10/28/18. Perioperative Pain Management in Orthopedic Surgery. Purpose. Patient Education
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1 Perioperative Pain Management in Orthopedic Surgery Paul J. Duwelius, MD OAOS 2018 Annual Meeting Portland, Or. Nov, 2, 2018 Purpose ØReview pain management options ØExplore new multimodal approaches ØDecreasing the need for opioids ØWhat really works? Patient Education ØDiscuss preoperatively your goals ØAnesthetic choice ØImportance of rapid mobilization ØRational for earlier discharge ØOvercome patients fear of pain ØExplain multimodal approach ØWhy narcotics are not always the best drug choice 1
2 The Care Pathway Surgical Technique Department of Preventative Surgery Hurdles (Anesthesia) ØInitially resisted regional anesthesia ØNeed to discuss your expectations ØGet them on board ØAsk for their input on new medications or techniques ØFemoral nerve block bad (falls & delayed discharge ØAdductor canal and periarticular blocks good! 2
3 Regional vs General Anesthesia? ØRegional provides better outcome ØDecreased blood loss ØLower DVT & PE rates ØLower mortality ØRehabilitation is facilitated Advantages of Regional + Propofol ØIntraoperative sedative ØPatient fully awake afterward ØImmediate PT Multimodal analgesic protocol ØActs at peripheral wound site ØSpinal cord ØBrain 3
4 What to Avoid ØIntravenous narcotics & pain pumps ØNarcotics in spinal ØNausea & vomiting are the enemy Preemptive Analgesia ØCox-2 anti-inflammatory ØOxycodone or other opioid ØTramadol ØTylenol ØAntiemetic ØOndansetron ØMetaclopramide ØIV corticosteroid Benefits of Preemptive Protocols ØIncreases functional recovery ØMinimizes postoperative nausea ØIncreases patients alertness for PT ØRapid mobilization key for DVT ØAntibiotic protocols key for infection 4
5 DVT Protocol ØIntraoperative & postoperative PCS ØCompression stockings X 2 weeks ØImmediate weight bearing ØPostoperative ASA x 6 weeks ØRivaroxiban/Coumaden (Higher risk) ØSpinal anesthetic ØDuplex US any clinical suspicion DVT Origin of Pain from Trauma or Surgery Ø Local inflammation at the noxious stimuli Ø This releases inflammatory markers ØBradykinin ØSubstance P ØHistamine & Prostaglandins Ø Afferent signals are relayed through the peripheral nervous system via unmyelinated C or myelinated A fibers (Opioids, Cox-2 pathway and alpha adrenergic agonist act here) Momomodal vs. Multimodal Pain Management ØMultimodal pain control targets various points in the pain pathway ØMultimodal pain control supports preemptive anesthesia ØAcetaminophen ØCox inhibitors ØPeriarticular injections ØOpioid medications 5
6 AAOS Evidence Based Guidelines ØStrong evidence of periarticular injection vs. placebo in TKA ØStrong evidence for adductor canal block for TKA (improves mobility) ØAbove AAOS guidelines decrease pain and opioid consumption Source: CDC.gov/drugoverdose Leading the Way to Solutions to the Opioid Epidemic AOA Critical Issues 6
7 Large Opioid Prescriptions are Unnecessary after Total Joint Arthroplasty: A Randomized Controlled Trial Charles P. Hannon 1, Tyler E. Calkins 1, Jefferson Li 1, Chris Culvern 1, Brian Darrith 1, Denis Nam 1, Tad L. Gerlinger 1, Asokumar Buvanendran 2, Craig J. Della Valle 1 Rush University Medical Center, Chicago, IL Conclusions A single prescription for 30 pills of 5mg OxyIR is sufficient for a majority patients after TKA & THA Prescribing fewer OxyIR pills associated with: Significantly fewer leftover pills after surgery Decreased opioid consumption No difference in pain scores or patient reported outcomes Ultimate Perioperative Pathway: Outpatient TJA 7
8 Thank You! U.S. Prescribing Rates Map 2016 Source: CDC.gov/drugoverdose Opioid Pain Reliever Prescriptions Ø Oregon providers wrote 78.1 opioid prescriptions per 100 persons (3.1 million prescriptions) Ø California providers wrote 54.9 opioid prescriptions for every 100 persons (approximately 21 million prescriptions) Ø Alaska providers wrote 63.5 opioid prescriptions per 100 persons (approximately 468,000 prescriptions) Ø Montana providers wrote 90 opioid prescriptions per 100 persons (approximately 722,011 prescriptions) Ø Texas providers wrote 58.0 opioid prescriptions per 100 persons (15.9 million prescriptions) Ø Washington providers wrote 68.2 opioid prescriptions per 100 persons (4.88 million prescriptions) 8
9 Thoughts for discussion Ø What are your experiences locally? Ø What alternatives are you pursuing? Ø What are the risks? Ø What struggles are you encountering related to: ØInsurance companies? ØLocal regulatory environments? 9
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