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 Objectives Opioid Monotherapy should not be the primary option for perioperative pain management Multimodal Analgesic techniques can reduce or even eliminate the necessity of perioperative opioid therapy 1
Agenda Background Pre op Intra op PACU Post op Historical Context Opium in Mesopotamia Mandrake in Roman Civilization Fentanyl Remifentanyl Today European Consideration Hysterectomy Case What happened to non opioid analgesics? Historical Context Opioids as Monotherapy Algesic Substances Pain Pathways and Modulation 2
American Pain Society Guidelines on the Management of Post operative Pain APS, ASRA, ASA Feb 2016 OOO (Rec 10, Strong, MQE) Oral Opioids Only, when patient can tolerate PO Initiate Taper Plan at onset. Peri operative Analgesia Begins at or before the Decision to have Surgery Team Effort Taper Chronic Opioids? Buprenorphine? APS Guidelines Recommendations 1,2,3 (Strong Rec, LQE) Pre Op Assessment Discuss/Educate Set Expectations and Goals Esp. ERAS History Screen for anxiety/depression, chronic opioid use, Illicit drug use, Catastrophizing behavior, Alcohol, Chronic Pain Syndromes, hx of post op pain 3
Pre Op Assessment What are the Goals of Analgesia? ORAE s?/morphine Consumption/Sparing? Concept of ERAS and Functional Recovery Pre Op Formulate a Multi Modal Plan (Rec 6: Strong, HQE) Team Effort Concept of Pre emptive Analgesia Many, Many, Many tools in the toolkit But. Pre Op 4
Pre Op Acetaminophen and NSAIDs (Rec 16, 17: Strong Rec, HQE)(WHO) May be synergistic Formulation COX 2 vs Non selective Celecoxib 200 mg PO BID or 400 mg PO once Acetaminophen 1000 mg q6 8 Bone healing, anastomotic leakage Concern Appreciated but lack of HQE Pre Op Pre Op Gabapentinoids (Rec 17: Strong Rec, MQE) Gabapentin, Pregabalin Modulation of Voltage Gated Calcium Channels Most Appropriate Dose and Dosing Schedule Unknown Gabapentin 600 1200 mg preop +/ post op Pregabalin 150 300 mg preop +/ post op Side Effects, especially elderly 5
Pre Op Peripheral Regional Anesthesia (Rec 23: Strong Rec, HQE) Cervical Plexus Brachial Plexus Lumbar Plexus Femoral Saphenous/Adductor Canal Sciatic/Popliteal Ankle TAP/QL/Rectus Sheath/ II IH PECs/Serratus Plane Paravertebral/ESP Block/RL Block TAP variations and nomenclature Surgery/Anesthesia Discussion to be on same page Classic TAP Subcostal TAP 4Quadrant TAP itap Continuous TAP Blocks QL Blocks Rectus Sheath Blocks TAP Anatomy 6
TAP Anatomy TAP Anatomy QL Block (1,2,3) 7
Chest Blocks PEC 1/PEC 2 (Blanco 2011) Breast, Chest, CRD Implantation Serratus Plane As Above, Rib Trauma, Thoracic Surgery Low Side Effect Profile Chest Wall Blocks PVB and Friends Goal Analgesia, preferably Long acting Risks/Side Effects Searching for the Optimum Risk/Benefit Ratio So Introduce ESP and RL Blocks 8
Pre Op Neuraxial Techniques Epidural Analgesia (Rec 26: Strong Rec, HQE) Benefits Well Documented Risk/Benefit/Side Effect profile starting to fall out of favor (a little) Intrathecal/Epidural Non Opioid Adjuvants (Rec 27: Strong, MQE) Not Recommended Mag, Neostigmine, Ketamine, Benzodiazepines, Tramadol Intra Op Concept of Pain under Anesthesia Nociception Monitoring (EEG, HRV, Skin Conductance, Pupils, etc) Treatise of Man concept Endogenous Opioid Receptor Opioid Free Anesthesia Desire Analgesics and Anti hyperalgesics Paradigm Shift on necessity of opioids Potential of opioid hyperalgesia Intra Op Ketamine (Rec 18, Weak, MQE) but (Updated July 2018) Sub anesthetic Dosing Mechanism Dosing varies Side Effects: psych, CV Post op infusion 1 mg/kg/hr or less 9
Intra Op Lidocaine Infusion (Rec 19: Weak, MQE) Benefits Limitations Concurrent Block Dosing 1.5 mg/kg bolus with 2 mg/kg/hr Dosing/Continuation/Monitoring in PACU/Surgical Ward/ICU Intra Op Clonidine/Dexmetatomidine Low Dose Combination with Ketamine Data favors dexmetatomidine Emergence Delirium benefit Long Acting Intra Op Magnesium NMDA Optimal Dose and duration unknown Prevalent hypomagnesemia 10
Intra Op Dexamethasone 8 10 mg Control Group in older studies Retracted Studies POD#1 dose Infection/hyperglycemia/agitation/burning on injection Miscellaneous Esmolol Muscle Relaxants TCA s Duloxetine Dextromethorphan Amantadine Caffeine Nefopam PACU IV/Oral Opioid Rescue Block? Muscle Relaxant Dexmetatomidine/Ketamine 11
Post Op/Floor Acetaminophen Cox 2 or non selective Cox Oral Opioid Dexamethasone x 1 Check magnesium levels? Muscle Relaxant Lidocaine Infusion? On Discharge Benefit of Multi modal Therapy Decreased Readmission Decreased ER/Urgent Care visits Decreased Pain scores Desai et al J Surg Res April 2018 Over 40,000 patients, VA and Academic Center Blend Non Pharmacologic TENS (Rec 7: Weak, MQE) Meta Analysis Regimen not defined Others (Rec 8: Insufficient Evidence) Massage, Accupuncture, Cold, Bracing 12
Non Pharmacologic Cognitive Behavioral Modalities (Rec 9, Weak, MQE) Guided Imagery, Reflexology (relaxation techniques) Music Aromatherapy Hypnosis Intraoperative Suggestions Multitude of Studies, small pain relief benefit, favorable safety profile General Approach Screen and Identify Risk Factors Make Pre, Intra, and Post Pain Plan Pre Op Start with acetaminophen/cox 2 Add Gabapentinoid for elevated risk (patient or surgical) Consider/Encourage Peripheral Regional Block where applicable General Approach Intra Consider Opioid Free Anesthesia If not free, then Opioid Sparing Encourage Ketamine, Dexmetatomidine, Mg Possibly Lidocaine or High Dose Dexamethasone Add additional agents as patient/surgical pain risk goes up 13
General Approach Post (Opioid Free Analgesia) Start with Acetaminophen/NSAID Oral Opioids only (if applicable) Consider Gabapentanoid? Consider Dexamethasone x 1 Consider Muscle Relaxant Monitor Magnesium Dexmetatomidine/Ketamine infusions as rescue General Approach Most Importantly Continue to Educate, Reassure, Encourage If using Opioids, Make a tapering plan (with the patient) at the time of initiation Discussion 55 y/o female for bilateral mastectomy with reconstruction Pertinent Hx anxiety, fibromyalgia What s our plan? 14
Discussion 82 y/o VATS with Decortication Pertinent Hx COPD, CAD, PCI (hx plavix, VTE proph TID Heparin) Pain Plan? Citations Chou et al. Guidelines on the Management of Postoperative Pain. J Pain 2016;17:131 157 Thomazeau et al. Acute pain factors predictive of post operative pain and opioid requirement in multimodal analgesia following knee arthroplasty. Eur J Pain 2016;20 822 832 Lavand homme P, Estebe J. Opioid free anesthesia: a different regard to anesthesia practice. Curr Opin Anesthesiol 2018:31 Forget P. Opioid free anaesthesia. Why and how? A contextual analysis. Anaesth Crit Care Pain Med 2018 Bruhn J, Scheffer G, van Geffern G. Clinical Application of perioperative multimodal analgesia. Curr Opin Support Palliat Care 2017; 11:106 111 Luo J, Min S. Postoperative pain management in the postanesthesia care unit: an update. J Pain Res 2017:10 2687 2698 Kumar K et al. A Review of Opioid Sparing Modalities in Perioperative Pain Management: Methods to Decrease Opioid Use Postoperatively Anesth Analg 2017:125 1749 1760 Desai k et al. Utilization and effectiveness of multimodal discharge analgesia for postoperative pain management J Surg Res 2018:228 160 169 15