General principles

If possible, identify and treat underlying precipitating factors.

If needed, administer fluids orally, or intravenously as 5 percent dextrose in water or in a 25 percent normal saline solution.

Use oxygen therapy only if hypoxemia is present.

Acute pain management

Avoid delays in administering analgesia.

Administer an opioid analgesic parenterally (preferably intravenously) on a regular basis in a full therapeutic dosage or by patient-controlled analgesia. Avoid “as-needed” dosing.

Reassess the patient every 30 minutes for pain severity, sedation, vital signs and respiratory rate.

Use pain measurement scales as an objective guide to titrate the maintenance dosage of an analgesic and to determine treatment effects.

For breakthrough pain, administer one fourth to one half of the maintenance dosage, depending on the degree of sedation.

If three or more rescue doses are needed within a 24-hour period, increase the maintenance dosage by 25 to 50 percent, and repeat the same steps until analgesia is achieved.

Pain management after an acute crisis

Begin tapering the parenterally administered analgesic when the pain severity score is less than 5 on the visual analog scale or verbal pain scale and the patient's mood improves. Reduce the maintenance dosage by 25 percent every 24 hours, and replace the parenterally administered drug with an equianalgesic oral agent given in divided doses.

Consider hospital discharge when the patient's pain is controlled with an orally administered analgesic or no analgesia is needed.

If the patient still has pain at the time of hospital discharge, provide a prescription for a sufficient quantify of analgesic drug to treat resolving or relapsing pain until the patient's next office appointment.