Skip to content

Acute Pain Service (APS) Consult Protocol

Definition

The Acute Pain Service (APS) provides multidisciplinary, evidence-based pain management for post-operative and trauma patients. Consults are indicated for patients requiring regional anesthesia, complex multimodal analgesia, or pain refractory to standard regimens.

Typical indications: - RIG (Regional Indication Group) score ≥ 6 - Surgeon discretion for complex pain control or regional block consideration - Early identification at admission preferred

Principles

  • Goal: Optimize analgesia, minimize opioid use, and facilitate mobilization and recovery.
  • Timing: Early consult improves outcomes; initiate at admission or preoperatively if possible.
  • Safety: Coordination with anticoagulation protocols is essential before neuraxial or regional procedures.
  • Communication: Maintain clear lines between APS, surgical team, and nursing regarding analgesia plan and anticoagulation holds.

Stepwise Evaluation

1. Identify Candidates

  • RIG score ≥ 6
  • Significant injury burden (e.g., multiple rib fractures, major abdominal or orthopedic trauma)
  • Uncontrolled pain despite multimodal regimen
  • Anticipated high postoperative pain intensity

2. Initiate Discussion with Patient

  • Explain APS role and adjunct options (e.g., epidural, paravertebral, ESP, serratus anterior blocks).
  • Document patient understanding and consent.

3. Anticoagulation Status

  • Hold DVT prophylaxis prior to block placement:
  • NOACs/antiplatelets: APS will proceed if TEG is normal.
  • If recently admitted: hold per medication chart.
  • If inpatient: confirm last dose and follow institutional hold times (see table below).

4. Consult APS

  • Phone: (520) 449-1468
  • After 5 PM: text APS and call between 7–8 AM next morning.
  • Provide:
  • Patient name and MRN
  • Indication for consult (injuries/operative site)
  • ACS team contact and phone number

Management

Anticoagulation Holding Times for Regional Procedures

Catheter Type Pre-Placement Hold While Catheter In Situ Pre-Removal Hold Restart Prophylaxis After Removal
Epidural Lovenox: 12 h
Heparin 5,000 U BID/TID: 6 h
Heparin 7,500–10,000 U BID: 12 h		 Hold as above Lovenox: 12 h
Heparin 5,000–10,000 U BID/TID: 6–12 h		 Lovenox: 4 h after
Heparin: immediately
Paravertebral / ESP Lovenox: 12 h
Heparin 5,000–10,000 U BID/TID: 12 h		 Hold as above Lovenox: 6 h
Heparin 5,000–10,000 U BID/TID: 6 h		 Lovenox: 4 h after
Heparin: immediately
Serratus Anterior Lovenox: 12 h
Heparin 5,000–10,000 U BID/TID: 6–12 h		 Hold as above Lovenox: 12 h
Heparin: 6 h		 Lovenox: 4 h after
Heparin: immediately

Red Flags / Urgent Triggers

  • Coagulopathy (INR > 1.4, Platelets < 75 K, abnormal TEG) → Hold APS procedure
  • New neurological deficit while catheter in place → Immediate removal and notification
  • Active bleeding or hemodynamic instability
  • Catheter dislodgement or malfunction requiring APS review
  • Failure of pain control despite regional block

References

  • American Society of Regional Anesthesia and Pain Medicine (ASRA), 2018. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: 4th Edition Guidelines.
  • Washington University Department of Surgery, 2024. The Washington Manual of Surgery, 9th Edition.
  • Cameron JL, Cameron AM. Current Surgical Therapy, 14th Edition, Elsevier, 2023.
  • *Institutional APS Protocols and Consensus, 2025.