Multimodal Pain Management
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Transcript of Multimodal Pain Management
Multimodal Pain Management
Tong Joo (TJ) Gan, MD, FRCA, FFARCS(I) Professor of Anesthesiology
Vice Chairman Clinical ResearchDuke University Medical Center
Durham, North Carolina
It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.
Dr. Gan has received grants/research support from Acacia, Baxter, Durect, Eisai, and NICOM. He has received honoraria from Baxter, Eisai, Fresenius, Hospira, and Xanodyne.
Faculty Disclosure
Educational Learning Objectives• Describe the importance of improving time to
gastrointestinal recovery that occurs postsurgery and consider how this affects length of hospital stay and overall quality of patient care
• Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures
• Describe how interprofessional collaboration surrounding gastrointestinal surgery can result in better alignment with current surgical quality measures and formulate strategies to integrate this into current practice
Patient Case
• 65-year-old man, 95 kg, with a history of biopsy positive cancer of the rectum
• Scheduled for a left hemicolectomy• Past medical history
– Non-insulin dependent diabetes– Hypertension– Chronic back pain
• Previous surgery – Appendectomy– Knee arthroscopy– ACL repair
• Social history– Occasional drinker– Nonsmoker
Patient Case – Medical History
• Medication history– Vicodin® 1 tab TID– Ibuprofen PRN– Atenolol 50 mg OD– Multivitamin daily– Gliclazide 30 mg
Patient Case – Medical History
• Patient scheduled for partial colectomy • Anesthetic
– General anesthesia– Fentanyl 100 mcg and midazolam 3 mg as
premedication– Induction with propofol, anesthetic maintained with
sevoflurane, air and oxygen– Rocuronium as the neuromuscular blocker– Ondansetron as prophylactic antiemetic
Patient Case – Anesthetic Plan
• Surgery duration 3.5 hrs• Patient extubated and transferred to PACU• Postoperative pain management
– Patient-controlled analgesia (PCA) with morphine, with 2 mg bolus, 8 min lockout and 30 mg 4 hr maximum dose
• In the PACU, complained of pain 9/10 on a verbal rating scores (VRS) of 0-10
Patient Case – Postoperative Pain Management
• Does the use of systemic opioids contribute to postoperative ileus?
Opioids and Postoperative Ileus
Opioid-based Analgesia and Bowel Function• 40 colectomy patients
– Correlation between morphine PCA dose and first bowel sounds (P = 0.001), flatulence, (P = 0.003), and first bowel movement (shown, P = 0.002)
– No correlation between incision length and morphine dose
• ICD-9-CM coded POI correlates with systemic morphine (OR = 12.1; 95% CI, 5.4-27.1)
Hours to First Bowel Movement
R = 0.48P = 0.002
Total Morphine (mg) 350.0
300.0
250.0
200.0
150.0
100.0
50.0
040 60 80 100 120 140 160 180
Cali RL, et al. Dis Colon Rectum. 2000;43:163-168. Goettsch WG, et al. Pharmacoepidemiol Drug Saf. 2007;16:668-674.
• While opioids are often the analgesic of choice following abdominal surgery, they decrease gastric motility, inhibit small and large
intestinal propulsion, and have other GI effects that contribute to the abdominal discomfort associated with POI
Postoperative Analgesia and Postoperative Ileus
What would you do?A. Change to a different opioid in the PCAB. Add ketorolacC. Insert an epiduralD. Boluses of morphine
Postoperative Pain Management
Postoperative Pain Management
There are a number of possible options.
The following slides provide some evidence to support the use of nonsteroidal anti-inflammatory drugs and epidurals as opioid-sparing approaches.
Opioid-sparing Effects of Ketorolac – Postoperative Bowel Function in Colorectal Surgery Patients
Chen JY, et al. Clin J Pain. 2009;25:485-489.
M: IV patient-controlled analgesia morphine M+K: IV patient-controlled analgesia morphine plus ketorolac
Epidural Analgesia and Duration of Postoperative Ileus
Adapted from Person B, Wexner S. Curr Probl Surg. 2006;43:12-65.
Study Surgery Earlier Gas Earlier Stool *P-valueHjortso et al, 1985 Major abdominal No No NS
Wallin et al, 1986 Major abdominal No No NS
Scheinin et al, 1987 Colonic --- Yes < 0.05Ahn et al, 1988 Colorectal Yes Yes < 0.001Bredtmann et al, 1990 Colonic --- Yes < 0.001Jayr et al, 1993 Major abdominal Yes --- < 0.05Morimoto et al, 1995 Proctocolectomy/IPAA --- Yes < 0.01Liu et al, 1995 Colonic Yes Yes < 0.005Scott et al, 1996 Proctocolectomy/IPAA Yes Yes < 0.05Bradshaw et al, 1998 Colorectal Yes Yes < 0.001Welch et al, 1998 Gastrointestinal No No NS
Neudecker et al, 1999 Laparoscopic sigmoidectomy --- No NS
Carli et al, 2001 Colorectal Yes Yes < 0.001Carli et al, 2002 Colonic Yes Yes < 0.01Steinberg et al, 2002 Colonic Yes Yes < 0.002
*Compared with systemic analgesic regimens;IPAA: ileal pouch anal anastomosis
Meta-analysis of Epidural Analgesia (EA) vs Opioid Parenteral Analgesia after Colorectal Surgery
Marret E, et al. Br J Surgery. 2007;94:665-673.
• 16 randomized, controlled trials (1987-2005) compared postoperative epidural analgesia (local anesthetic) with parenteral opioid analgesia in patients following colorectal surgery– Length of hospital stay: no statistically significant difference between
the groups– Pain intensity: Lower visual analog scale pain scores at 24 and 48
hours with EA (P < 0.001)– Duration of postoperative ileus: reduced by 36 hr with EA (P < 0.001)– Anastomotic leak and cardiopulmonary complications: no significant
difference between groups– Hypotension, pruritus, and urinary retention were more common in the
EA group
• The use of epidural analgesia and nonsteroidal anti-inflammatory drugs (NSAIDs) for
postoperative pain management both help to minimize postoperative opioid consumption. Along with providing pain relief, these strategies
help to minimize opioid-related GI dysfunction. Both approaches are associated with a reduction in the duration of postoperative ileus compared with parenteral opioids
Postoperative Pain Management – Opioid-sparing Strategies
• Treatment– Added ketorolac 15 mg– Gave bolus dose of morphine 6 mg (in 2 mg aliquots)– Increased PCA dose of morphine to 3 mg per push
Patient Case – Postoperative Pain Management
• Patient’s pain score is 7/10• Complaint of persistent nausea and 2 episodes
of retching• Itching of the front of chest and back• Treatment
– Promethazine 12.5 mg– Meperidine 25 mg
Patient Case – Postoperative Day 1
• Day 3 after surgery, pain range between 4/10 to 8/10. Still on PCA morphine, not helping too much
• 5 doses of ketorolac, maximum doses given• Still complains of nausea • Used 70 mg morphine on first 24 hrs and 80 mg
over the next 24 hrs
Patient Case – Postoperative Day 3
• No bowel sounds, no flatus, no bowel movement• Abdomen slightly distended • Nasogastric tube drained yellowish fluid• Persistent nausea• Drowsiness and slight confusion
Patient Case – Postoperative Day 4
What would you do?A. Additional boluses of morphineB. Start a morphine infusion via the PCAC. Change to a different opioidD. Insert an epidural
Postoperative Pain Management
Since the patient had not responded well to fairly large doses of morphine, starting an infusion or further boluses of morphine would not be helpful. Some patients may respond better to a different opioid with a lower incidence of side effects. Hence this could be a viable option. Insertion of an epidural at this stage may also be considered if there are no other contraindications.
Postoperative Pain Management
• Pain team consulted• Change to hydromorphone PCA• Started celecoxib 200 mg BID
Patient Case – Postoperative Pain Management
• Postoperative Day 7: presence of flatus and bowel sounds
• Advanced diet to semi-solid• Continue to make progress• Day 10: full bowel function established• Day 11: patient discharged
Patient Case – Postoperative Course
• Suspicious looking left kidney found during surgery
• Renal mass confirmed on MRI• 6 weeks later, patient admitted for left partial
nephrectomy
Patient Case – Continued
What Would Be Your Anesthetic and Pain Management Plan?
A. Preoperative epiduralB. Preoperative celecoxibC. Preoperative gabapentinD. Intraoperative small dose ketamine infusionE. All the above
Ho KY, et al. Pain. 2006;126:91-101.
Gabapentin and Postoperative Pain–Systematic Review
Pain Scores
Morphine Consumption
Ho KY, et al. Pain. 2006;126:91-101.
Gabapentin and Postoperative Pain
Perioperative Gabapentin 1200 mgAdverse Events
Adverse Events Odds Ratio P value
Nausea 0.72 (0.51-1.01) 0.06
Vomiting 0.58 (0.39-0.86) 0.007
Pruritus 0.27 (0.1-0.74) 0.01
Sedation 3.86 (2.5-5.94) 0.00001
Respiratory Depression 1.07 (0.21-5.49) 0.93
Ho KY, et al. Pain. 2006;126:91-101.
Odds ratio < 1 favors gabapentin over control (reduced risk for opioid-related side effects)
White P, et al. Can J Anaesth 2007;54:342-348.
Celecoxib 400 mg/day in Laparoscopic Surgery
* P < 0.05 vs Control (actual P values listed)
Intravenous Ketamine and Postoperative Pain Systematic Review
Elia N, Tramèr M. Pain. 2005;113:61-70.
Visual Analogue Scale (VAS)of pain intensity
WMD: weighted mean difference
Multimodal Perioperative Pain Management
Preoperative gabapentin, short-term use of celecoxib, and intraoperative ketamine infusion are additional evidence-based strategies for improving perioperative analgesia, reducing opioid requirements, and minimizing opioid-related side effects.
• T9/T10 thoracic epidural placement preoperatively for postoperative pain control
• Preoperative celecoxib 400 mg followed by celecoxib 200 mg BID
• Preoperative single dose of gabapentin 1200 mg• Intraoperative ketamine bolus 0.5 mg/kg followed
by an infusion of 10 kg mcg/kg/min
Patient Case – Anesthetic and Postoperative Pain Management Plan
• Surgery uneventful• Lasted for 3 hrs• Postoperative epidural infusion with bupivacaine
0.125% with hydromorphone 10 mcg/mL infused at 8 mL/h
• Continued with celecoxib 200 mg BID• Pain score 2-3/10
Patient Case – Postoperative Pain Management
• Postoperative Day 2: epidural discontinued • Patient tolerated a full meal the day after surgery
with no nausea and vomiting• Urine through catheter started to be clear• Normal renal function established• Continued on celecoxib 200 mg BID• Pain score 2-3/10
Patient Case – Postoperative Course
• Day 3: patient discharged• Patient was satisfied with the pain management
during his second surgery• Use of multimodal strategy greatly enhanced
pain control with reduction in side effects
Patient Case – Postoperative Course
Summary• This case illustrates
– Opioid use can result in many adverse effects including nausea and vomiting and delayed bowel recovery after surgery
– Pain involves complex mechanisms– Opioid adjuncts improve pain control– A multimodal pain management strategy improves
analgesia and lowers the incidence and severity of side effects