Updated Pain Guidelines

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Rigshospitalet Copenhagen University, Copenhagen, Denmark. henrik.kehlet@rh.regionh.dkRecently, the American Society of Anesthesiologists Task Force on Acute Pain Management published an “updated report and practice guidelines for acute pain management in the perioperative setting.”1Although this is a laudable effort and the Task Force committee includes anesthesiologists with established expertise in the topic, I must admit as a surgeon with an interest in analgesia and postoperative recovery that I have several concerns on the overall message of the practice guidelines. First, it is claimed that the present guidelines differ from existing guidelines by providing “new evidence in an updated evaluation of scientific literature,” but a closer look at the reference material including almost 250 references shows less than 10 references from 2009 and upward. Many publications on single analgesic interventions as well as multimodal techniques have been published in the last 3 yr, which may change their conclusions if updated. For instance, by several meta-analyses or reviews on interventions like preventive analgesia, paravertebral blocks in pulmonary surgery, epidural analgesia in laparoscopic colonic surgery, local infiltration analgesia versus spinal analgesia in hernia surgery, and high-volume infiltration analgesia in major lower-limb arthroplasty versus peripheral blockades as well as the many efforts to provide improved analgesia and/or opioid-sparing by a combination of nonopioid analgesics. Importantly, many publications from the PROSPECT Collaboration Group have provided procedure-specific recommendations for perioperative acute pain management—which was not discussed in the present guidelines. This may be clinically important, because it has become evident that choice of analgesia is highly dependent on the specific surgical procedure regarding analgesic efficacy, potential side effects, and effects on recovery.Neither was there a comment on the extensive Australian and New Zealand guidelines for perioperative pain management.*†In summary, updated practice guidelines for acute pain management therefore must be based upon the available procedure-specific, multimodal opioid-sparing techniques and within a context to provide a rational basis for enhanced postoperative recovery and reduction of morbidity.2Rigshospitalet Copenhagen University, Copenhagen, Denmark. henrik.kehlet@rh.regionh.dk