Multi-modal Anesthesia!

Transcription

1 Multi-modal Anesthesia! Because our patients deserve evidence-based care! for Enhanced Recovery! Objectives!!! Define multi-modal analgesia!! List 3 ways using a multimodal approach benefits patients!! Define options for Multimodal analgesia!! List a change in your personal practice based on new understanding regarding current research on multimodal analgesia! 1!

2 4/16/17 Shift to Value-based Care Fee for Service Pay for Performance or Value-based purchasing 2014 PQRS Physician Quality Reporting System 2017 QPP Quality Payment Program MACRA final rule MIPS Merit-based Incentive Program + incentive APMs Alternative Payment Models 5% incentive Patient Focus of Accountable Care Current System Avoidable readmission Variable length of stay Avoidable complications Unsubstantiated variation Current Costs continue Current patient experience Current return to work rates Perioperative Surgical Home Minimize readmission Dynamic pathways Minimize complications Evidence-based care Costs decreased Increase in satisfaction Increase in productivity è 2

3 Average Costs In CRS Per Year! MERP SSIB Current Surgical Challenges! 3!

4 How to Evaluate Anesthesia?! Health-care Report Cards and Implications for Anesthesia" Anesthes. 1998;88(3): ! Date of download: 4/12/2017!! Copyright 2017 American Society of Anesthesiologists. All rights reserved. 4!

5 How to Evaluate Anesthesia?! 1: 43-99%! 2: 8 92%! Enhanced Recovery Model! Adapted from ERAS Society. www. ErasSociety.org! 5!

6 ! Preoperative Phase! Scheduling of surgery to arrival in preop holding!! Information management /Healthcare literacy!!!!!! Postop Pain Expectations! Nutritional optimization and carbohydrate loading! Exercise / prehabilitation! Mental health assessment! Smoking & alcohol cessation! Intraoperative Phase!! Timeframe: arrival in preop holding until discharge to ward!! Surgical Care Improvement Project (SCIP) measures!! Avoidance of NG tubes!! Selective bowel preparation!! Goal-directed fluid therapy!! Appropriate premedication!! Use of short-acting anesthetics! SCIP + Anesthetic Standardization!! Avoidance of PONV!! Maximal use of multimodal analgesia including regional! 6!

7 Postoperative Phase!! Time: arrival on ward until return to baseline!! Maximal use of multimodal analgesia!! Early mobilization!! Stimulation of gut motility!! Early enteral feeding!! Early removal of drains/catheters!! Information management: healthcare literacy & expectations! Potential Consequences of Unrelieved Acute Pain!!"#$%&'()* +&,-./($0%$)"&!"$)1)$- 2%(34&!*5)%$-,/6)*$)*74&,0(6689& :3%($0)*7 ;("0-"(3<)(4& =-/%3$%*>)8*,6%%/6%>>*%>>4& =%6/6%>>*%>>!$%6%"$(>)>4& =-/%3"(3?)(4&=-/85)( A & B8*>#./$)8* C&&D%7)8*(6& :688<&2689 E-8"(3<)(6& F>"0%.)( F*G%"$)8*4& F>"0%.)( F./()3%<& D%0(?)6)$($)8* '*%#.8*)( Adapted from Ghori MK, Zhang YF, Sinatra RS. In: Sinatra RS, Leon-Casasola OA, Ginsberg B, Viscusi ER, eds. Acute Pain Management. 1st ed. New York, NY: Cambridge University Press; 2009: ! 7!

8 Opioids have Historically been the Foundation for Acute Pain Management! In a 2012 research database of 1,665,418 patients, 72% of inpatients treated with IV analgesia received IV opioid monotherapy! Joint Commission! 5 th Vital Sign 1996! 28% other! 72% opioid only! n=459,674! n=1,205,744! Data from the hospital research database maintained by the Premier healthcare alliance. July 17, Pain scores and Opioid Consumption # in US versus Europe! 8!

9 Why Treat Pain Aggressively!! Prevent chronic pain!! Improve patient satisfaction!! Improve rehabilitation!! Improve outcome & decrease costs!! Reduce POCD!! Decrease incidence of cancer metastasis and recurrence!! Decrease opioid dependence addiction and death! Incidence of Post-surgical Chronic Pain! Retrospective survey (n = 250 / random sample) Evaluation until 2 weeks after hospital discharge SLIGHT MODERATE SEVERE EXTREME 84% of outpatients experienced acute pain Anesth Analg 97(2):534-40, 2003 Aug Percentage of patients who develop chronic pain Breast surgery!!!67%! Thoracotomy!!!67%! Sternotomy!!!33%! Hysterectomy!!!67%! Inguinal Hernia Repair!67%! Breivik H, Postoperative pain: towards optimal pharmacological and epidural analgesia. Pain 2002! 9!

10 !! Evolution from Acute to Chronic Pain! Complex and poorly understood! Perioperative, psychosocial, socio-environmental, socioeconomic and patient-related factors!! Tissue damage! Inflammation! Hyperalgesia!! Estimated annual cost of chronic pain in U.S. estimated to be $ billion (2010)! Multi-modal Definition!! Use of different two or more drugs/techniques to provide synergistic, superior dynamic pain relief with reduced analgesic-related side effects.!! Prevention of peripheral pain progressing to chronic regional pain syndrome through neuroplastic remodeling.!! Combined with a multi-disciplinary rehabilitation, may enhance recovery, improve patient experience, facilitate early convalescence and reduce overall cost.! Joshi GP. Multimodal analgesia techniques and postoperative rehabilitation. Anesthesiol Clin North America Mar;23(1):q ! 10!

11 Pain Pathways and where we intercede! Descending! Modulation! Inflammatory Mediators! Adenosine! Bradykinin! Cytokines! Interleukin 1B! TNF-a! GABA! Glutamate! Glycine! Histamine! Leukotrienes! Neurokinins! Nitric oxide! Prostaglandins! Serotonin! Substance P! 2012!! Predictive multifactorial etiology! P! Preoperative pain at surgical site!! Other chronic preoperative pain!! Inpatient surgery!! Non-laparoscopic surgery!! Capacity overload: sleeping disorder, tachycardia, exhaustion, frightening thoughts!! Severe postoperative pain!! Assist high-risk patient with coping and early intervention! 11!

12 Opioid-induced Hyperalgesia!! OIH through rapid tolerance at the mu receptor!!! Decreased pain threshold unrelated to original stimulus! The higher the intraoperative dose of fentanyl or remifentanil, the larger the pain area, and the greater the narcotic requirement postoperatively! Groban Leanne, Butterworth J. Fentanyl: Destiny or Devil? Anesthesia & Analgesia 2009, editorial.! Opioid-induced Hyperalgesia Anesthesiology, 104(3) Mar 2006 pp !! Opioid avoidance is a growing movement! Raymond S. Sinatra, MD, PhD, director of pain management at Yale-New Haven Hospital in New Haven, Conn.! Successful multimodal strategies require skill and experience in regional and neuraxial analgesia, as well as a knowledge of drugs' pharmacokinetics and pharmacodynamics.! The payoff is greater efficiency in pain relief and patient care.! Society for Opioid Free Anesthesia! 12!

13 4/16/17 Ultrasound-guided Blocks Block Application Interscalene Shoulder, rotator cuff and shoulder replacement Infra/supraclavicular Hand wrist, elbow, distal arm Continuous lumbar plexus+ Single sciatic Hip, hip replacement, I&D Continuous femoral + Continuous Sciatic Knee, knee replacement Adductor canal Knee, knee replacement Continuous Sciatic Foot, knee, above and below knee amputations Continuous paravertebral PECs I and II Single paravertebral Chest wall, thoracic, breast, abdominal surgery, iliac crest bone graft Inguinal hernia, prostatectomy, hysterectomy TAP Block C-section, Inguinal hernia, Lap Chole, Appy, TAH VAUltrasound.com Ultrasound-guided Regional Block website Niesen, Liam and Hebl James Multimodal Clinical Pathways Perineural Catheters and Ultrasound-guided Regional Anesthesia. Clinical & Health Affairs, March

14 Thoracotomy epidural prevented chronic pain 25% (OR = 0.33)! Breast cancer surgery paravertebral block 25% (OR = 0.37)! TAP block! 14!

15 Non-Opioids Used in Multimodal Therapy! Acetaminophen! Alpha-2 agonists! Gabapentinoids! Acetaminophen! Clonidine! Gabapentin! Dexmedetomidine! Pregabalin! Local Anesthetics! NMDA antagonists! NSAIDS! & COX-2 Inhibitors! Bupivacaine! Lidocaine! Liposomal bupivacaine! Corticosteroids! Dexamethasone! Ketamine! Magnesium! Nitrous! Benzodiazepines & Antidepressants! Venlafaxine! Celecoxib! Ibuprofen! Ketorolac! Diclofenac! Cannabinoids! Acetaminophen!! IV acetaminophen co-administered in studies with morphine, patients required 20% to 30% less morphine!! Adult dose: 1000 mgm q6, max 4000/24 hours!! Pediatric dose: 15 mg/kg, max 75 mg/kg/24 hours.!! Reduce dose in hepatic impairment! 15!

16 Clonidine!! Mechanism of action!!alpha-2 adrenergic blockade, inhibits norepinephrine release!!attenuates opioid-induced post-infusion hyperalgesia!! Indications reduce acute pain and perioperative narcotic use. Prevent chronic pain. Treat neuropathic pain.!! Contraindications- sedation, hypotension!! Dosage!!Intrathecal - Clonidine mcg (+morphine)!!epidural/intravenous 150 mcg (+lidocaine)!!topical patch 30 mcg/cm/day 7 or 10.5 cm 2 patch!! Gabapentin!!!Mechanism of action modulate voltage dependent Ca 2+ channels to reduce transmitter release and decrease neuronal excitability. Inhibits release of glutamate, aspartate, substance P and calcitonin peptide!!indications! neuropathic pain: reduced odds ratio of CPSP to 0.52! anti-inflammatory, blunts response to tracheal intubation,! reduces PONV and POCD!!Contraindications additional monitoring for somnolence!!dosage 900 mg po 1-2 hours before surgery! Intrathecal % effective! 16!

17 Gabapentin!- surgery specific?!!single preoperative dose significantly reduced pain intensity at 6 and 24 h after operation.! Breast, thyroidectomy, lap tubal, TAH, thoracotomy, hand, lower extremity!!significant reduction in 24 hour cumulative opioid consumption: no advantage to multiple over single dose.!!no effect on incisional or burning pain 6 months postop: lumpectomy, radical mastectomy, TAH.!!Not effective in reducing postoperative analgesic use for shoulder arthroscopy under GA w/ interscalene block! Kong, VKF: Gabapentin: a multimodal perioperative drug? BJA 2007;99(6):775-86! Spence, D. et al. AANA Journal 2011; 79(4): S73! Lidocaine!!! IV administration!! Pain reduction akin to regional anesthesia!! Dose 1.5 mg/kg/hr IV!! RCT breast cancer surgery reduced CPSP!! Inexpensive, time-tested, why not?! Rashiq, Post-surgical pain syndromes, Can J Anesth (2014) 61: ! 17!

18 Exparel: liposomal bupivacaine!! Liposomal foam for injection into soft tissue via infiltration.!! Hepatic metabolism, renal excretion.!! Original FDA warning letter, restricted to hemorrhoidectomy and podiatry.!! 2013 had failed to show efficacy in nerve block studies!! Appropriate for TAP blocks, rectus sheath, subcostal!! Orthopedic: Intra-articular wound infiltration by surgeon.!! Adductor canal? Femoral? Not yet approved.!! Numerous phase 3 trials. Incidence of nerve injury very low!! Paravertebral, PECS I and II fascial plane blocks!!!nmda Antagonists!! Mechanism of action- inactivate NMDA receptor!!ketamine non-competitive!!magnesium & N 2 O un-competitive!! Indications prevent chronic pain, peripheral and central sensitization (wind-up), treatment of neuropathic pain, mood elevator, pain relief without respiratory depression, decrease hyperalgesia, prevent tolerance.!! Contraindications- severe HTN, high doses, prolonged administration! 18!

19 ! Use sufficient dosage > 0.15 mg/kg!! Give throughout case!! Major: 0.5mg/kg pre-incision, bolus 0.2mg/kg q30 min or infusion 500 mcg/kg/hr, last dose 60 minutes before end!! Minor: 0.25 mg/kg bolus, q30 minutes mg/kg or infusion 250 mcg/kg/hr!! Epidural 0.5 mg/kg vs. IV 0.5 mg/kg!! Benzodiazepine premed recommended!! NSAIDS, COX-2 Inhibitors!!! Mechanism of action decrease inflammation via prostaglandin synthesis, prevent sensitization of peripheral nerves. Desensitizes NMDA receptors before activation, attenuates development of opioid tolerance.!! Indications mild to moderate pain.!! Contraindications GI ulceration, impaired renal function, platelet inhibition, exacerbation of asthma!! Ketorolac mg IV or po;! Caldalor mg IV q6h in >200cc over 20 minutes! Celecoxib 200mg po! 19!

20 4/16/17 Corticosteroids Glucocorticoids reduce inflammation and tissue edema. Giving dexamethasone preoperatively improves pain relief considerably more than giving it after induction. (Optimally 1-2 hours before incision.) Doses under 0.1 mg/kg great for PONV but don t help with pain relief. Doses of about 0.15 mg/kg cover PONV and reduce postoperative pain and opioid demand. No benefit to going above 0.2 mg/kg No increase in infection rate. Increased glucose level at 24 hours. Reduces risk of PDPH after SAB for C/S Half-life hours Perioperative single dose systemic dexamethasone for postoperative pain: meta-analysis of randomized controlled trials Anesthesiology. 2011;115: De Oliveira GS Jr, Almeida MD, Benzon HT, McCarthy RJ Antidepressants Serotonin/Norepinephrine reuptake inhibitors (SNRIs) Venlafaxine ER mg daily Duloxetine mgm BID Milnacipran mg BID 20

21 Naltrexone!!! Pure opioid antagonist, competitive binding at receptor!! Used in treatment of opioid abuse or alcohol dependence! Contrave combination naltrexone and bupropion! POCD! $7 Billion in Medicare expenses! Surgery-induced neuroinflammation resulting in! damage to the blood-brain barrier is the pathogenic mechanism! 21!

22 Risk Factors for POCD!! Non-modifiable:!!Age over 65!!Education!!Genetic polymorphism predisposing to Alzheimer s!!alzheimer s disease!!! Modifiable!!Metabolic syndrome!! Risk Factors for POCD! PLoS ONE. Jun2012, Vol. 7 Issue 6!! Surgical!! Intraoperative hypotension!! Hypoxia!! Embolism!! Medications!! Postoperative infections!! Anesthetic to mimic normal sleep!! Postoperative!! Sleep disruption!! Sedation practices BZs increase delirium!! Cholinergic stimulation protects BBB! Anticholinergics open the BBB! 22!

23 ! Interdisciplinary awareness & training for early dx & treatment!! Optimize pain control with regional anesthesia and non-opioid meds!! Insufficient evidence for or against antipsychotics!! Avoid medications that contribute considerably to rise of postop delirium!! Anticholinergics, sedative hypnotics!! Do not initiate cholinesterase inhibitors (Aricept)!! Meperidine x2.7!! Diphenhydramine x2.3!! Benzodiazepines x3.0!! Polypharmacy more than 5 medications! Reduce Cancer Recurrence! 23!

24 4/16/17 Substance P induces mitogenesis of tumor cells at Neurokinin-1 receptor in the dorsal horn. Stress response decreases Natural Killer cells that fight tumor cells. Opioids known to inhibit cellular and humoral immune function EGA % GA % P Overall recurrence Prostate Ca Recurrence < 2 yrs

25 ! Neuraxial anesthesia alone is not enough to prevent immune suppression, used with varying opioid regimens.!! Its use is recommended for effective pain control, improved postop respiratory function and early ambulation.!! Human Genome Project! Pharmacogenetics - rare! Pseudocholinesterase deficiency!!porphyria!!malignant hyperthermia!! Pharmacogenomics common! Phar!Polymorphisms contributory to disease development!! Pharmacodynamics differences in response to equal dose!! Pharmacokinetics how soon after administration effect is reached and how long it is maintained.! 25!

26 Mu 118A>G! GG AG AA! Melanocortin-1! MTHFR! 2x alfentanil for pain relief and respiratory depression.! May be more sensitive to intrathecal opioids! 118A>G more common in chronic pain patients! Mediates kappa-opioid receptor sensitivity! Pale skin and red hair more likely to carry inactivating variants of MC1R gene! Reduced sensitivity to noxious stimuli, increased analgesic response to morphine! N2O >2 hours inactivates B12, methionine synthetase. Neuropathy, demyelination, homocysteine elevation and MI.! CYP2D6! Poor metabolizers 5-10%! Intermediate metabolizer 10-15%! Extensive metabolizers 65-80% (normal)! Ultra-rapid metabolizers 5-10% (China 0.5%, Ethiopia 29%)! January 26, 2015! 26!

27 4/16/17 Multi-modal Approach POSTOP INTRAOP PREOP Mild Moderate Severe Gabapentin or Pregabalin Gabapentin or Pregabalin Acetaminophen Acetaminophen Acetaminophen NSAIDS or COX-2 inhibitors NSAIDS or COX-2 inhibitors NSAIDS or COX-2 inhibitors Regional analgesia or local Regional analgesia Regional analgesia Decadron Decadron Decadron Ketamine Minimal narcotics Ketamine Minimal narcotics Local infiltration Consider TAP block Regional analgesia post op Continue NSAIDS & Acetaminophen Continue NSAIDS & Acetaminophen Continue NSAIDS & Acetaminophen No narcotics Minimal narcotics Breakthrough narcotics Example of Multimodal Approach Total Hip Replacement Total Knee Replacement acetaminophen celecoxib pregabalin Pre-operative period acetaminophen celecoxib pregabalin Spinal with LA + morphine OR CSE with Epidural (sleep apnea or opioid intolerant) OR General anesthesia Operative period Spinal with LA OR CSE with LA OR Spinal with FNB OR General anesthesia FNB acetaminophen celecoxib pregabalin IV PCA/PO opioids Post-operative period LA = local anesthetic; CSE = combined spinal-epidural; FNB = femoral nerve block; IV = Intravenous; GA = general anesthesia; PO = oral. Adapted from Parvizi J et al. J Bone Joint Surg Am 2011; 93(11): Epidural with LA FNB acetaminophen celecoxib pregabalin IV PCA 54 27

28 Mayo Clinic Clinical Pathway! Total Hip Arthroplasty! Posterior lumbar plexus catheter, dosed preop! Total Knee Arthroplasty! Femoral nerve catheter, dosed preop! Sciatic nerve single injection! Preoperative! Intraoperative! Postoperative! Extended release oxycodone! Celecoxib! 200 mg po! Gabapentin! mg po! Spinal or GA! Limited opioid administration! No IV opioids! Ketorolac or! 15 mg IV q6h PRN pain >4! Celecoxib! 200 mg PO BID x5 days (! Acetaminophen! 1000 mg PO TID before PT! Oxycodone! 5 to 10 mg PO q4h PRN! 5mg for pain <4, 10 mg pain >4! Tramadol! mg PO q6h in opioid sensitive patients! Gynecological Fast Track!! Thorough preoperative information and education! Thor!Optimum dynamic pain relief with minimal opioids!!early mobilization!! Minimally invasive surgery!! Regional and local anesthesia, GA as needed!! Relaxed NPO standards per Cochrane review 2003.!! Controlled fluid management!! Normothermia!! Regional results in better pain relief first 24 hours than GA.!! TAP blocks effective.!!"#$%&'(')&#'(%$**"&'+,'-./'#/0/$"12/&3'"4'4)*3536)78'16%&7%1$/*'%&'9:&/7"$"9%7)$'*;69/6:,'' <73)'=>*3/36%7)'/3'?:&/7"$"9%7)'@7)&#%&)0%7),'ABCA,'DAEABCFGCH5AH,'' 28!

29 4/16/17 Sample protocol - preoperative Nutrition Nutritional assessment, protein containing supplement 3x/ day x 5 days preop CHO Loading Gatorade juice morning of surgery. NPO clear liquids 2 hours prior to surgery Strength Incentive spirometry 1 week prior to surgery, increase exercise daily x 2 weeks Bowel Prep Standardized for all surgeons doing similar procedures Premeds Avoid sedatives in patient over 70 or with dementia or confusion Education and Expectations All patients must attend a presurgical education class with friend/family. Sample Protocol Intraop Goal directed fluid therapy Anesthetic optimization IV fluids on pump throughout case Consider SVV/ PVV monitoring for specific high risk patients Use short-acting anesthetics (Sevo/Des) Lidocaine infusion 1.5 mg/kg with induction followed by 2 mg/kg until emergence 29

30 4/16/17 Sample Protocol All phases Multimodal Analgesia Thoracic epidurals for all scheduled open procedures Gabapentin 600 mg preop then 300 mg TID for 3 days (not PRN) Ketamine 0.5 mg/kg IV with induction Ketorolac 30 mg IV in OR, then 15 mg q6h for 3 days (not PRN) Acetaminophen 1000 mg IV in OR, then IV or po q6h for 3d (not PRN) Glycemic Control Check HgbA1C on all patients 3d prior to surgery. Cancel if level is >9% If elevated in non diabetics: check glucose on morning of surgery. Treat as you would a type-2 diabetic. Continue glycemic control through perioperative phase. Education and Appropriately written patient education brochure provided postop. Expectations Baribault Narcotic-free Protocol Preoperative Induction Intraoperative Emergence PO for larger cases: Acetaminophen 1 G Celebrex mg Cymbalta 60 mg Lyrica mg or Gabapentin mg Clonidine 200 mcg (2-5mcg/kg) Ketamine 20 mg ( mg/kg Decadron 8-10 mg Regional anesthesia if possible If no block: Lidocaine infusion 1.5 mg/kg bolus and 2mg/kg/hr infusion Induction doses usually last 4 hours. If BP and HR start trending upwards redose: Clonidine 100mcg Ketamine 10 mg If not given preoperatively: NSAID Ofirmev 30

31 4/16/17 Implementation Strategies * Identify surgeon, anesthesia, nursing and admin champion * Gather local data on length of stay, readmits, SSI, satisfaction and surgeon variability * Target long length of stay/high complication procedures * Generate protocol * Collect data, analyze, adjust protocol * Plan for face-to-face kickoff meeting * Monitor and measure first few months * Follow up weekly 31