Postoperative Pain Management, ERAS, Focus on …...Postoperative Pain Management, ERAS, Focus on...
Transcript of Postoperative Pain Management, ERAS, Focus on …...Postoperative Pain Management, ERAS, Focus on...
Postoperative Pain Management, ERAS,
Focus on Policies and Protocols
ARAKESHISIHAN,MD,FACS
16thAnnualCME&CDEMeetingLasVegas,Nevada
May2019
Disclaimer
NoFinancialRelationshiptoDisclose
• EnhancedRecoveryAfterSurgery(ERAS)andPostoperativePainManagement.
• MultimodalAnalgesiaforPostoperativePain.Risks,Safety,andEfficacy,ReducingCostsandLOS.
• ReviewofAmericanPainSocietyPostoperativePain
Objective(1)
•ERASSociety,ObjectivePatientCentered•http://erassociety.org•http://erasusa.org•RegionalPartners•DifferenceDisciplines•Multimodal,Multidisciplinary•“EvidenceBasedMedicine”
•OutcomesDriven•BasedonData
ERAS-EvolutionEnhancedRecoveryAfterSurgery
• 1990’sProfessorHenrikKehlet–UniversityofCopenhagen(Denmark)Conceptofmultimodalsurgicalcare
• 2001KenFearonandOlleLjungqvistmetinLondonatanutritionsymposiaanddecidedtostartacollaborativegrouponperi-operativecare
• 2001-2002ERASStudyGroup• 2003FirstERASSymposiaStockholm• 2005Fearonetal.ClinNutrStudyGroupdevelopedandpublishedanevidence-
basedconsensusprotocolforpatientsundergoingcolonicsurgery• 2007Maessenetal.BrJSurg2007Concludedthatjustaddingaprotocolwasnot
sufficienttochangepracticetoERAS• 2010TheERASSocietywasofficiallyregisteredasanon-profitmedicalsociety
basedinStockholm,Sweden• 2016USAchapterhelditsfoundingmeetinginWashingtonDC• ERASProtocolindifferentdevelopmentalstagesfordifferentdisciplines
ERAS-History
OverviewBestoutcomeneedtolookatallvariables
ERAS
• SimilartotheconceptofCareplan• Improvingpatientcarebyreducing• Postoperativecomplications(infections)• Patientpainanddiscomfort(narcotics)• Shorteninghospitalstays(cost)
• UseoftheERASshownto: • Reducecaretime30% • Reducepostoperativecomplications50%
• Colorectal,Thoracic
ERAS
• Pre/Intra/PostinGYN-ONCsurgery• GIsurgery• Gastrectomy• RadicalCystectomy• Pancreaticoduodenectomy• ElectiveColonic,pelvic,RectalSurgery• BariatricSurgery• LiverSurgery• HeadandNeckSurgery• Esophagectomy• LungSurgery
Guidlinesfor
•ThekeyelementsofERASinclude:•Patient/familyeducation•Patientoptimizationpriortoadmission-Expectations•Pain,functionalstatus
•Minimalfasting-liquidsthemorningofsurgery•Multimodalanalgesia,useofopioidswhenindicated•Return-normaldietandactivitiesthedayofsurgery•Returntohome
Components
Akimuret.alSurgeryforObesityandRelatedDiseases14(2018)1850–1856
Example-ERAS
GoalToBeAccomplished
IfYouHaveEverWondered
• EnhancedRecoveryAfterSurgery(ERAS)andPostoperativePainManagement.
• MultimodalAnalgesiaforPostoperativePain-Risks,Safety,andEfficacy,ReducingCostsandLOS.
• ReviewofAmericanPainSocietyPostoperativePain
Objective(2)
WhatDoINeedToKnow?
•Definitions•Painassessment•Typesofanalgesics
•Theiraction•Sideeffects
Pain
“Painisanunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage…”
IASP(InternationalAssociationfortheStudyofPain)
• Isaprotectivemechanism
• Causesavoidance• Littletonotissueinjury• Painstopsoncethestimulusisremoved• Inflammationoccursinthearea• Nervedamage• Persistsafterthestimulusisremovedifchronic
Pain
•PossibleSelfCreatedProblem•Almostanythingwedoinvolvespain
•Comewithit,willhaveit,livewithit•Realistic,Honest,specific
WorldJGastroenterol.2003Apr15;9(4):847–850.OperativestressresponseandenergymetabolismafterlaparoscopiccholecystectomycomparedtoopensurgeryKaiLuo,Jie-ShouLi,Ling-TangLi,Kei-HuiWang,andJing-MeiShun
LangenbecksArchSurg.2017Nov;402(7):1023-1037.Systemicinflammatoryresponseafterherniarepair:asystematicreview.KokotovicD1,BurcharthJ2,HelgstrandF2,GögenurI2.
PatientExpectation
• Pain≠Nociception• Paininthebrain-perception• Nociception-peripheral-Visceralnervestimulation
• Fourstagesofprocessingpain:• Transduction
• Blockedbylocalanesthetics,NSAIDprostaglandins(Inflammation)• Transmission
• Preventedbylocalanestheticsperipheralnerves,nerveplexus,epiduralorsubarachnoidspaces
• Modulation• Localanesthetics&Gabapentin
• Perception• Generalanesthetics&Opioids
Pain&PainControl
Analgesics
Classesbasedonmodeofaction•Opioids•Non-steroidalanti-inflammatorydrugs•Localanesthetics•Miscellaneousdrugs•IVTylenol,Antidepressants,Anxiolytic
Pain&PainControl
Transduction Transmission Modulation Perception
Localanesthetics(topical)
Localanesthetics(regionalanesthesia)
Opioids Opioids
NSAIDs,Cox2inhibitors
Opioids Acetaminophen NMDArantagonists
Opioids Alpha2-agonists Cox2inhibitors Generalanestheticagents
Antihistamines Gabapentinoids SNRIs Acetaminophen
Capsaicin NMDArantagonists
NMDArantagonists
KehletH,DahlJB.(1993(Thevalueof‘‘multimodal’’or‘‘balancedanalgesia’’inpostoperativepaintreatment.AnesthAnalg.77:1048-56)
• Bind to opioid receptor sites within CNS (mostly µ but also κ)
• Are agonists, partial agonists or mixed agonists-antagonists
• Are controlled DEA • Reminder - Prescription Pads
Opioids
Opioids-SideEffects
OrganSystem SideEffects Intervention
CNS Drowsiness,DeliriumRespiratoryfailure
EarlyinterventionDeath
GI Nausea,Constipation longterm
CV Hypotension,Tachycardia,
orthostatichypo.
Treatsymptoms
Theultimategoalistodecreasedose,andalwaysconsideralternative.WhatistheExitstrategy?
NSAIDs
• NSAIDs organic acids • Anti-inflammatory, analgesic, and antipyretic • Inhibit prostaglandin production by inhibiting COX
enzymes
NSAIDs-SideEffectsOrganSystemSideEffect
• Na+ permeability neurons • Classified by duration of action
•Lidocaine is short acting with a rapid on-set
•Bupivicaine is long acting with a slow on-set
•Epinephrine
LocalAnesthetics
LocalAnesthetics-SideEffects
*4mg/kgIBW
Whymultimodalapproach?
KehletH,DahlJB:Thevalueof“multimodal”or“balancedanalgesia”inpost-operativepaintreatment.AnesthAnalg1993;77:1048–56
• optimizespainrelief• reducesideeffectburden• providesynergistic/additiveeffects• lowerdosesofeachmedicationneeded• opioidsparingpaincontrol• preventscentralsensitization
➢ Nonpharmacologic➢ Acetaminophen➢ NSAIDs➢ Adjuvants➢ RegionalAnesthesia
MaintainandOf
OpioidsOpioid
OptimizedProtocol
Manworren,R.C.E.(2015).Multimodalpainmanagementandthefutureofapersonalizedmedicineapproachtopain.AORNJournal101(3),308-314
Plan
• DifferentDisciplineofhealthcareproviders-RN,NP,MD
• Acutepainandchronicpain• Comfortlevelforcertain
meds• Plan
• Whatisnext?
• EnhancedRecoveryAfterSurgery(ERAS)andPostoperativePainManagement.
• MultimodalAnalgesiaforPostoperativePain.Risks,Safety,andEfficacy,ReducingCostsandLOS.
• ReviewofAmericanPainSocietyPostoperativePain
Objective
AmericanPainSocietyManagmentOfPostoperativePain
AmericanPainSocietyManagmentOfPostoperativePain
• August2009toJanuary2011• APS,ASA,and23memberswithexpertiseinanesthesia,painmedicine,surgery,obstetricsandgynecology,pediatrics,hospitalmedicine,nursing,primarycare,physicaltherapy
• Systematicreviewoftheevidenceonpostoperativepainmanagement
• GradingofRecommendations,Assessment,Development,andEvaluation
• Evaluatedallvariables,(procedure,discipline,patientAcuity,medicationHx.etc.
StrengthOfData-GRADE
“Ingeneral,astrongrecommendationisonthebasisofthepanel’sassessmentthatthepotentialbenefitsoffollowingtherecommendationclearlyoutweighpotentialharmsandburdens.Inlightoftheavailableevidence,mostcliniciansandpatientswouldchoosetofollowastrongrecommendation.Aweakrecommendationisonthebasisofthepanel’sassessmentthatbenefitsoffollowingtherecommendationoutweighpotentialharmsandburdens,butthebalanceofbenefitstoharmsorburdensissmallerorevidenceisweaker.Decisionstofollowaweakrecommendationcouldvarydependingonspecificclinicalcircumstancesorpatientpreferencesandvalues.Forgradingthequalityofabodyofevidencethatsupportsarecommendation,weconsideredthetype,number,size,andqualityofstudies;strengthofassociationsoreffects;andconsistencyofresultsamongstudies.
StrengthOfData
QualityofEvidence StrengthofRecommenda>on
BenefitsDoorDoNotClearlyOutweighRisks
BenefitsandRisksandBurdensareFinelyBalanced
High Strong Weak
Moderate Strong Weak
Low Strong Weak
Insufficientevidencetodeterminenetbenefitsor
harmsI
*FromthesystemdevelopedbytheGradingofRecommendaions,Assessment,Development,andEvaluaion(GRADE)workgroupandadaptedbytheAmericanPain
Society
Chou,R.,etal.(2016)Guidelinesonthemanagementofpostoperativepain.TheJournalofPain17(2).131-157
GuidelinesMultimodalAnalgesiaRecommendation Summary StrengthofData
1-2 EducatepatientEducationforParentofadultcaregiver
Strongrec.LowqualityStrongrec.Lowquality
3 EvaluateforpsychiatricCo-morbidities,substanceabuse Strongrec.Lowquality
4-6LowestDose
TreatproblemathandChildren(Dosing)
Strongrec.LowqualityStrongrec.LowqualityStrongrec.Highquality
7-8 TENSunitsAcupuncture,massagecoldtherapy
Weakrec.ModeratequalityNoposition
9-14
BehaviormodificationOralVIVAvoidIM
PCA(noBasal)#13,monitor#14
Weakrec.ModeratequalityStrongrec.ModeratequalityStrongrec.ModeratequalityStrongrec.Moderatequality
15-20(32)
AcetaminophenandNSAIDPreoperativedosing
Gabapentin(singledose)#17Katamine#18
LocalLidocaine(openandlap)#19,20
Strongrec.HighqualityStrongrec.ModeratequalityStrongrec.ModeratequalityWeakrec.ModeratequalityWeakrec.Moderatequality
Chou,R.,etal.(2016)Guidelinesonthemanagementofpostoperativepain.TheJournalofPain17(2).131-157
GuidelinesMultimodalAnalgesia
Chou,R.,etal.(2016)Guidelinesonthemanagementofpostoperativepain.TheJournalofPain17(2).131-157
GuidelinesMultimodalAnalgesia
Chou,R.,etal.(2016)Guidelinesonthemanagementofpostoperativepain.TheJournalofPain17(2).131-157
GuidelinesMultimodalAnalgesia
#26-32PainspecialistforinpatientPolicyandprocedureforfollowupThoraciccases-EpiduralPeripheralBlockandtopical
Strongrec.lowquality
Chou,R.,etal.(2016)Guidelinesonthemanagementofpostoperativepain.TheJournalofPain17(2).131-157
Summary
• ERAS• Itscomingtoyou-ifnottherealready-Careplan
• MultimodalAnalgesiaforPostoperativePain.Risks,Safety,andEfficacy,ReducingCostsandLOS.
• Utilizealltools,Educate,tameexpectation• ReviewofAmericanPainSocietyPostoperativePain• Alreadyinplaceindifferentforms
Thank you
ArmenianAmericanMedicalSocietyCMEcommittee
fortheopportunityprovided
Questions?