Chapter 130

TABLE 130-1. Responsibilities of an APS
CHAPTER 130 ■ Acute Pain Service 2133
Regional Analgesia Techniques Opioid Based Analgesia Techniques Consultations for Inpatients
Continuous epidural infusions
Follow-up after intrathecal
opioids
Continuous peripheral nerve
block infusions
Follow-up after single-shot
peripheral nerve block
Patient-controlled analgesia (PCA)
PCA by proxy (nurse- or parent-controlled PCA)
Continuous opioid infusions
Weaning schedules for patients on opioids and
other sedatives
Intensive care unit patients
Trauma patients with multiple injuries
Burn patients
Hematology/oncology/rheumatology,
abdominal pain, miscellaneous
physician-directed pain services. 7 Nurse-directed services had a
physician advisor. Physician certification in pain management was
not commonly found among the pediatric APSs.
Anesthesiologists have a specialized and specific knowledge of
neurophysiology, pharmacology, anatomy, and pathophysiology,
and perform many of the techniques used for postoperative care
in the operating room; they plan intraoperative analgesia regimens
with an eye towards optimizing postoperative analgesia. Anesthe -
siolo gists are also excellent liaisons between surgery, nursing,
pharmacy, and families. However, in many institutions, physicians
from other specialties (e.g., rheumatology, pediatrics) that have a
particular interest in pain management function as the APS
director.
PERSONNEL
Each institutions will need to determine an approach that is most
practical and beneficial given its resources. Certain elements
should always be present.
Physicians
There should be at least one physician with an interest in acute
pain management involved in the APS. This person may be an
anesthesiologist, pediatrician, or other pediatric subspecialist
with an interest in pain management. Additional physicians
are usually needed to assist with communication, development,
and institution of policies and procedures, education of nurses,
physicians, and other health care providers, and day-to-day patient
management.
Nurses
TABLE 130-2. Goals of the APS
Optimize pain management
Choose the most appropriate pain assessment tools
Maximize multimodal approach to pain management
Minimize and treat side effects of medications
Develop safe and effective protocols and guidelines
Educate health care providers, patients, and families
Monitor outcomes and develop quality improvement programs
Communicate with surgeons, pediatricians, and other members
of health care team
Nurses may serve as the backbone of the service, helping to ensure
appropriate and timely follow-up of procedures, policies, and
physician orders. They are often the primary resource for educating
floor nurses and other health care providers and communicating
with team members.
Physician’s Assistants and
Advanced Practice Nurses
Physician’s assistants or advance practice nurses can assist with
more efficient functioning of an APS. As the demand on physicians
increases, the physician’s assistant or advanced practice nurse
can help with much of the daily management of these patients with
input from the APS physicians.
PAIN ASSESSMENT
Pain is a subjective experience, and neonates, infants, and young
children do not have the ability or vocabulary to describe their
pain. Older children with developmental delays have similar
limitations. In the past this has lead to under treatment and
confusion. There are now many measurement instruments available
that have extensively studied and validated in children of
different ages, developmental abilities, and cultures. However, the
sheer number of scales can add to the confusion of comparing the
efficacy of treatment modalities. The APS’s first task is to determine
which scales or evaluation tools work best within their
institution and to work with nursing to ensure timely and accurate
use of these scales. Appendix 1 provides some examples of commonly
used assessment tools.
MODALITIES
Pharmacodynamics and pharmacokinetics of medication vary
with age and development. Hepatic enzyme systems and renal
clearance are not mature in neonates, and may lead to the
accumulation of drugs or their metabolites. Children from 2 to
6 years of age have more-rapid drug clearance that can require
more frequent dosing. There are differences in body composition
that change with age. 8 Neonates have greater total body water
content than older children and adults, a higher percentage of
highly perfused tissue (e.g., brain, heart), and decreased plasma
binding proteins such as albumin and alpha-1 acid glycoprotein.
These variations can make neonates more susceptible to toxicity
and adverse side effects. (See Chapters 17 and 18)
Nonopioid Analgesics
The nonopioid analgesics are a heterogeneous group of drugs
that exert their effect by inhibiting peripheral prostaglandin
production. The majority of these medications are administered