9 multimodalperioperativepaindrhamedumedaly1 res gak ppt
TRANSCRIPT
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Multimodal Perioperative Pain Management and Multimodal Strategies to Enhance Post Operative Outcomes
Hamed Umedaly MD FRCPCAnesthesiologist Medical Director POPSVancouver AcuteUniversity of British Columbia
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Why ? What's wrong with the status quo ?
Improved Anesthesia & Pain management can be achieved !Improved potential for Recovery ?Unidimensional approaches limit outcomeImprovements not realizing optimal patient outcome ?
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4 A’s of Changing Physician 4 A’s of Changing Physician Behavior ( Pathman model)Behavior ( Pathman model)AwareAgree
AdoptAdhere
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For every complex problem there is an answer that is simple, neat and wrong
H.L Menken 1880-1956
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Concept of Perioperative Pain Management and Acute Rehabilitation
Pre- Op Education Preparation & PlanningPre & Intraop Pain Management & Physiological StabilizationPost-op pain management and Acute Rehabilitation
Kehlet 1995-2005
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Preemptive Pain Management: Neurobiology
Noxious stimuli initiate cascade of events peripherally and centrally to produce PAINSensitization (Dynamic) Nociceptive stimuli amplified ( Primary and Secondary Hyperalgesia)Non painful stimuli produce PAIN (Allodynia)
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Preemptive Pain Management:Prevent Sensitization ( duration and Intensity)
Reduce the Nociceptive input (Minimally invasive surgery,LA, NSAIDS, Opioids)Attenuate Transmission ( Blocks, Spinal, Epidural)Modulate mechanisms that underlie sensitization ( NMDA blockade, Opioids)
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Multimodal Pain Management
Pain Neurobiology is a complex of Dynamic Interrelated systemsUnimodal Analgesia cannot be sufficient to provide optimal pain managementAdditive & Synergistic effects of Multiple modes should improve outcome
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4 principles of Multimodal Pain Management
Multiple Mechanisms/ Sites of actionAvoid Opioid Dominance Opioid Sparing vs side effectsMultimodal / Lower Doses / Reduce adverse effectsTreat and Prevent Toxicity / Side effectsi.e PONV /Delirium/Pruritis
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VA Quality Improvement Study N=300
~ 40 % of joint arthroplasty have PONV if untreated Joint Arthroplasty patients are at high risk of PONV
~ 10 % of have PONV if Risk Reduction Strategy and Prophylaxis ( combination therapy)
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Consensus Guidelines for Managing PONV
Evaluate Risk ( Patient, Anesthetic Surgical)Strategies to reduce baseline risk (Modify Anesthetic Technique)Antiemetic prophylaxis Moderate Risk: Monotherapy 5 HT3 Receptor antagonistHigh risk: Combination therapy
Gan A&A 2003
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art64_fig11.gif
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Acetaminophen
Synergy with Opioids / Opioid sparingSynergy with NSAID’sInexpensive
Routes PO / PRUse 3-4 g/24 hr short term<2 wks
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Model for Post surgical Chronic Pain
Acute pain ( Nociceptive and Affective Components)
Preop Psychological factors
Acute injury (Surgery)
Physiological Factors
Chronic Pain
Physiological Maintaining Factors
Psycho/social Maintaining Factors
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Multimodal pain management and Outcomes
Multiple PRCT’s in 10 yrsImproved Pain Scores and Patient SatisfactionDecreased use of PCA and Parenteral AnalgesiaBUT no change in LOS/Outcome
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Beyond Multimodal Pain Management: A Multimodal Strategy to Enhance Postoperative Recovery
Multimodal Rehabilitation modelIntegrated (Patient, Nurse,PT/OT.Pharmacist, Surgeon, Anesthesiologist)Use the Improved pain management to accelerate recovery discharge & Really Improve outcome
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Multimodal Recovery
Wellness modelPerioperative model ( seamless)Architecture from Bed oriented wards to Activity Oriented Units“Postoperative Rehabilitation Unit”Now lets look at Outcome
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Opioid Tolerance: Reality Check
Increasing incidence of Opioid Tolerant Patients presenting for Surgery
CPS & APS approve the use of Opioids for Chronic Non malignant Paini.e Osteoarthritis
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Opioid Tolerance (Chronic Pain)
Morphine equivalence > 30 mg/ day for > I month
Central sensitization ; afferent nociceptive facilitatationPrimary and secondary hyperalgesia Allodynia
Opioid mu receptor down regulation
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Opioid Tolerance : Features
Tolerance to: pain management, respiratory depression Sedation
Non Nociceptive Suffering ( anxiety)Renders Perioperative Pain Management Challenging
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Opioid Tolerance in the Perioperative Period
Its too late postop ( in the PACU )Start preop ( identify , plan , preop Opioid , Acetaminophen, NSAID, +/- Clonidine Continue Intraop ( Opioid , Local, Regional , Ketamine)Extend strategy Postop (Opioid , Regional , +/- Ketamine, NSAIDs, Acetaminophen
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Opioid Tolerance: Multimodal Strategies
Use Neuraxial Blockade/ Regional Anesthesia/Analgesia with LANSAID’sAcetaminophen at max dose ( 1.5-2 g load and 4 g/day)Low dose Ketamine intra +/- postopTreat Non Nociceptive Suffering
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Opioid Tolerance
IdentifyDiscuss Complexity and Potential Toxicity with Patients Resume PO Opioid asap at higher dose and provide breakthrough
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Strategy and Goals
IntegratedPre, Intra & post operative CareSeamlessMultimodal pain management Treat Pain with activityAvoidance of routine PCA OpioidImprove pain management and outcomes
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Perioperative vs Postoperative
Preop: Recognition, Assessment, Discussion, Plan, Pre emptive
Intraop: Modification of Surgical approach Anesthesia and Pain Management Strategy
Post Op: Multimodal Pain Management and Intervention
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VA Approach: Preop
Consultation and preparationIdentify Risk of Difficult to manage painHigh dose Acetaminophen+/- NSAID Low dose long acting Opioid (Oxycodone CR 10 mg)
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VA Approach:”Intraop”
Intrathecal LA(Spinal) and low dose Opioid( PF Morphine 100 ug)+/- GA or Epidural for Revisions or Opioid TolerancePreincision LALA in capsule and closurePONV prophylaxisFast track PACU
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VA Approach:”Post op”
Full reg dose Acetaminophen+/- NSAID Reg low dose long acting Opioid (Oxycodone CR) plus breaktrough prn opioid ( Oxycodone IR)PCA only for unsatisfactory pain control“Fast track” early mobilization
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Rehabilitation / Recovery
Achieve best pain control with minimal side effectsUse that pain control to achieve early :RecoveryMobilizationFunction
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Ambulatory or Short stay Hip Replacement
Minimally Invasive approach85 % with same day DC N= 100
Duwelius JBJS 2000
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Short Stay Total Knee Arthroplasty
Spinal AnesthesiaMultimodal pain managementFemoral Nerve LA Catheter Infusion
Anesthesia and Analgesia Jan 2006
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MIS Surgery:Purported Benefits
Surgical InvasivenessBetter Pain ManagementImproved Rehabilitation Protocols
?Higher Complication rate with MIS
Woolson JBJS 2004, Ogonda JBJS 2005Wright J.Artroplasty 2004
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Periop Pain Management
Talk about it “Can and should focus on pain”
Work on Periop Strategies and utilize them to enhance satisfaction /outcome
Manage PONV
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The Future
Perioperative infusion of ContinuosRegional Anesthesia(PICRA)PCOAAntineuropathic agents ( gabapentin/pre gabalin)Microsphere impregnated Local anesthetic agents
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A Multimodal Strategy to Enhance Postoperative Recovery: Conclusions
Integrated Perioperative approachEnhanced Perioperative Pain managementPerioperative stress response and Organ Dysfunction reduction ( eg blood loss, PONV )Utilize to achieve Fast Track Recovery and Enhance Outcome
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Divinum est sedare dolorum
Blessed are those who treat pain.-Galen
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COX 2 Inhibiters : Background
Inducible vs Constitutive enzymesNo apparent GI or Renal SparingPlatelet Aggregation Sparing ( Thromboxane inhibition)
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Cyclooxygenase Isoforms
Cox-1 Cox-2Constitutive, and found in most tissues -“housekeeping”. Inducible 2- to 4-fold by inflammatory stimuli
Only isoform present in platelets TxA2
Main isoform in gastric mucosa CytoprotectivePG’s
Predominately inducible enzyme in many tissues -10- to 20-fold by inflamstimuli or cancer
Stimulates PGI2 production in endothelium
Constitutive in CNS, fem. reproductive tract, and kidney
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COX 2 Inhibiters : When ?
Pain Management Challenging and Intraop Bleeding an Issue Pain Management responsive to NSAIDS (Bone, Gyne etc and potential for intraop /post op bleeding)Concurrent Anticoagulation or LMW HeparinEpidural insitu and pain outside covered dermatomes
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Cardiovascular and Platelet Effects
Platelets:- ASA: irreversibly acetylates Cox-1,
selectively inhibits TxA2 formation
- Nonselective NSAIDs: Inhibit TxA2 and PGI2 to a similar degree. Effect is reversible
during the dosing interval
- COXIBS: Inhibit (reversibly) Prostacyclinformation which mediates platelet inhibition
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CLASS and VIGOR studiesCLASS:
- Celebrex Long-term Arthritis Safety StudyVIGOR:
- VIoxx Gastrointestinal Outcomes Research
Very large (n = >4,000 and >8,000), multicenter, double-blind, randomized trials (no placebo arm) examining efficacy and safety of Celecoxib and Rofecoxib
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CLASS- 28% with RA, 72% OA
- compared coxib Vs ibuprofen & diclofenac
- ASA allowed for Cardiac prophylaxis (21%)
- no difference in ulcer frequency,but fewer symptomatic ulcers
- no sig difference in MI frequency
VIGOR- 100% with RA
- compared coxib (2x max dose) Vs naproxen
- ASA not allowed
- sig lower rates of upper GI events and GI bleeding with vioxx
- sig higher rates of thrombotic events and MI with Rofecoxib, altho’ CV mortality rates similar
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Why do Cox-2s Increase SAEs??
Not completely explained by the trials
Increase of thrombotic CV events more than cancels reduction in complicated ulcer risk
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COX 2 Inhibiters : Cost
COX 2 $ 1.25/dayRofecoxib and Valdecoxib once daily dosing
Nonselective po nonselective COXIB $30-60 cents (eg Diclofenac)IV nonselective COXIB (~$ 8.00 day)
(eg Ketorolac)
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COX 2 Inhibiters : Add to formulary ?
Minimal cost
Selective Use When IndicatedAvoid use when known or risk factors for CAD
Platelet sparing really only benefit
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The FutureIV Acetaminophen = “Propacetamol
will be available in Canada “soon”
IV Parecoxibimmediately converted to Valdecoxib
Nitric Oxide-donating NSAIDsNO functions as an endogenous mediator of gastric mucosal health and defence
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Multimodal Perioperative Pain Management and Multimodal Strategies to Enhance Post Operative Outcomes
Hamed Umedaly MD FRCPCAnesthesiologist Medical Director POPSVancouver Acute