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 Review published guidelines APA acute pain guideline Guidelines in Paediatric Acute Pain Practice

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

Guideline protocols

AGREE Collaboration Appraisal of Guidelines Research and Evaluations Assess quality of guidelines AGREE instrument http://www.agreecollaboration.org/

Levels of Evidence SIGN 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 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

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

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

GRADE Grading 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 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

Clinical Practice Guidelines the 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

Content 6 sections –Introduction –Quick reference guide –Pain Assessment –Procedural Pain –Postoperative Pain –Review of Analgesia 4 appendices technical 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) –483articles included in total –43pain assessment –120procedural pain –310postoperative pain

Recommendations 83 Recommendations –Grade A32% –Grade B13% –Grade C43% –Grade D10% 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 Pain good 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

r.howard@ich.ucl.ac.uk

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 100 Paediatric citations Level I & II50% (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 Finding the ‘evidence’ Appraising the evidence Integrating critical appraisal with clinical expertise and patient biology and values 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

APA Acute Pain Guidelines Richard Howard Great Ormond Street Hospital London.

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