February 2007

Surgical Site Pain Management

Improving Outcomes

ObjectivesAt the end of the presentation, you will be able to:

Discuss current pain theories. Differentiate various types of pain. List key components of a pain management

program. Review the TJC pain standards. Describe the role of a surgical site pain

management system. Describe outcomes related to surgical site

pain management systems.

What is Pain?

Pain is a complex phenomenon derived from sensory stimuli or neurologic injury and modified by individual memory, expectations, and emotions.

Sternbach RA, ed. The Psychology of Pain. 1978. p 223-39.

Pain: Subjective Component

“whatever the experiencing person says it is and exists whenever he says it does.”

McCaffery, M. Nursing practice theories related to cognition, bodily pain, and man-environment interactions. 1968, Pg 95.

Understanding Pain Pain is different for every person. Pain is part of a historical and cultural

framework. Everyone’s experience and perceptions of

pain will differ.

Neurophysiology Of Pain Stimulation of nerve receptors for pain

(nociceptors) - free nerve endings in almost all tissue types

Mechanical, chemical, thermal sources Once stimulated, impulse travels to

spinal cord and brain Impulse becomes experience of pain

February 2007

Classification Of Pain

Acute

Chronic

Referred

Acute Pain One-dimensional

Underlying cause Acute injury, disease or

surgery. Sudden onset, defined

area, quick response Treatment goal:

Eradication of underlying disease Analgesics used as adjunctive therapy

Chronic Pain Multidimensional Persists at least one month beyond usual course Worsened by physical, psychological, social factors Types:

Chronic condition Osteoarthritis Cancer

Chronic pain from acute source Post-mastectomy chronic pain syndrome (PMCPS) Post-thoracotomy chronic pain syndrome (PTCPS)

Acute injury that results in chronic pain (back injury) No discernable cause

Referred Pain Referred pain occurs when pain

affecting one of the visceral organs is referred to the external body, not necessarily in the same location.

Are We Undertreating Pain? 217 adults in a university teaching hospital

61% pain of 7-10 during past 24 hours 49% pain of 4-10 “right now” 20% pain of 4-10 despite analgesics

Despite efforts to improve pain management, no change in patients pain ratings

Ward SE, Gordon D. Application of the American Pain Society quality assurance standards Pain 1994 Mar;56(3):299-306

Postoperative Pain Experience

80% of patients experienced acute pain after surgery

Most patients had moderate, severe or extreme pain

Ambulatory patients experienced more pain after discharge than when they were in facilities

Apfelbaum JS, et al. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be

undermanaged. Anesth Analg 2003;97:534-40.

When Treatment Fails,Pain is Imprinted

Noxious stimuli can sensitize the nervous system response to subsequent stimuli.

Would “pre-emptive analgesia” make a difference?

Under-Treated Acute Pain Side Effects

Increased risk of thromboembolism Catecholamine secretion

Vasoconstriction, Increased heart rate Increased myocardial oxygen

consumption Decreased oxygen delivery Increased cardiac morbidity Potential increased risk of infection

Potentially Serious

Complications

Tetzlaff JE. Cardiovascular consequences of severe acute pain. Practical pain management Mar/Apr 2004;11-13.

American Pain SocietyGuidelines for Assessment

PAIN – The Fifth Vital Sign

In 1995 the American Pain Society (APS) created this phrase to elevate awareness of pain treatment among health care professionals.

TJC Standards

Addresses the assessment and management of pain Recognize the right of patients to appropriate

assessment and management of pain Screen patients for pain during their initial

assessment and, when critically required, during outgoing periodic re-assessments

Educate patients suffering from pain & their families about pain management

Establish Institutional Nursing Protocol Acknowledge pain is real. Respect patient’s reactions and attitudes. Inform patients about pain and therapies. Administer pain medication appropriately. Explain actions and side effects. Decrease noxious stimuli. Document treatment and patient response.

Assessing Pain VAS = Visual Analogue Scale VRS = Visual Response Scale 0-10 scale 10 = worst pain imaginable 0-100 scale Wong-Baker Faces Scale

Assessment of Pain Location

Where? Does it radiate? Pattern

Does it occur at a special time? Onset

When did it begin?Was it sudden or gradual?

Assessment of Pain

Type Dull, sharp, aching, stabbing, burning

Intensity: How strong? How long does it last? Does it vary?

Causative Factors: What brings on the pain? What makes it worse?

Evolution of Pain Control

OpioidsGeneral Anesthesia

Local Anesthesia

Regional Anesthesia

Epidural/

Spinal anesthesia

Acute Pain - Control Methods Pharmacological

Opioid Non-Opioid Local anesthetics

Non-Pharmacological Change/Adjust Position Diversion Activities Relaxation Techniques Meditation Acupuncture/Acupressure Heat, cold, massage Hypnosis

Opioids

Mainstay of pain management Morphine Dilaudid Fentanyl (IV, Transdermal) Demerol Oral opioids

Percocet, Vicodin, Lortab, Oxycontin

PCA vs intermittent

injection

Opioid Side Effects

Nausea and vomiting Ileus/Constipation Urinary retention Respiratory depression Apnea Sedation Confusion Tolerance Restricted Ambulation

Longer Hospital Stays

&

Increased Costs

Opioids and Surgical Infections

Is there a link? Maybe

Two studies in particularHorn et al Surgical Infections 2002;3(2):109-18. Alverdy et al Surgical Infection Society Annual Meeting, La Jolla, CA 2006

PCA and SSI Chart review of 515 randomly selected

patients who had major rectal or intestinal surgery.

214 had PCA Results: Use of PCA significantly

associated with increased in-hospital surgical site infection (10.7% vs 4.0%)

Possibly due to suppression of natural killer cells causing immune compromise.

Horn SD et al. Association between patient-controlled analgesia pump use and postoperative surgical site infection in intestinal surgery patients. Surgical Infections 2002;3(2):109-18.

Non-Opioid Analgesics

NSAIDs Aspirin, ibuprofen, naproxen, acetominophen Toradol® ketorolac (injection)

Side Effects: Gastrointestinal distress, clotting disorders, dependence, kidney failure (ibuprofen) liver failure (acetominophen)

COX-2 Inhibitors Vioxx® - rofecoxib Bextra® - valdecoxib Celebrex® - celecoxib

Less gastrointestinal and bleeding issues

Not Available

The abolition of painful impulses from any region or regions of the body by temporarily interrupting the sensory nerve conductivity with local anesthetics.

Motor function may or may not be involved.

The patient does not lose consciousness.

Regional-Local Anesthesia

Types of Regional Anesthesia Peripheral nerve block

Types of Procedures Ortho: Upper, Lower & Spine (including trauma Rib & Hip

Fractures) General: Mastectomy & Abdominal Procedures CV/CT & Cath Lab: VATs, Thoracotomies, TAVR OB/GYN: C-Sections

Single injection or continuous infusion of local anesthetic near nerve

Performed by anesthesiologist

Surgical site Can be used for multiple types of surgery Catheter placed by surgeon Can be incisional or near incision

Surgical Site Pain Management

A continuous, regulated flow of local anesthetic through a fenestrated antimicrobial Soaker® catheter directly into or near an intra-operative site

Soaker® catheters provide wider, more even distribution of local to incisional area

Portable, easy-to-use, disposable for outpatient or inpatient

Therapy continues up to five days

Surgical Site Pain Management Procedure Landscape

Spine ALIF, PILF, TLIF Iliac Crest

General Colectomy/Ventral

Hernia Hemorrhoidectomy

CV/CT Thoracotomy Open Heart/AAA Vascular Amputation

Bariatric Open/Laparoscopic

Plastic Surgery Breast Surgery Abdominoplasty

Urology Prostatectomy Nephrectomy/Kidney

transplants OB/GYN

Hysterectomy/Oncology C-Section

Local Anesthetics

Bupivacaine (Marcaine®, Sensorcaine®) 0.25% or 0.5%

Lidocaine (Xylocaine®) 0.5% or 1%

Ropivacaine (Naropin™) 0.2%, 0.1% or 0.5%

Levobupivacaine (Chirocaine®) 0.25% or 0.5%

Avoid local with epinephrine!!!

Filling the Pump USP 797 Pharmaceutical

Compounding – Sterile Preparations Prior January 2008: Pumps

were filled anywhere & everywhere, most common was the Back Table in the OR

HIGH RISK Post January 2008:Filled in

Pharmacy under a hood by a trained Personnel OR by a Third Party Vendor and shipped to the Hospital’s Pharmacy

LOW RISK

Surgical Site Pumps

Benefits of a Soaker™ Catheter for Surgical Site

Infuses local anesthetic over a broader area compared to point-source catheters

Greater versatility in catheter placement

More even distribution of medication

5”

2.5”

Standard

24 holes

11 holes

3 holes

Soaker Catheter

New Techniques: Tunneling Benefits:

Catheter(s)are placed deeper and closer to key nerves May eliminate the need to close a separate layer –

peritoneum Minimizes risk of nerve damage and bleeding Blunt tunneling minimizes needle stick risk to the

surgeon Less leakage Better pain results because of proximity to

innervations Catheter are placed further away from the incision

(fear of fluid build up or infection) Catheters can now be placed pre-incision

Tunneler

Tunneling Through Rectus Sheath The catheter is

placed in the pre-peritoneal space using a tunneler.

This places the catheter near larger nerves and away from the incision.

Demonstrated Clinical Evidence Many published and presented studies Typical Results

1 to 3 day length of stay reduction 40-70% reduction in narcotics 8-30% reduction in treatment costs 90%+ patient satisfaction Infection rates less than national averages Substantial reductions in pain scores

Clinical Research Results

CV/CT Surgeries: Decrease in PCA requirements by 63% Length of stay reduced PACU time reduced 12% Significant decrease in pain No infections Serum levels <30% of toxicity Decrease in costs by 8% Increase in lung volume – spirometry

White PF, et al. Anesthesiology 2003; 99(4): 918-23Dowling R, et al. J Thoracic CV Surgery 2003; 126(5): 1271-8.

Paravertebral Approach

Can be approached

either Anterior or Posterior

Extrapleural Placement

MastectomyNarcotic Use

0

10

20

30

40

50

60

70

80

No Post op Narcotics No Narcotics > Day 1

% o

f P

atie

nts

Placebo ON Q

Morrison JE, Jacobs VR. Zentralblatt fur Gynakologie 2003;125:17-22.

Mastectomy

Lumbar Laminectomy & Fusion Paraspinal Muscle of the

back Multifidus Longissimu Interspinous Intertransverse

Lumbar Results

Meta-analysis Surgery Types

Surgery Number of Trials

Number of Patients

Cardiothoracic 14 565

General 11 602

Gynecology-urology 7 412

Orthopedics 12 562

Meta-analysis of Wound Catheters

Meta-analysis of 44 randomized controlled trials (RCTs)

Published in peer-reviewed journal. 2141 patients Studies used a variety of infusion devices

and methods. Studies covered multiple types of

surgeries. Studies published during 1983 - 2006

Liu SS, Richman JM, Thirlby RC, Wu CL. J Am Coll Surg 2006; 203(6): 914-32.

Clinical Research Results Orthopedic Surgery

Total Joint Replacement Decreased length of stay Decreased nausea and vomiting Earlier return to physical therapy More abmulatory

Rotator Cuff-ACL Repair Earlier return to physical therapy Decreased narcotic use

Gottschalk A et al. Anesth Analg 2003;97:1086-91.

Ford PJ, Slavagno RT, Pianta T, Dine A. Presented at NAON 2004

Total Joint Replacement

0

0.5

1

1.5

2

2.5

1997 1998 1999 2000 2001 2002 2003

Yearp<0.05 Years 2001-2003 compared to previous

Mea

n d

ays

Ford PJ, Slavagno RT, Pianta T, Dine A. Presented at NAON 2004.

Postop Nausea and Vomiting

Began using therapy

Meta-analysis Results Pain scores at rest: lower in all groups

combined (p< 0.001) 10mm reduction

Pain scores with activity: lower in all groups combined (p < 0.001) 22 mm reduction

Opioid rescue medication: Fewer patients required in all groups (p< 0.001) 41% vs. 66%

Total opioid required: less in all groups combined (p< 0.001) reduction of 11 mg/day

Results continued

Postoperative nausea and vomiting (PONV): less in all groups combined (p< 0.001) 24% vs. 40%

Patient satisfaction better in all groups combined (p< 0.007) 43% vs. 13% had excellent satisfaction

No local anesthetic toxicity Infection rates 0.7% in active group and

1.2% in control group

Potential Cost Savings

Narcotic reduction savings 50% on average reduction in narcotics Pharmacy charges to fill PCA orders

Narcotic complication treatments Anti-emetic medications reduction Elimination of foley catheter

Decrease UTI Reduction in Benadryl

Minimized ICU and PACU times $800 per hour

Potential Cost Savings Minimize or eliminate electronic pump usage

$20-50/day with supplies and labor to maintain Minimize nurse labor to teach, monitor and

maintain narcotic delivery Viscusi Study

$1240 cost for 3 days of PCA Cost Drivers are time spent – not drugs or

devices

Viscusi E, et al. A multidimensional model for evaluating the key cost drivers associated with perioperative pain.

Postop Nursing Care Assess surgical site pain.

Distinguish from other sources of pain. Provide adjunct analgesia prn.- THIS IS A MULTIMODAL THERAPY

Check that clamps are open and tubing not kinked. Verify label(s) Verify flow rate are set properly OR secure flow

restrictor (if present) to skin. Check pump for remaining drug. Check site for redness, drainage, intact dressing. Observe for signs of local anesthetic toxicity. When removed, check for intact tip.

REMEMBER…Safety is Key! Assessment

Fall Risk Pts who have lower extremity surgery are High Fall

Risk (with or without a RA) Do pts have the proper precautions (knee

stabilizers)?

Does It Make A Difference?? Reduced time in PACU Reduced time to discharge readiness Reduced PONV Reduced concerns for opioid induced

respiratory depression Better pain management w/ fewer side

effects Improved pain scores Great satisfaction

HCAHPS

HCAHPS

HCAHPS

Why Regional Anesthesia???

Patient Decreased narcotic

usage = less side effects

Earlier ambulation Shortened recovery

time Less incidence of

breakthrough pain Decreased length of

stay Better patient outcomes Higher patient

satisfaction

Hospital Decreased PONV Increase through put Controlled pain =

happier pts = better experience

Higher HCAHP Scores Lower readmissions

rates

Summary

New modalities exist that improve traditional pain management by providing site-specific, non-narcotic relief of pain.

Undertreatment of acute pain persists despite decades of efforts to improve clinician knowledge.

Thanks for your attention!

Questions?