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Multimodal Pain Management

Multimodal Pain Management. Tong Joo (TJ) Gan, MD, FRCA, FFARCS(I) Professor of Anesthesiology Vice Chairman Clinical Research Duke University Medical Center Durham, North Carolina. Faculty Disclosure.

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Multimodal Pain Management

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  1. Multimodal Pain Management Tong Joo (TJ) Gan, MD, FRCA, FFARCS(I) Professor of Anesthesiology Vice Chairman Clinical Research Duke University Medical Center Durham, North Carolina

  2. Faculty Disclosure It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity. Dr. Gan has received grants/research support from Acacia, Baxter, Durect, Eisai, and NICOM. He has received honoraria from Baxter, Eisai, Fresenius, Hospira, and Xanodyne.

  3. Educational Learning Objectives Describe the importance of improving time to gastrointestinal recovery that occurs postsurgery and consider how this affects length of hospital stay and overall quality of patient care Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures Describe how interprofessional collaboration surrounding gastrointestinal surgery can result in better alignment with current surgical quality measures and formulate strategies to integrate this into current practice

  4. Patient Case • 65-year-old man, 95 kg, with a history of biopsy positive cancer of the rectum • Scheduled for a left hemicolectomy • Past medical history • Non-insulin dependent diabetes • Hypertension • Chronic back pain

  5. Patient Case – Medical History • Previous surgery • Appendectomy • Knee arthroscopy • ACL repair • Social history • Occasional drinker • Nonsmoker

  6. Patient Case – Medical History • Medication history • Vicodin® 1 tab TID • Ibuprofen PRN • Atenolol 50 mg OD • Multivitamin daily • Gliclazide 30 mg

  7. Patient Case – Anesthetic Plan • Patient scheduled for partial colectomy • Anesthetic • General anesthesia • Fentanyl 100 mcg and midazolam 3 mg as premedication • Induction with propofol, anesthetic maintained with sevoflurane, air and oxygen • Rocuronium as the neuromuscular blocker • Ondansetron as prophylactic antiemetic

  8. Patient Case – Postoperative Pain Management • Surgery duration 3.5 hrs • Patient extubated and transferred to PACU • Postoperative pain management • Patient-controlled analgesia (PCA) with morphine, with 2 mg bolus, 8 min lockout and 30 mg 4 hr maximum dose • In the PACU, complained of pain 9/10 on a verbal rating scores (VRS) of 0-10

  9. Opioids and Postoperative Ileus • Does the use of systemic opioids contribute to postoperative ileus?

  10. Opioid-based Analgesia and Bowel Function • 40 colectomy patients • Correlation between morphine PCA dose and first bowel sounds (P = 0.001), flatulence, (P = 0.003), and first bowel movement (shown, P = 0.002) • No correlation between incision length and morphine dose • ICD-9-CM coded POI correlates with systemic morphine (OR = 12.1; • 95% CI, 5.4-27.1) Total Morphine (mg) 350.0 300.0 250.0 200.0 150.0 100.0 50.0 0 R = 0.48P = 0.002 40 60 80 100 120 140 160 180 Hours to First Bowel Movement Cali RL, et al. Dis Colon Rectum. 2000;43:163-168. Goettsch WG, et al. Pharmacoepidemiol Drug Saf. 2007;16:668-674.

  11. Postoperative Analgesia and Postoperative Ileus • While opioids are often the analgesic of choice following abdominal surgery, they decrease gastric motility, inhibit small and large intestinal propulsion, and have other GI effects that contribute to the abdominal discomfort associated with POI

  12. Postoperative Pain Management What would you do? A. Change to a different opioid in the PCA B. Add ketorolac C. Insert an epidural D. Boluses of morphine

  13. Postoperative Pain Management There are a number of possible options. The following slides provide some evidence to support the use of nonsteroidal anti-inflammatory drugs and epidurals as opioid-sparing approaches.

  14. Opioid-sparing Effects of Ketorolac – Postoperative Bowel Function in Colorectal Surgery Patients M: IV patient-controlled analgesia morphine M+K: IV patient-controlled analgesia morphine plus ketorolac Chen JY, et al. Clin J Pain. 2009;25:485-489.

  15. Epidural Analgesia and Duration of Postoperative Ileus *Compared with systemic analgesic regimens; IPAA: ileal pouch anal anastomosis Adapted from Person B, Wexner S. Curr Probl Surg. 2006;43:12-65.

  16. Meta-analysis of Epidural Analgesia (EA) vs Opioid Parenteral Analgesia after Colorectal Surgery • 16 randomized, controlled trials (1987-2005) compared postoperative epidural analgesia (local anesthetic) with parenteral opioid analgesia in patients following colorectal surgery • Length of hospital stay: no statistically significant difference between the groups • Pain intensity: Lower visual analog scale pain scores at 24 and 48 hours with EA (P < 0.001) • Duration of postoperative ileus: reduced by 36 hr with EA (P < 0.001) • Anastomotic leak and cardiopulmonary complications: no significant difference between groups • Hypotension, pruritus, and urinary retention were more common in the EA group Marret E, et al. Br J Surgery. 2007;94:665-673.

  17. Postoperative Pain Management – Opioid-sparing Strategies • The use of epidural analgesia and nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain management both help to minimize postoperative opioid consumption. Along with providing pain relief, these strategies help to minimize opioid-related GI dysfunction. Both approaches are associated with a reduction in the duration of postoperative ileus compared with parenteral opioids

  18. Patient Case – Postoperative Pain Management • Treatment • Added ketorolac 15 mg • Gave bolus dose of morphine 6 mg (in 2 mg aliquots) • Increased PCA dose of morphine to 3 mg per push

  19. Patient Case – Postoperative Day 1 • Patient’s pain score is 7/10 • Complaint of persistent nausea and 2 episodes of retching • Itching of the front of chest and back • Treatment • Promethazine 12.5 mg • Meperidine 25 mg

  20. Patient Case – Postoperative Day 3 • Day 3 after surgery, pain range between 4/10 to 8/10. Still on PCA morphine, not helping too much • 5 doses of ketorolac, maximum doses given • Still complains of nausea • Used 70 mg morphine on first 24 hrs and 80 mg over the next 24 hrs

  21. Patient Case – Postoperative Day 4 • No bowel sounds, no flatus, no bowel movement • Abdomen slightly distended • Nasogastric tube drained yellowish fluid • Persistent nausea • Drowsiness and slight confusion

  22. Postoperative Pain Management What would you do? • Additional boluses of morphine • Start a morphine infusion via the PCA • Change to a different opioid • Insert an epidural

  23. Postoperative Pain Management Since the patient had not responded well to fairly large doses of morphine, starting an infusion or further boluses of morphine would not be helpful. Some patients may respond better to a different opioid with a lower incidence of side effects. Hence this could be a viable option. Insertion of an epidural at this stage may also be considered if there are no other contraindications.

  24. Patient Case – Postoperative Pain Management • Pain team consulted • Change to hydromorphone PCA • Started celecoxib 200 mg BID

  25. Patient Case – Postoperative Course • Postoperative Day 7: presence of flatus and bowel sounds • Advanced diet to semi-solid • Continue to make progress • Day 10: full bowel function established • Day 11: patient discharged

  26. Patient Case – Continued • Suspicious looking left kidney found during surgery • Renal mass confirmed on MRI • 6 weeks later, patient admitted for left partial nephrectomy

  27. What Would Be Your Anesthetic and Pain Management Plan? • Preoperative epidural • Preoperative celecoxib • Preoperative gabapentin • Intraoperative small dose ketamine infusion • All the above

  28. Gabapentin and Postoperative Pain–Systematic Review Ho KY, et al. Pain. 2006;126:91-101.

  29. Gabapentin and Postoperative Pain Pain Scores Morphine Consumption Ho KY, et al. Pain. 2006;126:91-101.

  30. Perioperative Gabapentin 1200 mgAdverse Events Odds ratio < 1 favors gabapentin over control (reduced risk for opioid-related side effects) Ho KY, et al. Pain. 2006;126:91-101.

  31. Celecoxib 400 mg/day in Laparoscopic Surgery * P < 0.05 vs Control (actual P values listed) White P, et al. Can J Anaesth 2007;54:342-348.

  32. Intravenous Ketamine and Postoperative Pain Systematic Review Visual Analogue Scale (VAS) of pain intensity Elia N, Tramèr M. Pain. 2005;113:61-70. WMD: weighted mean difference

  33. Multimodal Perioperative Pain Management Preoperative gabapentin, short-term use of celecoxib, and intraoperative ketamine infusion are additional evidence-based strategies for improving perioperative analgesia, reducing opioid requirements, and minimizing opioid-related side effects.

  34. Patient Case – Anesthetic and Postoperative Pain Management Plan • T9/T10 thoracic epidural placement preoperatively for postoperative pain control • Preoperative celecoxib 400 mg followed by celecoxib 200 mg BID • Preoperative single dose of gabapentin 1200 mg • Intraoperative ketamine bolus 0.5 mg/kg followed by an infusion of 10 kg mcg/kg/min

  35. Patient Case – Postoperative Pain Management • Surgery uneventful • Lasted for 3 hrs • Postoperative epidural infusion with bupivacaine 0.125% with hydromorphone 10 mcg/mL infused at 8 mL/h • Continued with celecoxib 200 mg BID • Pain score 2-3/10

  36. Patient Case – Postoperative Course • Postoperative Day 2: epidural discontinued • Patient tolerated a full meal the day after surgery with no nausea and vomiting • Urine through catheter started to be clear • Normal renal function established • Continued on celecoxib 200 mg BID • Pain score 2-3/10

  37. Patient Case – Postoperative Course • Day 3: patient discharged • Patient was satisfied with the pain management during his second surgery • Use of multimodal strategy greatly enhanced pain control with reduction in side effects

  38. Summary • This case illustrates • Opioid use can result in many adverse effects including nausea and vomiting and delayed bowel recovery after surgery • Pain involves complex mechanisms • Opioid adjuncts improve pain control • A multimodal pain management strategy improves analgesia and lowers the incidence and severity of side effects

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