Opioid-Sparing Anesthesia Techniques: The Multimodal Wave

Hawai’i ANA, March 2017

John P. McDonough, CRNA, EdD, Dr.(habil.)NScA, ARNP, FRSM

Professor & Director, Graduate Nursing ProgramsDirector, Nurse Anesthetist Program

BROOKS COLLEGE of HEALTH

SCHOOL of NURSING

NURSE ANESTHETIST PROGRAM

• Acute pain affects people of all ages1

• >80% of patients report pain after surgery2

– 75% of these patients report moderate, severe, or extreme pain

• Postoperative pain is the primary concern of most patients prior to surgery2

• Pain is a major component of the recovery process3

Postoperative Pain Considerations

References: 1. Berry PH et al. Pain: current understanding of assessment, management, and treatments. Glenview,IL: American Pain Society; 2006. 2. Gan TJ et al. Curr Med Res Opin.

2014;30(1):149-160. 3. Pavlin DJ et al. J Clin Anesth. 2004;16(3):200-206.

Potential Consequences of Unrelieved Acute Pain

Adapted from Ghori MK, Zhang YF, Sinatra RS. In: Sinatra RS, Leon-Casasola OA, Ginsberg B, Viscusi ER, eds. Acute Pain Management.

1st ed. New York, NY: Cambridge University Press; 2009: 3-20.

Acute pain

Fear, Anxiety

Sleeplessness,

Helplessness

Splinting,

Shallow Breathing

Atelectasis,

Hypercarbia, Hypoxia

Sympathetic

Activity

Tachycardia,

Hypertension

O2

Consumption

Regional

Blood Flow

Myocardial

Ischemia

Infection,

Ischemia

Impaired

RehabilitationPneumonia

Pain Management Remains Suboptimal in the Acute Care Setting

4

0

10

20

30

40

50

60

70

80

90

Any Pain Slight Moderate Severe Extreme

Warfield 1995 Apfelbaum 2003 Gan 2014

77

8286

19

13

25

4947 45

2321

23

8

18

8

1. Warfield CA, Kahn CH. Anesthesiology. 1995; 83(5): 1090-1094. 2. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Anesth Analg.

2003; 97(2): 534-540. 3. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Curr Med Res Opin. 2014; 30 (1): 5149-160.

(N=500) (N=250) (N=300)

Pa

tie

nts

(%

)

Patient is the Focus of Accountable Care1,2

• How will hospitals successfully navigate the shift from Volume-Based to Value-Based care?

1. Shoemaker P. Healthc Financ Manage. 2011; 65(8): 60-68. 2. Health Research & Educational Trust. Metrics for the Second Curve of Health

Care. Chicago: April 2013. www.hpoe.org/Reports-HPOE/Second_Curve_RoadMap_1to4.pdf. Accessed September 10, 2014.

Oct 2012

2017

A payment reform under which

hospitals are provided financial

incentives based on their

performance against quality

measures

Payment of claims based

on volume of care

Current Surgical Challenges

Preoperative Intraoperative Postoperative

STANDARDIZED CARE

Le

ng

th o

f S

tay/

Incid

en

ce

of C

om

plic

atio

ns

Adapted from Cohen ME et al. Ann Surg. 2009;250(6):901-907.

Variability reduction is critical Surgeon 1

Surgeon 2

Surgeon 3

Surgeon 4

Surgeon 5

Surgeon 6

0%

10%

20%

30%

40%

50%

60%

70%

Vomiting (V) Constipation (C) Itchiness (I) Nausea (N) Dizziness (D)*

30%

35% 35%40%

35%

70%65% 65%

60%65%

“Moderate”V +

“good”

pain relief

No side effects +

“fair”pain relief

“Severe” C +

“excellent”pain relief

“Mild” C +

“good”

pain relief

“Severe” I +

“excellent”

pain relief

“Mild” I +

“good”

pain relief

Importance of Balancing Pain Management with Risk of Adverse Events•Most post-surgical patients in one study chose less pain relief than increased/more severe side effects (N=50)

Patients

Report

ing S

ele

cte

d P

rofile

(%

)

Gan TJ, Lubarsky DA, Flood EM, et al. Br J Anæsth. 2004; 92(5): 681-688.

* Mental cloudiness/dizziness

“Moderate” N +

“good”pain relief

“No” N +

“fair”pain relief

“Severe” D +

“excellent”pain relief

“Mild” D +

“good”pain relief

Pain Management Remains Suboptimal in the Acute Care Setting

0

10

20

30

40

50

60

70

80

90

Any Pain Slight Moderate Severe Extreme

Warfield 1995 Apfelbaum 2003 Gan 2014

77

8286

19

13

25

4947 45

2321

23

8

18

8

1. Warfield CA, Kahn CH. Anesthesiology. 1995; 83(5): 1090-1094. 2. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Anesth Analg.

2003; 97(2): 534-540. 3. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Curr Med Res Opin. 2014; 30 (1): 5149-160.

(N=500) (N=250) (N=300)

Pa

tie

nts

(%

)

Opioids have Historically been theFoundation for Acute Pain Management

• In a 2012 research database of 1,665,418 patients, 72% of inpatients treated with IV analgesia received IV opioid monotherapy

Data from the hospital research database maintained by the Premier healthcare alliance. July 17, 2013.

28% …

72% opioid …

n=459,674

n=1,205,744

Current versus ERAS

Business as Usual

• Avoidable readmissions

• Avoidable complications

• Unsubstantiated variation

• Current costs continue

• Current patient experience

• Current return to work

ERAS

• Minimized readmissions

• Minimized complications

• Evidence-based care

• Costs decreased

• ↑ satisfaction / ↓ suffering

• Increased productivity

or

Cost Per Hospital Day

1. Lee L, Mata J, Ghitulescu GA, et al. Ann Surg. 2014 Nov 3. [Epub ahead of print], 2. National Health Service. Personal Social Services Research Unit,

Unit Costs of Health & Social Care 2011. Available at: http://www.pssru.ac.uk/archive/pdf/uc/uc2011/section1.pdf. Accessed October 8, 2015.

1

191

UK$10532CAN

$4681

US$19601

Note: Costs converted to US dollars.

Chapman CR, Stevens DA, Lipman AG. Quality of postoperative pain management in American versus European institutions. J Pain Palliat Care

Pharmacother. 2013 Dec;27(4):350-8.

Pain Scores and Opioid Consumption in the United States versus Europe

• European patients reported significantly less pain on the first day after orthopedic surgery than American patients

• A larger proportion of American patients received opioids on the first postoperative day compared to Europeans 0

123456789

1011

Mean Worst Pain (+/- SD) Day 1

United States Europe

98.3%

70.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Opioid Use on Post-Op Day 1

United States Europe

Multimodal Analgesia in the Era of Enhanced Recovery After Surgery

“The immediate challenge to improving the quality of surgical care is not discovering new knowledge, but rather how to integrate what we already know into practice.”11. Urbach DR, Baxter NN. BMJ. 2005; 330(7505):1401-1402.

Adapted from ERAS Society.

www.erassociety.org.

The Preoperative Piece: Prehabilitation and Education

• Timeframe

– Scheduling of surgery to arrival in pre-op holding

• Information management/Healthcare literacy/Expectation management

• Nutritional optimization and carbohydrate loading

• Exercise/ “prehabilitation”

• Mental health assessment

• As applicable, smoking cessation

Healthcare Literacy and Patient Factors

• A third of all patients function at or below a basic level of literacy1

• This complicates matters when these tasks are difficult1:

– Complete intake forms

– Follow written pre-op instructions

– Follow written prescriptions instructions or calculate a dose

• Only 63% of patients receive education on pain management prior to surgery2

151. Mitka M. JAMA. 2012; 307(7):653. 2. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Anesth Analg. 2003; 97(2): 534-540.

Variable Any Education

Before surgery

Total (n=250) 63%

Inpatient (n=129) 63%

Outpatient (n=121) 63%

After surgery

Total (n=250) 66%

Inpatient (n=129) 70%

Outpatient (n=121) 61%

Patient Education

The Pre-op Piece: Enhanced Recovery

• Avoid N/G tubes

• Selective bowel prep

• Goal directed therapy

• Appropriate use of medications

• Use short acting anesthetics

• Avoid PONV

• Maximize use of MMA

The Intraoperative Piece: SCIP + Anesthetic Standardization

• Timeframe– Arrival in preop holding until discharge to ward

• Surgical Care Improvement Project (SCIP) Measures

– Antibiotics, glucose, bladder, temperature, beta-blocker, venous thromboembolism (VTE)

Intra-op (Con’t)

Avoidance of nasogastric tubes

Selective bowel preparation

Goal-directed fluid therapy

Appropriate use of premedication

Use of short-acting anesthetics

Avoidance of post-operative vomiting

Maximize use of multimodal analgesia

The PostOperative Piece: Enhanced Recovery

• Timeframe

– Arrival on ward until return to baseline function

• Maximize use of multimodal analgesia

• Stimulation of gut motility

• Early enteral feeding

• Early mobilization

• Early removal of drains/catheters

• Information management

– Healthcare literacy

– Expectation management

Opioid Monotherapy and the Shift to Multimodal Analgesia

for Pain Management

Chapman CR, Stevens DA, Lipman AG. Quality of postoperative pain management in American versus European institutions. J Pain Palliat Care

Pharmacother. 2013 Dec;27(4):350-8.

Pain Scores and Opioid Consumption in the United States versus Europe

• European patients reported significantly less pain on the first day after orthopedic surgery than American patients

• A larger proportion of American patients received opioids on the first postoperative day compared to Europeans 0

1

2

3

4

5

6

7

8

9

10

Mean Worst Pain (+/- SD) Day 1

United States Europe

98.3%

70.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Opioid Use on Post-Op Day 1

United States Europe

Multimodal Techniques for Perioperative Pain Management

• Multimodal analgesia combines two or more analgesic agents or techniques that act by different mechanisms to provide analgesia

• American Society of Anesthesiologists (ASA) Task Force recommendations – Unless contraindicated, all patients should receive an around-

the-clock regimen of a non-opioid agent

• Non-steroidal anti-inflammatory drugs (NSAIDs)

• Cyclooxygenase-2 specific drugs (COXIBs)

• Acetaminophen

– Consider supplemental regional anesthesia techniques

American Society of Anesthesiologists (ASA) Task Force. Anesthesiology. 2012; 116(2): 248-273.

Multimodal Analgesia Sites of Action

• Multimodal analgesia combines two or more analgesic agents or techniques that act by different mechanisms to provide analgesia to optimize efficacy while minimizing risk of adverse events1

Opioids2

α2-agonists2

Acetaminophen3

NMDA antagonists4

Local anesthetics2

Opioids2

α2-agonists2

Local anesthetics2

NSAIDs2

COXIBs2

Redrawn with permission from Kehlet H, Dahl JB. The value of

multimodal analgesia in postoperative pain treatment. AnesthAnalg.

1993;77:1049. NMDA=N-methyl-D-aspartate.

1. American Society of Anesthesiologists. Anesthesiology. 2012: 116: 248-273. 2. Gottschalk A, Smith DS. Am Fam Physician.

2001; 63: 1979-1984. 3. Smith HS. Pain Physician. 2009; 12: 269-280. 4. Wu CL, Raja SN. Lancet. 2011; 377: 2215-2225.

Opioid Monotherapy vs. Multimodal Approach to Acute Pain Management

NSAIDs = non-steroidal anti-inflammatory drugs; COX-2 = cyclooxygenase-2

1. Aubrun F, Langeron O, Quesnel C, Coriat P, Riou B. Anesthesiology. 2003; 98(6): 1415-1421. 2. Crews JC. JAMA. 2002; 288: 629-632.

3. World Health Organization. Pain relief ladder. http://www.who.int/cancer/palliative/painladder/en/. Accessed September 10, 2014.

4. Ventafridda V, Tamburini M, Caraceni A, De Conno F, Naldi F. Cancer. 1987; 59: 850-856. 5. ASA Task Force. Anesthesiology. 2004; 100: 1573-1581.

+++

Opioids

+

Opioids

++

Opioids

Mild Pain

Moderate Pain

Severe Pain

1. Aubrun et al., 2003

Step 3

Steps 1 & 2 and

Local Anesthetic

Peripheral

Neural Blockade

and Sustained

Release Opioids

Step 1

Acetaminophen, NSAIDs, or COX-2 Selective Inhibitors

and

Local/regional anesthesia

Step 2

Step 2

Step 1 and

Low Doses of Opioids

Low Doses of Opioids

2. Crews 2002

3. WHO pain relief ladder

4. Ventafridda et al., 1987

5. ASA Task Force 2004

Opioid Monotherapy Multimodal Analgesia

Multiple Organizations Recommend a Non-Opioid Foundation to Multimodal Analgesia• Society Recommendations

– American Society of Anesthesiologists (ASA)1

– American Society of Pain Management Nursing (ASPMN)2

– American Society of PeriAnesthesia Nurses (ASPAN)3

– American Geriatrics Society (AGS)4

– Society for Critical Care Medicine (SCCM)5

– Surgical Societies (e.g., American Academy of Orthopaedic Surgeons)6

– Enhanced Recovery After Surgery (ERAS) Society7

• Accrediting and Quality Organizations– The Joint Commission (TJC)3

– Agency for Healthcare Research and Quality (AHRQ)3

1. ASA Task Force on Acute Pain Management. Anesthesiology. 2012; 116: 248-273. 2. Jarzyna D, Jungquist CR, Pasero C, et al. Pain Manage Nurs. 2011; 12:

118-145. 3. Wells N , Pasero C, McCaffery M. In Hughes RD, ed. Agency for Healthcare Research and Quality; 2008. 4. The American Geriatrics Society. Pain

management in the elderly. http://www.americangeriatrics.org/gsr/anesthesiology/pain_management.pdf. Accessed September 10, 2014. 5. Barr JU, Fraser GL,

Puntillo K, et al. Crit Care Med. 2013; 41(1): 263-306. 6. American Academy of Orthopaedic Surgeons. Management of hip fractures in the elderly: evidence-based

clinical practice guideline. September 5, 2014. Available at: http://www.aaos.org/Research/guidelines/HipFxGuideline_rev.pdf. Accessed March 23, 2015. 7.

Feldman LS, Delaney CP, Ljungqvist O, Carli F. (Eds.) The SAGES/ERAS ® Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery. Springer:

2015.

Treatment Considerations for Implementing Multimodal Analgesia

• Base multimodal analgesia decision on:

– Optimizing efficacy for procedure being performed1,2

– Side effects of individual medications2

– Patient factors3

– Type of surgery

– Expected severity of post-op pain

– Underlying medical conditions

– Risk-benefit ratio for the available MMA techniques

– Patient preferences or previous experience with pain

– Ease of use (around-the-clock vs as-needed)3

– Acquisition Cost vs Global Value4

1. Halawi MJ et al. Orthopedics. 2015; 38(7):616-625. 2. Buvanendran A. IARS Review Course Lectures. 2011; 58-62. Available at:

www.iars.org/assets/1/7/11_RLC_Buvanendran.pdf. Accessed October 7, 2015. 3. American Society of Anesthesiologists.

Anesthesiology. 2012; 116: 248-273. 4, Gora-Harper ML et al. Ann Pharmacother. 2001; 35(11):1320-1326.

Types of Non-Opioids Used inMultimodal Pain Treatment Plans

NMDA = N-methyl-D-aspartate; NSAIDs = non-steroidal anti-inflammatory drugs

Wu CL, Raja SN. Lancet. 2011; 377: 2215-2225.

Acetaminophen Alpha-2 agonists Gabapentinoids

acetaminophen

clonidine

dexmedetomidinegabapentin

pregabalin

Local anesthetics NMDA receptor antagonists NSAIDs

bupivacaine

lidocaine

liposomal bupivacaine

ketamine

celecoxib

ibuprofen

ketorolac

diclofenac

Note: The agents listed above are commonly employed in the perioperative management of acute pain.

This list is not meant to be a comprehensive directory of all available analgesic agents.

Sample Protocol

Intervention Details Phase of care

NutritionNutritional assessment, and protein containing supplement 3x/day x 5 days pre-op

Pre-op

CHO Loading Gatorade/juice on morning of surgery Pre-op

StrengthIncentive spirometry for 1 week prior to surgery, increase exercise daily x 2 weeks

Pre-op

Bowel PrepStandardized for all surgeons doing similar procedure (mechanical/antibiotic)

Pre-op

PremedsAvoid sedatives in patients >70 or with dementia/confusion

Pre-op

Sample Protocol

InterventionDetails Phase of care

Goal Directed Fluid Therapy

• IV Fluids on pump throughout case

• Consider SVV/PPV monitoring for specific high-risk patients

Intra-Op

Anesthetic Optimization

• Use short-acting anesthetics (avoid volatile agents)• Ketamine infusion (0.5 mg/kg for induction, followed by

0.10-0.15 me/kg/hr)• IV lidocaine infusion (1.0-1.5mg/kg with induction followed

by 1-2mg/kg/hr until emergence)• Propofol infusion (dose as needed for induction, the 50-150

mic/kg/min• Use N2O as needed

Intra-Op

GlycemicControl

• Check HgbA1C on all patients 3d prior to surgery. Cancel if level is >9%.

• If elevated in non-diabetics: Check glucose on morning of surgery, Treat as you would a Type-2 patient

• Continue glycemic control throughout perioperative period

Pre/Intra/Post-Op

Education & Expectation Management

• All patients taught by ARNP with friend/family

• Appropriately written patient education brochure providedPre/Intra/Post-Op

Sample Protocol

Intervention Details Phase of Care

Multimodal Analgesia

• Thoracic epidurals for all scheduled open procedures

• Infiltrate all wounds

• Gabapentin 600mg preop, then 300mg TID for 3d (not PRN)

• Ketamine 0.5mg/kg IV with induction of anesthesia

• Ketorolac 30mg IV in OR, then 15mg q6hr for 3d (not PRN)

• Acetaminophen 1000mg IV in OR, then IV or po q6hr for 3d (not PRN)

Pre/Intra/Post-Op

Sample Protocol

Intervention Details Phase of Care

Nausea and Vomiting Control

• 1 risk factor: ondansetron 4mg prior to induction. 2 risk factors: Dexamethasone 4mg with induction. 3 risk factors: Scopolamine patch prior to surgery OR diphenhydramine 25mg OR droperidol 0.625mg OR metoclopramide10mg. 4 risk factors: Add from the list above.

• Postoperative prophylaxis with ondansetron 4mg q6hr x 24hr (not PRN)

• Patients encouraged to chew gum for nausea treatment ad lib

Intra/Post-Op

Early Removal of Tubes and

Catheters

• Nasogastric tubes avoided unless patients have activebowel obstruction

• Bladder catheters to be removed as soon as possible

• Avoid use of invasive drains for most procedures

Intra/Post-Op

Sample Protocol

Intervention Details Phase of Care

Early Feeding and Bowel Stimulation

• Clear liquids on evening of surgery

• Gum chewing encouraged after their surgery

• Regular/full diet day after their surgery

Post-Op

Early Mobilization and Conditioning

• Patients with weakness or instability or patients over 70 receive PT consult

• Out of bed to chair on evening of surgery

• Walk 20min 4x/d starting on POD 1

• Sit in chair 6-8 hours a day

• limb and breathing exercises per hour while awake

Post-Op

Implementation Strategies

long length of stay/high complication procedures

Colorectal surgery, esophagectomy, cystectomy, pancreatectomy, hepatic resection, spine

FOLLOW-UP

IDENTIFY

GATHER

TARGET

GENERATE

COLLECT

TEAM WORK is key

surgeon, anesthesia, nursing, and admin champion

local data on length of stay, re-admits/revisits, SSI, Satisfaction and variability

protocol

analyze/re-analyze data/massage protocol

before face-to-face kickoff meeting (the most time intensive)

and measure daily for first few months

weekly

PLAN

MONITOR