Postoperative Pain Management, ERAS,

Focus on Policies and Protocols

ARAKESHISIHAN,MD,FACS

16thAnnualCME&CDEMeetingLasVegas,Nevada

May2019

Disclaimer

NoFinancialRelationshiptoDisclose

• EnhancedRecoveryAfterSurgery(ERAS)andPostoperativePainManagement.

• MultimodalAnalgesiaforPostoperativePain.Risks,Safety,andEfficacy,ReducingCostsandLOS.

• ReviewofAmericanPainSocietyPostoperativePain

Objective(1)

•ERASSociety,ObjectivePatientCentered•http://erassociety.org•http://erasusa.org•RegionalPartners•DifferenceDisciplines•Multimodal,Multidisciplinary•“EvidenceBasedMedicine”

•OutcomesDriven•BasedonData

ERAS-EvolutionEnhancedRecoveryAfterSurgery

• 1990’sProfessorHenrikKehlet–UniversityofCopenhagen(Denmark)Conceptofmultimodalsurgicalcare

• 2001KenFearonandOlleLjungqvistmetinLondonatanutritionsymposiaanddecidedtostartacollaborativegrouponperi-operativecare

• 2001-2002ERASStudyGroup• 2003FirstERASSymposiaStockholm• 2005Fearonetal.ClinNutrStudyGroupdevelopedandpublishedanevidence-

basedconsensusprotocolforpatientsundergoingcolonicsurgery• 2007Maessenetal.BrJSurg2007Concludedthatjustaddingaprotocolwasnot

sufficienttochangepracticetoERAS• 2010TheERASSocietywasofficiallyregisteredasanon-profitmedicalsociety

basedinStockholm,Sweden• 2016USAchapterhelditsfoundingmeetinginWashingtonDC• ERASProtocolindifferentdevelopmentalstagesfordifferentdisciplines

ERAS-History

OverviewBestoutcomeneedtolookatallvariables

ERAS

• SimilartotheconceptofCareplan• Improvingpatientcarebyreducing• Postoperativecomplications(infections)• Patientpainanddiscomfort(narcotics)• Shorteninghospitalstays(cost)

• UseoftheERASshownto: • Reducecaretime30% • Reducepostoperativecomplications50%

• Colorectal,Thoracic

ERAS

• Pre/Intra/PostinGYN-ONCsurgery• GIsurgery• Gastrectomy• RadicalCystectomy• Pancreaticoduodenectomy• ElectiveColonic,pelvic,RectalSurgery• BariatricSurgery• LiverSurgery• HeadandNeckSurgery• Esophagectomy• LungSurgery

Guidlinesfor

•ThekeyelementsofERASinclude:•Patient/familyeducation•Patientoptimizationpriortoadmission-Expectations•Pain,functionalstatus

•Minimalfasting-liquidsthemorningofsurgery•Multimodalanalgesia,useofopioidswhenindicated•Return-normaldietandactivitiesthedayofsurgery•Returntohome

Components

Akimuret.alSurgeryforObesityandRelatedDiseases14(2018)1850–1856

Example-ERAS

GoalToBeAccomplished

IfYouHaveEverWondered

• EnhancedRecoveryAfterSurgery(ERAS)andPostoperativePainManagement.

• MultimodalAnalgesiaforPostoperativePain-Risks,Safety,andEfficacy,ReducingCostsandLOS.

• ReviewofAmericanPainSocietyPostoperativePain

Objective(2)

WhatDoINeedToKnow?

•Definitions•Painassessment•Typesofanalgesics

•Theiraction•Sideeffects

Pain

“Painisanunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage…”

IASP(InternationalAssociationfortheStudyofPain)

• Isaprotectivemechanism

• Causesavoidance• Littletonotissueinjury• Painstopsoncethestimulusisremoved• Inflammationoccursinthearea• Nervedamage• Persistsafterthestimulusisremovedifchronic

Pain

•PossibleSelfCreatedProblem•Almostanythingwedoinvolvespain

•Comewithit,willhaveit,livewithit•Realistic,Honest,specific

WorldJGastroenterol.2003Apr15;9(4):847–850.OperativestressresponseandenergymetabolismafterlaparoscopiccholecystectomycomparedtoopensurgeryKaiLuo,Jie-ShouLi,Ling-TangLi,Kei-HuiWang,andJing-MeiShun

LangenbecksArchSurg.2017Nov;402(7):1023-1037.Systemicinflammatoryresponseafterherniarepair:asystematicreview.KokotovicD1,BurcharthJ2,HelgstrandF2,GögenurI2.

PatientExpectation

• Pain≠Nociception• Paininthebrain-perception• Nociception-peripheral-Visceralnervestimulation

• Fourstagesofprocessingpain:• Transduction

• Blockedbylocalanesthetics,NSAIDprostaglandins(Inflammation)• Transmission

• Preventedbylocalanestheticsperipheralnerves,nerveplexus,epiduralorsubarachnoidspaces

• Modulation• Localanesthetics&Gabapentin

• Perception• Generalanesthetics&Opioids

Pain&PainControl

Analgesics

Classesbasedonmodeofaction•Opioids•Non-steroidalanti-inflammatorydrugs•Localanesthetics•Miscellaneousdrugs•IVTylenol,Antidepressants,Anxiolytic

Pain&PainControl

Transduction Transmission Modulation Perception

Localanesthetics(topical)

Localanesthetics(regionalanesthesia)

Opioids Opioids

NSAIDs,Cox2inhibitors

Opioids Acetaminophen NMDArantagonists

Opioids Alpha2-agonists Cox2inhibitors Generalanestheticagents

Antihistamines Gabapentinoids SNRIs Acetaminophen

Capsaicin NMDArantagonists

NMDArantagonists

KehletH,DahlJB.(1993(Thevalueof‘‘multimodal’’or‘‘balancedanalgesia’’inpostoperativepaintreatment.AnesthAnalg.77:1048-56)

• Bind to opioid receptor sites within CNS (mostly µ but also κ)

• Are agonists, partial agonists or mixed agonists-antagonists

• Are controlled DEA • Reminder - Prescription Pads

Opioids

Opioids-SideEffects

OrganSystem SideEffects Intervention

CNS Drowsiness,DeliriumRespiratoryfailure

EarlyinterventionDeath

GI Nausea,Constipation longterm

CV Hypotension,Tachycardia,

orthostatichypo.

Treatsymptoms

Theultimategoalistodecreasedose,andalwaysconsideralternative.WhatistheExitstrategy?

NSAIDs

• NSAIDs organic acids • Anti-inflammatory, analgesic, and antipyretic • Inhibit prostaglandin production by inhibiting COX

enzymes

NSAIDs-SideEffectsOrganSystemSideEffect

• Na+ permeability neurons • Classified by duration of action

•Lidocaine is short acting with a rapid on-set

•Bupivicaine is long acting with a slow on-set

•Epinephrine

LocalAnesthetics

LocalAnesthetics-SideEffects

*4mg/kgIBW

Whymultimodalapproach?

KehletH,DahlJB:Thevalueof“multimodal”or“balancedanalgesia”inpost-operativepaintreatment.AnesthAnalg1993;77:1048–56

• optimizespainrelief• reducesideeffectburden• providesynergistic/additiveeffects• lowerdosesofeachmedicationneeded• opioidsparingpaincontrol• preventscentralsensitization

➢ Nonpharmacologic➢ Acetaminophen➢ NSAIDs➢ Adjuvants➢ RegionalAnesthesia

MaintainandOf

OpioidsOpioid

OptimizedProtocol

Manworren,R.C.E.(2015).Multimodalpainmanagementandthefutureofapersonalizedmedicineapproachtopain.AORNJournal101(3),308-314

Plan

• DifferentDisciplineofhealthcareproviders-RN,NP,MD

• Acutepainandchronicpain• Comfortlevelforcertain

meds• Plan

• Whatisnext?

• EnhancedRecoveryAfterSurgery(ERAS)andPostoperativePainManagement.

• MultimodalAnalgesiaforPostoperativePain.Risks,Safety,andEfficacy,ReducingCostsandLOS.

• ReviewofAmericanPainSocietyPostoperativePain

Objective

AmericanPainSocietyManagmentOfPostoperativePain

AmericanPainSocietyManagmentOfPostoperativePain

• August2009toJanuary2011• APS,ASA,and23memberswithexpertiseinanesthesia,painmedicine,surgery,obstetricsandgynecology,pediatrics,hospitalmedicine,nursing,primarycare,physicaltherapy

• Systematicreviewoftheevidenceonpostoperativepainmanagement

• GradingofRecommendations,Assessment,Development,andEvaluation

• Evaluatedallvariables,(procedure,discipline,patientAcuity,medicationHx.etc.

StrengthOfData-GRADE

“Ingeneral,astrongrecommendationisonthebasisofthepanel’sassessmentthatthepotentialbenefitsoffollowingtherecommendationclearlyoutweighpotentialharmsandburdens.Inlightoftheavailableevidence,mostcliniciansandpatientswouldchoosetofollowastrongrecommendation.Aweakrecommendationisonthebasisofthepanel’sassessmentthatbenefitsoffollowingtherecommendationoutweighpotentialharmsandburdens,butthebalanceofbenefitstoharmsorburdensissmallerorevidenceisweaker.Decisionstofollowaweakrecommendationcouldvarydependingonspecificclinicalcircumstancesorpatientpreferencesandvalues.Forgradingthequalityofabodyofevidencethatsupportsarecommendation,weconsideredthetype,number,size,andqualityofstudies;strengthofassociationsoreffects;andconsistencyofresultsamongstudies.

StrengthOfData

QualityofEvidence StrengthofRecommenda>on

BenefitsDoorDoNotClearlyOutweighRisks

BenefitsandRisksandBurdensareFinelyBalanced

High Strong Weak

Moderate Strong Weak

Low Strong Weak

Insufficientevidencetodeterminenetbenefitsor

harmsI

*FromthesystemdevelopedbytheGradingofRecommendaions,Assessment,Development,andEvaluaion(GRADE)workgroupandadaptedbytheAmericanPain

Society

Chou,R.,etal.(2016)Guidelinesonthemanagementofpostoperativepain.TheJournalofPain17(2).131-157

GuidelinesMultimodalAnalgesiaRecommendation Summary StrengthofData

1-2 EducatepatientEducationforParentofadultcaregiver

Strongrec.LowqualityStrongrec.Lowquality

3 EvaluateforpsychiatricCo-morbidities,substanceabuse Strongrec.Lowquality

4-6LowestDose

TreatproblemathandChildren(Dosing)

Strongrec.LowqualityStrongrec.LowqualityStrongrec.Highquality

7-8 TENSunitsAcupuncture,massagecoldtherapy

Weakrec.ModeratequalityNoposition

9-14

BehaviormodificationOralVIVAvoidIM

PCA(noBasal)#13,monitor#14

Weakrec.ModeratequalityStrongrec.ModeratequalityStrongrec.ModeratequalityStrongrec.Moderatequality

15-20(32)

AcetaminophenandNSAIDPreoperativedosing

Gabapentin(singledose)#17Katamine#18

LocalLidocaine(openandlap)#19,20

Strongrec.HighqualityStrongrec.ModeratequalityStrongrec.ModeratequalityWeakrec.ModeratequalityWeakrec.Moderatequality

Chou,R.,etal.(2016)Guidelinesonthemanagementofpostoperativepain.TheJournalofPain17(2).131-157

GuidelinesMultimodalAnalgesia

Chou,R.,etal.(2016)Guidelinesonthemanagementofpostoperativepain.TheJournalofPain17(2).131-157

GuidelinesMultimodalAnalgesia

Chou,R.,etal.(2016)Guidelinesonthemanagementofpostoperativepain.TheJournalofPain17(2).131-157

GuidelinesMultimodalAnalgesia

#26-32PainspecialistforinpatientPolicyandprocedureforfollowupThoraciccases-EpiduralPeripheralBlockandtopical

Strongrec.lowquality

Chou,R.,etal.(2016)Guidelinesonthemanagementofpostoperativepain.TheJournalofPain17(2).131-157

Summary

• ERAS• Itscomingtoyou-ifnottherealready-Careplan

• MultimodalAnalgesiaforPostoperativePain.Risks,Safety,andEfficacy,ReducingCostsandLOS.

• Utilizealltools,Educate,tameexpectation• ReviewofAmericanPainSocietyPostoperativePain• Alreadyinplaceindifferentforms

Thank you

ArmenianAmericanMedicalSocietyCMEcommittee

fortheopportunityprovided

Questions?