NEW DEVELOPMENTS IN ACUTE PAIN MANAGEMENT DISCLOSURES ACUTE PAIN SERVICES. The Changing Practice of Anesthesia September 19, 2014 MEDICINE

Transcription

1 NEW DEVELOPMENTS IN ACUTE The Changing Practice of Anesthesia September 19, 2014 DISCLOSURES Honararium from Medtronic Coverage of Travel Expenditures from Boston Scientific Ramana (Ramo) K. Naidu, MD UCSF Assistant Professor Department of Anesthesia and Perioperative Care Director of Acute Pain Services MEDICINE Keown, O. Lessons from Eight Countries on Diffusing Innovation in Health Care. Health Affairs, Sep 2014 NEW ACUTE PAIN SERVICES Started in academic centers in the late 1980s. Regional Catheter Service Medication Management Multi-Disciplinary Service Reedy, Anesthesiology, 1988 Zimmerman, CJA, 1990 Cartwright, Anaesthesia, 1991 Wheatley, BJA, 1991

2 PLANNED TOC PAIN ASSESSMENT INTRA-OP ACUTE PAIN UNPLANNED MEDICATIONS INTERVENTIONS PT PSYCH CIM X X X X X X X X Some of the topics covered today are not particularly new. Not all new (recently developed) subjects will be covered Just those deemed relevant by the presenter. FDA indications, or lack thereof, will be stated. PAIN ASSESSMENT 7 ANALGESIA NOCICEPTION INDEX (ANI) Not FDA Approved Ledowski, BJA, 2013 Boselli, BJA, 2014 MDoloris Medical Systems

3 PERI-OP ENHANCED RECOVERY AFTER SURGERY [ERAS] PERI-OP ENHANCED RECOVERY AFTER Evidence Lovely, Brit J of Surg, 2011 Adamina, Surgery, 2011 Fawcett, BJA, 2012 Joshi, Colorectal Disease, 2012 Danninger, World J of Surgery, 2014 Mortensen, Brit J of Surg, 2014 Lucas, Int J of Obst, 2013 Wijk, Acta Obs Gynecol Scand, 2014 COLORECTAL KNEE ARTHROPLASTY GASTRECTOMY CESAREAN SECTION HYSTERECTOMY COLORECTAL ARTHROPLASTY GYNECOLOGICAL ONCOLOGY SPINE CYSTECTOMY HEPATOBILIARY MASTECTOMY THORACOTOMY LIVER TRANSPLANT CRANIOTOMY UCSF COLORECTAL ENHANCED RECOVERY PATHWAY ANESTHESIA SURGERY NURSING PATIENT Order Pre-Op Warming and IV fluids 30 ml/hr No bowel prep for Please complete Pre-Op RN checklist 45 No food until 8 hours before surgery. Water right, transverse, minutes prior to OR start time and Boost Breeze taken up until two hours MEDS Gabapentin 600mg PO once colectomy Apply Warming Blanket to patient before surgery Acetaminophen 1000mg PO once IV Placed. Crystalloid started at 30ml/hr. Risks of surgery and anesthesia will be Diclofenac 100mg PO once Boost Breeze and Gabapentin 600, APAP 1000, Celecoxib given discussed. You will sign a consent for the (if egfr>60) water ok until 2 hours once with water (<100ml). procedure, and discuss the possibility of receiving blood products. PRE Scopolamine 1.5mg TTS x 1 Pre-Op Anti-Emetics may also be ordered (Optional) Meclizine 25mg PO x 1 (Optional) Consent, Site If there is any chance you might be (Optional) Marking, and 24-hr pregnant, please discuss with surgery and 30 minutes before start time, complete anesthesia H&P completed 40 anesthesia minutes before OR REGIONAL assessment, go to Block Room, and place Thoracic Epidural placed at T8-10 start time. Antibiotic: Cefazolin 25mg/kg IV over 10 minutes Patient temperature must not drop below 36.0 C. Orogastric Tube with LIWS. MEDS Opioid of Choice: Hydomorphone or Morphine Titrate to RR 10bpm at time of extubation. If Opioid-Tolerant, continue their opioid regimen intraop. Start ketamine load and infusion. 0.2 mg/kg x 1. INTRA Then 2 mcg/kg/min. Dexamethasone 4mg IV x 1 after induction. Ondansetron 4mg IV x 1 REGIO Thoracic Epidural % Ropi + Fentanyl 2 NAL 8 ml/hr OR Bilateral TAP Block. 20ml of Ropi 0.2% with dexamethasone 4mg. Done prior to prep & drape. PREHABILITATION: Exercise program prior to surgery to address functional recovery and strength. Evidence: TKA (Swank, 2013) Colorectal (Gillis, Anesthesiology, 2014; Carli, B J Surg, 2010) Spine (Nielsen, Clin Rehabil, 2010) POST MEDS REGIONAL Order opioid of Choice: Hydomorphone or Morphine Order Antiemetics Thoracic Epidural % Ropi + Fentanyl 2 8 ml/hr Hydomorphone or Morphine IV PRN Titrate to RR 10bpm Thoracic Epidural % Ropi + Fentanyl 2 8 ml/hr POD1 REGIONAL Gabapentin 600mg PO qhs DVT Proph: Heparin 5kU SQ TID Vital Signs q 4H, I&O shift, weight daily, surgical incision care abdomen, Out of bed ad lib Acetaminophen 1000mg IV q6h Ambulation: OOB ad lib Incentive Spirometry x15 q 1H Toradol (if egfr>60) 15mg IV q6h Incentive Spirometry x15 q 1H If Opioid-Tolerant, continue ketamine infusion 2 mcg/ kg/min If Opioid-Tolerant, continue their daily opioid requirement. Thoracic Epidural % Ropi + Fentanyl 2 8 ml/hr Foley Catheter to gravity. DVT Proph: Heparin 5kU SQ TID Clears. Gum chewing ok. Clears. Gum chewing ok.

4 CATASTROPHIZATION: characterized by the tendency to magnify the threat value of pain stimulus and to feel helpless in the context of pain, by a relative inability to inhibit painrelated thoughts in anticipation of, during or following a painful encounter. (Quartana, Expert Review Neurotherapeutics, 2009) INTRA and LIPOSOMAL BUPIVACAINE No catheter. No pump. Less worries about antithrombotics Does it work? Is it safe? Evidence: Catastrophization in the Prediction of Post-Op Pain (Papaionnou, Pain Med, 2009) Catastrophization and Pre-Op Anxiety play a role in the development of Persistent Post-Surgical Pain (Theunissen, Clin J of Pain, 2012) Pre-Op Catastrophizing and Post-Op Pain in Cardiac Surgery (Khan, Pain Med, 2012) FOCUSED COLD THERAPY / COOLED RADIOFREQUENCY ABLATION / PULSED RADIOFREQUENCY ABLATION Ilfeld, Brian. A 4-day peripheral nerve block? Liposome Bupivacaine: An Introduction and Update. ASA Newsletter. Aug FOCUSED COLD THERAPY / COOLED RADIOFREQUENCY ABLATION / PULSED RADIOFREQUENCY ABLATION FDA Approved. Hemorrhoidectomy & Bunionectomy Hsu, M. J of Neur Disorders, Jun 2014

5 INTRA and PROGRAMMED INTERMITTENT BOLUS INTRA and LOW-DOSE KETAMINE INFUSION LOW-DOSE LIDOCAINE INFUSION LOW-DOSE DEXMEDETOMIDINE INFUSION NMDA NA-CHANNEL ALPHA-2 Evidence: THA (Remerand, A&A, 2009)(Martinez, Anaesthesia, 2014) TKA (Aveline, Eur J Pain, 2009) Spine (Loftus, Anesthesiology, 2010) Laparoscopy (Kaba, Anesthesiology, 2007) Abdominal Surgery (Marret, Brit J of Surg, 2008) Hysterectomy (Grady, A&A, 2012) Bariatric Surgery (Tufanogullari, A&A, 2008) NMDA NA -CHANNEL ALPHA-2 FDA Approved Jan INTRANASAL KETOROLAC SUFENTANIL NANOTAB (ZALVISO) Completed Phase III Trials

6 HYDROCODONE-CONTAINING COMPOUNDS. #1 Rx in USA. NALOXONE HOME KIT JAN 14, 2014: ACETAMINOPHEN RESTRICTED TO 325mg or less OCTOBER 6, 2014: WILL BE MOVED FROM SCHEDULE III to SCHEDULE II Evzio FDA Approved. METHYLNATREXONE (RELISTOR) ALVIMOPAN (ENTEREG) NALOXEGOL (MOVANTIK) : Oral peripheral mu-antagonist for opioid-induced constipation. to HOME HEALTH SENSORS Chey, NEJM, Statistically improved constipation (40% vs 29%) with naloxegol vs placebo. FDA Approved

7 THE STATE OF ACUTE Correll et al. No evidence of real progress in treatment of acute pain : scientometric analysis. J of Pain Research THE FUTURE OF ACUTE Collaborative strategies that: Reduce Cost: length of stay (LOS) & readmission rates- ERAS Reduce Opioid Consumption. Improve HCAHPS scores Employ The Perioperative Surgical Home. Reduce Persistent Post-Surgical Pain. Methods to prolong neural blockade Methods to manage opioid-related complications. Disconnecting from the IV. Health sensors that interface with our EMR to track patient progress. Tracking of outcomes. A need to more efficiently and safely adopt new ideas and technologies that can reduce severe acute pain and the development of chronic pain. In addition to the references cited during the slides: J Strength Cond Res Feb;25(2): doi: /JSC.0b013e318202e431. Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis. Swank AM1, Kachelman JB, Bibeau W, Quesada PM, Nyland J, Malkani A, Topp RV. Br J Surg Aug;97(8): doi: /bjs Randomized clinical trial of prehabilitationtion in colorectal surgery. ry. Carli F1, Charlebois P, Stein B, Feldman L, Zavorsky G, Kim DJ, Scott S, Mayo NE. Clin Rehabil Feb;24(2) 24(2): doi: / Prehabilitation and early rehabilitation after spinal surgery: randomized clinical trial. Nielsen PR1, Jørgensen LD, Dahl B, Pedersen T, Tønnesen H.