postoperative pain control what to do after pca? spencer s. liu, md clinical professor of...
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Postoperative pain controlWhat to do after PCA?
Spencer S. Liu, MD
Clinical Professor of Anesthesiology
Director Acute and Recuperative Pain Services
Disclosure
HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation.
Spencer S. Liu, MD
Hospital for Special Surgery
Disclosure: I do not have a financial relationship with any commercial interest.
Background
• Postoperative pain is a key issue for patients
• Large surveys indicate patients are more concerned about pain (59%) than surgical outcome (51%)
• Unfortunately, this concern remains justified
Anesth Analg 2003:97:534
Background
• Multiple surveys report continued poor postoperative pain control
• Most recently in 2003– 250 adults– Mix of in-patient and ambulatory– 75% reported experiencing pain during or
after surgery– 73% reported moderate to severe pain
Is postoperative pain that bad?
• Inherently, who wants pain– Guidelines from:
• WHO• APS• ASA
• Regulatory requirement: JCAHO• Key patient satisfaction surveys: Press Ganey• Pain can create bad outcomes
– Morbidity– HRQOL– Development of chronic pain
Anesth Analg 2007:104:689Anesth Analg 2007:105:789
What can one do?
• Acute Pain Services are popular and effective
• Typically expensive
• Typically manage PCA modalities
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Anesthesiology. 104(5):1033-1039,2006
How well is pain controlled after the APS signs off?
• What happens after the APS signs off?
• Typically, the surgeons alone manage postoperative pain with po analgesia and write the home prescriptions
• Not so good per patient surveys
• Same here at HSS
• In March 2007– Negative patient letters
Recuperative Pain Medicine• RPM rolled out in
August 2007– Recurrent negative
themes in patient letters, comments, and New York Times editorials
• Post-PCA patients experienced inadequate pain management with oral analgesics
• Post-PCA patients did not have easy access to a pain management expert
Based on these reports, a plan was formed
• Multidisciplinary team– Surgeon in Chief– Anesthesiologist in Chief– Executive Leadership– Director of Risk Management– Director of APS– Director of CPS– CAMS– Director of Patient education
Patient Education and Pain Management
Preoperative
Postoperative PCA
Postoperative PO
APS
Education“Pre-emptive” medications
Pain management Patient education Staff education
How to measure impact?
• No currently standardized, validated tools• We chose 3 outcome measure for before and
after implementation measurement– Press Ganey Survey
• Administered to all postoperative patients to assess satisfaction
• Has specific questions on pain management• Benchmarked against similar institutions
– Staff satisfaction survey– Number of calls to Helpline
• Less is better• Do all the work upfront
Preoperative educational role of RPM
• Worked with Patient education to update and expand sections on perioperative analgesia for pre-operative patient education classes for total joint replacement and spine surgery
Clinical role of RPM
• Designed to fill identified gaps
• Provide a seamless transition from the IV/Epidural PCA to oral medications
• Continued pain management monitoring thru to discharge.
• The RPM service collaborates with both the Acute Pain Service and Chronic Pain Service.
Administrative and Educational Role of RPM for postoperative care• Created discharge medication
policy– Correct meds– Enough pain meds until first FU
visit
• Created discharge booklet – Written resource for patients
on basic pain management information.
• Expectations for pain control• Common pain medications• Common expected side
effects
– All inpatients receive at discharge.
Patient Education and Pain Management
Preoperative
Postoperative PCA
Postoperative PO
APS
Education“Pre-emptive” medications
Pain management Patient education Staff education
RPM Patient Volume
• Since August 2007, the volume of inpatient consults has steadily increased yearly
• Confirming need for further medical pain management after discontinuation of PCA therapy.
2007 2008 2009 2010
Jan 0 74 107 102
Feb 0 60 92 81
Mar 0 48 76 101
Apr 0 76 100 116
May 0 49 96 107
Jun 0 68 103 90
Jul 0 53 117 83
Aug 0 86 90 108
Sep 16 142 86 128
Oct 56 62 104 154
Nov 56 103 81 106
Dec 24 60 74 156
Total 152 881 1126 1332
Results of RPM Implementation
• Our primary outcome measure was the Press Ganey satisfaction survey.
• Philips, B., Liu, S., et al. “Creation of a Novel Recuperative Pain Medicine Service to Optimize Postoperative Analgesia and Enhance Patient Satisfaction”,HSS Journal (February 2010).
75
80
85
90
95
100
Perc
entil
e Ra
nkin
g
Large PG 91 97 99 97 98 99 99 99 99 99 99
Magnet PG 84 97 99 98 97 99 99 98 99 98 97
HSS PG 92 92 99 90 99 99 99 99 99 99 99
2008 1st
Quart
2008 2nd
Quart
2008 3rd
Quart
2008 4th
Quart
2009 1st
Quart
2009 2nd
Quart
2009 3rd
Quart
2009 4th
Quart
2010 1st
Quart
2010 2nd
Quart
2010 3rd
Quart
RPM HelpLine
0
5
10
15
20
25
30
35
40
45
50
Jan-0
9
Mar-
09
May-0
9
Jul-09
Sep-0
9
Nov-0
9
Jan-1
0
Mar-
10
May-1
0
Jul-10
Sep-1
0
Nov-1
0
Jan-1
1
Number of Phonecalls
Start of RPM/ARJR Pilot Program (October 2010)
Staff satisfaction survey
• Returned by– 81 RNs– 7 surgical PAs
• 92% rated RPM as extremely helpful
Cost of RPM
• Cost for an NP ~ 150,000 USD
• 12.5-15 USD/pt visit• Could also use a
Physician’s Assistant
0
2000
4000
6000
8000
10000
12000
14000
2009 2010
Number of PCAs
Systemic multimodal analgesia
NSAIDs, COX2, Acetaminophen
Impact of Reuben retractions
• NSAIDs– No effect as no RCT retracted
• COX2– Only 1 RCT with 60 patients retracted– One additional RCT demonstrating analgesic
benefit with celecoxib in TKR• BMC Musculoskelet Disord 2008;9:77.
• Acetaminophen– No effect as no RCT retracted
Gabapentin
Copyright restrictions apply.
Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556
Figure 1. Flow diagram of the review
Copyright restrictions apply.
Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556
Figure 2. Pain intensity difference between the control and gabapentin groups (PIDc-g) at rest (panel A) and on movement (panel B) on VAS 0-100 during 24 h observation after a
single 1200 mg dose 1-2 h before surgery
Copyright restrictions apply.
Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556
Figure 3. Effect of preoperative gabapentin on postoperative opioid consumption
Side effects
• Reduction in opioid related side effects– Nausea: NNT=25– Vomiting: NNT=6– Urinary retention: NNT=7
• Adverse effects– Sedation: NNH=35– Dizziness: NNH=12
Pregabalin
• Laparoscopic hysterectomy– Opioid sparing– Increased dizziness
• Laparoscopy– Better analgesia– Trend toward increased dizziness
• Laparoscopic cholecystectomy– Better analgesia– Opioid sparing BJA 2008:101:700
Conclusions
• Discussed agents are efficacious
• Modest benefit
• NSAIDs and gabapentanoids have most to offer– Reduced opioid consumption– Reduced side effects– NSAIDs have more risk
Non-traditional techniques
• Acupuncture• Music• Static magnet• Massage
Acupuncture
Anesth Analg 2008:106:611
Acupuncture
• May also depend on belief system
• 47/47 studies from China, Japan, and Taiwan found efficacy
• 53/96 studies from US, UK, and Sweden found efficacy
Music
Music
• Several RCTs
• Soft, relaxing music vs none during general anesthesia– Open inguinal hernia repair– Varicose vein stripping– Hysterectomy
• Very modest and short lived benefit from music Acta Anaesthesiol Scand 2003:47, 278
Acta Anaesthesiol Scand 2001:45, 812Eur J Anaesthesiol 2005:22, 96
Ambulatory procedures
Intraop
music
Control
Pain in PACU
(0-10)
4.2 3.9
Patient satisfaction
4 3.9
Morphine
(mg)
14.4 16.9 Anesth Analg 2010:110:208
Magnet therapy
• Multi-billion dollar industry
• Mecanisms?– Increased blood flow– Altered neuron firing
thresholds
Massage
Summary
• RPM service is efficacious– Probably cost effective– Can use different staffing models
• Optimize systemic analgesics
• Role of CAMS?– Acupuncture has best evidence