Foreword, Introduction & Acronyms
Foreword Introduction List of acronyms Foreword Pain is inevitable. Suffering is optional. (Haruki Murakami) The Japanese novelist might not necessarily have had physical pain in mind, but this quote is eminently applicable to acute pain of patients. Acute pain sensations accompany many diseases and all surgery. The prevention and treatment of pain have made great surgical progress possible, part
Foreword
Pain is inevitable. Suffering is optional. (Haruki Murakami)
The Japanese novelist might not necessarily have had physical pain in mind, but this quote is eminently applicable to acute pain of patients. Acute pain sensations accompany many diseases and all surgery. The prevention and treatment of pain have made great surgical progress possible, particularly over the past two centuries. All doctors have a responsibility to relieve pain and suffering. This responsibility is particularly applicable to doctors, usually anaesthesia providers, in treating perioperative pain.
All patients, whether from rich or poor countries, can experience pain. The International Association for the Study of Pain (IASP) declared that access to pain management is a fundamental human right. Yet, they found that pain management is inadequate in most of the world, including rich countries, due to a lack of access, knowledge deficits, stigma, inadequate national policies, status of pain medicine as specialist area, and restrictions to and unavailability of opioids and other drugs needed for the treatment of pain. This finding is also true for South Africa, where people live in both first- and third-world conditions. Recent studies showed that perioperative outcomes are far worse in Africa than in developed, richer countries. Pain most likely plays a role in this as adequate pain relief reduces inflammation and aids recovery, and may reduce the development of chronic postoperative pain.
People use the word ‘pain’ to describe emotional, psychological, social and other unpleasant human conditions. This emphasises that the nature of pain is not merely physical, but relates to individual patients as well as environmental factors. This should alert the medical practitioner to the physio-psycho-social aspects which need attention when physical pain is addressed and treated according to these guidelines.
Pain treatment requires an understanding of not only the physiology and nature of pain, but also the drugs and interventions available for treatment as well as the impact thereof on patients. The current opioid epidemic as seen in the USA is, to a large extent, the result of irresponsible and inappropriate prescribing of medication for postoperative pain. The SASA Guidelines for the management of acute pain in specific scenarios provides guidance on the effective and appropriate treatment of pain. Though it is not a protocol, it does provide information which can be adapted to the unique circumstances of each individual patient. Treatment and approaches within different clinical contexts are covered in these guidelines. Also, a health economic approach should be followed in limited resource contexts to ensure that pain treatment is affordable for both rich and poor patients.
The SASA Guidelines for the management of acute pain in specific scenarios comprehensively addresses the treatment of acute pain in a wide range of situations. We owe gratitude to a team that spent countless hours reviewing and updating these guidelines to be aligned with current best practice in simple to sophisticated pain treatment. With these guidelines, SASA hopes to play a role in relieving the suffering of patients with acute pain.
Prof. Johan Diedericks
SASA Guidelines Convener
Introduction
Welcome to the third edition of the Guidelines for the management of acute pain in specific scenarios. It has been revised, incorporating new drugs and recent advances in acute pain management. These guidelines are recommended for use by all medical practitioners involved in acute pain management of adults and children.
Guideline development and revisions thereof is a dynamic process. The Regulation Business Unit of the South African Society of Anaesthesiologists therefore would appreciate inputs on these guidelines from all sectors of the medical profession over the next few years. Contributions and opinions can be addressed to the SASA CEO via email (ceo@sasaweb.com), who will ensure that the contributors and councillors responsible for these guidelines, are informed.
The COVID-19 pandemic caused many challenges in completing this third edition review. However, through the dedication and perseverance of the contributors and councillors, we have produced an excellent guideline of international standard once again.
The South African Society of Anaesthesiologists appointed a consensus group of practitioners from varying specialities, with varying areas of expertise and interest, to update these guidelines, which cover a wide range of important clinical topics.
On behalf of the consensus group:
- Prof. Sean Chetty
- Dr Eric Hodgson
- Prof. Analee Milner
- Dr Anthony Travers
- Dr Cecile van Rooyen
- Prof. Johan Diedericks
- Dr Sudha Bechan
- Dr Faheem Baba
- Dr Anisa Bhettay
- Dr Annemie Burke
- Prof. Frans Smith
- Dr Chloe van den Bosch
- Dr Gary Simpson
- Dr Theresa Samuel
- Dr Karen van Zijl
List of acronyms
| Acronym | Definition |
| % | per cent |
| 5-HT | 5-hydroxytryptamine |
| AA | arachidonic acid |
| AACT | acceptance and commitment therapy |
| ABM | adjusted body mass |
| ACEI | angiotensin I converting enzyme inhibitor |
| ACT | activated clotting time |
| ACTH | adrenocorticotropic hormone |
| ADH | antidiuretic hormone |
| ADMA | asymmetrical dimethylarginine |
| ADP | adenosine diphosphate |
| AHN | acute herpetic neuralgia |
| AIDS | acquired immunodeficiency syndrome |
| AMPA | α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid |
| ANP | acute neuropathic pain |
| ANS | autonomic nervous system |
| APTT | activated partial thromboplastin time |
| ARA | angiotensin II receptor antagonist |
| ARV | antiretroviral drugs |
| ASD | autism spectrum disorders |
| ASIC | acid-sensing ion channel |
| ATP | adenosine triphosphate |
| BBB | blood–brain barrier |
| bd | twice daily |
| BK | bradykinin |
| BMI | body mass index |
| BPS | behavioural pain scale |
| Ca2+ | calcium |
| CB1-2 | cannabinoids |
| CBT | cognitive behaviour therapy |
| CGH | cervicogenic headache |
| CGRP | calcitonin gene-related polypeptide |
| CI | continuous infusion |
| CL | clearance |
| cm | centimetre |
| CNP | central neuropathic pain |
| CNS | central nervous system |
| CO | carbon monoxide |
| COX | cyclo-oxygenase |
| coxib | selective COX-2 inhibitor |
| CPR | cardiopulmonary resuscitation |
| CrC | creatinine clearance |
| CRPS | chronic regional pain syndrome |
| CS | caesarean section |
| CSD | cortical spreading depression |
| CSE | combined spinal and epidural |
| CSF | cerebrospinal fluid |
| CT | computed tomography |
| CV | cardiovascular |
| CH | cluster headache |
| DMME | daily milligram morphine sulfate equivalent |
| DRG | dorsal respiratory group |
| DVT | deep vein thrombosis |
| EBP | epidural blood patch |
| EMLA | eutectic mixture of local anaesthetics |
| eNOS | endothelial nitric oxide synthase |
| Entonox | nitrous oxide 50% in oxygen |
| EP1-4 | prostaglandin E2 receptors |
| ETTH | episodic tension-type headache |
| FDA | Food and Drug Administration |
| FLACC scale | face, legs, activity, cry, consolability |
| FPS | FACES pain scale |
| g | gram |
| GA | general anaesthesia |
| GABA | gamma-aminobutyric acid |
| GCA | giant cell arteritis |
| GFR | glomerular filtration rate |
| GH | growth hormone |
| GI | gastrointestinal |
| GIT | gastrointestinal tract |
| HAART | highly active antiretroviral therapy |
| HCU | high care unit |
| HGF | hepatocyte growth factor |
| HH | hypnic headache |
| HITT | heparin-induced thrombocytopenia and thrombosis |
| HIV | human immunodeficiency virus |
| HS | hyperserotoninergic syndrome |
| HSV | herpes simplex virus |
| IASP | International Association for the Study of Pain |
| IBS | irritable bowel syndrome |
| ICP | intracranial pressure |
| ICU | intensive care unit |
| IHS | International Headache Society |
| IIH | idiopathic intracranial hypertension |
| IL | interleukin |
| IM | intramuscular |
| IMI | intramuscular injection |
| IN | intranasal |
| INR | international normalised ratio |
| IO | intraosseous |
| IV | intravenous |
| IVI | intravenous injection |
| kg | kilogramme |
| LA | local anaesthetic |
| LAST | local anaesthetic toxicity |
| LD | loading dose |
| LMA | laryngeal mask airway |
| LMWH | low-molecular-weight heparin |
| LPH | low intracranial pressure headache |
| MAD | mucosal atomisation device |
| MAOI | monoamine oxidase inhibitor |
| Mcg | microgram |
| MD | maintenance dose |
| mg | milligram |
| mg/kg | milligram per kilogram |
| MI | myocardial infarction |
| MIAs | mechanically insensitive afferents/nociceptors |
| ml | millilitre |
| mm | millimetre |
| MME | milligram morphine sulphate equivalents |
| Mmol/l | millimol per litre |
| MOBID | Mobilization-Observation-Behaviour-Intensity-Dementia |
| MOH | medication overuse headache |
| N/A | not applicable |
| N2O | nitrous oxide |
| NA | noradrenalin |
| Na+ | sodium |
| NIPS | Neonatal Infant Pain Scale |
| NK-1 | neurokinin 1 |
| NMDA | N-methyl-D-aspartate |
| NNT | numbers needed to treat |
| NO | nitric oxide |
| NPO | nil per os |
| NRI | noradrenaline reuptake |
| NRS | numeric rating scale |
| NSAIDs | nonsteroidal anti-inflammatory drugs |
| NTS | nucleus tractus solitarius |
| OFA | opioid-free analgesia |
| OIH | opioid-induced hyperalgesia |
| ON | occipital neuralgia |
| OSA | obstructive sleep apnoea |
| OTC | over-the-counter |
| OWS | opioid withdrawal syndrome |
| p.o | per os/orally |
| PaCO2 | partial pressure of carbon dioxide |
| PACSLAC | Pain Assessment Checklist for Seniors with Limited Ability to Communicate |
| PACU | postanaesthetic care unit |
| PAG | periaqueductal grey matter |
| PAINAD | pain assessment in advanced dementia |
| PCA | patient-controlled analgesia |
| PCEA | patient-controlled epidural analgesia |
| PDPH | postdural puncture headache |
| PE | pulmonary embolism |
| PET | preeclampsia |
| PF | preservative free |
| PG | prostaglandin |
| PGD2 | prostaglandin D2 |
| PGE2 | prostaglandin 2 |
| PGF2α | prostaglandin F2 alpha |
| PGG2 | prostaglandin G2 |
| PGH2 | prostaglandin H2 |
| PGI2 | prostacyclin |
| PHN | postherpetic neuralgia |
| PK-PD | pharmacokinetic-pharmacodynamic |
| PLA2 | phospholipase A2 |
| PMA | post menstrual age |
| PMC | post conceptual age |
| PNP | peripheral neuropathic pain |
| PNS | peripheral nervous system |
| PO2 | partial pressure of oxygen |
| PPI | proton pump inhibitor |
| PR | per rectal |
| PRN | per request needed |
| RCT | randomised control trial |
| RR | respiratory rate |
| RVM | rostral ventromedial medulla |
| Rx | treatment |
| SAH | subarachnoid haemorrhage |
| SAMF | South African Medicines Formulary |
| SBP | systolic blood pressure |
| SC | subcutaneous |
| SIH | spontaneous intracranial hypotension |
| SL | sublingual |
| SNRI | serotonin and noradrenalin reuptake inhibitor |
| SR | slow-release |
| SRI | serotonin reuptake inhibitor |
| SSRI | selective serotonin uptake inhibitor |
| Stat | immediately |
| TAP | transversus abdominis plane |
| TCA | tricyclic antidepressants |
| TD | trans dermal |
| TENS | transcutaneous electrical nerve stimulation |
| TIA | transient ischaemic attack |
| TNF | tumour necrosis factor |
| tNSAIDs | traditional nonsteroidal anti-inflammatory drugs |
| TRP | transient receptor potential |
| TRPA | transient receptor potential ankyrin |
| TRPV1 | transient receptor potential vanilloid 1 |
| TRPV2 | transient receptor potential vanilloid type-2 |
| TTH | tension-type headache |
| TXA2 | thromboxane A2 |
| UFH | unfractionated heparin |
| UP-3 | uvulo-palato-pharyngoplasty |
| UWC | use with caution |
| UWECO | use with extreme caution |
| VAS | visual analogue scale |
| Vd | volume of distribution |
| VDS | verbal descriptor scale |
| VNRS | verbal numeric rating scale |
| WDR | wide dynamic range |
South African Society of Anaesthesiologists (SASA) Guidelines for the Management of Acute Pain in Specific Scenarios 2022