9 multimodalperioperativepaindrhamedumedaly1 res gak ppt
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Multimodal Perioperative Pain Management and Multimodal Strategies to Enhance Post Operative Outcomes
Hamed Umedaly MD FRCPCAnesthesiologist Medical Director POPSVancouver AcuteUniversity of British Columbia
Why ? What's wrong with the status quo ?
Improved Anesthesia & Pain management can be achieved !Improved potential for Recovery ?Unidimensional approaches limit outcomeImprovements not realizing optimal patient outcome ?
4 A’s of Changing Physician 4 A’s of Changing Physician Behavior ( Pathman model)Behavior ( Pathman model)AwareAgree
AdoptAdhere
For every complex problem there is an answer that is simple, neat and wrong
H.L Menken 1880-1956
Concept of Perioperative Pain Management and Acute Rehabilitation
Pre- Op Education Preparation & PlanningPre & Intraop Pain Management & Physiological StabilizationPost-op pain management and Acute Rehabilitation
Kehlet 1995-2005
Preemptive Pain Management: Neurobiology
Noxious stimuli initiate cascade of events peripherally and centrally to produce PAINSensitization (Dynamic) Nociceptive stimuli amplified ( Primary and Secondary Hyperalgesia)Non painful stimuli produce PAIN (Allodynia)
Preemptive Pain Management:Prevent Sensitization ( duration and Intensity)
Reduce the Nociceptive input (Minimally invasive surgery,LA, NSAIDS, Opioids)Attenuate Transmission ( Blocks, Spinal, Epidural)Modulate mechanisms that underlie sensitization ( NMDA blockade, Opioids)
Multimodal Pain Management
Pain Neurobiology is a complex of Dynamic Interrelated systemsUnimodal Analgesia cannot be sufficient to provide optimal pain managementAdditive & Synergistic effects of Multiple modes should improve outcome
4 principles of Multimodal Pain Management
Multiple Mechanisms/ Sites of actionAvoid Opioid Dominance Opioid Sparing vs side effectsMultimodal / Lower Doses / Reduce adverse effectsTreat and Prevent Toxicity / Side effectsi.e PONV /Delirium/Pruritis
VA Quality Improvement Study N=300
~ 40 % of joint arthroplasty have PONV if untreated Joint Arthroplasty patients are at high risk of PONV
~ 10 % of have PONV if Risk Reduction Strategy and Prophylaxis ( combination therapy)
Consensus Guidelines for Managing PONV
Evaluate Risk ( Patient, Anesthetic Surgical)Strategies to reduce baseline risk (Modify Anesthetic Technique)Antiemetic prophylaxis Moderate Risk: Monotherapy 5 HT3 Receptor antagonistHigh risk: Combination therapy
Gan A&A 2003
art64_fig11.gif
Acetaminophen
Synergy with Opioids / Opioid sparingSynergy with NSAID’sInexpensive
Routes PO / PRUse 3-4 g/24 hr short term<2 wks
Model for Post surgical Chronic Pain
Acute pain ( Nociceptive and Affective Components)
Preop Psychological factors
Acute injury (Surgery)
Physiological Factors
Chronic Pain
Physiological Maintaining Factors
Psycho/social Maintaining Factors
Multimodal pain management and Outcomes
Multiple PRCT’s in 10 yrsImproved Pain Scores and Patient SatisfactionDecreased use of PCA and Parenteral AnalgesiaBUT no change in LOS/Outcome
Beyond Multimodal Pain Management: A Multimodal Strategy to Enhance Postoperative Recovery
Multimodal Rehabilitation modelIntegrated (Patient, Nurse,PT/OT.Pharmacist, Surgeon, Anesthesiologist)Use the Improved pain management to accelerate recovery discharge & Really Improve outcome
Multimodal Recovery
Wellness modelPerioperative model ( seamless)Architecture from Bed oriented wards to Activity Oriented Units“Postoperative Rehabilitation Unit”Now lets look at Outcome
Opioid Tolerance: Reality Check
Increasing incidence of Opioid Tolerant Patients presenting for Surgery
CPS & APS approve the use of Opioids for Chronic Non malignant Paini.e Osteoarthritis
Opioid Tolerance (Chronic Pain)
Morphine equivalence > 30 mg/ day for > I month
Central sensitization ; afferent nociceptive facilitatationPrimary and secondary hyperalgesia Allodynia
Opioid mu receptor down regulation
Opioid Tolerance : Features
Tolerance to: pain management, respiratory depression Sedation
Non Nociceptive Suffering ( anxiety)Renders Perioperative Pain Management Challenging
Opioid Tolerance in the Perioperative Period
Its too late postop ( in the PACU )Start preop ( identify , plan , preop Opioid , Acetaminophen, NSAID, +/- Clonidine Continue Intraop ( Opioid , Local, Regional , Ketamine)Extend strategy Postop (Opioid , Regional , +/- Ketamine, NSAIDs, Acetaminophen
Opioid Tolerance: Multimodal Strategies
Use Neuraxial Blockade/ Regional Anesthesia/Analgesia with LANSAID’sAcetaminophen at max dose ( 1.5-2 g load and 4 g/day)Low dose Ketamine intra +/- postopTreat Non Nociceptive Suffering
Opioid Tolerance
IdentifyDiscuss Complexity and Potential Toxicity with Patients Resume PO Opioid asap at higher dose and provide breakthrough
Strategy and Goals
IntegratedPre, Intra & post operative CareSeamlessMultimodal pain management Treat Pain with activityAvoidance of routine PCA OpioidImprove pain management and outcomes
Perioperative vs Postoperative
Preop: Recognition, Assessment, Discussion, Plan, Pre emptive
Intraop: Modification of Surgical approach Anesthesia and Pain Management Strategy
Post Op: Multimodal Pain Management and Intervention
VA Approach: Preop
Consultation and preparationIdentify Risk of Difficult to manage painHigh dose Acetaminophen+/- NSAID Low dose long acting Opioid (Oxycodone CR 10 mg)
VA Approach:”Intraop”
Intrathecal LA(Spinal) and low dose Opioid( PF Morphine 100 ug)+/- GA or Epidural for Revisions or Opioid TolerancePreincision LALA in capsule and closurePONV prophylaxisFast track PACU
VA Approach:”Post op”
Full reg dose Acetaminophen+/- NSAID Reg low dose long acting Opioid (Oxycodone CR) plus breaktrough prn opioid ( Oxycodone IR)PCA only for unsatisfactory pain control“Fast track” early mobilization
Rehabilitation / Recovery
Achieve best pain control with minimal side effectsUse that pain control to achieve early :RecoveryMobilizationFunction
Ambulatory or Short stay Hip Replacement
Minimally Invasive approach85 % with same day DC N= 100
Duwelius JBJS 2000
Short Stay Total Knee Arthroplasty
Spinal AnesthesiaMultimodal pain managementFemoral Nerve LA Catheter Infusion
Anesthesia and Analgesia Jan 2006
MIS Surgery:Purported Benefits
Surgical InvasivenessBetter Pain ManagementImproved Rehabilitation Protocols
?Higher Complication rate with MIS
Woolson JBJS 2004, Ogonda JBJS 2005Wright J.Artroplasty 2004
Periop Pain Management
Talk about it “Can and should focus on pain”
Work on Periop Strategies and utilize them to enhance satisfaction /outcome
Manage PONV
The Future
Perioperative infusion of ContinuosRegional Anesthesia(PICRA)PCOAAntineuropathic agents ( gabapentin/pre gabalin)Microsphere impregnated Local anesthetic agents
A Multimodal Strategy to Enhance Postoperative Recovery: Conclusions
Integrated Perioperative approachEnhanced Perioperative Pain managementPerioperative stress response and Organ Dysfunction reduction ( eg blood loss, PONV )Utilize to achieve Fast Track Recovery and Enhance Outcome
Divinum est sedare dolorum
Blessed are those who treat pain.-Galen
COX 2 Inhibiters : Background
Inducible vs Constitutive enzymesNo apparent GI or Renal SparingPlatelet Aggregation Sparing ( Thromboxane inhibition)
Cyclooxygenase Isoforms
Cox-1 Cox-2Constitutive, and found in most tissues -“housekeeping”. Inducible 2- to 4-fold by inflammatory stimuli
Only isoform present in platelets TxA2
Main isoform in gastric mucosa CytoprotectivePG’s
Predominately inducible enzyme in many tissues -10- to 20-fold by inflamstimuli or cancer
Stimulates PGI2 production in endothelium
Constitutive in CNS, fem. reproductive tract, and kidney
COX 2 Inhibiters : When ?
Pain Management Challenging and Intraop Bleeding an Issue Pain Management responsive to NSAIDS (Bone, Gyne etc and potential for intraop /post op bleeding)Concurrent Anticoagulation or LMW HeparinEpidural insitu and pain outside covered dermatomes
Cardiovascular and Platelet Effects
Platelets:- ASA: irreversibly acetylates Cox-1,
selectively inhibits TxA2 formation
- Nonselective NSAIDs: Inhibit TxA2 and PGI2 to a similar degree. Effect is reversible
during the dosing interval
- COXIBS: Inhibit (reversibly) Prostacyclinformation which mediates platelet inhibition
CLASS and VIGOR studiesCLASS:
- Celebrex Long-term Arthritis Safety StudyVIGOR:
- VIoxx Gastrointestinal Outcomes Research
Very large (n = >4,000 and >8,000), multicenter, double-blind, randomized trials (no placebo arm) examining efficacy and safety of Celecoxib and Rofecoxib
CLASS- 28% with RA, 72% OA
- compared coxib Vs ibuprofen & diclofenac
- ASA allowed for Cardiac prophylaxis (21%)
- no difference in ulcer frequency,but fewer symptomatic ulcers
- no sig difference in MI frequency
VIGOR- 100% with RA
- compared coxib (2x max dose) Vs naproxen
- ASA not allowed
- sig lower rates of upper GI events and GI bleeding with vioxx
- sig higher rates of thrombotic events and MI with Rofecoxib, altho’ CV mortality rates similar
Why do Cox-2s Increase SAEs??
Not completely explained by the trials
Increase of thrombotic CV events more than cancels reduction in complicated ulcer risk
COX 2 Inhibiters : Cost
COX 2 $ 1.25/dayRofecoxib and Valdecoxib once daily dosing
Nonselective po nonselective COXIB $30-60 cents (eg Diclofenac)IV nonselective COXIB (~$ 8.00 day)
(eg Ketorolac)
COX 2 Inhibiters : Add to formulary ?
Minimal cost
Selective Use When IndicatedAvoid use when known or risk factors for CAD
Platelet sparing really only benefit
The FutureIV Acetaminophen = “Propacetamol
will be available in Canada “soon”
IV Parecoxibimmediately converted to Valdecoxib
Nitric Oxide-donating NSAIDsNO functions as an endogenous mediator of gastric mucosal health and defence
Multimodal Perioperative Pain Management and Multimodal Strategies to Enhance Post Operative Outcomes
Hamed Umedaly MD FRCPCAnesthesiologist Medical Director POPSVancouver Acute