Utilizing a Structured Pain Management Approach in Total Hip and Total Knee Arthroplasty Jennifer Watson, Medication Safety Pharmacist Gina Anderson-Malum, Total Joint Specialist, Bone & Joint Center Conflict of Interest We hereby certify that, to the best of our knowledge, no aspect of our current personal or professional situation ti might reasonably be expected to affect significantly our views on the subject on which we are presenting. Objectives. Differentiate the assigned pain protocol for the opioid naïve or opioid tolerant patient 2. Design a pain management plan to include adjunct medications Background Why? Why? Why? Why? Why? Adverse events-patient safety Educational conferenes Decrease opioid id usage Structured approach Patient Satisfaction Culture of pain management Adverse Events Naloxone Administered Flumazenil Administered Both reversal agents administered 22 (prior to implementation of RL Solutions) 9 23 63 2 24 7 77 8 2 (through June) 28 4 4
Patient Scenario 69 y/o, right total knee IV in OR 4mcg Fentanyl in PACU mg Hydromorphone PACU IV x2 on unit 3mg IV Morphine in 24 hrs on unit st 4 hrs=6mg. 4mg Oxycontin Vistaril mg Norco -mg tabs Opioid Naïve vs. Tolerant: What does that really mean? Definitions Opioid Tolerant: Patient who has been taking the following for longer than week: 6mg oral Morphine/day 2mcg transdermal Fentanyl/hour 3mg oral Oxycodone/day 8mg oral Hydromorphone/day 2mg oral Oxymorphone/day Opioid Naïve: any patient not taking the above amounts of medications. Perspective Percocet /32mg -2tabs PO q6h prn = 8 tabs per day = 4mg of PO Oxycodone, 2mg of IV Morphine, 3mg of IV Hydromorphone or 2mcg of IV Fentanyl Norco /32mg -2 tabs PO q6h prn = 8 tabs per day = 4mg of PO Morphine, 3mg of IV Morphine, 2mg of IV Hydromorphone or 3mcg of IV Fentanyl Fentanyl 2mcg = 2.mg of IV Morphine or.38mg of Hydromorphone Hydromorphone mg = 6.7mg of IV Morphine or 7mcg of Fentanyl Pharmacokinetics IV medications: Fentanyl Onset: almost immediate Peak: minutes Half life: 2-4 hours Pharmacokinetics IV medications: Hydromorphone Morphine Onset: minutes Onset: - minutes Peak: -2 minutes Peak: -6 minutes Half life: 2-4 hours Half life: 2-4 hours 2
Oral Medications: Hydrocodone/acetaminophen /32mg Onset: 4-9 minutes Peak:.3 hours Half life: 3.8 hours Oxycodone/acetaminophen /32mg Onset: 4-9 minutes Peak:. hours Half life: 3.9 hours Pain Adjuvants Tylenol (acetaminophen) Mild to moderate pain dosing: 6-3mg po q4-6hrs prn; max of 4mg/24hrs Caution in patients with hepatic compromise/failure Advil (ibuprofen) Pain/anti-inflammatory dosing: 6-8mg po q6h prn; max of 24mg/24hrs Caution in patients with renal failure Toradol (ketorolac) Pain/anti-inflammatory dosing: IV: -3mg IV q6hrs prn; max of 6mg/24hrs PO: mg po q6h prn; max of 4mg/24 hrs Max of days of therapy for IV and PO Caution in patients with renal failure Implementation Barriers and Challenges Stakeholders Input other facilities Technical fixes Adaptive Changes Culture Education-Nursing AND Providers Order Set Build Implementation Reinforcement LEARNING TO FAIL Continuum of Care Education The How does this affect me? CSC pre-op medications, orders OR intra-op dose-iv, pain meds PACU IV Dilaudid Bone & Joint, culture PT/OT need of pain meds vs. anticipation 3
Non-Rx Pain Management Data Collection Ice Position Elevation Mobility dangle get in chair Exercise walk in hall Aromatherapy Healing touch Shoulder massage Animal therapy Volunteer visitor Diversion ipad, TV, reading, music, cards Others??? Adverse events Opioid totals Patient satisfaction Process analysis Chart review # of Mo orphine Doses Bone & Joint: Elective Knee, Opiod & Pain Management 3 3 2 2 Pre Implementation Post Implementation Avg. # Morphine Doses 332.44 89.92 *42.6% decrease in opioid use for patients with elective knee after implementation of protocol % Patient Reported Pain Hours to First Dose Perc cent 8% 6% 4% 2% Tolerable Not Tolerable ours Ho 4 3 2 4.2 2.8 3.7 % 2 3 4 Post Op Day IV w/ Tiered Tiered w/o IV.2 First 24 hours: IV Opioid Usage 3 First 24 hours: Oral Opioid Usage Dosag ge (mg).8.6.4.2.7 IV w/ Tiered..6 Tiered w/o IV Dosa age (mg) 2 2 IV w/ Tiered 24 7 Tiered w/o IV 4
Feedback Larger Impact Providers Patients Staff Face to face Survey Monkey Focus Groups Hospital wide efforts Acute Pain Management Order Set Surgical and Medical Start with smaller population to trial Back surgery Pediatrics-waiting Summary Key Points: Review current pain management practice Consider structured approach; opiate naïve or tolerant Be flexible to change Feedback, feedback, feedback Educate patient and families Reinforce behavior Address pain management culture References Food and Drug Administration (24). Definition of opioid naïve and opioid tolerant. Retrieved November 2, 24 from http://www.fda.gov/ Governale, L. (2, July 22). Outpatient Prescription Opioid Utilization in the U.S., Years 2-29. Retrieved from http://www.fda.gov. Kang, H., Ha, Y., Kim, J., Woo, Y., Lee, J., & Jang, E. (23). Effectiveness of multimodal pain management after bipolar hemiarthroplasty for hip fracture: a randomized, controlled study. Journal Of Bone And Joint Surgery. American Volume, 9(4), 29-296. Lachiewicz, P. (23). The role of intravenous acetaminophen in multimodal pain protocols for perioperative p orthopedic patients. Orthopedics, 36(2), -9. doi:.3928/477447-2322-2. Munir, M. A., Enany, N., & Zhang, J. (27). Nonopioid analgesics. Anesthesiology Clinics, 2(4), 76. Micromedex (22-24), Truven Analytics Parvizi, J., & Bloomfield, M. (23). Multimodal pain management in orthopedics: implications for joint arthroplasty surgery. Orthopedics, 36(2), 7-4. doi:.3928/477447-2322-. (Practice Guidelines, 22). Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology, 6(2), 248 73. [242 references] Retrieved from https://www.guideline.gov Tsang, K., Page, J., & Mackenney, P. (23). Can intravenous paracetamol reduce opioid use in preoperative hip fracture patients?. Orthopedics, 36(2), 2-24. doi:.3928/477447-2322-3.