Beth Israel Deaconess Medical Center Department of Anesthesia and Critical Care

SOP

Title: Lumbar Spinal Fusion Pain Management Pathways

SOP #: ANES CLN 100-020

Owner: Dr. Lisa Kunze Review Date: Dec. 2018 Next Review Date: Dec. 2021

Lumbar Spinal Fusion Pain Management Pathways

Lisa Kunze

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Holding Area Meds

• All patients should get the following meds unless there is a contraindication:

– Acetaminophen 1000 mg PO

– Pregabalin 75-150 mg or Gabapentin 300-600 mg PO (or the patient’s usual dose)

– Celecoxib 400 mg PO (except Dr. Glazer’s patients)

– Oxycontin 10 mg PO, or the patient takes his/her usual dose if already on Oxycontin.

Holding Area Discussion

• Discuss with the spine team and confirm the following.

– Is neuromonitoring being planned?

– Is an intraoperative epidural being planned?

• If YES call APS (Page 3PAIN)

– Discuss the Pathway (A, B, C) the patient falls under (see next slide)

– Is a CPS consult required for any patient?

• If YES call CPS (Page 3OUCH) (See next slide)

Patients on opioid agonist/antagonists

Examples: Naltrexone, Suboxone, Methadone, Subutrex, Buprenorphine

CPS Consult Required

Patients strictly NPO or unable to get comfortable in the PACU on PO meds

Pathway C: IV Analgesia

Patient taking MORE than 60 mg of morphine equivalents/day for > 2 weeks

Pathway B: Opioid Tolerant

Patient taking LESS than 60 mg of morphine equivalents/day for 2 weeks

Pathway A: Opioid Naïve

Decide which pathway the patient falls under and click the title

Morphine Equivalents in mg/Day

IV PO

Morphine 20 mg 60 mg

Oxycodone n/a 40 mg

Hydromorphone 4 mg 20 mg

Oxycontin n/a 40 mg

MS Contin n/a 60 mg

Oxymorphone n/a 50 mg

Intraoperative pain management for Pathway A (Opioid Naïve) patients

Pathway A

• Administer antibiotics as per ID recommendations as posted in the OR and Anesthesia intranet • Minimize or omit intraoperative Fentanyl use • Use one of these per clinical judgment:

• Hydromorphone or Morphine boluses • Consider Ketamine bolus (0.1-0.2 mg/kg) and

Infusion (0.1-0.2 mg/kg/hr)

Intraoperative pain management for Pathway B (Opioid Tolerant) patients

Pathway B

• Administer antibiotics as per ID recommendations as posted in the OR and Anesthesia intranet • Minimize or omit intraoperative Fentanyl use • Use one of these per clinical judgment:

• Hydromorphone or Morphine • Consider Ketamine bolus (0.1-0.2 mg/kg) and

Infusion (0.1-0.2 mg/kg/hr) • Consider Dexmedetomidine infusion 0.2-0.7

mcg/kg/hr

Intraoperative pain management for Pathway C (IV Analgesia) patients

Pathway C

• Administer antibiotics as per ID recommendations as posted in the OR and Anesthesia intranet • Minimize Fentanyl use • Use one of these per clinical judgment:

• Hydromorphone or Morphine • Consider Ketamine bolus (0.1-0.2 mg/kg) and

Infusion (0.1-0.2 mg/kg/hr) • Consider Dexmedetomidine infusion 0.2-0.7

mcg/kg/hr

Intraoperative pain management for CPS Consult Required patients

CPS Consults

• Please discuss the intraoperative analgesic management with CPS if appropriate.

• Administer antibiotics as per ID recommendations as posted in the OR and Anesthesia intranet

• Minimize or omit intraoperative Fentanyl use

• Use one of these per clinical judgment: • Hydromorphone or Morphine

• Consider Ketamine bolus (0.1-0.2 mg/kg) and Infusion (0.1-0.2 mg/kg/hr) • Consider Dexmedetomidine infusion 0.2-0.7 mcg/kg/hr.

PACU pain management for Pathway A (Opioid Naïve) patients

The goal of PACU pain management is to try to keep patients on PO pain medications as far as possible and resort to IV pain medications in exceptional cases.

Pathway A

• Acetaminophen • Opioid (Choose one):

• Oxycodone PO • Hydromorphone PO • Morphine PO

• Anticonvulsants • Oral spinal cord skeletal muscle relaxants • Oxycontin or MS Contin • Ketamine infusion (with APS consult) • Celecoxib (if not administered previously)

PACU pain management for Pathway B (Opioid Tolerant) patients

The goal of PACU pain management is to try to keep patients on PO pain medications as far as possible and resort to IV pain medications in exceptional cases.

Pathway B

• Acetaminophen • Opioid (Choose one):

• Oxycodone PO • Hydromorphone PO • Morphine PO

• Anticonvulsants • Oral spinal cord muscle relaxants • Oxycontin or MS Contin • Clonidine patch or tablet (with APS consult) • Ketamine infusion (with APS consult) • Celecoxib (if not administered previously)

PACU pain management for Pathway C (IV Analgesia) patients

The goal of PACU pain management is to try to keep patients on PO pain medications as far as possible and resort to IV pain medications in exceptional cases.

• Opioid (Choose one):

• PCA Hydromorphone • PCA Morphine

• Acetaminophen IV • Oral spinal cord muscle relaxants

Pathway C

PACU Pain management for CPS Consult Required patients

• Please discuss the PACU analgesic management with CPS (see tables for suggestions).

CPS Consults

1st line Oral drug administration table for Pathway A (Opioid Naïve) patients

Opioid Naïve Pathway A

Drug Initial Dose Adjustment

Acetaminophen 1000 mg 500-1000 mg Q6-8H

Oxycodone 5- 10 mg 10-15 mg Q4H

Hydromorphone 2-4 mg 4-6 mg Q3-4H

Morphine 15 mg 15 mg Q4H

Oxycontin 10 mg 10mg Q12H (check with APS)

MS Contin 15 mg 15 mg Q8-12H (check with APS)

Gabapentin 100-300 mg 300-900 mg Q8H

Pregabalin 25-75 mg 75-300 mg Q12H

Topiramate Use patient’s regimen Use patient’s regimen

Diazepam 5 mg 5-10 mg QD-BID

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

Cyclobenzaprine 5 mg 5-10 mg Q8H

1st line Oral drug administration table for Pathway B (Opioid Tolerant) patients

Opioid Tolerant Pathway B

Drug Initial Dose Adjustment

Acetaminophen 1000 mg 500-1000 mg Q6-8H

Oxycodone 10-15 mg 20 mg Q4H

Hydromorphone 4-6 mg 4-8 mg Q3-4H

Morphine 15-30 mg 30 mg Q4H

Oxycontin 10 mg or patient's dose 10 mg Q12H (check with APS/CPS)

MS Contin 15 mg or patients dose 15 mg Q8-12H (check with APS)

Gabapentin 300-600 mg 300-900 mg Q8H

Pregabalin 25-75 mg 75-300 mg Q12H

Topiramate Use patient’s regimen Use patient’s regimen

Diazepam 5 mg 5-10 mg QD-BID

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

Cyclobenzaprine 5 mg 5-10 mg Q8H

Drug administration table for Pathway C (IV Analgesia) patients

IV Analgesia Pathway C

Drug Initial Dose Adjustment PCA

Hydromorphone

0.5 to 1 mg IV Q4H, 0.25mg if >70 years old

0.12-0.36 mg Q6min

Morphine 1-2 mg IV Up to 4 mg IV Q4H 0.5-2.0 mg Q6min

Acetaminophen 1000 mg IV 500 mg Q6H or 1000 mg Q8H

Lorazepam 0.5-1 mg IV/IM 0.25-2 mg IV Q6-8H

Diazepam 5 mg IV/IM Up to 10 mg IV Q6-8H

Drugs that should be initiated or adjusted with CPS consult only

Drug Initial Dose Adjustment

Metaxalone 800 mg Q8H to Q6H

Methocarbamol 500 mg Q4H Up to 1500 mg Q8H

Meperidine 25-100 mg PO/IV/IM Q6H

Baclofen PO 5 mg Q8H Up to 15 mg Q8H

Baclofen pump Consult CPS interrogation preop and postop

Clonidine 0.1 mg Q12H Up to 0.2 mg Q12H

Clonidine transdermal

0.1 mg Q 7 days None

Tizanidine 2-4 mg PO Q8H 4 mg Q8H after several days

Topiramate 25-50 mg Q12H Up to 200 mg/day