POST-OP MULTIMODAL PAIN MANAGEMENT. Maripat Welz-Bosna Reading Hospital Medical Center Department of Medicine Hospitalist Services/Pain Management

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1 POST-OP MULTIMODAL PAIN MANAGEMENT Maripat Welz-Bosna Reading Hospital Medical Center Department of Medicine Hospitalist Services/Pain Management

2 Objectives Understand the basic neurobiology of the pain pathway Understand whet "Multimodal" pain management means and why it is effective List 3 medical co morbidities that need to be addressed and can affect both pre/post operative care Describe conservative management options for the post-surgical joint replacement patient who is not progressing well

3 Relieving Pain in America (IOM) $ Billion per year financial costs 30 Million cases of acute & post operative pain 4 Billion work days lost per year due to pain 22 Million adults use prescription pain medication Increased numbers of misuse of Opioids/Addiction 2006 Estimated 53.3 Million Surgical/Non-Surgical procedures performed in the US 1 in 200 patients who had out patient surgical procedure end up being hospitalized due to inadequate pain control Ambulatory surgical procedures make up 70% of the volume of hospital based elective surgical procedures

4 "The major difference between iatrogenic pain and other types of pain is iatrogenic pain is anticipated. Therefore, the provider has an excellent opportunity to deal with such pain in a planned and expeditious manner". Brian Goldman MD

5 Prevalence of Post Operative Pain Stannard, Kalso, & Ballantyne, 2010 Caesarean Section 4-6% Inguinal Hernia Repair 12% Vasectomy 15% Laparoscopic Cholecystectomy 23% Hysterectomy 32% Colectomy 28% Sternotomy 32% Radical Prostatectomy 32% Thoracotomy 50% Mastectomy & Axillary Node Surgery 50% Lower Extremity Amputation (Stump Pain 62%) (Phantom Pain 70%)

6 What's the easiest pain to bear?

7 Components of Acute Pain: The Heart of Multimodal Analgesia Nociceptive Visceral Neuropathic Inflammatory Myofascial (Muscle Spasm)

8 Multimodal Analgesia Balanced Involves the selected use of specific drugs in combination Use of multiple analgesic drugs with different modes of action Non-Opioid with an Opioid Local Anesthetic Block combined with systemic analgesic Improve analgesia through synergy

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10 Preemptive Pain Management "Stop the pain before it Starts" PreSurgical or PreRehabilitation Program Educate the patient about surgical procedure, pre/post operative care and Rehabilitation Discuss with the patient that "providers" will do everything to help control pain Find out what the patients most "prominent fears" are prior to Joint Surgery Change the Focus from "Post Surgical" paradigm of injury management to "Healing Advancement"

11 Importance of Pain Education The nervous system will be in a "Hyper" protective mode As a result of the nervous system being hyper protective, pain will occur well before tissue damage occurs: Not just as tissue damage is happening Pain is no longer an indicator of tissue injury or danger The sensitized post surgical nervous system can produce pain in the absence of tissue danger Knowledge can be utilized to control pain

12 Language is Important Move from: "Reactive" to "Proactive" "From the time you wake from surgery the focus will be about healing, your injury will be a past process". Educate the patient that swelling, inflammation, and pain help to facilitate healing

13 Multimodal Perioperative Preemptive Analgesia Analgesic Medication or Intervention prior to surgical tissue injury MAY produce greater pain relief then the same medication/intervention administered following surgical tissue injury Has been shown effective in some animal studies, but collecting data from post-operative patients is more difficult Based on "Wind-Up" Theory (Hyperalgesic Response)

14 Main Goals Preemptive Analgesia Decrease pain after tissue injury Prevent Spinal Sensitization Reduce the incidence of inflammatory or chronic pain Senturk, 2002

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18 Bandolier, 2007 Table comparing efficacy of many different oral and injectable medications for pain Injection of 10 MG Morphine ( NNT 2.9) is roughly equivalent to an oral 200 MG dose of Ibuprofen (NNT 2.7)

19 Drugs in Post/Preoperative Pain Management Opioids Tramadol Nonopioids NSAIDS & Cox-2 Alpha-2 adrenergic agonists N-methyl-D-aspartate antagonists (Ketamine, Magnesium, Dextramethorphan, Methadone) Gabapentin, Pregabalin & Carbamazepine Glucocorticoids Capsaicin Local Anesthetics (Sodium Channel Blocking)

20 Pre-Operative Intradermal Accupuncture 50 % reduction in post-operative morphine requirement 20-30% reduction in post-operative nausea 30-50% reduction in plasma cortisol and epinephrine Kotani N., Hashimoto H; Anesthesiology 2001;95

21 Factors that have been associated with Poor Outcomes in Joint Replacement Surgeries Sex- Female General Health Complications BMI Past Post Surgical Complications Anxiety Depression (Untreated) Fear Avoidance Behaviors Propensity to Catastrophize Externalization of Locus of Control High Presurgical Pain Levels Genetic or Epigenetic determined sensitivity to heightened sensory or noxious input

22 Factors NOT associated with Poor Outcomes ROM or Strength Limitations Imaging Findings Level of Disability

23 The factors that are most responsible for poor outcomes are produced by the nervous system NOT the Musculoskeletal System Johnny Appleseed

24 Management of Continued Post-Operative Pain R/O Post surgical complications Assess for concurrent pathology Maximize Therapeutic Intervention: Both Pharmacologic & Non pharmacologic Mindfulness and Guided Imagery Both help with control of "Fight / Flight" Heat, Cold, Message, & TENS Unit Look at medication options Biopsychosocial Model Support emotionally and clinically Do not automatically assume that Psychiatric issues are the cause of struggles Coordination and Communication Healthcare team Patient, Family, Stakeholders

25 Take Home Points Multimodal analgesia can help improve pain control and minimize side effects Persistent post surgical pain may be influenced by improved acute pain control Order routine pain medications initially for moderate to sever pain (Rather than PRN) Patient specific factors need to be considered in prescribing the BEST postoperative analgesic regime Around the clock NSAIDS + Acetaminophen are effective in minimizing opioid use Patient Education, Mindfulness, and Guided Imagery have been used successfully to address Psychosocial Risk Factors

26 Questions & Comments?