MANAGING PAIN IN THE PACU

Transcription

1 MANAGING PAIN IN THE PACU Capt David Bradley, RN, BSN,CNOR Uniformed Services University

2 OBJECTIVES Describe the importance of pain management in regards to the organization, family and patient Describe how pharmacological and non pharmacological interventions affect pain pathways Recognize the appropriate use of non pharmacological pain management nursing interventions in the immediate post - operative period Discuss the appropriate application of evidence-based multimodal pain management interventions in the immediate post-operative period Discuss pain management issues encountered in the obese and elderly populations and identify specific pain management interventions Discuss the development of a comprehensive pain management plan using EBP guidelines

3 IMPORTANCE OF PAIN MANAGEMENT Organization Decreased use of resources Increased patient satisfaction Family Decreased cost Decreased stress and anxiety Patient Reduce length of stay Increased healing Decreased stress/anxiety

4 PHYSIOLOGY OF PAIN

5 WHAT IS PAIN? Pain is an unpleasant sensory and emotional experience associated with potential or actual tissue damage Pain is a complex interaction of Sensory factors Emotional factors Behavioral factors Stimuli activate the nociceptive system which is conveyed to the brain by an adaptable pathway (Marsh, 2013)

6 PHYSIOLOGY OF PAIN (Marsh, 2013)

7 PAIN FIBERS (Marsh, 2013)

8 (Marsh, 2013)

9 (Freudenrich, 2013)

10 WHERE DOES PHARMACOLOGICAL METHODS WORK WITH PAIN PATHWAYS?

11 Retrieved from

12 POSTOP PHARMACOLOGICAL PAIN MANAGEMENT

13 OPIOID RECEPTORS (Marsh, 2013)

14 EVIDENCE BASED ADJUNCTS TO OPIOIDS Anticonvulsants Gabapentin Pregabalin NSAIDs IV acetaminophen IV ibuprofen Capsaicin Ketamine Tapentadol

15 ANTICONVULSANTS Gabapentin Decrease in vomiting Decrease in postop analgesic consumption Pregabalin Shown to have efficacy neuropathic pain Decreased respiratory depression Relief of anxiety Gastric sparing Opioid sparing effects Improved pain scores seen after abdominal and pelvic surgery (Argoff, 2013 & Vadivelu et al., 2010)

16 NSAIDS Single dose ketorolac IM intraoperatively reduced postop nausea and vomiting IV ibuprofen given at wound closure then every 6 hours Resulted in significant decrease in morphine consumption with patients undergoing orthopedic or abdominal surgery (Argoff, 2013) IV acetaminophen (propacetamol) shown to reduce opioid requirements up to 50% in combination with non steroidal agents Shown to effective following dental extractions and lower limb arthroplasty (Vadivelu et al., 2010)

17 CAPSAICIN A non narcotic injectable or a cream Acts peripherally Decreases C fiber activation Used postop pain-total knee replacement, hernia repair, shoulder arthroscopy, bunionectomy (Vadivelu et al., 2010)

18 KETAMINE Ketamine is a hypnotic drug that is commonly used for induction of anesthesia Greatest opioid sparing effects in surgeries associated with greater postop pain IV ketamine provided greater long term postop pain relief (Argoff, 2013)

19 TAPENTADOL Centrally acting, opioid agonist, and norepinephrine reuptake inhibitor Two or three fold less potent than morphine No renal adjustment needed Improved GI tolerability compared to opioids (Argoff, 2013 & Vadivelu et al., 2010)

20 POSTOP NON PHARMACOLOGICAL PAIN MANAGEMENT

21 POSTOP NON PHARMACOLOGICAL PAIN MANAGEMENT Patient Education Warmed Air/Ice Music Guided Imagery (Marsh, 2013)

22 PATIENT EDUCATION AND PAIN Starts in pre-op and continues through discharge Decreases anxiety Allows for patient involvement with pain plan Understand importance of reporting pain Why pain scale is used What is baseline for the patient Increase knowledge of recovery time Have updated postop surgeon preference cards for every surgery (Reiter, 2014)

23 THERMAL REGULATION AND PAIN Hypothermia can cause a plethora of complications Lowered resistance to surgical wound infection Clotting issues Life threatening cardiac events After TKA those with warming gowns Used less opioid Had higher satisfaction At 12 and 24 hour postop reported lower pain scores (Benson et al., 2012 & Marsh, 2013)

24 ICE AND PAIN Effective in reducing perineal pain after 20 minutes (Leventhal et al., 2011) Open abdominal procedures Patients required 22.5 % less opioid pain medications Patients reported 50 % less pain on the first and third day postop Self care thus gives patient empowerment Used after orthopedic surgeries (Master & Van, 2013)

25 MUSIC AND PAIN Improved pain management listening to favorite music Most effective with preprogrammed, low decibel, non lyrical Decreases environmental noise perception (Cromeaux and Steele-Moses, 2013 & Marsh, 2013)

26 GUIDED IMAGERY EXERCISE

27 GUIDED IMAGERY AND PAIN Those in the guided imagery group listened first in preop holding area for 28 minutes, then throughout induction in the OR. Easily implemented Benefits to guided imagery Anxiety levels decreased significantly Decreased pain reported at 2 hours postop Decreased length of stay in PACU by 9 minutes (Gonzalez et al., 2010 & Marsh, 2013)

28 SPECIAL POPULATIONS

29 PAIN MANAGEMENT INTERVENTIONS FOR SPECIAL POPULATIONS Obese Patients Recognize potential for acute respiratory events OSA (Mendonca et al., 2012) Pharmacokinetics Residual medication stored in fat. Assess all skin Geriatric Altered pharmacokinetics Confusion/mental impairment Hard of hearing Altered thermodynamics nstatement/1214/pos_stmt_7_older_adult.pdf (Rang et al., 2011)

30 HOW DO I INCORPORATE ALL OF THIS?

31 MODIFY A COMPREHENSIVE PAIN MANAGEMENT PLAN Support the Joint Commission statement that all individuals have the right to effective pain/symptom management. American Society of PeriAnesthesia Nurses nes/aspan_clinicalguideline_paincomfort.pdf (ASPAN, 2014)

32 ASPAN PHARMOCOLOGICAL GUIDELINES (ASPAN, 2014)

33 ASPAN NONPHARMACOLOGICAL GUIDELINES (ASPAN, 2014)

34 SUMMARY Identified the importance of pain management to the organization, family and the patient Discussed CNS pain pathways Described current evidence based pharmacological and nonpharmacological multimodal approaches for pain management in the immediate postoperative period Recognized the different factors that complicate pain management in obese and elderly patients Discussed the development of a comprehensive pain management plan using EBP guidelines

35 REFERENCES American Society of PeriAnesthesia Nurses. (2014). ASPAN pain and comfort clinical guideline. Retrieved from Guidelines/Pain-and-Comfort Argoff, C. (2013). Recent management advances in acute postoperative pain. Pain Practice, doi: /papr Benson, E., McMillan, D.,& Ong B.(2012). The effects of active warming on patient temperature and pain after total knee arthroplasty. American Journal of Nursing, 112(5), doi: /01.NAJ bf. Corke, P. (2013). Postoperative pain management. Australian Prescriber, 36(6), Retrieved from

36 REFERENCES Comeaux T. (2013).The effect of complementary music therapy on the patient's postoperative state anxiety, pain control, and environmental noise satisfaction. Medsurg Nursing, 22(5), Retrieved from Elvir-Lazo, O.L., & White, P. F. (2010). Postoperative pain management after ambulatory surgery: Role of multimodal analgesia. Anesthesiology Clinics, 28 (2), doi: /j.anclin. Freudenrich, C. (2014) Descending pain pathways. Retrieved from fworks.com/life/inside-themind/human-brain/pain3.htm Gonzales E.,Ledesma,R., McAllister, D., Perry,S., Dyer, C.,& Maye,JP.(2010). Effects of guided imagery on postoperative outcomes in patients undergoing same-day surgical procedures: a randomized, single-blind study. AANA Journal,78(3), Retrieved from

37 REFERENCES Leventhal, L. C., Oliveira, S.M., Nobre, M.R., & Silva, F. (2011). Perineal analgesia with an ice pack after spontaneous vaginal birth; a randomized controlled trial. Journal Midwifery Womens Health, 56 (2), doi: /j x.Epub2011Mar1. Lin, P. (2013). An evaluation of the effectiveness of relaxation therapy for patients receiving joint replacement surgery. Journal of Clinical Nursing, 21, DOI: /j x Marsh, J. D. (2013). Pain. In Copstead, L. & Banasik, J. (5 th Ed.), Pathophysiology (pp ). St. Louis, MO: Elsevier. Mendonca, J., Pereira, H., Santos, A., & Abelha, F. J. (2012). Obese patients: Respiratory complications in the post -anesthesia care unit. Pneumologia, 20, Retrieved from

38 REFERENCES Rang, H.P., Dale, M.M., Ritter, J.M., Flower, R.J., & Henderson, G. (2012). Drug absorption and distribution. In (7 th Ed.), Rang and Dale s pharmacology (pp ). Philadelphia, PA: Elsevier. Reiter,K. (2014).A look at best practices for patient education in outpatient spine surgery. AORN Journal, 99(3), doi: /j.aorn Swain, J. & Dahlen, H. (2013). Putting evidence into practice: a quality activity of proactive pain relief for postpartum perineal pain. Women Birth,26(1), doi: /j.wombi Vadivelu, N., Mitra, S., & Narayan, D. (2010). Recent advance in postoperative pain management. Yale Journal of Biology and Medicine, 83(1), Retrieved from

39 QUESTIONS OR IS YOUR MIND JELLY?