In settings where there are high nurse‐patient ratios there may be no difference in
effectiveness of PCA and conventional parenteral opioid regimens (N) (Level I).
4. Patient preference for intravenous PCA is higher when compared with conventional
regimens (U) (Level I).
5. The addition of ketamine to PCA morphine does not improve analgesia or reduce the
incidence of opioid‐related side effects (U) (Level I).
6. Iontophoretic fentanyl PCA may not be as effective as intravenous morphine PCA, with
more patients withdrawing from studies because of inadequate pain relief (Level I).
7. There is little evidence that one opioid via PCA is superior to another with regards to
analgesic or adverse effects in general; although on an individual patient basis, one
opioid may be better tolerated than another (U) (Level II).
Acute pain management: scientific evidence xxix
