the role of multi-modal analgesia and the burden of opioids...
TRANSCRIPT
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S
The Role of Multi-Modal Analgesia and the Burden of Opioids
Jacob Hutchins MDDirector of Regional Anesthesia, Acute Pain, and Ambulatory Anesthesia
Department of AnesthesiologyUniversity of Minnesota
Disclosures/Off-Label
S Speaker’s bureau, consultant, and research funds from Pacira Pharmaceuticals
S Speaker’s bureau for Halyard Health
S Consultant for Atricure
S Consultant for Worrell
S I will talk about off-label medication use but it will be of my own experience
Is Improved Pain Control Needed?
SYes!
Current State of Pain Control
S Pain control remains the number one concern for patients leading up to surgery
S Opioids remain the mainstay of post surgical pain regimens
S Non opioids are often prescribed prn and thus depends on the nurse to give to patient
S Pain as fifth vital sign has led to emphasis on undermedication and less focus on overmedication
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Why is Pain Control Important?
S Uncontrolled postoperative pain can lead toS Longer Hospital stay and increased PACU/Phase 1 timeS Readmissions for painS Decreased satisfaction and quality of lifeS Progression to chronic painS Major stress response from body
S Increased sympathetic toneS Increased Heart rate and blood pressureS HypercoagulabilityS Decreased Immune functionS Urinary retentionS Endocrine changes: increased ACTH, cortisol, epinephrine, aldosterone, ADH, Ang
IIS Decreased GI motility
Risk Factors for Acute Postoperative Pain
S Females
S Young age
S Increased BMI
S Preop use of opioids
S General anesthesia
S History of Chronic pain
Why Minimize Opioids?
S 70 million patients receive opioids in hospital or clinic following surgery each year1
S Opioids have multiple adverse eventsS Nausea/vomiting, pruritis, constipation, urinary retentionS May play role in cancer recurrence
S JCAHO sentinel event respiratory depression and even death for increased risk patientsS Elderly, OSA, chronic pain, and obese
1. Adamson, et al. Hosp Pharm. 2011;46(6 Suppl 1):1-3.
Oversedation is a problem
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Why Minimize Opioids?
S Postoperative opioid use contributes to misuse of opioidsS 1 in 15 patients with acute opioid use go on to long term use1,2
S Due in part to rapid proliferation of new users from acute care setting. S 46 Americans die each day from opioid overdoseS 5.1 million Americans used opioids illicitly last monthS The number of opioid/heroin related deaths in Minnesota each year
is similar to number killed in MVA
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.
Why Minimize Opioids?
S 18% of opioid naïve patients were still on opioids 1 year after elective spine surgery
S 6% of patients after orthopedic procedures were still on opioids 150 days after surgery
United States’ Opioid Problem Our Elderly and Children are at Risk
S In patients ˃65 undergoing low-risk surgery who received an opioid Rx within a week of surgery 1:
S were still taking opioids a year later
S There was a in the likelihood they would become long-term opioid users
S Compared to non-athletes, adolescents males who participate in organized sports have2:
1.Alam A, et al. Arch Intern Med. 2012;172:425-30. 2. P. Veliz et al. Journal of Adolescent Health 54 (2014) 333e340
10.3%44% ↑
2x 4x 10xthe odds of misusing opioids to get high
the odds of medical misuse of opioids due to taking too much
the risk for being prescribed an opioid medication
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Overprescription Leads to a High Potential for Diversion
S In patients undergoing outpatient upper extremity surgery1
1. Rogers J, et al. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am. 2012;37:645-50.
55%Obtained for
free from friend or relative
Prescribed by one Doctor 17.3%
Bought from friend or relative 11.4%
Took from friend or relative w/o asking 4.8%
Got from drug dealer or stranger 4.4%
Other source7.1%
Resulting in Access to Excess Pills From Multiple Sources1
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
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Minnesota’s Opioid Epidemic Multiple Organizations Have Urged a Shift Toward Non-Opioid Options
S JCAHO recommends “An individualized, multimodal treatment plan should be used to manage pain—upon assessment, the best approach may be to start with a non-narcotic”
S 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
S ASA 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 Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999—2008. Nov 2011;60(43);1487-1492. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm
Multimodal Analgesia
S Utilization of more than 2 analgesics which act at different sites in CNS and PNS
S Goal to Minimize pain as well as minimize opioids
S Should be started prior to surgery and continued in acute postoperative period
S Requires coordination between Preoperative, Intraoperative, and Postoperative periods
S Surgeon, Anesthesiologist, Providers, and Nurses all on same page
Options for Multimodal Analgesia
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Sample Multimodal Approach
S SETTING EXPECTATIONS
S Preoperative MedicationS Gabapentin or Pregabalin: started evening before surgeryS Acetaminophen: IV or oral started evening before surgeryS NSAIDs if allowed by surgeonS Regional AnesthesiaS Attempt to minimize opioids preop even with block sedation
Sample Multimodal Approach
S IntraoperativelyS Regional anesthesia if not done in preop phaseS Surgeon Infiltration in select procedures: liposomal bupivacaine or
catheter technique preferredS Minimal Opioids and only short acting (rare need for opioids on
induction and premedication with 2mg versed)S Continue acetaminophen intraop (redose 4 hours after last dose)S Ketorolac at closure if appropriateS Lidocaine, ketamine, or dexmedetomidine infursions where
appropriate
Sample Multimodal Approach
S PostoperativelyS Scheduled Acetaminophen every 6-8 hours for up to
one week post operatively: Oral as soon as ableS Intermittent opioids: Oral as soon as ableS NSAIDS as soon as possible and then scheduled for
up to one week post operativelyS Gabapentin (300mg) or Pregabalin (75mg) continued
for one week S Lidocaine infusions, ketamine intermittent or
infusion, and dexmedetomidine infusion where appropriate.
Additional Multimodal
S Muscle relaxants or Diazepam for muscle spasms
S Topical medications or lidocaine patches for pain
S Non pharmacologic interventionsS Ice to areaS Healing touchS MassageS Pet TherapyS AcupunctureS Relaxation techniques
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Regional Anesthesia
S Interscalene: Shoulder procedures
S Supraclavicular: Arm and Hand procedures
S Adductor canal/Femoral: Thigh and Knee procedures
S Popliteal/Distal Sciatic: Foot and ankle
S Lumbar Plexus/Fascia Iliaca: Hip
S Transversus abdominis plane blocks for abdominal procedures
S Pec blocks for breast and chest procedures
S Paravertebrals for thoracic and abdominal procedures
Why Regional Anesthesia?
S Provides Pre-emptive Analgesia
S Decreases likelihood of development of Chronic Pain
S More precise placement of local anestheticS Able to use less local anesthetic in most cases
S Low failure rate
S Quick and low risk to place
S Can be either single injection or catheter infusion
Single Shot
S Can be Long Acting Local AnestheticsS Bupivacaine or RopivacaineS Last 6-12 hours postoperatively
S Or Short ActingS Mepivacaine or LidocaineS Last duration of procedure 1-4 hours
S Additives can extend duration of actionS EpinephrineS ClonidineS DexamethasoneS Dexmedetomidine
Catheters
S Can remain in place for 1-7 days after placement
S Usually run low dose bupivacaine or ropivacaine
S Can titrate to effect
S Allows intermittent bolus
S Risk of dislodgement and infection as are indwelling
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Local Anesthetics
S Are an essential part of a multimodal pain control regimen
S Can be used to provide pain control that targets the site of surgery via infiltration of skin and subcutaneous tissue (liposomal bupivacaine)
S Also used for regional anesthesia to target specific peripheral or central nerves (single shot or catheter technique)
S Finally can be given intravenously to provide effective postoperative pain control (IV lidocaine)
Liposomal Bupivacaine
S On-label use for infiltration (surgeon infiltration, TAP, Pec)
S Off-label use for peripheral nerve blocks
S Provides 40-72 hours of analgesia via single shot
S Multivesicular liposome formulation of 1.3% bupivacaine
S Provides Day 1 dense block, day 2 50-75% block and day 3 25-50% blockadeS Minimal motor blockade after day 1S Unable to bolus or titrate dosage
TAP Blocks
S Transversus Abdominis Plane Block
S Provides analgesia to skin muscle fascia and parietal peritoneal layers but not viscera
S Ultrasound Guided and can be done prior to surgery intraoperatively or in PACU
S Catheters can be kept in for up to 7 days, Liposomal Bupivacaine provides 40-72 hours pain relief
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Hutchins et al. Ultrasound Guided Subcostal Transversus Abdominis Plane (TAP) Infiltration with Liposomal Bupivacaine for Patients Undergoing Robotic Assisted Hysterectomy: A Prospective Randomized Controlled Study.
Data presented at IARS Honolulu, Hawaii 2015
S Liposomal bupivacaine TAP vs. bupivacaine TAP
S LB TAP had decreased total opioids, decreased nausea/vomiting, and decreased maximal pain at all time points studied.
S 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.
S No adverse events noted in either group
Paravertebral Blocks
S Unilateral blockade of spinal nerves outside vertebral canal
S Single Shot with Bupivacaine or Liposomal Bupivacaine (off label use) or Catheter
S Injection level depends on surgical site
S Lasts 12-24 (bupivacaine) or 40-72 hours (liposomal bupivacaine) or 72 hours or longer (catheter)
Paravertebral Blocks Pec Blocks
S Pecs 1 targets lateral and medial pectoral nerves
S Pecs 2 targets lateral and medial pectoral nerves, intercostobrachial, intercostals III, IV, V, and VI, and long thoracic nerve
S Used for breast procedures, subclavian TAVR, chest wall, and even thoracic procedures.
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Pec Blocks
PM
Pm
PM
SA Pm
Interscalene
S Used for Shoulder and distal clavicle procedures
S Blocks brachial plexus at level of roots/trunks
S Frequent sparing of C8-T1
S 100% will have some phrenic nerve involvementS Perform suprascapular to avoid phrenic
S May cause intermittent Horner’s syndrome
S Single shot (15-25 mL) 6-12 hours
Interscalene Literature Support
S Park et al: Interscalene single shot (ISB) decreased pain scores compared to intraarticular injection
S Lehman et al: ISB superior to GA and GA + ISB in terms of recovery and pain medications used
S Ullah et al: ISB had improved pain control compared to no block and ultrasound ISB had less complications compared to nerve stimulator ISB
S Hughes et al: ISB decreased supplemental analgesics and decreased pain
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Supraclavicular
S Useful for surgery below shoulder level
S Blocks brachial plexus at level of divisions
S Misses suprascapular nerve (60-70% of shoulder)
S Risk of Pneumothorax and phrenic nerve involvement
S Single shot (15-25 mL) 6-12 hours
S Catheter not ideal (infraclavicular better position)
Supraclavicular
Brachial Plexus
First Rib
Pleura
A
Literature Support
S Gamo et al: Supraclavicular block permitted operating conditions without general in 99.5% of cases and 96.7% were satisfied with analgesia
S Ahsan et al: 26% failure on day 1 after hand surgery for supraclavicular catheter
S Renes et al: U/S guided supraclavicular decreased diaphragm paralysis compared to nerve stim
S Lam et al: improved satisfaction with distal blocks compared to supraclavicular
Other Brachial Plexus Blocks
S Infraclavicular: good for catheter placement for arm procedures
S Axillary: superficial and may be easier in super obese population as it poses no lung risk.
S Suprascapular and Axilary for shoulder procedures as described by Checucci et al with no phrenic involvement
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Adductor Canal
S Useful for TKA, ACL, other knee procedures, and for foot/ankle
S Distal block of Femoral nerveS Saphenous nerve, nerve to vastus medialis, obturator branches
S Block occurs mid thigh
S Decreased quad weakness compared to femoral
S Single Shot (15-20 mL)
Adductor Canal
VastusMedialis
Nerve
Sartorius
A
V
Literature Support
S Jaeger et al: Adductor 8% weakness, Femoral 49% weakness
S Jenstrup et al: Adductor decreased pain and improved PT compared to placebo
S Hanson et al: Adductor catheters provided pain relief up to 48 hours and improved quad strength
S Shah and Jain: Adductor provided improved early ambulation with no difference in pain compared to femoral
S Perlas et al: Adductor plus local infiltration had best early ambulation and highest incidence of home discharge.
Femoral Nerve Block
S Useful for knee surgery, thigh surgery, femoral neck fractures
S Increased weakness of quad compared to adductor canal
S Single shot (15-25 mL)
S Liposomal bupivacaine (off label) Phase 3 data showed improved pain control and no difference in weakness compared to placebo
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Femoral Nerve
Femoral Nerve
A
Fascia Lata
Fascia Iliaca
V
Literature Support
S Minkowitz et al: showed femoral with liposomal bupivacaine superior than placebo up to 72 hours after injection with no increased motor
S Luo et al: Femoral nerve block associated with persistent strength deficits at 6 months after ACL repair in pediatric and adolescents
S Chisholm et al: Saphenous equal to Femoral nerve block with regards to analgesia after ACL
S 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 Sciatic
S Block of sciatic nerve just prior or just after split into fibular and tibial divisions
S Useful for calf, tibia, ankle, foot, and toe surgery
S Saphenous is only nerve of foot/ankle not covered by this block
S Blockade of sciatic nerve will cause foot drop (fibular)S Selective Tibial or IPACK blocks will provide back of knee pain relief
without foot drop
S Single shot (20-40 mL)
S Onset of action is slowest of all major nerve blocks
Popliteal/Distal Sciatic
A
Tibial Nerve Fibular Nerve
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Literature Support
S Saporito 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
S Gallardo et al: continuous popliteal block for total ankle arthroplasty decreased pain, decreased opiates, and increased satisfaction
Lumbar Plexus
S Covers T12 to L4
S Useful for hip, femoral neck, and knee surgery
S Deep block and increased patient discomfort compared to other blocks
S Block with increased risk of morbidity and mortality
Lumbar Plexus Literature Support
S Karlsen et al: No best intervention for total hip arthroplasty
S Amiri et al: Lumbar plexus and MAC anesthesia were sufficient for femoral neck fracture surgery
S Lee et al: Continuous lumbar plexus decreased total opioids after total knee replacement
S Nye et al: Continuous lumbar plexus block for hip arthroscopy had risk of significant complications (3.8%)
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Fascia Iliaca
S Proximal blockade of lumbar plexus
S High Volume Block
S Useful for femoral neck fractures and total hip replacement (?)
S Allows for ease of spinal placement in femoral neck fractures
Fascia Iliaca
Iliacus Fascia
Ilium
Literature Support
S Foss et all showed FICB decreased Pain scores and opioid use after femoral neck fractures
S Shariat et al no difference between fascia iliaca vs sham for total hip arthroplasty
S Hanna et al: FICB decreased pain after femoral neck fractures
S McRae et al: FICB performed by paramedics for femoral neck fractures decreased pain scores compared to standard of care
Other Lower Extremity Blocks
S Obturator
S Lateral Femoral Cutaneous
S Ankle Blockade