reference guide for pacu lumbar fusion · muscle relaxants start with low dose see list below...

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

Lumbar Fusion

PACU Lumbar Fusion Clinical Pathway

PAIN 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.

Epidural?

Yes

No

No

Tolerates PO?

No

Is this a

CPS patient?

Yes

Yes No

Patient taking

< 60 mg

morphine/day

No

Patient taking

> 60 mg

morphine/day

Yes

Yes

Is there

adequate

analgesia?

Yes

No

Suboxone,

subutex,

Naltrexone?

Yes

CPS/POP

Consult

required

Yes

Yes

No

Lumbar Fusion

Pain Pathway

Excludes

Dr. Glazer

patients

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

Lumbar Fusion Pain Pathway

Consult APS

37246

(3PAIN)

Pathway “C” IV pathway (least

preferred) Patient

should be changed

to PO ASAP

Follow

CPS plan

Prepare discharge plan

including:

1) Weaning from opioids

2) PRN-(or) as needed

Pathway “B” Opioid tolerant

Pathway “A” Opioid Naive

Contact

CPS

3OUCH

36824

Pathway A: Opiate naïve or uses < 60 mg morphine equivalent/day (see table) “B”

Preferred

Restrict use

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

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

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 caution 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

-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

Preferred

Restrict use

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.


Patients should remain on all preoperative medications during the hospitalization unless contraindicated for the surgery.




o Obstructive sleep apnea,


o Over 70 years old.

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











































Oxycodone n/a 40 mg


Oxycontin n/a 40mg

MSContin n/a 60 mg



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.

Pathway C: IV Pathway Primary 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.

Preferred

Restrict use

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.


Patients should remain on all preoperative medications during

the hospitalization unless contraindicated for the surgery.




o Obstructive sleep apnea


o Over 70 years old


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











































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





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

Important Practice Changes for the Lumbar Fusion Pathway

Documentation Clinical Pathway in Patient’s Chart

Pa

in M

an

ag

em

en

t

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

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

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

Other 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

STANDARDIZED PATHWAY VALUE Better Pain Management

Increased Mobility, Decreased Risk Factors

Epidural? Yes

No

No

Tolerates PO?

No

Is this a

CPS patient?

Yes

Yes No

Patient taking

< 60 mg

morphine/day

No

Patient taking

> 60 mg

morphine/day

Yes

Yes

Is there

adequate

analgesia?

Yes

No

Suboxone,

subutex,

Naltrexone?

Yes

CPS/POP

Consult

required

Yes

Yes

No

Lumbar Fusion

Pain Pathway

Excludes

Dr. Glazer

patients





CPS Consult Patients on Methadone, Suboxone, Subutex,

Buprenorphine, and Naltrexone IM or for any patient taking > 60 mg

morphine equivalents/day for > 2 weeks

Lumbar Fusion Pain Pathway

Consult APS

37246

(3PAIN)

Pathway “C” IV pathway (least

preferred) Patient

should be changed

to PO ASAP

Follow

CPS plan

Prepare discharge plan

including:

1) Weaning from opioids

2) PRN-(or) as needed

Pathway “B” Opioid tolerant

Pathway “A” Opioid Naive

Contact

CPS

3OUCH

36824

reference guide for pacu lumbar fusion · muscle relaxants start with low dose see list below...

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