11/2/2017. Background. Background. Role of On-Q Marcaine Infusion Pump in Reducing Post-operative Narcotic use in Cesarean Delivery

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1 Role of On-Q Marcaine Infusion Pump in Reducing Post-operative Narcotic use in Cesarean Delivery Quinn Collins, UDSN Melanie Chichester, BSN, RNC-OB, CPLC Lynn Bayne, RN, PhD, NNP-BC Background Pain is a significant concern of women having a cesarean delivery, and many times patient satisfaction and pain relief is inadequate. (Rackelboom et al., 2010) Although there are a variety of resources to manage post-op pain including NSAIDs, narcotics, and/or the use of an infusion pump, it has been found that multimodal pain relief is the best way to manage the pain. (Rackelboom et al., 2010) Background Narcotics have undesirable side effects such as nausea and vomiting, constipation, weakening of muscles, low blood pressure, and dizziness, and long-term use can potentially lead to abuse and addiction (Chung et al., 2013 ). 1

2 Background An elastomeric infusion pump (such as a brand like the On-Q) places Bupivicaine (Marcaine) in the subcutaneous layer as a local anesthetic with the goal of reducing pain at the incision site. The idea is that using the pump will provide additional relief and reduce the amount of narcotics needed to manage pain. On-Q Infusion Pump 2

3 Background Other local anesthetics, bupivacaine and lidocaine, have been studied with cesarean patients for post-operative pain relief, and the results showed a reduction in the overall consumption of analgesics in the first 24 hours (Monsef, et al., 2015). In addition, there was a significant difference in the visual analog scale scores and ambulation time as compared to the control group. Background The On-Q infusion pump has been used for post-operative pain management in a variety of surgical procedures, and the literature is divided on its effectiveness; however, its use in cesarean deliveries specifically is limited. Abdominal hysterectomy; On-Q use not significant (Bolles, 2012, unpublished study) Elective gynecology oncologic surgery; post-operative pain scores lower with On-Q (Chung, et al., 2013) Paramedian laparotomy; On-Q use not significant (Groeger,et al., 2016) 3

4 Background However, there are many other factors to consider, including cost and (we wish) nurses satisfaction. In addition to cost of pump, there is cost of the local anesthetic, cost/time of pharmacy preparing, and cost of extra OR time to place it Percocet costs $0.21/tablet On-Q cost to institution $ charge to patient $ (if reimbursed. C/S is a bundled charge) Objectives The purpose of this research is to determine if use of an On-Q Marcaine infusion pump after cesarean delivery reduces the amount of Post- Operative Day (POD) #1 & 2 oral narcotic use. Secondary objectives were to determine if pain scores were reduced, and to look for trends in postoperative complications. Methods Retrospective study/irb approval obtained Sequential retrospective chart review of women age who had a repeat cesarean section at CCHS between January 1, 2007 through December 31, 2010 Patients whose charts contained full data for all variables of interest were included from the cesarean registry who did and did not use the On-Q infusion pump in addition to oral narcotics for post-op pain 4

5 Methods AccessAnywhere was used to examine patient records and determine the amount of Percocet PO taken the first 24 and 48 hours postoperatively Data was analyzed using t-tests to see if there was a reduction in post-op narcotic use in women using the On-Q infusion pump as compared to women not on the pump Strengths/elimination of other variables/confounders All patients in both arms received Acetaminophen 325/oxycodone 5mg (Percocet), 2 tabs every 3-4 hours prn for pain management All patients were scheduled, first repeat cesarean delivery, low-transverse incisions None were laboring All received spinal anesthesia for the delivery Results Neither age, race/ethnicity, nor BMI were significant Dressing changes, while anecdotally an issue, were not frequently documented, therefore also NS 5

6 Results ON-Q No On-Q P value POD #1 Percocet tablets * POD #2 Percocet tablets * Both POD #1 & #2, patients who had an On-Q infusion device used a statistically less amount of Percocet Results ON-Q No On-Q P value POD #1 mean pain score * POD #2 mean pain score * Both POD #1 & #2, patients who had an On-Q infusion device had a statistically lower mean pain score Additional Results ON-Q No On-Q P value No other abd procedure POD #1 Percocet tablets * Other abd procedure POD #1 Percocet tablets * While both patients used less Percocet on POD #1, those with a history of a prior abdominal surgical procedure (other than the first cesarean) used almost 2 less tablets (pot. clinically significant) 6

7 Additional Results ON-Q No On-Q P value No other abd procedure POD #2 Percocet tablets NS Other abd procedure POD #2 Percocet tablets * While both patients used less Percocet on POD #2, those with a history of a prior abdominal surgical procedure (other than the first cesarean) used 2 less tablets (pot. clinically significant) Implications for practice Because narcotic abuse is such a large concern today, there is a growing trend to use adjunctive therapies in treatments to reduce post-operative pain. Adding the On-Q infusion pump has pros and cons. Pros- reduces narcotic use, relative ease of placement, few complications, pump is portable (Thornton & Buggy, 2011) Cons- expensive, leaking, more work for nurses, pharmacy time, increased OR time A variety of factors will need to be considered for this pump to be used in the population of cesarean delivery patients, such as cost to hospital, reimbursement, ease of use, and patient satisfaction. Conclusions Clinically, nurses today need to be aware of narcotic abuse and the fact that this should be prevented using evidence based care (Costello & Thompson, 2015). Based on the results, the On-Q did reduce Percocet use on both the first and second POD, as well as mean pain scores. However, considering the cost, is there clinical significance in a reduction in one Percocet each day? 7

8 Conclusions There is insufficient evidence from this study that this device will provide a substantial amount of pain relief and lead to a reduction in narcotic use With a cost of $385 a unit, not covered by insurance, it is most likely not beneficial for the hospital to use these devices for post-op pain relief. Conclusions However, would this be worthwhile for women with a history of previous abdominal surgeries, as they had a 2 tablet/day reduction in Percocet use? What if she is having a 3 rd or 4 th cesarean? (not recommended, but it happens) Limitations This study was limited to using a retrospective method and therefore it was not possible to ask questions or gather additional data. Legibility of written records? Missing data? None of the patients in either group had a (known/disclosed) history of substance abuse/narcotic addition 8

9 Further Limitations Placement- Which is more effective in relieving painplacement of the catheter above or below the fascia? A randomized controlled trial found that in studying 56 post-op caesarean patients pain relief was greater with the catheter under the fascia (Rackelboom et al., 2010). Insertion of the catheter below the fascia may allow nociceptive blockade of both fascia of the abdominal muscles and peritoneum, resulting in better efficacy. (Rackelboom et al., 2010, p. 656) Further Limitations For this particular study there was no way of knowing exactly where the catheter was placed since it was a retrospective study, and this could have affected its success. Future research Future studies using more diverse populations and exploring multiple procedural history would be more useful in determining the significance of using this pump to decrease post-op narcotic use. 9

10 Future research In addition, there are many other factors that play a role in whether or not to use the On-Q device in practice. Nurses should be interviewed about their concerns Hospital should factor in other costs Patient interviews about likes and dislikes of this device Discussion These methods of collecting data are the most relevant to trying to put a new technique into a clinical setting. While this research using quantitative data is the best way to test the effectiveness of the On-Q, qualitative studies would better show the practicality of its use in a clinical setting. In a short period of time only one aspect was able to be researched, however with additional resources to perform a larger study, this device may prove to be beneficial in reducing narcotic use when compared to other adjunctive therapies. Hospitals may find that the cost is worth the safety of the patients from becoming tolerant or addicted to narcotics. Implications for Future Research Use in patients with a history of Multiple abdominal procedures History of narcotic/substance abuse 10

11 References Chung, D., Lee, Y. J., Jo, M. H., Park, H. J., Lim, G. W., Cho, H., Kim, S. (2013). The ON-Q pain management system in elective gynecology oncologic surgery: Management of postoperative surgical site pain compared to intravenous patient-controlled analgesia. Obstetrics & Gynecology Science, 56(2), Costello, M., Thompson, S. (2015). Prescription opioid analgesics: Promoting patient safety with better patient education. AJN The American Journal of Nursing, 115(11), Groeger, C., Schomaker, M., Raue, W., Pratschke, J., & Haase, O. (2016). Influence of different positioning of a local pain catheter on postoperative pain after paramedian laparotomy a blinded, randomized trial. Langenbeck's archives of surgery, 401(4), References Monsef, A. E., Hamedsedek, A. E., & Kassab, F. A. (2015). Study of The Effectiveness of Local Anesthetic Wound Infiltration in Post Cesarean Section Pain Relief [Abstract]. Al- Azhar Assiut Medical Journal, 13(1), 152. ON-Q* Pain Relief System. Retrieved from Rackelboom, T., MD, Strat, S. L., MD, Silvera, S., MD, Schmitz, T., MD,PhD, Bassot, A., MD, Beaussier, M., MD, PhD,... Goffinet,, F., MD, PhD. (2010). Improving Continuous Wound Infusion Effectiveness for Postoperative Analgesia After Cesarean Delivery: A Randomized Controlled Trial [Abstract]. Obstetrics & Gynecology, 116(4) References Thornton, P. and Buggy, D. (2011). Local anaesthetic wound infusion for acute postoperative pain: a viable option?. British Journal of Anaesthesia, 107(5),

12 Acknowledgements Carolee Polek, RN, PhD, AOCNS (UD) Judy Stoltz, BSN, RNC Megan Zimmerman, BSN, RN And we owe Dr. Lynn Bayne dinner for crunching the numbers while preparing for a wedding this week! Questions? Thank you! 12