The Role of Multi-Modal Analgesia and the Burden of Opioids Jacob Hutchins MD Director of Regional Anesthesia, Acute Pain, and Ambulatory Anesthesia Department of Anesthesiology University of Minnesota Disclosures/Off-Label peaker s bureau, consultant, and research funds from Pacira Pharmaceuticals peaker s bureau for Halyard Health Consultant for Atricure Consultant for Worrell I will talk about off-label medication use but it will be of my own experience Is Improved Pain Control Needed? Current tate of Pain Control Yes! Pain control remains the number one concern for patients leading up to surgery Opioids remain the mainstay of post surgical pain regimens Non opioids are often prescribed prn and thus depends on the nurse to give to patient Pain as fifth vital sign has led to emphasis on undermedication and less focus on overmedication
Why is Pain Control Important? Risk Factors for Acute Postoperative Pain Uncontrolled postoperative pain can lead to Longer Hospital stay and increased PACU/Phase 1 time Readmissions for pain Females Decreased satisfaction and quality of life Progression to chronic pain Major stress response from body Young age Increased BMI Increased sympathetic tone Increased Heart rate and blood pressure Preop use of opioids Hypercoagulability Decreased Immune function General anesthesia Urinary retention Endocrine changes: increased ACTH, cortisol, epinephrine, aldosterone, ADH, Ang II History of Chronic pain Decreased GI motility Why Minimize Opioids? Oversedation is a problem 70 million patients receive opioids in hospital or clinic following surgery each year 1 Opioids have multiple adverse events Nausea/vomiting, pruritis, constipation, urinary retention May play role in cancer recurrence JCAHO sentinel event respiratory depression and even death for increased risk patients Elderly, OA, chronic pain, and obese 1. Adamson, et al. Hosp Pharm. 2011;46(6 uppl 1):1-3.
Why Minimize Opioids? Why Minimize Opioids? Postoperative opioid use contributes to misuse of opioids 1 in 15 patients with acute opioid use go on to long term use 1,2 Due in part to rapid proliferation of new users from acute care setting. 46 Americans die each day from opioid overdose 5.1 million Americans used opioids illicitly last month The number of opioid/heroin related deaths in Minnesota each year is similar to number killed in MVA 18% of opioid naïve patients were still on opioids 1 year after elective spine surgery 6% of patients after orthopedic procedures were still on opioids 150 days after surgery 1. Alam A, et al. Arch Intern Med, 2012; 172(5): 425-30. 2. Carroll I, et al. Anesth Analg, 2012; 115(3): 694-702. United tates Opioid Problem Our Elderly and Children are at Risk In patients 65 undergoing low-risk surgery who received an opioid Rx within a week of surgery 1 : 10.3% 44% were still taking opioids a year later There was a in the likelihood they would become long-term opioid users Compared to non-athletes, adolescents males who participate in organized sports have 2 : the risk for being prescribed an opioid medication 2x 4x misusing opioids 10x 1.Alam A, et al. Arch Intern Med. 2012;172:425-30. 2. P. Veliz et al. Journal of Adolescent Health 54 (2014) 333e340 the odds of to get high the odds of medical misuse of opioids due to taking too much
Overprescription Leads to a High Potential for Diversion In patients undergoing outpatient upper extremity surgery 1 Resulting in Access to Excess Pills From Multiple ources 1 Other source 7.1% Got from drug dealer or stranger 4.4% Took from friend or relative w/o asking 4.8% 55% Obtained for free from friend or relative Bought from friend or relative 11.4% Prescribed by one Doctor 17.3% 1. Rogers J, et al. Opioid consumption following outpatient upper extremity surgery. J Hand urg Am. 2012;37:645-50. 1. Centers for Disease Control. Policy Impact: Prescription Painkiller Overdoses; Nov 2011. Available at: http://www.cdc.gov/homeandrecreationalsafety/rxbrief/ Minnesota s Opioid Epidemic Minnesota s Opioid Epidemic
Minnesota s Opioid Epidemic Multiple Organizations Have Urged a hift Toward Non-Opioid Options JCAHO recommends An individualized, multimodal treatment plan should be used to manage pain upon assessment, the best approach may be to start with a nonnarcotic CDC recommends Health care providers should only use opioids in carefully screened and monitored patients when non-opioid treatments are insufficient to manage pain 2 AA recommends a multimodal approach to pain management often beginning with a local anesthetic where appropriate 1.The Joint Commission. Revisions to pain management standard effective January 1, 2015. Available at: http://www.jointcommission.org/ assets/1/23/jconline_november_12_14.pdf. Accessed November 19, 2014 2.CDC. Vital igns: Overdoses of Prescription Opioid Pain Relievers --- United tates, 1999 2008. Nov 2011;60(43);1487-1492. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm Multimodal Analgesia Options for Multimodal Analgesia Utilization of more than 2 analgesics which act at different sites in CN and PN Goal to Minimize pain as well as minimize opioids hould be started prior to surgery and continued in acute postoperative period Requires coordination between Preoperative, Intraoperative, and Postoperative periods urgeon, Anesthesiologist, Providers, and Nurses all on same page
ample Multimodal Approach ample Multimodal Approach ETTING EXPECTATION Intraoperatively Preoperative Medication Gabapentin or Pregabalin: started evening before surgery Acetaminophen: IV or oral started evening before surgery NAIDs if allowed by surgeon Regional Anesthesia Attempt to minimize opioids preop even with block sedation Regional anesthesia if not done in preop phase urgeon Infiltration in select procedures: liposomal bupivacaine or catheter technique preferred Minimal Opioids and only short acting (rare need for opioids on induction and premedication with 2mg versed) Continue acetaminophen intraop (redose 4 hours after last dose) Ketorolac at closure if appropriate Lidocaine, ketamine, or dexmedetomidine infursions where appropriate ample Multimodal Approach Additional Multimodal Postoperatively cheduled Acetaminophen every 6-8 hours for up to one week post operatively: Oral as soon as able Intermittent opioids: Oral as soon as able NAID as soon as possible and then scheduled for up to one week post operatively Gabapentin (300mg) or Pregabalin (75mg) continued for one week Lidocaine infusions, ketamine intermittent or infusion, and dexmedetomidine infusion where appropriate. Muscle relaxants or Diazepam for muscle spasms Topical medications or lidocaine patches for pain Non pharmacologic interventions Ice to area Healing touch Massage Pet Therapy Acupuncture Relaxation techniques
Regional Anesthesia Why Regional Anesthesia? Interscalene: houlder procedures upraclavicular: Arm and Hand procedures Provides Pre-emptive Analgesia Adductor canal/femoral: Thigh and Knee procedures Decreases likelihood of development of Chronic Pain Popliteal/Distal ciatic: Foot and ankle More precise placement of local anesthetic Lumbar Plexus/Fascia Iliaca: Hip Transversus abdominis plane blocks for abdominal procedures Pec blocks for breast and chest procedures Paravertebrals for thoracic and abdominal procedures Able to use less local anesthetic in most cases Low failure rate Quick and low risk to place Can be either single injection or catheter infusion ingle hot Catheters Can be Long Acting Local Anesthetics Bupivacaine or Ropivacaine Last 6-12 hours postoperatively Can remain in place for 1-7 days after placement Or hort Acting Mepivacaine or Lidocaine Last duration of procedure 1-4 hours Usually run low dose bupivacaine or ropivacaine Can titrate to effect Additives can extend duration of action Epinephrine Clonidine Allows intermittent bolus Risk of dislodgement and infection as are indwelling Dexamethasone Dexmedetomidine
Local Anesthetics Liposomal Bupivacaine Are an essential part of a multimodal pain control regimen Can be used to provide pain control that targets the site of surgery via infiltration of skin and subcutaneous tissue (liposomal bupivacaine) Also used for regional anesthesia to target specific peripheral or central nerves (single shot or catheter technique) Finally can be given intravenously to provide effective postoperative pain control (IV lidocaine) On-label use for infiltration (surgeon infiltration, TAP, Pec) Off-label use for peripheral nerve blocks Provides 40-72 hours of analgesia via single shot Multivesicular liposome formulation of 1.3% bupivacaine Provides Day 1 dense block, day 2 50-75% block and day 3 25-50% blockade Minimal motor blockade after day 1 Unable to bolus or titrate dosage TAP Blocks Transversus Abdominis Plane Block Provides analgesia to skin muscle fascia and parietal peritoneal layers but not viscera Ultrasound Guided and can be done prior to surgery intraoperatively or in PACU Catheters can be kept in for up to 7 days, Liposomal Bupivacaine provides 40-72 hours pain relief
Hutchins et al. Ultrasound Guided ubcostal Transversus Abdominis Plane (TAP) Infiltration with Liposomal Bupivacaine for Patients Undergoing Robotic Assisted Hysterectomy: A Prospective Randomized Controlled tudy. Data presented at IAR Honolulu, Hawaii 2015 Paravertebral Blocks Liposomal bupivacaine TAP vs. bupivacaine TAP LB TAP had decreased total opioids, decreased nausea/ vomiting, and decreased maximal pain at all time points studied. Trend towards decreased length of stay (p=0.055) 11 +/- 9.1 hours in LB TAP group vs. 17 +/- 13.9 hours in bupivacaine group. No adverse events noted in either group Unilateral blockade of spinal nerves outside vertebral canal ingle hot with Bupivacaine or Liposomal Bupivacaine (off label use) or Catheter Injection level depends on surgical site Lasts 12-24 (bupivacaine) or 40-72 hours (liposomal bupivacaine) or 72 hours or longer (catheter) Paravertebral Blocks Pec Blocks Pecs 1 targets lateral and medial pectoral nerves Pecs 2 targets lateral and medial pectoral nerves, intercostobrachial, intercostals III, IV, V, and VI, and long thoracic nerve Used for breast procedures, subclavian TAVR, chest wall, and even thoracic procedures.
Pec Blocks Interscalene Used for houlder and distal clavicle procedures Blocks brachial plexus at level of roots/trunks PM PM Frequent sparing of C8-T1 Pm A Pm 100% will have some phrenic nerve involvement Perform suprascapular to avoid phrenic May cause intermittent Horner s syndrome ingle shot (15-25 ml) 6-12 hours Interscalene Literature upport Park et al: Interscalene single shot (IB) decreased pain scores compared to intraarticular injection Lehman et al: IB superior to GA and GA + IB in terms of recovery and pain medications used Ullah et al: IB had improved pain control compared to no block and ultrasound IB had less complications compared to nerve stimulator IB Hughes et al: IB decreased supplemental analgesics and decreased pain
upraclavicular upraclavicular Useful for surgery below shoulder level Blocks brachial plexus at level of divisions Brachial Plexus Misses suprascapular nerve (60-70% of shoulder) Risk of Pneumothorax and phrenic nerve involvement ingle shot (15-25 ml) 6-12 hours Pleura A Catheter not ideal (infraclavicular better position) First Rib Literature upport Other Brachial Plexus Blocks Gamo et al: upraclavicular block permitted operating conditions without general in 99.5% of cases and 96.7% were satisfied with analgesia Ahsan et al: 26% failure on day 1 after hand surgery for supraclavicular catheter Infraclavicular: good for catheter placement for arm procedures Axillary: superficial and may be easier in super obese population as it poses no lung risk. Renes et al: U/ guided supraclavicular decreased diaphragm paralysis compared to nerve stim Lam et al: improved satisfaction with distal blocks compared to supraclavicular uprascapular and Axilary for shoulder procedures as described by Checucci et al with no phrenic involvement
Adductor Canal Adductor Canal Useful for TKA, ACL, other knee procedures, and for foot/ankle Distal block of Femoral nerve aphenous nerve, nerve to vastus medialis, obturator branches artorius Block occurs mid thigh Decreased quad weakness compared to femoral ingle hot (15-20 ml) V A Nerve Vastus Medialis Literature upport Femoral Nerve Block Jaeger et al: Adductor 8% weakness, Femoral 49% weakness Jenstrup et al: Adductor decreased pain and improved PT compared to placebo Hanson et al: Adductor catheters provided pain relief up to 48 hours and improved quad strength hah and Jain: Adductor provided improved early ambulation with no difference in pain compared to femoral Perlas et al: Adductor plus local infiltration had best early ambulation and highest incidence of home discharge. Useful for knee surgery, thigh surgery, femoral neck fractures Increased weakness of quad compared to adductor canal ingle shot (15-25 ml) Liposomal bupivacaine (off label) Phase 3 data showed improved pain control and no difference in weakness compared to placebo
Femoral Nerve Literature upport Fascia Lata Minkowitz et al: showed femoral with liposomal bupivacaine superior than placebo up to 72 hours after injection with no increased motor A Fascia Iliaca Luo et al: Femoral nerve block associated with persistent strength deficits at 6 months after ACL repair in pediatric and adolescents V Femoral Nerve Chisholm et al: aphenous equal to Femoral nerve block with regards to analgesia after ACL Krych et al: No difference in return to sport for femoral nerve block patients but decreased motor/function at 6 months post ACL Popliteal/Distal ciatic Popliteal/Distal ciatic Block of sciatic nerve just prior or just after split into fibular and tibial divisions Useful for calf, tibia, ankle, foot, and toe surgery Tibial Nerve Fibular Nerve aphenous is only nerve of foot/ankle not covered by this block Blockade of sciatic nerve will cause foot drop (fibular) elective Tibial or IPACK blocks will provide back of knee pain relief without foot drop ingle shot (20-40 ml) Onset of action is slowest of all major nerve blocks A
Literature upport aporito et al: no difference in cost or readmissions in those who had continuous regional block popliteal block decreased costs and allowed surgery to be performed as outpatient Gallardo et al: continuous popliteal block for total ankle arthroplasty decreased pain, decreased opiates, and increased satisfaction Lumbar Plexus Lumbar Plexus Covers T12 to L4 Useful for hip, femoral neck, and knee surgery Deep block and increased patient discomfort compared to other blocks Block with increased risk of morbidity and mortality Literature upport Karlsen et al: No best intervention for total hip arthroplasty Amiri et al: Lumbar plexus and MAC anesthesia were sufficient for femoral neck fracture surgery Lee et al: Continuous lumbar plexus decreased total opioids after total knee replacement Nye et al: Continuous lumbar plexus block for hip arthroscopy had risk of significant complications (3.8%)
Fascia Iliaca Fascia Iliaca Proximal blockade of lumbar plexus High Volume Block Iliacus Fascia Useful for femoral neck fractures and total hip replacement (?) Allows for ease of spinal placement in femoral neck fractures Ilium Literature upport Other Lower Extremity Blocks Foss et all showed FICB decreased Pain scores and opioid use after femoral neck fractures hariat et al no difference between fascia iliaca vs sham for total hip arthroplasty Obturator Lateral Femoral Cutaneous Ankle Blockade Hanna et al: FICB decreased pain after femoral neck fractures McRae et al: FICB performed by paramedics for femoral neck fractures decreased pain scores compared to standard of care