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Minerva Anestesiologica 2015 February;81(2):205-25


language: English

Italian Intersociety Recommendations on pain management in the emergency setting (SIAARTI, SIMEU, SIS 118, AISD, SIARED, SICUT, IRC)

Savoia G. 1, Coluzzi F. 2, Di Maria C. 3, Ambrosio F. 4, Della Corte F. 5, Oggioni R. 6, Messina A. 5, Costantini A. 7, Launo C. 8, Mattia C. 2, Paoletti F. 9, Lo Presti C. 10, Bertini L. 11, Peduto A. V. 9, De Iaco F. 12, Schiraldi F. 13, Bussani F. 14, De Vito L. 15, Giagnorio G. 16, Marinangeli F. 17, Coaccioli S. 18, Aurilio C. 19, Valenti F. 17, Bonetti C. 17, Piroli A. 17, Paladini A. 17, Ciccozzi A. 17, Matarazzo T. 20, Marraro G. 21, Paolicchi A. 22, Martino A. 23, De Blasio E. 3, Cerchiari E. 24, Radeschi G. 25

1 UOSC TIGU-CAV, AORN A. Cardarelli, Napoli, Italia; 2 Dipartimento di Scienze e Biotecnologie Medico Chirurgiche, Sapienza Università di Roma, Roma, Italia; 3 Unità Operativa Complessa di Anestesia e Rianimazione, AORN “G. Rummo”, Benevento, Italia; 4 Dipartimento di Farmacologia e Anestesiologia, Università di Padova, Padova, Italia; 5 Dipartimento di Emergenza, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italia; 6 Anestesia e Rianimazione, Ospedale del Mugello, ASL 10, Firenze, Italia; 7 Unità Operativa Dipartimentale, Centro di Fisiopatologia e Terapia del Dolore e Cure Palliative, Ospedale SS. Annunziata, Chieti, Italia; 8 Università degli Studi di Genova, Genova, Italia; 9 Università degli Studi di Perugia, Perugia, Italia; 10 Unità Operativa Dipartimentale, Terapia del Dolore e Cure Palliative, AOC S. Filippo Neri, Roma, Italia; 11 Unità Operativa Complessa di Anestesia e Terapia del Dolore, Presidio S. Caterina della Rosa ASL RMC, Roma, Italia; 12 Dipartimento di Emergenza, ASL 1 “Imperiese”, Imperia, Italia; 13 Medicina di Urgenza, ASL NA 1 centro, Napoli, Italia; 14 .118 Umbria Soccorso, Policlinico Monteluce, Perugia, Italia; 15 SOCM 118, Firenze, Italia; 16 Dipartimento di Emergenza, Ospedale di Gorizia, Azienda per i Servizi Sanitari n. 2 Isontina, Gorizia, Italia; 17 Università degli Studi dell’Aquila, L’Aquila, Italia; 18 Università degli Studi di Perugia, Polo Didattico di Terni, Terni, Italia; 19 Università degli Studi di Napoli, Napoli, Italia; 20 Anestesia e Rianimazione, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italia; 21 Università di Milano, Milano, Italia; 22 Azienda Ospedaliero-Universitaria Pisana, Pisa, Italia; 23 Dipartimento di Emergenza, Accettazione, AORN Cardarelli, Napoli, Italia; 24 Anestesia e Terapia Intensiva, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italia; 25 Struttura Complessa Dipartimentale Ospedaliera di Anestesia e Rianimazione, Università di Torino, Centro Didattico San Luigi Gonzaga, Beinasco, Torino, Italia


BACKGROUND: Pain is the primary reason for admission to the Emergency Department (ED). However, the management of pain in this setting is often inadequate because of opiophagia, fear of excessive sedation, and fear of compromising an adequate clinical assessment.
METHODS: An intersociety consensus conference was held in 2010 on the assessment and treatment of pain in the emergency setting. This report is the Italian Intersociety recommendations on pain management in the emergency department setting.
RESULTS: The list of level A recommendations includes: 1) use of IV acetaminophen for opioid sparing properties and reduction of opioid related adverse events; 2) ketamine-midazolam combination preferred over fentanyl-midazolam fentanyl-propofol in pediatric patients; 3) boluses of ketamine IV (particularly in the population under the age of 2 years and over the age of 13) can lead to impairment of the upper airways, including the onset of laryngospasm, requiring specific expertise and skills for administration; 4) the use of ketamine increases the potential risk of psychomotor agitation, which can happen in up to 30% of adult patients (this peculiar side effect can be significantly reduced by concomitant systemic use of benzodiazepines); 5) for shoulder dislocations and fractures of the upper limbs, the performance of brachial plexus block reduces the time spent in ED compared to sedation; 6) pain relief and the use of opioids in patients with acute abdominal pain do not increase the risk of error in the diagnostic and therapeutic pathway in adults; 7) in newborns, the administration of sucrose reduces behavioural responses to blood sampling from a heel puncture; 8) in newborns, breastfeeding or formula feeding during the procedure reduces the measures of distress; 9) in pediatric patients, non-pharmacological techniques such as distraction, hypnosis and cognitive-behavioural interventions reduce procedural pain caused by the use of needles; 10) in pediatric patients, preventive application of eutectic mixtures of prilocaine and lidocaine allows arterial and venous samples to be taken in optimum conditions; 11) in pediatric patients, the combination of hypnotics (midazolam) and N2O is effective for procedural pain, but may be accompanied by loss of consciousness.
CONCLUSION: The diagnostic-therapeutic pathway of pain management in emergency should be implemented, through further interdisciplinary trials, in order to improve the EBM level of specific guidelines.

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