reference guide for pacu lumbar fusion - harvard · pdf filelumbar fusion clinical pathway all...

Lumbar Fusion

CLINICAL PATHWAY All patient variances to the pathway are to be circled and addressed in the progress notes.

This Clinical Pathway is intended to assist in clinical decision making by describing a range of generally acceptable intervention and outcomes. The guidelines attempt to define practices that meet the needs of most patients under most circumstances. However, the ultimate judgment must be made based on circumstances that are relevant to that patient and treatment may be modified according to the individual patients needs.

Reference Guide for PACU

PACU Lumbar Fusion Clinical PathwayPAIN MANAGEMENT / COMFORT – PAIN GUIDE

Preoperative Medications:

1) Acetaminophen Dose: 1000 mg PO Contraindications: severe liver dysfunction,

allergy, use within previous 6 hours

2) Pregabalin OR Gabapentin OR Home Dose if taking Mscontin or Oxycontin

Doses: Please consider contributions from other sedating agents or medical comorbidities and modify dose accordingly.

i. Pregabalin: • 150 mg if < 70 yr old and > 70 kg • 75 mg if > 70 old or < 70 kg ii. Gabapentin: • 600 mg if < 70 yr old and > 70 kg • 300 mg if > 70 yr old or < 70 kg Contraindications: renal dysfunction (GFR < 30),

allergy Chronic users should receive their scheduled dose

in preop holding if they did not take it prior to coming to the hospital.

3) Oxycontin Dose: 10 mg if not taking long-acting narcotic

chronically Patients taking MScontin, oxycontin, methadone

should receive their regularly scheduled dose instead.

4) Celecoxib Dose: 400 mg x 1 Contraindications: • Significant renal dysfunction, platelet

dysfunction • Severe CAD • Allergy (remember this drug may be

problematic in patients with sulfa allergy)

Intraoperative Analgesia Management suggestions:

1) Opioids a. Fentanyl: minimize use b. Hydromorphone/Morphine/Methadone:

Use intraoperatively as needed.

2) Ketamine: this is useful to spare opioids and to reduce risk of hyperalgesia. It is useful in highly opioid tolerant patients and in neuromonitoring cases.

Bolus dosing: 0.1-0.2 mg/kg after induction Drip: 0.1-0.2 mg/kg/hr Side effect profile is minimal using these

dosing strategies

3) Dexmedetomidine: This is very effective in highly opioid tolerant patients. Can cause significant sedation in higher doses. Can cause bradycardia and hypotension, dry mucous membranes.

Dose: 0.2-0.7 mcg/kg/hr (IBW) Bolus (use great caution) 5-10 mcg q 5 minutes

up to 1 mcg/kg IBW

4) Anti-Infectives: Antibiotics are per ID recommendations. These recommendations are posted in the OR or available on the portal.

Lumbar Fusion Pain Pathway

Epidural?

Tolerates PO?

Patient taking < 60 mg

morphine/day

Suboxone, subutex,

Naltrexone?

Patient taking> 60 mg

morphine/day

Pathway “B”Opioid tolerant

CPS/POP Consultrequired

Follow CPS plan

Pathway “A”Opioid Naive

Pathway “C”IV pathway (least preferred) Patient

should be changed to PO ASAP

Consult APS 37246

(3PAIN)

Is this aCPS patient?

Is thereadequate

analgesia?

Contact CPS

3OUCH36824

Prepare discharge plan including:1) Weaning from opioids2) PRN-(or) as needed

Excludes Dr. Glazerpatients


Yes

Yes

Yes

Yes

No

No

No

Yes

No

No

Yes

YesNo

Yes

No

Yes

Generalized Pain Pathway Descriptions:

A Patients that are Opiate Naive: < 60 mg Morphine Equivalent/day

B Patients that are Opiate Tolerant: > 60 mg Morphine Equivalent/day

C Patients Intolerant of oral medications or strictly NPO

CPS Consult Patients on Methadone, Suboxone, Subutex, Buprenorphine, and Naltrexone IM or for any patient taking > 60 mg morphine equivalents/day for > 2 weeks

Pathway A: Opiate naïve or uses < 60 mg morphine equivalent/day (see table) “B”Drug Initial dose Frequency Adjustment options

Acetaminophen1 1000 mg Q 8 hours 500 mg Q 6-8 hours

Oxycodone 5-10 mg PO Q 4 hours 10-15 mg Q 4 hours

Hydromorphone 2-4 mg PO Q 4 hours 4-6 mg, can give Q 3hours

Morphine PO (MSIR)

15mg PO Q 4 hours None, contact APS

Anticonvulsants Start with low dose

See list below

Muscle relaxants Start with low dose

See list below

Oxycontin2 10 mg PO Q 12 hours Contact APS

MSContin2 15 mg PO Q 12 hours Q 8 hours, Contact APS

Ketamine drip (with APS consult only)

0.1-0.3 mg/kg/hr Infusion Contact APS

Celecoxib3 400 mg PO Once/day 200 mg BID3 x 24 hr

1. Acetaminophen: decrease dose or avoid in patients with liver dysfunction.

2. Consider omitting in opioid naïve patients who are not taking any opioids at baseline.

3. Single preoperative celecoxib dose OK. If celecoxib or ketorolac are needed postop, attending surgeon approval is required.

PO Pain Medication Pathways:Patients should remain on all preoperative medications during

the hospitalization unless contraindicated for the surgery.

Use fewest number of medications required at lowest doses necessary.

Limit long-acting opioids to 5 days following discharge unless patients are stabilized on them prior to surgery.

Use caution with combining narcotics and sedatives in patients with:

o Obstructive sleep apnea

o Cognitive dysfunction

o Over 70 years old

Restrict use

Preferred

IV breakthrough Pain Medications:Drug Dose Frequency Adjustments

Hydromorphone 0.5-1 mg Q 4 hours 0.25 mg patients > 70 years old

Morphine 1-2 mg Q 4 hours 0.5 – 4 mg

Meperidine 25-100 mg PO/IV/IM Q 6 hours APS/CPS only

Anticonvulsant Medications for Pain Management (all PO only):Drug Dose Frequency Adjustments 1) Decrease the dose in renal

insufficiency

2) Decrease the dose in patients > 70 years old.

3) Use caution (avoid) in patients with cognitive dysfunction.

Gabapentin 100-300 mg (naïve) Q 8 hours 300 mg-900 mg Q 8 hr

Pregabalin 75-150 mg Q 12 hours 75-300 mg Q 12 hr

Topiramate 25-50 mg (APS/CPS only unless stabilized on drug)

Q 12 hours 25-200 mg/day

Muscle Relaxants for Pain Management:Drug Dose Frequency Adjustments 1. Increased risk of serotonin syndrome

when used in patients on SSRIs.

2. Initiate with recommendation by APS or CPS only. Continue drug if patient has been stabilized on one of these drugs preoperatively.

With all of these drugs use great cau-tion in patients > 70 years old. They may increase the risk of delirium especially in combination with other medications.

If patient is stabilized on regimen, please consider modifying dose rather than add-ing another drug in the same class.

Diazepam 5 mg PO BID-QID prn 10 mg BID-QID

Lorazepam 0.5-1 mg PO BID-TID prn 2 mg BID-TID

Flexeril1 (cyclo-benzaprine)

5 mg PO Q 8 hours 10 mg Q 8 hours

Skelaxin (metaxalone)

800 mg PO(APS/CPS only2)

Q 8 hours 800 mg Q 6 hours

Robaxin (methocarba-mol)


Q 4 hours 1000 mg Q 6 hours, 1500 mg Q 8 hours x 48 hours

Baclofen PO 5 mg PO(APS/CPS only2)

Q 8 hours 10-15 mg Q 8 hours

Baclofen pump Consult CPS for interrogation preop and postop

α-2 adrenergic agonists: Drug Dose Frequency Adjustments These drugs should be initiated by APS

or CPS only.

If patients are taking these preoperatively, do NOT discontinue abruptly.

Avoid in patients > 70 years old unless stabilized on regimen.

Clonidine 0.1 mg PO Q 12 hr 0.2 mg Q 12 hrs over several days

Clonidine transdermal 0.1 mg patch Q 7 days none

Tizanidine 2-4 mg PO Q 8 hours 4 mg Q 8 hrs after several days

Morphine Equivalents (in mg/day):Drug IV PO Methadone and buprenorphine equivalents are controversial.

Do not make adjustments without consulting CPS or APS.

Consult CPS for patients on Methadone, Suboxone, Subutex, buprenorphine, Naltrexone IM or for any patient taking greater than 60 mg morphine equivalents per day for greater than 2 weeks.

Morphine Sulfate 20 mg 60 mg

Oxycodone n/a 40 mg

Hydromorphone 4 mg 20 mg

Oxycontin n/a 40mg

MSContin n/a 60 mg

Fentanyl patch 25 mcg/hr n/a

Oxymorphone n/a 40-50 mg

Pathway B: Opiate tolerant patients (> 60 mg morphine equivalents/day) “C”.

a) These patients should have a preoperative POP consult with CPS.

b) If patients do not have a CPS or POP consult, please use the suggested doses listed below. Consider APS consult.

c) Please use IV breakthrough narcotics as listed for opiate-naïve patients

Drug Initial dose Frequency Adjustment options

Oxycodone 10-15 mg PO Q 4 hours 20 mg Q 4 hours

Hydromorphone 4-6 mg PO Q 4 hours 4-8 mg, may give Q 3hours

Morphine PO (MSIR) 15-30mg PO Q 4 hours 30 mg Q 4 hours

Acetaminophen 1000 mg PO Q 8 hours 500 mg Q 6-8 hours1

Anticonvulsants4 Start with low dose. (see note 4 below)

See list below

Muscle relaxant Start with low dose.

See list below

Oxycontin 10 mg (or preoperative dose)

Q 12 hours Use APS/CPS recommended dose

MSContin 15 mg (or preoperative dose)

Q 8-12 hours Use APS/CPS recommended dose

Clonidine(APS consult unless patient taking preoperatively)

0.1 mg patch +/- tablet

Q 7 days Contact APS for any dosing adjustments

Ketamine drip(APS consult required)

0.1-0.3 mg/kg/hr Infusion Contact APS2

Celecoxib3 400 mg PO Once/day After initial dose: 200 mg BID3

1. Acetaminophen: decrease dose or avoid in patients with liver dysfunction.

2. APS will manage ketamine infusions in conjunction with CPS.

3. Single preoperative dose Celecoxib permitted. If celecoxib or ketorolac are needed postop, attending surgeon approval is required.

4. Patients who have been stabilized on anticonvulsants should continue on preoperative dose. Consider increasing dose for inadequate analgesia if patients are having pain and are not overly sedated.

PO Pain Medication Pathways:Patients should remain on all preoperative medications during the

hospitalization unless contraindicated for the surgery.Use fewest number of medications required at lowest doses necessary.



o Obstructive sleep apnea,


o Over 70 years old.

Restrict use

Preferred






insufficiency


























or CPS only.










Oxycodone n/a 40 mg


Oxycontin n/a 40mg

MSContin n/a 60 mg



Pathway C: IV PathwayPrimary use of IV analgesia should be reserved for patients who are:

1) Strictly NPO

2) Intolerant of PO analgesia due to N/V or other gastrointestinal concerns.

Avoid mixing IV and PO pathways without consultation from APS or CPS.

Drug Dose Frequency Adjustments

PCA hydromorphone 0.12-0.24 mg Q 6 min Up to 0.36 mg Q 6 min.

PCA morphine 0.5- 1 mg Q 6 min Up to 2 mg Q 6 min.

Acetaminophen 1000 mg IV Q 6 hours 500 mg Q 6 hours or 1000 mg Q 8 hours.

Lorazepam1 0.5-1 mg IV/IM Q 6-8 hours 0.25-2 mg IV Q 6-8 hours1

Diazepam 5 mg IV/IM Q 6-8 hours 10 mg IV Q 6-8 hours1

Ketorolac2 15-30 mg Q 6hr x 48 hr

1. Respiratory depression risk is high when combined with opioids. This is increased in patients with OSA, > 70 years old, those with cognitive or neurological dysfunction. Diazepam had active metabolites that result in increased sedative effects over time.

2. Must have attending surgeon approval before administering NSAIDS.

Contact APS for management of pain in post-operative patients with inadequate analgesia despite use of pathway medications. The number on the VAS may not reflect clinical picture. Consider baseline pain score.

Contact CPS for management of patients with a POP consult. If you are not sure, call APS.

PO Pain Medication Pathways:Patients should remain on all preoperative medications during

the hospitalization unless contraindicated for the surgery.Use fewest number of medications required at lowest doses necessary.



o Obstructive sleep apnea


o Over 70 years old

Restrict use

Preferred






insufficiency


























or CPS only.










Oxycodone n/a 40 mg


Oxycontin n/a 40mg

MSContin n/a 60 mg



Lumbar Fusion Clinical Pathway 2015

What: Clinical Pathway Practice Changes

Who: Lumbar Fusion Patients

Why: Clinical Pathway Education related to Pain Management, Mobility, Patient Education, and Discharge Planning

Goals:

1. Improved Pain Management with Early Utilization of Oral Pain Medications

2. Increase Early Mobilization to Prevent or Decrease Post-Operative Risk Factors. (ie. Ileus, Blood Clots, and Infections)

3. Improve Documentation of Patient Progress related to pain and mobility.

4. Enhanced Continuous Patient Education and Discharge Planning

5. Decrease the Length of Stay in the Patients S/P Lumbar Fusion Generalized Pain Pathway Descriptions:





Important Practice Changes for the Lumbar Fusion Pathway

Documentation Clinical Pathway in Patient’s Chart

Actual designation of a Pain Pathway A, B, C, or CPS Consult

Use of pre-op oral pain medications: Gabapentin, Tylenol, Oxycontin/MS Contin

No use of PCA’s post-op: Utilizing oral pain medications immediately post op, along with IV pain medications for breakthrough pain instead of PCA:

• Overview of doses

• “OK” to use full dose

• Explain adjustment options

Strict Q4H pain check-ins

• Important to stay ahead of the pain

• Set appropriate expectations with the patient (language?)

• Wake patients at night

If a brace is indicated, use of prefabricated braces are issued to patients by POD 0/POD 1. (Exception of Dr. Glazer’s patients)

Early Mobilization by Nursing. PT Eval and Treatment: POD#2 and POD#4.

Use of standing PO Bowel Medications and addition of SC Methylnaltrexone POD 1

Use of PO Flomax POD #1 in men ages 55 years of age or older

Starting SC Heparin POD #1, unless patient is ambulating

Pai

n M

anag

emen

t

Bracing

Activity

Other

STANDARDIZED PATHWAY VALUE Better Pain Management Increased Mobility, Decreased Risk Factors


Epidural?

Tolerates PO?

Patient taking < 60 mg

morphine/day

Suboxone, subutex,

Naltrexone?

Patient taking> 60 mg

morphine/day

Pathway “B”Opioid tolerant

CPS/POP Consultrequired

Follow CPS plan

Pathway “A”Opioid Naive

Pathway “C”IV pathway (least preferred) Patient

should be changed to PO ASAP

Consult APS 37246

(3PAIN)

Is this aCPS patient?

Is thereadequate

analgesia?

Contact CPS

3OUCH36824

Prepare discharge plan including:1) Weaning from opioids2) PRN-(or) as needed

Excludes Dr. Glazerpatients


Yes

Yes

Yes

Yes

No

No

No

Yes

No

No

Yes

YesNo

Yes

No

Yes

Generalized Pain Pathway Descriptions:





reference guide for pacu lumbar fusion - harvard · pdf filelumbar fusion clinical pathway all...

Documents