Slide 1 Acute Peri-Operative Pain Management Strategies Phillip Gallegos, MD USAP Pinnacle Anesthesiologist Director of Anesthesia and Peri-Operative Medicine BOSHA Slide 2 ERAS Enhanced Recovery After Surgery Prior to Surgery Pre-operative visit APN 2 to 6 weeks out Optimization of Obesity, HgbA1c, Albumin, Thyroid Function, & OSA. Cessatio of smoking. Stabilization of Medical Conditions as they relate to anesthesia. Pre-habilitation (Physical therapy prior to surgery to strengthen hips and legs) Plan and manage anticoagulation Joint Camp (education on the process of total joint replacement) SET REALIS EXPECTATIONS EARLY!!!! Slide 3 ERAS Continued DOS and Intraop Pre-op Cocktail - Celebrex, Neurontin, Acetaminophen, Oxycontin, Scopolamine Patch Pre-op Block or Spinal Intra-op pre-incision Ketamine, Ofirmev, Anti-nausea med TXA, Dyloject or Toradol, & Decadron, Narcotics PRN Capsular infiltration with LOCAL ANESTHETIC by Surgeon.
Slide 4 ERAS continued Post-operative Continue Multi-Modal Therapy Early Ambulation Cold Therapy DVT Prophylaxis Bowel Program Slide 5 Slide 6 Multi-modal Analgesia Local Anesthetics: Regional Anesthesia & Infiltration Acetaminophen: Ofirmev IV, Tylenol PO NSAIDS: Celebrex PO, Mobic PO, Toradol IV, Diclofenac IV Gabapentanoids: Gabapentin (Neurontin) & Pregabalin (Lyrica) Ketamine - subanesthetic dose Corticosteroids - primarily Decadron Narcotics - focus on PO administration
Slide 7 Slide 8 Ketamine Ketamine applied around the time of surgery as a single infusion has even been reported to limit the development of chronic pain 30 180 days postoperatively. Slide 9 NSAIDS Block COX1 (Ketorolac) and COX2 (Celecoxib & Diclofenac) COX2 at peripheral level mediates inflammation and prostaglandin release. COX2 at CNS level contributes to phenomenon of centralizatio hallmarked by hyperalgesia, and genetic changes, leads to chronic pain
Slide 10 Acetaminophen The precise mechanism of the analgesic and antipyretic properties of acetaminophen is not established but is though to primarily involve central actions. Max dose 4 Grams in 24 hours Slide 11 Gabapentanoids Gabapentin & Pregabalin block voltage-gated calcium channel activity: Inhibits uptake of calcium by spinal neurons at presynaptic level Blocks neurotransmitter release Activates spinal noradrenergic activity Reduces hypersensitivity after surgery Slide 12 Corticosteroids Corticosteroids inhibit the action of phospholipase and thus prevent the formation of arachidonic acid and subsequently t inflammatory mediators. Will increase serum glucose levels, so must institute aggressive glucose management in peri-operative period for about 3 to 5 days. Known to reduce the incidence of PONV
Slide 13 Narcotics Avoid PCAs at all costs unless managing Chronic Pain patient then consider Short Acting and Long Acting IV - Fentanyl, Demerol, Morphine, Dilauded Oral - Tramadol, Talwin, Codeine, Hydrocodone, Oxycodone, Dilauded Slide 14 Opioid Epidemic 1 in 10 of OUR patients will become opioid abusers and addic 1998-99 VA & JCAHO adopt idea of pain as 5th vital sign 2008 Drug overdoses; primarily from opiates, surpass auto fatalities as leading cause of accidental deaths in USA 2010 to 2013 Fatal Heroin overdoses tripled > 70 million patients per year prescribed opioids for postsurgical pain 91 deaths per day related to opiates Suggested Reading: Dream Land by Sam Quinones Slide 15 Regional Anesthesia Phillip Gallegos, MDUSAP Pinnacle AnesthesiologistDirector of Anesthesia and Peri-Operative Medicine BOSHA
Slide 16 What Keeps Patient in the Hospital? Surgical Pain Immobility Nausea Respiratory Depression DVT/PE Narcotics Slide 17 Lower Extremity Blocks Quadratus Lumborum Block (Lumbosacral plexus): Hip Surgery Fascia Iliaca Block (Anterior approach to lumbar plexus): Hip S Femoral Nerve Block: Femur & Patella Surgery Adductor Canal Block (Saphenous nerve): Knee Surgery & Medial Maleolus ipack Block: Knee Surgery (genicular & tibial division branches posterior capsule of knee) Popliteal Sciatic Nerve Block: Knee, Tibia, Fibula, Ankle, and Surgery Tibial Nerve Peroneal Nerve (foot drop if blocked) Slide 18 Upper Extremity Blocks Brachial Plexus: Roots C5, C6, C7, C8, & T Interscalene Block: Trunks Analgesia for shoulder surgery Supraclavicular Block: Divisions Analgesia for humerus and elbow surgery Infraclavicular Block: Cords Analgesia for elbow, forearm, wrist and hand surgery Axillary Block: Branches - Radial, Median, Ulnar, & Musculocutaneous Analgesia for forearm, wrist and hand surgery
Slide 19 Other Upper Extremity/Truncal Blocks Superficial Cervical Plexus Block Analgesia for clavicle fracture Used in combo with ISB PEC Block Analgesia for pectoralis major & minor repair May be used in combo with SCPB Slide 20 TAP Blocks Transversus Abdominus Plane External Oblique Internal Oblique Transversus Abdominus Anterior Approach for Spine Cases Anesthetizes anterior abdominal wall Better pain control; less guarding effect; improves respiratory effort; decreases atelectasis; improves bowel function.