Lumbar Fusion. Reference Guide for PACU CLINICAL PATHWAY. All patient variances to the pathway are to be circled and addressed in the progress notes.

Reference Guide for PACU Lumbar Fusion CLINICAL PATHWAY All patient variances to the pathway are to be circled and addressed in the progress notes. This Clinical Pathway is intended to assist in clinical decision making by describing a range of generally acceptable intervention and outcomes. The guidelines attempt to define practices that meet the needs of most patients under most circumstances. However, the ultimate judgment must be made based on circumstances that are relevant to that patient and treatment may be modified according to the individual patients needs.

PACU Lumbar Fusion Clinical Pathway PAIN MANAGEMENT / COMFORT PAIN GUIDE Preoperative Medications: 1) Acetaminophen Dose: 1000 mg PO Contraindications: severe liver dysfunction, allergy, use within previous 6 hours 2) Pregabalin OR Gabapentin OR Home Dose if taking Mscontin or Oxycontin Doses: Please consider contributions from other sedating agents or medical comorbidities and modify dose accordingly. i. Pregabalin: 150 mg if < 70 yr old and > 70 kg 75 mg if > 70 old or < 70 kg ii. Gabapentin: 600 mg if < 70 yr old and > 70 kg 300 mg if > 70 yr old or < 70 kg Contraindications: renal dysfunction (GFR < 30), allergy Chronic users should receive their scheduled dose in preop holding if they did not take it prior to coming to the hospital. 3) Oxycontin Dose: 10 mg if not taking long-acting narcotic chronically Patients taking MScontin, oxycontin, methadone should receive their regularly scheduled dose instead. Intraoperative Analgesia Management suggestions: 1) Opioids a. Fentanyl: minimize use b. Hydromorphone/Morphine/Methadone: Use intraoperatively as needed. 2) Ketamine: this is useful to spare opioids and to reduce risk of hyperalgesia. It is useful in highly opioid tolerant patients and in neuromonitoring cases. Bolus dosing: 0.1-0.2 mg/kg after induction Drip: 0.1-0.2 mg/kg/hr Side effect profile is minimal using these dosing strategies 3) Dexmedetomidine: This is very effective in highly opioid tolerant patients. Can cause significant sedation in higher doses. Can cause bradycardia and hypotension, dry mucous membranes. Dose: 0.2-0.7 mcg/kg/hr (IBW) Bolus (use great caution) 5-10 mcg q 5 minutes up to 1 mcg/kg IBW 4) Anti-Infectives: Antibiotics are per ID recommendations. These recommendations are posted in the OR or available on the portal. 4) Celecoxib Dose: 400 mg x 1 Contraindications: Significant renal dysfunction, platelet dysfunction Severe CAD Allergy (remember this drug may be problematic in patients with sulfa allergy)

Lumbar Fusion Pain Pathway Lumbar Fusion Pain Pathway Excludes Dr. Glazer patients Generalized Pain Pathway Descriptions: A B C Patients that are Opiate Naive: < 60 mg Morphine Equivalent/day Patients that are Opiate Tolerant: > 60 mg Morphine Equivalent/day Patients Intolerant of oral medications or strictly NPO CPS Consult Patients on Methadone, Suboxone, Subutex, Buprenorphine, and Naltrexone IM or for any patient taking > 60 mg morphine equivalents/day for > 2 weeks Epidural? Consult APS 37246 (3PAIN) Tolerates PO? Is this a CPS patient? Contact CPS 3OUCH 36824 Patient taking < 60 mg morphine/day Pathway A Opioid Naive Is there adequate analgesia? Patient taking > 60 mg morphine/day Pathway B Opioid tolerant Follow CPS plan Prepare discharge plan including: 1) Weaning from opioids 2) PRN-(or) as needed Suboxone, subutex, Naltrexone? CPS/POP Consult required Pathway C IV pathway (least preferred) Patient should be changed to PO ASAP

Pathway A: Opiate naïve or uses < 60 mg morphine equivalent/day (see table) B Drug Initial dose Frequency Adjustment options Acetaminophen 1 1000 mg 500 mg Q 6-8 hours Oxycodone 5-10 mg PO Q 4 hours 10-15 mg Q 4 hours Hydromorphone 2-4 mg PO Q 4 hours 4-6 mg, can give Q 3hours Morphine PO (MSIR) Anticonvulsants Muscle relaxants 15mg PO Q 4 hours ne, contact APS Start with low dose Start with low dose See list below See list below Oxycontin 2 10 mg PO Contact APS MSContin 2 15 mg PO, Contact APS Ketamine drip 0.1-0.3 mg/kg/hr Infusion Contact APS (with APS consult only) Celecoxib 3 400 mg PO Once/day 200 mg BID 3 x 24 hr Preferred Restrict use 1. Acetaminophen: decrease dose or avoid in patients with liver dysfunction. 2. Consider omitting in opioid naïve patients who are not taking any opioids at baseline. 3. Single preoperative celecoxib dose OK. If celecoxib or ketorolac are needed postop, attending surgeon approval is required. PO Pain Medication Pathways: Patients should remain on all preoperative medications during the hospitalization unless contraindicated for the surgery. Use fewest number of medications required at lowest doses necessary. Limit long-acting opioids to 5 days following discharge unless patients are stabilized on them prior to surgery. Use caution with combining narcotics and sedatives in patients with: o Obstructive sleep apnea o Cognitive dysfunction o Over 70 years old

IV breakthrough Pain Medications: Drug Dose Frequency Adjustments Hydromorphone 0.5-1 mg Q 4 hours 0.25 mg patients > 70 years old Morphine 1-2 mg Q 4 hours 0.5 4 mg Meperidine 25-100 mg PO/IV/IM Q 6 hours APS/CPS only Anticonvulsant Medications for Pain Management (all PO only): Drug Gabapentin Pregabalin Dose 100-300 mg (naïve) 75-150 mg Frequency Adjustments 300 mg-900 mg Q 8 hr 75-300 mg Q 12 hr 1) Decrease the dose in renal insufficiency 2) Decrease the dose in patients > 70 years old. Topiramate 25-50 mg (APS/CPS only unless stabilized on drug) Muscle Relaxants for Pain Management: 25-200 mg/day 3) Use caution (avoid) in patients with cognitive dysfunction. Drug Diazepam Lorazepam Dose 5 mg PO 0.5-1 mg PO Frequency BID-QID prn BID-TID prn Adjustments 10 mg BID-QID 2 mg BID-TID 1. Increased risk of serotonin syndrome when used in patients on SSRIs. 2. Initiate with recommendation by APS or CPS only. Continue drug if patient has Flexeril 1 (cyclo- 5 mg PO 10 mg benzaprine) been stabilized on one of these drugs preoperatively. Skelaxin (metaxalone) Robaxin (methocarbamol) Baclofen PO Baclofen pump 800 mg PO 500 mg PO 5 mg PO Consult CPS for interrogation preop and postop -2 adrenergic agonists: Q 4 hours 800 mg Q 6 hours 1000 mg Q 6 hours, 1500 mg x 48 hours 10-15 mg With all of these drugs use great caution in patients > 70 years old. They may increase the risk of delirium especially in combination with other medications. If patient is stabilized on regimen, please consider modifying dose rather than adding another drug in the same class. Drug Dose Frequency Adjustments These drugs should be initiated by APS Clonidine 0.1 mg PO Q 12 hr 0.2 mg Q 12 hrs or CPS only. over several days Clonidine transdermal 0.1 mg patch Q 7 days none Tizanidine 2-4 mg PO 4 mg Q 8 hrs after several days Morphine Equivalents (in mg/day): If patients are taking these preoperatively, do NOT discontinue abruptly. Avoid in patients > 70 years old unless stabilized on regimen. Drug IV PO Methadone and buprenorphine equivalents are controversial. Morphine Sulfate 20 mg 60 mg Do not make adjustments without consulting CPS or APS. Oxycodone n/a 40 mg Consult CPS for patients on Methadone, Suboxone, Subutex, buprenorphine, Naltrexone IM or for any patient taking Hydromorphone 4 mg 20 mg greater than 60 mg morphine equivalents per day for greater Oxycontin n/a 40mg than 2 weeks. MSContin n/a 60 mg Fentanyl patch 25 mcg/hr n/a Oxymorphone n/a 40-50 mg

Pathway B: Opiate tolerant patients (> 60 mg morphine equivalents/day) C. a) These patients should have a preoperative POP consult with CPS. b) If patients do not have a CPS or POP consult, please use the suggested doses listed below. Consider APS consult. c) Please use IV breakthrough narcotics as listed for opiate-naïve patients Drug Initial dose Frequency Adjustment options Oxycodone 10-15 mg PO Q 4 hours 20 mg Q 4 hours Hydromorphone 4-6 mg PO Q 4 hours 4-8 mg, may give Q 3hours Morphine PO (MSIR) 15-30mg PO Q 4 hours 30 mg Q 4 hours Acetaminophen 1000 mg PO 500 mg Q 6-8 hours 1 Anticonvulsants 4 Muscle relaxant Oxycontin MSContin Clonidine (APS consult unless patient taking preoperatively) Ketamine drip (APS consult required) Start with low dose. (see note 4 below) Start with low dose. 10 mg (or preoperative dose) 15 mg (or preoperative dose) 0.1 mg patch +/- tablet Q 8-12 hours Q 7 days See list below See list below 0.1-0.3 mg/kg/hr Infusion Contact APS 2 Use APS/CPS recommended dose Use APS/CPS recommended dose Contact APS for any dosing adjustments Celecoxib 3 400 mg PO Once/day After initial dose: 200 mg BID 3 Preferred Restrict use 1. Acetaminophen: decrease dose or avoid in patients with liver dysfunction. 2. APS will manage ketamine infusions in conjunction with CPS. 3. Single preoperative dose Celecoxib permitted. If celecoxib or ketorolac are needed postop, attending surgeon approval is required. 4. Patients who have been stabilized on anticonvulsants should continue on preoperative dose. Consider increasing dose for inadequate analgesia if patients are having pain and are not overly sedated. PO Pain Medication Pathways: Patients should remain on all preoperative medications during the hospitalization unless contraindicated for the surgery. Use fewest number of medications required at lowest doses necessary. Limit long-acting opioids to 5 days following discharge unless patients are stabilized on them prior to surgery. Use caution with combining narcotics and sedatives in patients with: o Obstructive sleep apnea, o Cognitive dysfunction o Over 70 years old.

Pathway C: IV Pathway Primary use of IV analgesia should be reserved for patients who are: 1) Strictly NPO 2) Intolerant of PO analgesia due to N/V or other gastrointestinal concerns. Avoid mixing IV and PO pathways without consultation from APS or CPS. Drug Dose Frequency Adjustments PCA hydromorphone 0.12-0.24 mg Q 6 min Up to 0.36 mg Q 6 min. Preferred PCA morphine 0.5-1 mg Q 6 min Up to 2 mg Q 6 min. Acetaminophen 1000 mg IV Q 6 hours 500 mg Q 6 hours or 1000 mg. Lorazepam 1 0.5-1 mg IV/IM Q 6-8 hours 0.25-2 mg IV Q 6-8 hours 1 Diazepam 5 mg IV/IM Q 6-8 hours 10 mg IV Q 6-8 hours 1 Ketorolac 2 15-30 mg Q 6hr x 48 hr 1. Respiratory depression risk is high when combined with opioids. This is increased in patients with OSA, > 70 years old, those with cognitive or neurological dysfunction. Diazepam had active metabolites that result in increased sedative effects over time. 2. Must have attending surgeon approval before administering NSAIDS. Restrict use Contact APS for management of pain in post-operative patients with inadequate analgesia despite use of pathway medications. The number on the VAS may not reflect clinical picture. Consider baseline pain score. Contact CPS for management of patients with a POP consult. If you are not sure, call APS. PO Pain Medication Pathways: Patients should remain on all preoperative medications during the hospitalization unless contraindicated for the surgery. Use fewest number of medications required at lowest doses necessary. Limit long-acting opioids to 5 days following discharge unless patients are stabilized on them prior to surgery. Use caution with combining narcotics and sedatives in patients with: o Obstructive sleep apnea o Cognitive dysfunction o Over 70 years old

Pain Management Lumbar Fusion Clinical Pathway 2015 What: Who: Why: Clinical Pathway Practice Changes Lumbar Fusion Patients Clinical Pathway Education related to Pain Management, Mobility, Patient Education, and Discharge Planning Goals: 1. Improved Pain Management with Early Utilization of Oral Pain Medications 2. Increase Early Mobilization to Prevent or Decrease Post-Operative Risk Factors. (ie. Ileus, Blood Clots, and Infections) 3. Improve Documentation of Patient Progress related to pain and mobility. 4. Enhanced Continuous Patient Education and Discharge Planning 5. Decrease the Length of Stay in the Patients S/P Lumbar Fusion Generalized Pain Pathway Descriptions: A Patients that are Opiate Naive: < 60 mg Morphine Equivalent/day B Patients that are Opiate Tolerant: > 60 mg Morphine Equivalent/day C Patients Intolerant of oral medications or strictly NPO CPS Consult Patients on Methadone, Suboxone, Subutex, Buprenorphine, and Naltrexone IM or for any patient taking > 60 mg morphine equivalents/day for > 2 weeks Important Practice Changes for the Lumbar Fusion Pathway Documentation Clinical Pathway in Patient s Chart Actual designation of a Pain Pathway A, B, C, or CPS Consult Use of pre-op oral pain medications: Gabapentin, Tylenol, Oxycontin/MS Contin use of PCA s post-op: Utilizing oral pain medications immediately post op, along with IV pain medications for breakthrough pain instead of PCA: Overview of doses OK to use full dose Explain adjustment options Strict Q4H pain check-ins Important to stay ahead of the pain Set appropriate expectations with the patient (language?) Wake patients at night Bracing If a brace is indicated, use of prefabricated braces are issued to patients by POD 0/POD 1. (Exception of Dr. Glazer s patients) Activity Early Mobilization by Nursing. PT Eval and Treatment: POD#2 and POD#4. Other Use of standing PO Bowel Medications and addition of SC Methylnaltrexone POD 1 Use of PO Flomax POD #1 in men ages 55 years of age or older Starting SC Heparin POD #1, unless patient is ambulating STANDARDIZED PATHWAY VALUE Better Pain Management Increased Mobility, Decreased Risk Factors