Disclosures/Off-Label. Current State of Pain Control
|
|
- Kristian Evans
- 5 years ago
- Views:
Transcription
1 The Role of Multi-Modal Analgesia and the Burden of Opioids Jacob Hutchins MD Director of Regional Anesthesia, Acute Pain, and Ambulatory Anesthesia Department of Anesthesiology University of Minnesota Disclosures/Off-Label peaker s bureau, consultant, and research funds from Pacira Pharmaceuticals peaker s bureau for Halyard Health Consultant for Atricure Consultant for Worrell I will talk about off-label medication use but it will be of my own experience Is Improved Pain Control Needed? Current tate of Pain Control Yes! Pain control remains the number one concern for patients leading up to surgery Opioids remain the mainstay of post surgical pain regimens Non opioids are often prescribed prn and thus depends on the nurse to give to patient Pain as fifth vital sign has led to emphasis on undermedication and less focus on overmedication
2 Why is Pain Control Important? Risk Factors for Acute Postoperative Pain Uncontrolled postoperative pain can lead to Longer Hospital stay and increased PACU/Phase 1 time Readmissions for pain Females Decreased satisfaction and quality of life Progression to chronic pain Major stress response from body Young age Increased BMI Increased sympathetic tone Increased Heart rate and blood pressure Preop use of opioids Hypercoagulability Decreased Immune function General anesthesia Urinary retention Endocrine changes: increased ACTH, cortisol, epinephrine, aldosterone, ADH, Ang II History of Chronic pain Decreased GI motility Why Minimize Opioids? Oversedation is a problem 70 million patients receive opioids in hospital or clinic following surgery each year 1 Opioids have multiple adverse events Nausea/vomiting, pruritis, constipation, urinary retention May play role in cancer recurrence JCAHO sentinel event respiratory depression and even death for increased risk patients Elderly, OA, chronic pain, and obese 1. Adamson, et al. Hosp Pharm. 2011;46(6 uppl 1):1-3.
3 Why Minimize Opioids? Why Minimize Opioids? Postoperative opioid use contributes to misuse of opioids 1 in 15 patients with acute opioid use go on to long term use 1,2 Due in part to rapid proliferation of new users from acute care setting. 46 Americans die each day from opioid overdose 5.1 million Americans used opioids illicitly last month The number of opioid/heroin related deaths in Minnesota each year is similar to number killed in MVA 18% of opioid naïve patients were still on opioids 1 year after elective spine surgery 6% of patients after orthopedic procedures were still on opioids 150 days after surgery 1. Alam A, et al. Arch Intern Med, 2012; 172(5): Carroll I, et al. Anesth Analg, 2012; 115(3): United tates Opioid Problem Our Elderly and Children are at Risk In patients 65 undergoing low-risk surgery who received an opioid Rx within a week of surgery 1 : 10.3% 44% were still taking opioids a year later There was a in the likelihood they would become long-term opioid users Compared to non-athletes, adolescents males who participate in organized sports have 2 : the risk for being prescribed an opioid medication 2x 4x misusing opioids 10x 1.Alam A, et al. Arch Intern Med. 2012;172: P. Veliz et al. Journal of Adolescent Health 54 (2014) 333e340 the odds of to get high the odds of medical misuse of opioids due to taking too much
4 Overprescription Leads to a High Potential for Diversion In patients undergoing outpatient upper extremity surgery 1 Resulting in Access to Excess Pills From Multiple ources 1 Other source 7.1% Got from drug dealer or stranger 4.4% Took from friend or relative w/o asking 4.8% 55% Obtained for free from friend or relative Bought from friend or relative 11.4% Prescribed by one Doctor 17.3% 1. Rogers J, et al. Opioid consumption following outpatient upper extremity surgery. J Hand urg Am. 2012;37: Centers for Disease Control. Policy Impact: Prescription Painkiller Overdoses; Nov Available at: Minnesota s Opioid Epidemic Minnesota s Opioid Epidemic
5 Minnesota s Opioid Epidemic Multiple Organizations Have Urged a hift Toward Non-Opioid Options JCAHO recommends An individualized, multimodal treatment plan should be used to manage pain upon assessment, the best approach may be to start with a nonnarcotic CDC recommends Health care providers should only use opioids in carefully screened and monitored patients when non-opioid treatments are insufficient to manage pain 2 AA recommends a multimodal approach to pain management often beginning with a local anesthetic where appropriate 1.The Joint Commission. Revisions to pain management standard effective January 1, Available at: assets/1/23/jconline_november_12_14.pdf. Accessed November 19, CDC. Vital igns: Overdoses of Prescription Opioid Pain Relievers --- United tates, Nov 2011;60(43); Available at: Multimodal Analgesia Options for Multimodal Analgesia Utilization of more than 2 analgesics which act at different sites in CN and PN Goal to Minimize pain as well as minimize opioids hould be started prior to surgery and continued in acute postoperative period Requires coordination between Preoperative, Intraoperative, and Postoperative periods urgeon, Anesthesiologist, Providers, and Nurses all on same page
6 ample Multimodal Approach ample Multimodal Approach ETTING EXPECTATION Intraoperatively Preoperative Medication Gabapentin or Pregabalin: started evening before surgery Acetaminophen: IV or oral started evening before surgery NAIDs if allowed by surgeon Regional Anesthesia Attempt to minimize opioids preop even with block sedation Regional anesthesia if not done in preop phase urgeon Infiltration in select procedures: liposomal bupivacaine or catheter technique preferred Minimal Opioids and only short acting (rare need for opioids on induction and premedication with 2mg versed) Continue acetaminophen intraop (redose 4 hours after last dose) Ketorolac at closure if appropriate Lidocaine, ketamine, or dexmedetomidine infursions where appropriate ample Multimodal Approach Additional Multimodal Postoperatively cheduled Acetaminophen every 6-8 hours for up to one week post operatively: Oral as soon as able Intermittent opioids: Oral as soon as able NAID as soon as possible and then scheduled for up to one week post operatively Gabapentin (300mg) or Pregabalin (75mg) continued for one week Lidocaine infusions, ketamine intermittent or infusion, and dexmedetomidine infusion where appropriate. Muscle relaxants or Diazepam for muscle spasms Topical medications or lidocaine patches for pain Non pharmacologic interventions Ice to area Healing touch Massage Pet Therapy Acupuncture Relaxation techniques
7 Regional Anesthesia Why Regional Anesthesia? Interscalene: houlder procedures upraclavicular: Arm and Hand procedures Provides Pre-emptive Analgesia Adductor canal/femoral: Thigh and Knee procedures Decreases likelihood of development of Chronic Pain Popliteal/Distal ciatic: Foot and ankle More precise placement of local anesthetic Lumbar Plexus/Fascia Iliaca: Hip Transversus abdominis plane blocks for abdominal procedures Pec blocks for breast and chest procedures Paravertebrals for thoracic and abdominal procedures Able to use less local anesthetic in most cases Low failure rate Quick and low risk to place Can be either single injection or catheter infusion ingle hot Catheters Can be Long Acting Local Anesthetics Bupivacaine or Ropivacaine Last 6-12 hours postoperatively Can remain in place for 1-7 days after placement Or hort Acting Mepivacaine or Lidocaine Last duration of procedure 1-4 hours Usually run low dose bupivacaine or ropivacaine Can titrate to effect Additives can extend duration of action Epinephrine Clonidine Allows intermittent bolus Risk of dislodgement and infection as are indwelling Dexamethasone Dexmedetomidine
8 Local Anesthetics Liposomal Bupivacaine Are an essential part of a multimodal pain control regimen Can be used to provide pain control that targets the site of surgery via infiltration of skin and subcutaneous tissue (liposomal bupivacaine) Also used for regional anesthesia to target specific peripheral or central nerves (single shot or catheter technique) Finally can be given intravenously to provide effective postoperative pain control (IV lidocaine) On-label use for infiltration (surgeon infiltration, TAP, Pec) Off-label use for peripheral nerve blocks Provides hours of analgesia via single shot Multivesicular liposome formulation of 1.3% bupivacaine Provides Day 1 dense block, day % block and day % blockade Minimal motor blockade after day 1 Unable to bolus or titrate dosage TAP Blocks Transversus Abdominis Plane Block Provides analgesia to skin muscle fascia and parietal peritoneal layers but not viscera Ultrasound Guided and can be done prior to surgery intraoperatively or in PACU Catheters can be kept in for up to 7 days, Liposomal Bupivacaine provides hours pain relief
9 Hutchins et al. Ultrasound Guided ubcostal Transversus Abdominis Plane (TAP) Infiltration with Liposomal Bupivacaine for Patients Undergoing Robotic Assisted Hysterectomy: A Prospective Randomized Controlled tudy. Data presented at IAR Honolulu, Hawaii 2015 Paravertebral Blocks Liposomal bupivacaine TAP vs. bupivacaine TAP LB TAP had decreased total opioids, decreased nausea/ vomiting, and decreased maximal pain at all time points studied. Trend towards decreased length of stay (p=0.055) 11 +/- 9.1 hours in LB TAP group vs. 17 +/ hours in bupivacaine group. No adverse events noted in either group Unilateral blockade of spinal nerves outside vertebral canal ingle hot with Bupivacaine or Liposomal Bupivacaine (off label use) or Catheter Injection level depends on surgical site Lasts (bupivacaine) or hours (liposomal bupivacaine) or 72 hours or longer (catheter) Paravertebral Blocks Pec Blocks Pecs 1 targets lateral and medial pectoral nerves Pecs 2 targets lateral and medial pectoral nerves, intercostobrachial, intercostals III, IV, V, and VI, and long thoracic nerve Used for breast procedures, subclavian TAVR, chest wall, and even thoracic procedures.
10 Pec Blocks Interscalene Used for houlder and distal clavicle procedures Blocks brachial plexus at level of roots/trunks PM PM Frequent sparing of C8-T1 Pm A Pm 100% will have some phrenic nerve involvement Perform suprascapular to avoid phrenic May cause intermittent Horner s syndrome ingle shot (15-25 ml) 6-12 hours Interscalene Literature upport Park et al: Interscalene single shot (IB) decreased pain scores compared to intraarticular injection Lehman et al: IB superior to GA and GA + IB in terms of recovery and pain medications used Ullah et al: IB had improved pain control compared to no block and ultrasound IB had less complications compared to nerve stimulator IB Hughes et al: IB decreased supplemental analgesics and decreased pain
11 upraclavicular upraclavicular Useful for surgery below shoulder level Blocks brachial plexus at level of divisions Brachial Plexus Misses suprascapular nerve (60-70% of shoulder) Risk of Pneumothorax and phrenic nerve involvement ingle shot (15-25 ml) 6-12 hours Pleura A Catheter not ideal (infraclavicular better position) First Rib Literature upport Other Brachial Plexus Blocks Gamo et al: upraclavicular block permitted operating conditions without general in 99.5% of cases and 96.7% were satisfied with analgesia Ahsan et al: 26% failure on day 1 after hand surgery for supraclavicular catheter Infraclavicular: good for catheter placement for arm procedures Axillary: superficial and may be easier in super obese population as it poses no lung risk. Renes et al: U/ guided supraclavicular decreased diaphragm paralysis compared to nerve stim Lam et al: improved satisfaction with distal blocks compared to supraclavicular uprascapular and Axilary for shoulder procedures as described by Checucci et al with no phrenic involvement
12 Adductor Canal Adductor Canal Useful for TKA, ACL, other knee procedures, and for foot/ankle Distal block of Femoral nerve aphenous nerve, nerve to vastus medialis, obturator branches artorius Block occurs mid thigh Decreased quad weakness compared to femoral ingle hot (15-20 ml) V A Nerve Vastus Medialis Literature upport Femoral Nerve Block Jaeger et al: Adductor 8% weakness, Femoral 49% weakness Jenstrup et al: Adductor decreased pain and improved PT compared to placebo Hanson et al: Adductor catheters provided pain relief up to 48 hours and improved quad strength hah and Jain: Adductor provided improved early ambulation with no difference in pain compared to femoral Perlas et al: Adductor plus local infiltration had best early ambulation and highest incidence of home discharge. Useful for knee surgery, thigh surgery, femoral neck fractures Increased weakness of quad compared to adductor canal ingle shot (15-25 ml) Liposomal bupivacaine (off label) Phase 3 data showed improved pain control and no difference in weakness compared to placebo
13 Femoral Nerve Literature upport Fascia Lata Minkowitz et al: showed femoral with liposomal bupivacaine superior than placebo up to 72 hours after injection with no increased motor A Fascia Iliaca Luo et al: Femoral nerve block associated with persistent strength deficits at 6 months after ACL repair in pediatric and adolescents V Femoral Nerve Chisholm et al: aphenous equal to Femoral nerve block with regards to analgesia after ACL Krych et al: No difference in return to sport for femoral nerve block patients but decreased motor/function at 6 months post ACL Popliteal/Distal ciatic Popliteal/Distal ciatic Block of sciatic nerve just prior or just after split into fibular and tibial divisions Useful for calf, tibia, ankle, foot, and toe surgery Tibial Nerve Fibular Nerve aphenous is only nerve of foot/ankle not covered by this block Blockade of sciatic nerve will cause foot drop (fibular) elective Tibial or IPACK blocks will provide back of knee pain relief without foot drop ingle shot (20-40 ml) Onset of action is slowest of all major nerve blocks A
14 Literature upport aporito et al: no difference in cost or readmissions in those who had continuous regional block popliteal block decreased costs and allowed surgery to be performed as outpatient Gallardo et al: continuous popliteal block for total ankle arthroplasty decreased pain, decreased opiates, and increased satisfaction Lumbar Plexus Lumbar Plexus Covers T12 to L4 Useful for hip, femoral neck, and knee surgery Deep block and increased patient discomfort compared to other blocks Block with increased risk of morbidity and mortality Literature upport Karlsen et al: No best intervention for total hip arthroplasty Amiri et al: Lumbar plexus and MAC anesthesia were sufficient for femoral neck fracture surgery Lee et al: Continuous lumbar plexus decreased total opioids after total knee replacement Nye et al: Continuous lumbar plexus block for hip arthroscopy had risk of significant complications (3.8%)
15 Fascia Iliaca Fascia Iliaca Proximal blockade of lumbar plexus High Volume Block Iliacus Fascia Useful for femoral neck fractures and total hip replacement (?) Allows for ease of spinal placement in femoral neck fractures Ilium Literature upport Other Lower Extremity Blocks Foss et all showed FICB decreased Pain scores and opioid use after femoral neck fractures hariat et al no difference between fascia iliaca vs sham for total hip arthroplasty Obturator Lateral Femoral Cutaneous Ankle Blockade Hanna et al: FICB decreased pain after femoral neck fractures McRae et al: FICB performed by paramedics for femoral neck fractures decreased pain scores compared to standard of care
Disclosures/Off-Label. Why is Pain Control Important?
Disclosures/Off-Label Is Improved Pain Control Needed? The Role of Multi-Modal Analgesia and the Burden of Opioids Jacob Hutchins MD Director of Regional Anesthesia, Acute Pain, and Ambulatory Anesthesia
More informationAcute Peri-Operative Pain Management Strategies
Slide 1 Acute Peri-Operative Pain Management Strategies Phillip Gallegos, MD USAP Pinnacle Anesthesiologist Director of Anesthesia and Peri-Operative Medicine BOSHA Slide 2 ERAS Enhanced Recovery After
More informationDr Kelly Jones Anesthesiologist at Northwest Orthopedics
Dr Kelly Jones Anesthesiologist at Northwest Orthopedics Decrease narcotic use in the immediate post operative period. Better Pain Control Less side effects then General Anesthesia Sedation Post operative
More informationEfficacy of single-shot fascia iliaca compartment blocks. Tom Brink Promotor: Dr. Ph. van Loon
Efficacy of single-shot fascia iliaca compartment blocks Tom Brink Promotor: Dr. Ph. van Loon Index Introduction About the FICB Methods Results o o o o o Search results Study characteristics Techniques
More informationNerve Blocks & Long Acting Analgesia for Plastic Surgeons. Karol A Gutowski, MD, FACS
Nerve Blocks & Long Acting Analgesia for Plastic Surgeons Karol A Gutowski, MD, FACS Disclosures None related to this topic Why is Non-Opioid Analgesia Important Opioid epidemic Less opioid use Less PONV
More informationLearning Objectives. Perioperative goals. Acute Pain in the Chronic Pain Patient for Ambulatory Surgery 9/8/16
Acute Pain in the Chronic Pain Patient for Ambulatory Surgery Danielle Ludwin, MD Associate Professor of Anesthesiology Division of Regional and Orthopedic Anesthesia Columbia University Medical Center
More informationPERIPHERAL REGIONAL BLOCKS. by Mike DeBroeck, DNP, CRNA
PERIPHERAL REGIONAL BLOCKS by Mike DeBroeck, DNP, CRNA Why am I bothering with this topic at all? Do CRNAs REALLY even do peripheral regional anesthetics? YES!!!!!!! TOPICS GENERAL INFO SUCCESS RATES
More informationPeripheral Nerve Blocks
Peripheral Nerve Blocks N U R S I N G E D U C A T I O N JPS Acute Pain Service Peripheral nerve blocks are used as part of a multimodal analgesic program which provides the patient with safe and effective
More informationJake Hutchins, M.D. Aaron Berg, D.O.
Jake Hutchins, M.D. Aaron Berg, D.O. Jacob Hutchins is on the speaker s bureau, is a consultant, and has received research funding from Pacira Pharmaceuticals He also is a consultant for Insitu Biologics,
More informationFASCIAL PLANE BLOCKS TOM BARIBEAULT MSN, CRNA
FASCIAL PLANE BLOCKS TOM BARIBEAULT MSN, CRNA TECHNIQUES Abdominal Wall TAP Rectus Sheath Quadratus Lumborum Erector Spinae Chest PECS I & II Erector Spinae TECHNIQUES Knee Ipack/LIA Hip Fascia Iliaca
More informationAustralian and New Zealand Registry of Regional Anaesthesia (AURORA)
Australian and New Zealand Registry of Regional Anaesthesia (AURORA) Overview of Results First 4000 procedures recorded to - www.anaesthesiaregistry.org June 1st 2011 to February 2012 Background Australian
More informationENHANCED RECOVERY PROTOCOLS FOR KNEE REPLACEMENT
ENHANCED RECOVERY PROTOCOLS FOR KNEE REPLACEMENT Jeff Gadsden, MD, FRCPC, FANZCA Associate Professor Duke University Department of Anesthesiology Regional Anesthesia and Acute Pain Medicine DISCLOSURES
More informationPerioperative Pain Management
Perioperative Pain Management Overview and Update As defined by the Anesthesiologist's Task Force on Acute Pain Management are from the practice guidelines from the American Society of Anesthesiologists
More informationSurgery Under Regional Anesthesia
Surgery Under Regional Anesthesia Jean Daniel Eloy, MD Assistant Professor Residency Program Director Rutgers-New Jersey Medical School Rutgers The State University of New Jersey Peripheral Nerve Block
More informationBaptist Health Lexington. ERAS Protocols
Baptist Health Lexington ERAS Protocols Enhanced Recovery After Surgery BHLex Colorectal ERAS Protocol Preoperative Patient/Family Education: PAT and office, ERAS brochure & educational flyer/checklist
More informationFiegel, Matthew, MD Regional Anesthesia and Pain Medicine Update 2013
Regional Anesthesia and Pain Medicine Update: 2013 CRASH I have no disclosures Disclosures Matthew J. Fiegel, M.D. Associate Professor of Anesthesiology University of Colorado Director, Acute Pain Service
More informationBrachial plexus blockade within the interscalene groove involves local anesthetic
Interscalene Brachial Plexus Block- How I do it. Part 1 of a 2 part discussion on technique. Stuart Grant Professor of Anesthesiology Duke University Medical Center Durham NC Brachial plexus blockade within
More informationAnesthetic Techniques for Rapid Recovery in Total Knee Arthroplasty
Anesthetic Techniques for Rapid Recovery in Total Knee Arthroplasty Scott T. Ball, MD Chief, Adult Joint Reconstruction Department of Orthopaedic Surgery University of California, San Diego Disclosures
More informationObjectives. Conflict of Interest Disclosure. Neuraxial and Regional Anesthesia in the Pediatric Population
Neuraxial and Regional Anesthesia in the Pediatric Population Lauren Renner, MS, RN-BC, PNP Sharon Wrona, DNP, RN-BC, PNP, PMHS, AP- PMN.... Conflict of Interest Disclosure Conflicts of Interest for ALL
More informationA Staged Approach to Analgesia After Hip Arthroscopy Using Multimodal Analgesia & Elective Ultrasound Guided Fascia Iliaca Block
A Staged Approach to Analgesia After Hip Arthroscopy Using Multimodal Analgesia & Elective Ultrasound Guided Fascia Iliaca Block James T. Beckmann MD Stephen K. Aoki MD Stephen Guyette MD Jeffrey Swenson
More informationPeripheral regional anaesthesia and outcome: lessons learned from the last 10 years
British Journal of Anaesthesia 114 (5): 728 45 (2015) Advance Access publication 17 February 2015. doi:10.1093/bja/aeu559 REVIEW ARTICLES Peripheral regional anaesthesia and outcome: lessons learned from
More informationLower Extremity Ultrasound-Guided Regional Anesthesia. Stephanie Duffy, CRNA Regional Anesthesia Faculty Acute Pain Service NMCSD
Lower Extremity Ultrasound-Guided Regional Anesthesia Stephanie Duffy, CRNA Regional Anesthesia Faculty Acute Pain Service NMCSD Objectives Review anatomy of lumbosacral plexus Lumbar plexus blocks Psoas
More informationUltrasound Guided Regional Nerve Blocks
Ultrasound Guided Regional Nerve Blocks In the country of the blind the one eyed man is King -Deciderius Erasmus (1466-1536) Objectives Benefits of Regional Anesthesia Benefits of US guidance Role of ultrasound
More informationAndrew B. Wolff, MD a Geoffrey Hogan, BA a James Capon, BS, MS a Hayden Smith, BA a Alexandra Napoli, BS a Patrick Gaspar, MD b
Pre-operative Lumbar Plexus Block Provides Superior Post-operative Analgesia when compared with Fascia Iliaca Block or General Anesthesia alone in Hip Arthroscopy Andrew B. Wolff, MD a Geoffrey Hogan,
More informationRegional anaesthesia in paediatric day case surgery. PA Lönnqvist Karolinska Institutet Karolinska University Hospital Stockholm, Sweden
Regional anaesthesia in paediatric day case surgery PA Lönnqvist Karolinska Institutet Karolinska University Hospital Stockholm, Sweden Ambulatory surgery in children Out-patient surgery in children did
More informationDORIS DUKE MEDICAL STUDENTS JOURNAL Volume V,
Continuous Femoral Perineural Infusion (CFPI) Using Ropivacaine after Total Knee Arthroplasty and its Effect on Postoperative Pain and Early Functional Outcomes Eric Lloyd Scientific abstract Total Knee
More informationClinical Fellowship Regional Anesthesia
Anesthesia and Perioperative Medicine Western University Regional Anesthesia Fellowship Program Directors Dr. Kevin Armstrong & Dr. Shalini Dhir Clinical Fellowship Regional Anesthesia The regional anesthesia
More informationCurrent Trends in Pain Management: Guidelines, Standards and Approaches
Current Trends in Pain Management: Guidelines, Standards and Approaches Kim Spinelli MSN, APRN, BC, CNS Pain Management Clinical Nurse Specialist Memorial Hospital; University of Colorado Health Colorado
More informationUltrasound Guided Lower Extremity Blocks
Ultrasound Guided Lower Extremity Blocks CONTENTS: 1. Femoral Nerve Block 2. Popliteal Nerve Block Updated December 2017 1 1. Femoral Nerve Block Indications Surgery involving the knee, anterior thigh,
More informationMultimodal perioperative pain management protocols
Multimodal perioperative pain management protocols Nader M. Hebela, MD كليفالند كلينك أبوظبي Dhabi Cleveland Clinic Abu معهد األعصاب Institute Neurological slide count: 30 January 2016 title slide explained
More informationCurrent evidence in acute pain management. Jeremy Cashman
Current evidence in acute pain management Jeremy Cashman Optimal analgesia Best possible pain relief Lowest incidence of side effects Optimal analgesia Best possible pain relief Lowest incidence of side
More informationAnalgesia for ERAS programs. Dr Igor Lemech VMO Anaesthetist Wagga Wagga Base Hospital
Analgesia for ERAS programs Dr Igor Lemech VMO Anaesthetist Wagga Wagga Base Hospital Disclosure I have received honoraria from Mundipharma and MSD The new Wagga Wagga Rural Referral Centre Scope Analgesic
More informationAnesthesia for OutPatient Spine Surgery. Michael A. Kellams, D.O.
Anesthesia for OutPatient Spine Surgery Michael A. Kellams, D.O. DISCLOSURE None! Hot Topics 2017 -Multimodal Analgesia/ERAS -TAP block -Inpatient procedures outpatient (Fusions) Multimodal Analgesia -Using
More informationON-Q * Pain Relief System ORTHOPEDIC SURGERY TECHNIQUES & CLINICAL EVIDENCE
ON-Q * Pain Relief System ORTHOPEDIC SURGERY TECHNIQUES & CLINICAL EVIDENCE BETTER OUTCOMES. SATISFIED PATIENTS. DISCLAIMERS The disclaimers contained herein pertain to all information included in this
More informationNew Kids on the Block: Advances in Regional Anesthesia Practice. Melissa Byrne DO,
New Kids on the Block: Advances in Regional Anesthesia Practice Melissa Byrne DO, MPH @dr_melissabyrne Precision Acute Care Medicine Chronic Pain Nurse, get on the internet, go to NYSORA.COM, scroll
More informationEffective Postoperative Pain Management for Children. Nancy L. Glass, MD, MBA,
Effective Postoperative Pain Management for Children Nancy L. Glass, MD, MBA, FAAP nglass@bcm.edu @DrNancyGlass1 None Disclosures Learning Objectives At the end of this presentation, participants will
More informationMr David A McDonald Service Improvement Manager Whole System patient Flow Improvement Programme Scottish Government
Mr David A McDonald Service Improvement Manager Whole System patient Flow Improvement Programme Scottish Government Introduction Brief update Two main topics Use of Gabapentin Local Infiltration Analgesia
More informationDisclaimer. Why Regional anesthesia? Peripheral Nerve Blocks: Upper/Lower Extremity & TAP BLOCKS
Peripheral Nerve Blocks: Upper/Lower Extremity & TAP BLOCKS Presented by: Nathan Merritt, MD Director of Regional Anesthesia and Acute Pain Parkhill Medical Center Fort Worth Co authored by: Mark Zimmerman,
More informationNEW KIDS ON THE BLOCK: THE NEW ERA OF REGIONAL ANESTHESIA PLANE BLOCKS
2017 CSA Fall Anesthesia Conference NEW KIDS ON THE BLOCK: THE NEW ERA OF REGIONAL ANESTHESIA PLANE BLOCKS Michael Barrington, MB BS, FANZCA, PhD Senior Staff Anaesthetist, St Vincent s Hospital, Melbourne.
More informationDigital RIC. Rhode Island College. Linda M. Green Rhode Island College
Rhode Island College Digital Commons @ RIC Master's Theses, Dissertations, Graduate Research and Major Papers Overview Master's Theses, Dissertations, Graduate Research and Major Papers 1-1-2013 The Relationship
More informationMANAGING PAIN IN THE PACU
MANAGING PAIN IN THE PACU Capt David Bradley, RN, BSN,CNOR Uniformed Services University OBJECTIVES Describe the importance of pain management in regards to the organization, family and patient Describe
More informationRegional Anesthesia. procedure if required. However, many patients prefer to receive sedation either during the
1 Regional Anesthesia Regional anaesthesia (or regional anesthesia) is anesthesia affecting only a large part of the body, such as a limb or the lower half of the body. Regional anaesthetic techniques
More informationRegional Anesthesia and Acute Pain Medicine Fellowship at Wake Forest University
Regional Anesthesia and Acute Pain Medicine Fellowship at Wake Forest University Fellowship Director: J. Douglas Jaffe, DO Assistant Professor and Member - Section of Regional Anesthesia & Acute Pain Management
More informationSatisfactory Analgesia Minimal Emesis in Day Surgeries. (SAME-Day study) A Randomized Control Trial Comparing Morphine and Hydromorphone
Satisfactory Analgesia Minimal Emesis in Day Surgeries (SAME-Day study) A Randomized Control Trial Comparing Morphine and Hydromorphone HARSHA SHANTHANNA ASSISTANT PROFESSOR ANESTHESIOLOGY MCMASTER UNIVERSITY
More informationUSRA OF THE LOWER EXTREMITY
USRA OF THE LOWER EXTREMITY Christian R. Falyar, CRNA, DNAP Department of Nurse Anesthesia Virginia Commonwealth University Disclosure Statement of Financial Interest I, Christian Falyar, DO NOT have a
More informationCONCERNED ABOUT TAKING OPIOIDS AFTER SURGERY?
CONCERNED ABOUT TAKING OPIOIDS AFTER SURGERY? ASK YOUR DOCTOR ABOUT EXPAREL FOR LONG-LASTING, NON-OPIOID PAIN RELIEF. VISIT EXPAREL.com/patient FOR MORE INFORMATION. YOU HAVE A SAY IN HOW YOUR PAIN IS
More information3/13/2018. Disclosure. Framing the Scenario. Research support received from: Arthrex MTF. Consultant: Arthrex
Outpatient Knee Arthroplasty Thomas M. DeBerardino, MD Professor of Orthopaedic Surgery, Baylor College of Medicine Co Director, Baylor BRIO Texas Sports Medicine Fellowship Medical Director, Burkhart
More informationParaspinal Blocks a new paradigm in truncal analgesia
Paraspinal Blocks a new paradigm in truncal analgesia Ki Jinn Chin, MBBS (Hons), MMed, FRCPC Associate Professor Toronto Western Hospital University of Toronto Online Resources https://youtu.be/lockhd
More informationAnaesthesia and Pain Management for Endo Exo Femoral Prosthesis (EEFP) Bridging the Gap from Surgery to Rehabilitation
Anaesthesia and Pain Management for Endo Exo Femoral Prosthesis (EEFP) Bridging the Gap from Surgery to Rehabilitation Dr Ajay Kumar Senior Lecturer Macquarie and Melbourne University Introduction Amputee
More informationMulti-Modal Pain Management
Multi-Modal Pain Management July 14th, 2017 Todd Edmiston, MD Disclosures None Fellowship training in Sports and Adult Reconstruction Director of Orthopaedic Center, South Baldwin Regional Medical Center,
More informationSource of pain relievers for nonmedical use among users 12 years or older:
ACUTE PAIN MANAGEMENT OF THE OPIOID TOLERANT TRAUMA PATIENT James D. Colson, MS, MD Department of Anesthesiology WVU Hospitals Learning Objectives Identify criteria pertaining to the opioid-tolerant patient;
More informationTicketed sessions require pre-registration. Please approach the Registration Desk to learn about last-minute availability and cancellations.
Sessions marked with the webcast icon will be webcasted and will be available to ESRA Members via the ESRA Academy after the Congress. Sessions marked with the voting icon will include the in-session voting
More informationAnatomy and principles of the fascia iliaca block
Anatomy and principles of the fascia iliaca block Dr Ganesh Kumar 23 rd November 2016 Courtesy Dr Fred Sage Objectives Why do peripheral nerves blocks work? Why choose FIB over FNB? How does it work? How
More informationAnesthesia for Total Hip and Knee Arthroplasty
Anesthesia for Total Hip and Knee Arthroplasty Typical approach Describe anesthesia technique Rather Describe issues with THA and TKA How anesthesia can modify Issues Total Hip Total Knee Blood Loss ++
More informationInnovative Approaches and New Technology to Gain Access
Innovative Approaches and New Technology to Gain Access The following is intended only for presentation to the Reimbursement and Access 2017 audience, August 17, 2017. This information is not for promotional
More informationCAESAREAN SECTION Brian Fredman
CHAPTER 3 GYNAECOLOGICAL SURGERY CAESAREAN SECTION Brian Fredman Review of evidence: surgical site infusion Of the seven studies on surgical site local anaesthetic infusion after Caesarean section performed
More informationDisclosures. Total knee and Total Hip Replacement, a Fast Track. Outline of my talk. What is Fast Track Arthroplasty? I have nothing to disclose
Total knee and Total Hip Replacement, a Fast Track Muhammad I Shaikh M.D.,Ph.D. Associate Professor of Anesthesiology, UCSF Outline of my talk Definition of Fast Track Principles of FT as applied to Orthopedics
More informationObjectives 9/7/2012. Optimizing Analgesia to Enhance the Recovery After Surgery CME FACULTY DISCLOSURE
Optimizing Analgesia to Enhance the Recovery After Surgery Francesco Carli, M.D.. McGill University, Montreal, QC, Canada. ASPMN, Baltimore, 2012 CME FACULTY DISCLOSURE Francesco Carli has no affiliation
More informationShow Me the Evidence: Epidurals, PVBs, TAP Blocks Christopher L. Wu, MD Professor of Anesthesiology The Johns Hopkins Hospital
Show Me the Evidence: Epidurals, PVBs, TAP Blocks Christopher L. Wu, MD Professor of Anesthesiology The Johns Hopkins Hospital Overview Review overall (ERAS and non-eras) data for EA, PVB, TAP Examine
More informationTurlough O Hare, MD, FRCPC, MSc Assistant Clinical Professor, Department of Anesthesia, St. Joseph s Healthcare Hamilton McMaster University
Turlough O Hare, MD, FRCPC, MSc Assistant Clinical Professor, Department of Anesthesia, St. Joseph s Healthcare Hamilton McMaster University To understand the current options available to best manage pain
More informationASA Closed Claims Project: Regional Anesthesia Claims 1990 or later Lorri A. Lee MD Department of Anesthesiology University of Washington, Seattle, WA
ASA Closed Claims Project: Regional Anesthesia Claims 1990 or later Lorri A. Lee MD Department of Anesthesiology, Seattle, WA OVERVIEW 1. Closed Claims Project 2. Peripheral Nerve Blocks 3. Neuraxial Claims
More informationObjectives. Opioid Free Anesthesia Surgery without opioids. Opioid Use In The United States
Opioid Free Anesthesia Surgery without opioids 2 Objectives Review of pain physiology Evaluate need for continuing opioid substitution therapy Review Neuraxial and Periperal Regional Anesthesia Learn ways
More informationDexamethasone Improves Outcome Of Infraclavicular Brachial Plexus Block
Tanta Medical Journal Vol. (6), April 2008 Original Article ABSTRACT Dexamethasone Improves Outcome Of Infraclavicular Brachial Plexus Block Mohamed Samy Seddik Department of Anesthesia & Intensive Care,
More informationThe Team. Regional Anesthesia for Postoperative Pain Management. How Can We Reduce Pain? Understanding the Principles of Pain Process
Regional Anesthesia for Postoperative Pain Management Chris Peltier, DNP, RN-BC, FNP-BC The Team Regional Anesthesia Pain Service (RAPS) University of Minnesota M-Health University of Minnesota Masonic
More informationAnesthesia Processing Guidelines
Anesthesia Processing Guidelines Policy Number: 10.01.511 Last Review: 5/2014 Origination: 10/1988 Next Review: 5/2015 Policy The following guidelines are utilized in processing anesthesia claims: 1) Anesthesia
More informationReversing the Opioid Epidemic: Pain & Symptom Management Inpatient Considerations and Peri operative Multi Modal Analgesia
Reversing the Opioid Epidemic: Pain & Symptom Management Inpatient Considerations and Peri operative Multi Modal Analgesia Aaron Wood 25 July 2018 Disclosures No Financial Interests Gratitude Feedback
More informationBalanced Analgesia With NSAIDS and Coxibs. Raymond S. Sinatra MD, Ph.D
Balanced Analgesia With NSAIDS and Coxibs Raymond S. Sinatra MD, Ph.D Prostaglandins and Pain The primary noxious mediator released from damaged tissue is prostaglandin (PG) PG is responsible for nociceptor
More informationUSRA OF THE UPPER EXTREMITY
USRA OF THE UPPER EXTREMITY Christian R. Falyar, DNAP, CRNA Department of Nurse Anesthesia Virginia Commonwealth University Disclosure Statement of Financial Interest I, Christian Falyar, DO NOT have a
More informationChapter 1: Introduction to the Human Body Test Bank
Chapter 1: Introduction to the Human Body Test Bank MULTIPLE CHOICE 1. What is the branch of science that studies how the body functions? a. Anatomy b. Histology c. Pathology d. Physiology 2. Which word
More informationHuman Anatomy and Physiology I Laboratory Spinal and Peripheral Nerves and Reflexes
Human Anatomy and Physiology I Laboratory Spinal and Peripheral Nerves and Reflexes 1 This lab involves the second section of the exercise Spinal Cord, Spinal Nerves, and the Autonomic Nervous System,
More informationAcute Postoperative Pain. David Radvinsky, MD March 24, 2016
Acute Postoperative Pain David Radvinsky, MD March 24, 2016 Objectives 1. Discuss the multimodal approach to pain management and discuss the various classes of drugs based on receptor mechanism. 2. Give
More informationThe Role of Surgeons in Addressing the Opioid Crisis. Friday, April 6, 2018
The Role of Surgeons in Addressing the Opioid Crisis Friday, April 6, 2018 What is the Surgical Collaborative of Wisconsin? A collaborative practice change community that aims to optimize quality and reduce
More informationABSTRACT TITLE: Near-OR Perioperative Interventions to Decrease Hospital Length
ABSTRACT NUMBER: 020-0094 ABSTRACT TITLE: Near-OR Perioperative Interventions to Decrease Hospital Length of Stay AUTHORS: Mark J. Lenart, MD Vanderbilt University 1301 Medical Center Drive Nashville,
More informationinerve Guide to Nerves 2009
inerve Guide to Nerves 2009 A guide to self learning and self assessment Context: The following guide is intended to help interpret the sono-anatomy and follow a systematic stepwise approach to the practice
More informationRunning Title: Tandem regional in laparoscopic inguinal herniorrhapy. Disclosures:
The Novel Use of Different Bupivacaine Preparations with Combined Regional Techniques for Postoperative Pain Management in Non Opioid Based Laparoscopic Inguinal Herniorrhaphy Andrew C. Eppstein (MD) a
More informationSynapse Homework. Back page last question not counted. 4 pts total, each question worth 0.18pts. 26/34 students answered correctly!
Synapse Homework Back page last question not counted 26/34 students answered correctly! 4 pts total, each question worth 0.18pts Business TASS hours extended! MWF 1-2pm, Willamette 204 T and Th 9:30-10:30am,
More informationRegional Anaesthesia
Regional Anaesthesia Lower limb anatomy and blocks Hip and Knee Joint Hip Joint: Nerve supply Lumbar plexus Femoral nerve through the nerve to the Rectus Femoris Ant division of the Obturator nerve The
More informationEvaluating the Effectiveness of Current Orthopaedic Pain Management Strategies
Evaluating the Effectiveness of Current Orthopaedic Pain Management Strategies TOPICS: Impact of Health Care Changes Current Strategies in Surgical Pain Management Implementing and Evaluating Pain Management
More informationManagement of Acute Pain in the Chronic Pain Patient. Eric Cannon, MD Mountain West Anesthesia December 1, 2017
Management of Acute Pain in the Chronic Pain Patient Eric Cannon, MD Mountain West Anesthesia December 1, 2017 Objectives 1. Describe the unique challenges of managing acute pain episodes in patients being
More informationPeripheral Nerve Blocks Overview and complications. Diane P. Welsh RN BSN MPA CCRN CAPA
Peripheral Nerve Blocks Overview and complications Diane P. Welsh RN BSN MPA CCRN CAPA Objectives Discuss the advantages and disadvantages of peripheral nerve blocks Discuss the physiology and pharmacology
More informationSTARTER PACK: Webinar #1 ADE4 - OPIOIDS
STARTER PACK: Webinar #1 ADE4 - OPIOIDS Welcome to the Starter Pack Webinar #1 Why this is important Establishing a Team Best practices Understanding the Measures Completing a gap analysis First Steps
More informationGUIDELINES FOR PERIPHERAL NERVE / PLEXUS BLOCK CATHETER MANAGEMENT DEPARTMENT OF ANAESTHESIOLOGY AND INTENSIVE CARE HOSPITAL KUALA LUMPUR
GUIDELINES FOR PERIPHERAL NERVE / PLEXUS BLOCK CATHETER MANAGEMENT DEPARTMENT OF ANAESTHESIOLOGY AND INTENSIVE CARE HOSPITAL KUALA LUMPUR INTRODUCTION Regional block provides superior pain relief, compared
More informationWITH ISOBARIC BUPIVACAINE (5 MG/ML)
, 49, 2013, 3 63 (5 MG/ML) (5 MG/ML).,.,.,..,..,, SPINAL ANESTHESIA: COMPARISON OF ISOBARIC ROPIVACAINE (5 MG/ML) WITH ISOBARIC BUPIVACAINE (5 MG/ML) D. Tzoneva, Vl. Miladinov, Al. Todorov, M. P. Atanasova,
More informationThe intensity of preoperative pain is directly correlated with the amount of morphine needed for postoperative analgesia
The intensity of preoperative pain is directly correlated with the amount of morphine needed for postoperative analgesia This study has been published: The intensity of preoperative pain is directly correlated
More informationGabapentin Does Not Improve Analgesia Outcomes For Total Joint Replacement. Manyat Nantha-Aree, MD
Gabapentin Does Not Improve Analgesia Outcomes For Total Joint Replacement Manyat Nantha-Aree, MD Objective n Preliminary results of MOBILE study in total hip and knee arthroplasty Background n Gabapentin=
More informationProfessor Narinder Rawal, MD, PhD, FRCA (Hon), EDRA Department of Anaesthesiology and Intensive Care University Hospital Örebro, Sweden
Professor Narinder Rawal, MD, PhD, FRCA (Hon), EDRA Department of Anaesthesiology and Intensive Care University Hospital Örebro, Sweden Infiltrative techniques in perioperative pain lecture outline Why
More informationWORRIED ABOUT PAIN AFTER ORAL SURGERY?
WORRIED ABOUT PAIN AFTER ORAL SURGERY? OPIOIDS ARE NOT THE ONLY WAY TO MANAGE PAIN Ask your doctor about opioid-free EXPAREL EXPAREL is indicated for single-dose infiltration in adults to produce postsurgical
More informationGrand Rounds from HSS MANAGEMENT OF COMPLEX CASES
MULTIMODAL ANESTHESIA & PAIN MANAGEMENT Grand Rounds from HSS MANAGEMENT OF COMPLEX CASES HSS AUTHORS Jonathan C. Beathe, MD Assistant Attending Anesthesiologist Clinical Assistant Professor of Anesthesiology
More informationREGIONAL/LOCAL ANESTHESIA and OBESITY
REGIONAL/LOCAL ANESTHESIA and OBESITY Jay B. Brodsky, MD Stanford University School of Medicine Jbrodsky@stanford.edu Potential Advantages Regional compared to General Anesthesia Minimal intra-operative
More informationMD (Anaesthesiology) Title (Plan of Thesis) (Session )
S.No. 1. Comparative Assessment of Sequential organ failure Assessment (SOFA) score and Multiple Organ Dysfunction Score (Mode) in Outcome Prediction among ICU Patients. 2. Comparison of Backpain after
More informationBUPIVACAINE LIPOSOME (EXPAREL): Adjunct to Regional Anesthesia
BUPIVACAINE LIPOSOME (EXPAREL): Adjunct to Regional Anesthesia NEBRASKA ASSOCIATION OF NURSE ANESTHETISTS Spring Meeting: April 27-29, 2018 Sallie Poepsel, PhD, MSN, CRNA, APRN Director, AANA Region IV
More informationRole and safety of epidural analgesia
Anaesthesia for Liver Resection Surgery The Association of Anaesthetists Seminars 21 Portland Place, London Thursday 15 th December 2005 Role and safety of epidural analgesia Lennart Christiansson MD,
More informationNavigating the Waters of Acute Postoperative Pain
Navigating the Waters of Acute Postoperative Pain ASPMN 28 th Annual Conference Susan Pendergrass MSN, MEd, FNP-BC Conflict of Interest Disclosure Author/Speaker: Susan Pendergrass, no conflict of interest
More informationINDIANA HEALTH COVERAGE PROGRAMS
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER CODE TABLES Note: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or national coding updates, inclusion of a code on the code tables
More informationResponding to The Joint Commission Alert on Safe Use of Opioids in Hospitals
Responding to The Joint Commission Alert on Safe Use of Opioids in Hospitals Suzanne A Nesbit, PharmD, CPE Clinical Pharmacy Specialist, Pain Management The Johns Hopkins Hospital Objectives and Disclosures
More informationperivascular, sensory and motor effects, 62, side effects, 64 and subfascial hematoma, 221 axillary plexus, 6 7 axonotmesis, 221, 222
249 Index A abscess, and continuous peripheral nerve block, 244 Achilles tendon rupture, 173 and saphenous nerve block, 208 and sural nerve block, 209 and tibial nerve block, 203, 204, 210, 211 acromion,
More informationLower Limb Nerves. Clinical Anatomy
Lower Limb Nerves Clinical Anatomy Lumbar Plexus Ventral rami L1 L4 Supplies: Abdominal wall External genitalia Anteromedial thigh Major nerves.. Lumbar Plexus Nerves relation to psoas m. : Obturator n.
More informationTHORACIC AND ABDOMINAL BLOCKS. Giovanni Cucchiaro MD MPP The Children s Hospital Los Angeles
THORACIC AND ABDOMINAL BLOCKS Giovanni Cucchiaro MD MPP The Children s Hospital Los Angeles 1 CONFLICTS OF INTEREST??? NONE ZERO 2 John Fiadjoe 3 DIFFERENT ANSWERS TO MY DILEMMA 4 WHICH? WHAT? WHY? 5 RAGIONAL
More informationBasic Standards for. Fellowship Training in. Acute and Chronic Pain Management. in Anesthesiology
Basic Standards for Fellowship Training in Acute and Chronic Pain Management in Anesthesiology American Osteopathic Association and American Osteopathic College of Anesthesiologists BOT, 7/1995 BOT, 11/2002
More informationThe Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page
The Egyptian Journal of Hospital Medicine (October 2018) Vol. 73 (1), Page 5736-5742 Supraclavicular Brachial Plexus Nerve Block versus Patient Controlled Analgesia for Post-Operative Pain Management in
More information