Management of Acute Pain in the Chronic Pain Patient. Eric Cannon, MD Mountain West Anesthesia December 1, 2017

Transcription

1 Management of Acute Pain in the Chronic Pain Patient Eric Cannon, MD Mountain West Anesthesia December 1, 2017

2 Objectives 1. Describe the unique challenges of managing acute pain episodes in patients being treated for chronic pain 2. Review the non-opiate modalities to treat acute pain indications and contraindications 3. Discuss sample cases and possible management plans

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4 Challenges of Chronic Pain Patients

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6 Goals the triple (quadruple) aim Improved patient satisfaction Improve Clinical Outcomes Reduce the Cost of Healthcare Improved Provider Satisfaction

7 Multimodal Analgesia Opiates Acetaminophen NSAID Antiepileptics Regional/Neuraxial Analgesia Lidocaine Alpha-2 receptor agonists Ketamine Hebl J, et al Reg Anesth Pain Med. 2008;33(6):

8 Multimodal Analgesia multimodal first introduced by Kehlet and Dahl in

9 Multimodal Analgesia involves the concurrent use of more than one class of medication to target different mechanisms of analgesia and has been advocated to improve analgesia through additive or synergistic effects while reducing opioid-induced adverse effects 2

10 Step 1 - PREPERATION Shah S, et al. Curr Opin Anesthesiology. 2015;28:

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12 Case #1 64 yo female history of prescription opiate abuse currently on Suboxone 4 mg PO BID Subacute empyema requiring a right VATS possible thoracotomy for decortication How will you manage her pain?

13 Multimodal Analgesia Opiates Acetaminophen NSAID Antiepileptics Regional/Neuraxial Analgesia Lidocaine Alpha-2 receptor agonists Ketamine Hebl J, et al Reg Anesth Pain Med. 2008;33(6):

14 Acetaminophen Metanalysis of 7 prospective trials Decreased morphine consumption by 20% during first 24 hours No effect on opiate induced side effects 3

15 Acetaminophen TJA 30% decrease in opiate consumption Better tolerated by the elderly and high-risk patients Decreased incidence of PONV 6

16 Multimodal Analgesia Opiates Acetaminophen NSAID Antiepileptics Regional/Neuraxial Analgesia Local Anesthetics Alpha-2 receptor agonists Ketamine Hebl J, et al Reg Anesth Pain Med. 2008;33(6):

17 NSAIDs Meta-analysis NSAIDs at least as effective as codeine 7 Biddle C. AANA J. 2002;70(2):111-4

18 Multimodal Analgesia Opiates Acetaminophen NSAID Antiepileptics Regional/Neuraxial Analgesia Lidocaine Alpha-2 receptor agonists Ketamine Hebl J, et al Reg Anesth Pain Med. 2008;33(6):

19 Anitconvulsants 8 Gabapentinoids (alpha 2-delta agonists) Chronic neuropathic pain Prevelant in most multimodal protocols Pregabalin -> improved oral bioavailability May be helpful in opiate tolerant patients Buvanendran A, et al. Pain Medicine (1):

20 Multimodal Analgesia Opiates Acetaminophen NSAID Antiepileptics Regional/Neuraxial Analgesia Lidocaine Alpha-2 receptor agonists Ketamine Hebl J, et al Reg Anesth Pain Med. 2008;33(6):

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22 Case #2 A 76 year old male with a history of chronic back pain is scheduled for a L2-3, L3-4, L4-5 lumbar fussion. His narcotic use has increased over the past three years, at the time of surgery he is currently taking 30 mg OxyContin TID, and 20 mg Oxicodone every 4 hours as needed (though he reports it is almost on a scheduled basis). At best he states his pain is 7/10. How will you manage his pain?

23 Multimodal Analgesia Opiates Acetaminophen NSAID Antiepileptics Regional/Neuraxial Analgesia Lidocaine Alpha-2 receptor agonists Ketamine Hebl J, et al Reg Anesth Pain Med. 2008;33(6):

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25 Multimodal Analgesia Opiates Acetaminophen NSAID Antiepileptics Regional/Neuraxial Analgesia Lidocaine Alpha-2 receptor agonists Ketamine Hebl J, et al Reg Anesth Pain Med. 2008;33(6):

26 Reported to inhibit and possibly reverse opiate tolerance 8 Yang L, et al Acta Cir Bras. 2014;29(12):819-25

27 Study group received 0.5 mg/kg ketamine boluse then 10 mcg/kg/min gtt Decreased morphine consumption at 24 hours, 48 hours and 6 weeks after surgery Loftus RW et al Anesthesiology (3):

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30 Case #3 A 82 year old male with a new diagnosis of metastatic colon cancer requires an urgent/semiemergent laparotomy and palliative colectomy for bowel obstruction. His had an intrathecal pump placed three years prior after failed back surgery and fussion at L2-3,L3-4. The pump has worked well to control his pain since it s placement. How will you manage his pain?

31 Multimodal Analgesia Opiates Acetaminophen NSAID Antiepileptics Regional/Neuraxial Analgesia Lidocaine Alpha-2 receptor agonists Ketamine Hebl J, et al Reg Anesth Pain Med. 2008;33(6):

32 Alpha-2 Adrenergic Agonists

33 Multimodal Analgesia Opiates Acetaminophen NSAID Antiepileptics Regional/Neuraxial Analgesia Lidocaine Alpha-2 receptor agonists Ketamine Hebl J, et al Reg Anesth Pain Med. 2008;33(6):

34 Opiate consumption decreased by up to 85% Inferior to epidural analgesia McCarthy GC et al Drugs 2010;70(9): and Reg Anesth Pain Med Jan-Feb;41(1):28-36

35 Unstable CAD Recent MI Heart Failure Heart Block Electrolyte disorders Liver Disease Seizure Disorder

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37 Case #4 A 91 year old female with mild baseline dementia has broken her right hip after falling at home where she lives with her daughter. Surgery is planned for tomorrow. Per the daughter narcotic cause the paitent extreme nausea and confusion. What is your plan to manage her pain?

38 Multimodal Analgesia Opiates Acetaminophen NSAID Antiepileptics Regional/Neuraxial Analgesia Local Anesthetics Alpha-2 receptor agonists Ketamine Hebl J, et al Reg Anesth Pain Med. 2008;33(6):

39 ASA PSH 2.0 Collaborative - Team Health - 77% reduction in pain meds in first 12 hours postoperatively - 51% reduction in average pre-operative pain scores (ave 3.3) AAOS Hip Fracture Guidelines:

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41 Foss NB, Kristensen BB, Bundgaard M et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology 2007;106(4): Guay J, Parker MJ, Griffiths R, Kopp S. Peripheral nerve blocks for hip fractures. Cochrane Database of Systematic Reviews 2017, Issue 5. Art. No.: CD DOI: / CD pub2.

42 Opiate Free Surgery Tylenol Celebrex Gabapentin Magnesium Ketamine Dexmedetomidine Regional Anesthesia

43 Safety

44 Questions Thank You and obligatory family photo

45 References 1. Kehlet H, Dahl JB. The Value of multimodal or balanced analgesia in postoperative pain treatment. Anesth Analg. 1993;77(5): Kopp et. al. Anesthesia and Analgesia Practice Pathway Options for Total Knee Arthroplasty. Regional Anesthesia and Pain Medicine. 2017;42(6): Remy C, Marrett E, Bonnet F. Effects of Acetaminophen on Morphine Side-Effects and Consumption After Major Surgery: Metaanalysis of Randomized Controll Trials. BJA 2005;94(4) 4. Shah S, et al. Curr Opin Anesthesiology. 2015;28: Hebl J, et al Reg Anesth Pain Med. 2008;33(6): McNicol ED et al Br J Anesth 2011;106: Biddle C. AANA J. 2002;70(2): Buvanendran A, et al. Pain Medicine. 2010;110(1): Yang L, et al Acta Cir Bras. 2014;29(12): Loftus RW et al Anesthesiology (3): McCarthy GC et al Drugs 2010;70(9): Reg Anesth Pain Med Jan-Feb;41(1):28-36