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Qualified The new evidence is consistent with the data used to formulate the original key
message. The key message in the original report remains unchanged but
applicability may be limited to specific patient groups/ circumstances.

Reversed The new evidence is inconsistent with the data used to inform the original key
message(s). The strength of the new evidence alters the conclusions of the original
document.
NB Clinical and scientific judgment informed the choices made by the Working Party
members; there was no mandatory threshold of new evidence (e.g. number of
studies, types of studies, magnitude of statistical findings) that had to be met
before classification to categories occurred.
The first letter of each of the words (New, Unchanged etc) were used to denote
the changes (if any) from the last edition of this document.
An example of the use of this system is taken from the Key Messages in Section 7.1 – Patient‐
controlled analgesia.

Key Messages
1. Intravenous opioid PCA provides better analgesia than conventional parenteral opioid
regimens (S) (Level I [Cochrane review]).
2. Opioid administration by IV 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).

Where the new evidence led to reversal of a conclusion and Key Message, this was noted in
the text. For the example above this appeared in the text as:

Note: reversal of conclusion
This partly reverses the Level 1 conclusion in the previous edition
of this document; earlier meta‐analyses had reported no
difference in opioid consumption or opioid‐related adverse effects

Key messages were based on the highest levels of evidence available. Key messages referring
to information extracted from Cochrane meta‐analyses were marked ‘Level I [Cochrane
Review]’, and these were listed first.
Search strategies
Searches of the electronic databases Medline or PubMed, Embase and Cochrane were
conducted for each of the main topics included in the review. Searches were limited to articles APPENDIX B
concerning humans published mainly in English, and literature published between January
2005 and August 2009 was highlighted. One of the members of the working party, who is
fluent in German, translated key texts written in German, which were highlighted during the
search. These texts were used for validation purposes only. The initial searches were inevitably
broad, given the very wide scope of the topic. ‘Pain’, ‘acute pain, ‘postoperative pain’ or
‘analgesia’ was searched with the key headings of the various sections and subsections of the

Acute pain management: scientific evidence 465