Perioperative Pain Management - Hospital Authority€¦ · Nurse-led Acute Pain Service •Link...
Transcript of Perioperative Pain Management - Hospital Authority€¦ · Nurse-led Acute Pain Service •Link...
Peri-operative Pain Management - a multi-disciplinary team-based approach
Dr Steven Wong Chief of Service
Department of Anaesthesiology & OT Services Queen Elizabeth Hospital
Outline
• Development of postoperative pain management
• Effectiveness of postoperative pain management
• From postoperative to perioperative pain management
Postoperative pain management
• Only began in late 80s of the last Century
• On-demand intramuscular opioids by surgeons
Intramuscular opioids
Adopted from: blog.daum.net
Revolution in Postoperative Pain
Management in the 20th Century
Epidural analgesia
Patient-controlled
analgesia device
Epidural analgesia
primumn0nn0cere.wordpress.com
Patient-controlled analgesia (PCA)
Ferrante & Covino 1990
Acute pain service
How effective is postoperative pain management?
Unfortunately, a reduction in postoperative morbidity and mortality by epidural analgesia has not actually been demonstrated.
“Surprisingly, “minor” surgical procedures were associated with high pain intensities … … procedures that have the reputation of being less painful received inadequate pain relief”
Editorial. Anesthesiology 2013;118:780-2
Does postoperative pain management shorten hospital stay?
Opioid-related adverse effects
• Nausea and vomiting
• Pruritus
• Urinary retention
• Constipation
• …
Chronic Postsurgical Pain
FM Perkins et al. Chronic pain as an outcome of surgery: a review of predictive factors. Anesthesiology 2000 93: 1123-1133.
Pathophysiology of chronic postsurgical pain
• Injury to the peripheral nerves
• Central sensitization
• Loss of descending control
• Influence from higher centres
• Genetic predisposition
Kehlet et al. Lancet 2006; 367:1618-25
International guidelines on postoperative pain management
• Published by NHMRC (Australia) – 1st edition: 1999
– 2nd edition: 2005
– 3rd edition: 2010
• The whole process of acute pain management was reviewed
• “Key messages” with level of evidence according to NHMRC designation
• Published by NHS in 2004
• “A designated consultant anaesthetist should be responsible for acute pain management.”
• “All nursing staff, and all other healthcare professionals involved in postoperative pain management should have an up-to-date, evidence-based and appropriate understanding of postoperative pain management.”
“Nurse-led” Acute Pain Service
• Started in some European countries
• More cost-effective
• Growing interest in the development of pain management as a nursing specialty
• “Pain as the Fifth Vital Sign” has been advocated to have pain assessment for all patients
• Published by ASA in 2004
• Revised in 2012
• “Preoperative evaluation” - formulation of pain plan
• “Multi-modal” techniques for pain management
• Working group consisting of anaesthesiologists and surgeons
• Postoperative pain management should be “procedure-specific” because the type, level and duration of pain may vary depending on the type of surgery.
PROSPECT
www.postoppain.org
ERAS protocol for radical cystectomy
Thoracic epidural is superior to systemic opioids in relieving pain. It should be continued
for 72h.
Multimodal postoperative analgesia, including thoracic
analgesia
European Urology 2014;65:263-6
Recommendations for acute pain service
• Include all patients after surgery
• Include all types of surgery
• Nurse-led service
• Perioperative service – from preoperative evaluation to postoperative follow-up
• Collaborate with surgeon
• Procedure-specific protocols
… the acute pain service has to be extended
to cover all patients having surgery.
With more nurses willing to participate in the management of postoperative pain,
anaesthesiologists can step back and assume a supervisory role.
In collaboration with the surgeons, postoperative pain management and
rehabilitation protocols should be established to facilitate recovery after
specific surgical procedures.
Editorial. Hong Kong Med J 2008;14:340-1
What have we done so far?
Nurse-led Acute Pain Service
• Advanced Practice Nurse (APN) in Pain Management
– Completed Post Registration Certificate Course (PRCC) in Pain Management
– Dedicated pain nurses providing full-time service
– Supervised by the anaesthesiologist
– Total number in the territory < 20
Nurse-led Acute Pain Service
• Link nurses
– Nurses from the operating theatre (OT) and ward
– Collaborating with the pain nurses
– Total about 70 from the OT and 380 from various wards (territory-wide)
– Most of them have not received formal training in pain management
Perioperative pain management
• Perioperative Care Enhancement Programme
– Piloted in QEH in July 2014
– A team of Pain Nurses and OT nurses, under anaesthesiologists’ supervision and endorsed by surgeons
– Pre-operative visit to all elective surgical patients undergoing anaesthesia
– Intra-operative care
– Post-operative visit within 48h after surgery
Patient Admission
Day Admission
Information Given By Pre-admission Service
Peri-operative Nurses Assess Patients
No Yes
Acute Pain Service
Patient Follow Up + Patient Satisfaction
Survey
Pain NurseAcute Pain
Nurse
No Yes
Anaesthetic-related Complications Detected
Inform Anaesthesiologist
Anaesthesiologist Assesses & Manages Patient
Peri-operative Care Case Closed
YesNo
Algorithm of Peri-operative Care Enhancement Programme
Version July 14
Pre-operative
Intra-operative
Post-operative
Operations
Peri-operative Care Enhancement Programme
Preliminary results
• July 2014 – February 2015
• No of preoperative visits: 1,106
• No of postoperative visits: 1,607
• Common postoperative problems:
– Postoperative pain (3%)
– Severe nausea and vomiting (2.6%)
Preliminary results
• Other rare postoperative complications: – Post-intubation hoarseness of voice (4 cases) – Post-dural puncture headache (1 case) – Persistent numbness after regional anaesthesia (1
case) – Stroke (1 case)
• All referred to the anaesthesiologists and surgeons for timely management
• Patient survey – Decreased anxiety after preoperative visit (96%) – Satisfied with postoperative visit (99%)
• Joint Replacement Centre at Hong Kong Buddhist Hospital since 2012
• Procedure-specific Perioperative Pain Management Protocol
D1 ambulation (June 2012)
Reduced Length of Stay
0.0
5.0
10.0
15.0
20.0
7.210.0 9.2
0
15.212.4
No. of Days
Primary Total Knee Replacement of HA from Jan 2013 to Oct 2014 and Year 2009
Average Post-OT LOS (days) 2013 to Oct 2014 Average Post-OT LOS (days) 2009
HAQEHBH
Reduced Length of Stay
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
8.610.8 11.6
0
17.8
14.7
No. of Days
Primary Total Hip Replacement of HA from Jan 2013 to Oct 2014 and Year 2009
Average Post-OT LOS (days) 2013 to Oct 2014 Average Post-OT LOS (days) 2009
QEH HA
Patient satisfaction
0%
10%
20%
30%
40%
50%
60%
70%
0.35% 0.59%5.87%
64.89%
28.30%Percentage
Satisfaction Level
Satisfaction Level with the Anaesthetic Care
Dissatisfed Barely acceptable Acceptable Satisfed Very satisfed
Evolution in perioperative pain management
• All patients
• Multi-disciplinary
• Perioperative (pre- & post-operative)
• Multi-modal
• Procedure-specific protocol
• Selective patients
• Single discipline
• Single time frame (post-operative)
• Single modality
• Single protocol
Thank you