Acute Pain in the Ambulatory Setting

Tessa Mandler, M.D.

Assistant Professor

Disclosure

I do not have any financial or research affiliations with any product or pharmaceutical manufacturer displayed in this

presentation

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Learning Objectives

• Understand consequences of poor pain control in the ambulatory setting

• Identify ways to improve pain control for outpatient surgeries

• Discuss the suitability of single shot peripheral nerve blocks versus continuous peripheral nerve catheters for ambulatory patients

• Discuss novel management strategies of outpatient peripheral nerve catheters in the setting of limited resources

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Consequences of Poor Pain Control

Post-operative

Pain

Rescue Opioids

Sedation

PONV

↑PACU/HopsitalLOS

↓Satisfaction

↑Respiratory Cx

↑Cost

Unplanned/Prolonged admission

4Hines R, Barash PG, Watrous G , et al. “Complications occurring in the postanesthesia care unit: a survey.” Anesth Analg. 1992;74(4):503.Kehlet H, Dahl JB. Anesthesia, surgery and challenges in postoperative recovery. Lancet 2003;362:1921–8.

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Marcario A. Anesth Analg. 1999 Sep;89(3):652-8.

6Macario A. Anesth Analg. 1999 May;88(5):1085-91.

Mandler, Tessa, MD Outpatient Issues: Acute Pain in the Ambulatory Setting

Effects of Poorly Managed Post-operative Pain

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Cardiovascular ↑HR, ↑BP, ↑cardiac work load

Pulmonary Splinting, ↓VC, atelectasis, hypoxia

Gastrointestinal Post-operative ileus

Renal ↑Risk oliguria and urinary retention

Coagulation ↑Risk thromboemboli

Immunologic ↓Immune function

Muscular Fatigue, ↓mobility

Psychological Anxiety, fear, frustration, ↓sa sfac on

Joshi GP, Ogunnaike BO: Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin North Am 2005; 23: 21.Kehlet H: Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78: 606.

Consequences of Rescue Opioids

Rescue opioids

Sedation

PONV8

Post-Operative Sedation

Differential diagnosis of post-operative sedation: Hypotension

Hypoxia

Hypercarbia

Hypoglycemia

Electrolyte abnormalities

Anemia

Cerebrovascular injury

Persistent anesthetic effect

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Fowler MA, Spiess BD: "Post Anesthesia Recovery." Clinical Anesthesia. 7th ed. Philadelphia: Lippencott, Williams & Wilkins, 2013. 1574-575.

Post-operative Nausea & Vomiting Effects

• Pulmonary aspiration

• Dehydration

• Electrolyte imbalance

• Fatigue

• Esophageal tear

• Wound dehiscence

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Apfel CC, Korttila K, Abdalla M, et al. “A factorial trial of six interventions for the prevention of postoperative nausea and vomiting.” N Engl J Med. 2004;350(24):2441.Gan TJ. “Risk factors for postoperative nausea and vomiting. Anesth Analg. 2006; 102(6):1884.

Additional Sequelae of Poor Pain Control

• Delayed PACU discharge delay in OR turnover

• Unplanned hospital admission

• Decreased patient satisfaction

• Patient discomfort with development of late PONV

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Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2007;105:1615.Macario A, Weinger M, Carney S, et al. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesthe Analg 1999; 89: 652.

Ways to Improve Pain Control for Outpatient Surgeries

A 65 year old otherwise healthy male presents for total knee replacement due to severe osteoarthritis. How many days do you anticipate hospitalization?

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Mandler, Tessa, MD Outpatient Issues: Acute Pain in the Ambulatory Setting

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• A 65 year old otherwise healthy male presents for total knee arthroplasty. The surgeon requests he go home the same day you therefore elect the following for his anesthetic plan:

a. Combined spinal epidural, femoral nerve catheter, ketorolac, acetaminophen, diazepam, fentanyl

b. Spinal, ketorolac, fentanyl, acetaminophen, pregabalin, diazepam

c. Spinal, ketorolac, acetaminophen, pregabalin, celecoxib

d. Combined spinal epidural, intraarticular block, ketorolac, acetaminophen

e. General anesthesia, paralytic, fentanyl, ketorolac

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15Neurowiki, 2014 16

Chronic Pain affects us all

• Quality of life

• Psychological

• Social

• Socioeconomic

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Page MG. J Pain Res. 2013; 6:167-80.

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Park PW. Pain Pract. 2015 Oct 7.

Mandler, Tessa, MD Outpatient Issues: Acute Pain in the Ambulatory Setting

How pain management impacts health care providers

• Bundled payments for care improvement initiative

• Hospital Consumer Assessment of Healthcare providers and systems (HCAHPS) Comparable data on the

patient’s perspective on care

Public reporting improve quality of care

Enhance public accountability19http://www.hcahpsonline.org Centers for Medicare & Medicaid Services, Baltimore, MD. Jan 2016. 20

Shipton EA Anaesth Intensive Care. 2011 Sept;39(5):824-36.

Multimodal Analgesia

Acetaminophen

Non-steroidal anti-inflammatory

drugs (NSAIDs)

Opioids

Anticonvulsants

NMDA Antagonists

Regional anesthesia/Local anesthetics

Antidepressants

Non-pharmacologic

methods

21Costantini R, et al. Controlling pain in the post-operative setting. Int J Clin Pharmacol Ther. 2011;49(2):116-27.Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol. 2009; 22(5): 588-93.

Quick Summary Non-Opioid MMA

• Non-selective NSAIDS: ↓ Opioid use 25-45%, pain intensity, PONV, sedation

Limitations: COX1 inhibition, renal dysfunction, GI

• Acetaminophen: Good tolerance and safety profile

Limitations: cost (IV) vs 1st pass effect; liver dysfunction

• NMDA antagonists (ketamine): ↓ Opioid requirements and hyperalgesia

Limitations: neuropsychiatric disturbances, PONV

• Other: alpha-2-agonists, anticonvulsants, antidepressants Limitations: sedation, dizziness

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Pavy TJ. Anesth Analg. 2001;92(4):1010. Ong KC. Anesth Analg. 2010;110(4):1170Laskowski K. Can J Anaesth. 2011;58(10):911-23. Koh W. Korean J Anesthesiol. 2015;6891):3-12.

Local anesthetics

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www.nysora.com/regional-anesthesia, Jan 19, 2016.

Quick Summary LA Adjuncts

• Epinephrine: Intra-vascular test dose, ↓ absorption from tissues

Limitations: ↑ HR, ↓ perineural blood flow

• Dexamethasone: Peripheral vs Systemic dosing

Limitations: not approved for peripheral administration

• Alpha-2-agonists: Prolongs sensory and motor blockade

Limitations: ↓ HR, ↓ BP, sedation; variation with LA, block, dose

• Opioids: Limitations: no clear benefit

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Neal JM. Reg Anesth Pain Med. 2009;34(2):134-70. Kirksey MA. PLoS One. 2015;10(9).Desmet M. Br J Anaesth. 2013;111(3):445-52. Popping DM. Anesthesiology. 2009;111(2):406.

Mandler, Tessa, MD Outpatient Issues: Acute Pain in the Ambulatory Setting

Bupivacaine liposome injectable suspension (Exparel)

• DepoFoam® slowly delivers bupivacaine ~72-96 hours analgesia

• Vial: 266 mg/20 ml 3% “free” bupivicaine

$285/each

Vial ≈ 300 mg Marcaine

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How DepoFoam® works. Pacira Pharmaceuticals, Inc. website. http://www.pacira.com/depofoam-platform/how-it-works.php. Accessed January 20, 2016.

Bupivacaine liposome injectable suspension

• Indications: Wound infiltration to produce post-surgical anesthesia

• Safety: 21 clinical studies, >1300 patients Additive toxic effects with other local anesthetics

Most common adverse reactions (~10%): nausea, vomiting, constipation

1 ml Marcaine ≠ 1 ml bupivacaine liposome injectable solution

Maximum dose recommended is 266 mg

Caution with liver and/or renal impairment

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Ilfeld BM. Anesth Pain Med. 2015;40(5):572-82

Bupivacaine liposome injectable suspension

27http://www.exparel.com/. Accessed January 20, 2016

Patient selection for ambulatory procedures/surgeries

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Patient selection for regional anesthesia

Anyone and everyone!

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Muhly WT. Local Reg Anesth. 2015 Nov 5; 8: 85-91.

Contraindications to Regional Anesthesia

Patient refusal

Infection at the site of needle/catheter placement

Coagulopathy

Allergy to local anesthetic

Pre-exiting peripheral neuropathy

Severe neurologic injury with precludes post-operative assessment for complications

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Ecoffey C. Paediatr Anaesth. 2012;22(1):25-30.

Mandler, Tessa, MD Outpatient Issues: Acute Pain in the Ambulatory Setting

Caution! Appropriate candidate for ambulatory surgery?

• Chronic pain disorders

• Cardiac history

• Chronic lung disease

• OSA

• Craniofacial disorders

• Neuromuscular disorders

• Failure to thrive

• Morbid obesity

• Other: sickle cell disease, central hypoventilation syndromes, genetic/metabolic/storage disease, Down’s syndrome, pre-maturity

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Marcus CL, Chapman D, Davidson WS, et al. Am Acad Ped, Pediatrics 2002; 109: 704-12.White PF. Anesth Analg 2012;114:1190-1215.

Single Shot Nerve Block

Pros:

• 12-24 hour analgesia

• Decreased opioid use

• Faster PACU discharge

• Cost effective

• Decreases stress response to surgery

• Decreases post-operative immunosuppression

Cons:

• Neuropraxia

• Hematoma

• Local anesthetic toxicity

• Infection

• Secondary injury

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Sites BD. Reg Anesth Pain Med. 2012;37(5):478-82..Fredrickson MJ. Anaesthesia. 2009;64(8):836-44.

Peripheral Nerve Catheters

Pros:

• Decrease opioid use

• Decrease in adjuvant pain medication use

• Prolonged blockade

• ↑ patient satisfaction

Cons:

• Catheter malfunction

• Catheter site infection or bacteremia

• Increased technical difficulty and increased time

• Post-op catheter management

• “Expensive”33

Walker BJ. Br J Anaesth. 2015;115(3):457-62.Capdevila X. Anesthesiology. 2005;103(5):1035.

Cost of materials

Catheter: $475-850

Single shot block: $10-20

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Novel management strategies of outpatient PNC’s

• Potential barriers to PNC’s: How are we going to

teach the families about the PNC without on site APS?

Who is going to order the pump and manage the catheter?

How will follow up be done?

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• General information about catheter and medicine inside it

• How the local anesthetic is not like other pain medicines

• Risks of complications

• Care of a child with a PNC: Protect the limb

The pump is your friend

How to remove the catheter

Instructions when to call (i.e. infection, leakage, prolonged block effects, local anesthetic toxicity, etc.)

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Mandler, Tessa, MD Outpatient Issues: Acute Pain in the Ambulatory Setting

Patient/Family Education sans APS

Face-to-face education Review highlights in the

handout

Use demo pain pump ball

Pen and paper exchange of contact information

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Lessons learned in developing patient/family education materials

Communication

Consumer

APS

Education

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Management of PNC

• RN’s connect pump in PACU

• APS follow up via phone +/- provider phone call

• Surgical team (i.e. post-op visits)

• Patient and his/her family

• Product representative41

Benefits Experienced

• Improved post-operative pain

• Decreased PACU length of stay

• Decreased number of unplanned admissions

• Decrease in unplanned hospital cost

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Mandler, Tessa, MD Outpatient Issues: Acute Pain in the Ambulatory Setting

Patients that received Combined Block spent less time in the PACU

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Fine tuning for the future

• Introduce anesthesia plan to patients pre-operatively to establish expectations and begin education on PNC’s

• Identify patient candidates for pre-operative block to ensure efficacy

• Continue to trial various combinations of the MMA wheel

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Mandler, Tessa, MD Outpatient Issues: Acute Pain in the Ambulatory Setting