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9 multimodalperioperativepaindrhamedumedaly1 res gak ppt


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  • 1. Multimodal Perioperative PainManagement and MultimodalStrategies to Enhance PostOperative OutcomesHamed Umedaly MD FRCPCAnesthesiologistMedical Director POPSVancouver AcuteUniversity of British Columbia
  • 2. Why ? Whats wrong with thestatus quo ? Improved Anesthesia & Pain management can be achieved ! Improved potential for Recovery ? Unidimensional approaches limit outcome Improvements not realizing optimal patient outcome ?
  • 3. 4 A’s of Changing PhysicianBehavior ( Pathman model)AwareAgreeAdoptAdhere
  • 4. For every complex problemthere is an answer that issimple, neatand wrong H.L Menken 1880-1956
  • 5. Concept of Perioperative PainManagement and AcuteRehabilitation Pre- Op Education Preparation & Planning Pre & Intraop Pain Management & Physiological Stabilization Post-op pain management and Acute Rehabilitation Kehlet 1995-2005
  • 6. Preemptive Pain Management:Neurobiology Noxious stimuli initiate cascade of events peripherally and centrally to produce PAIN Sensitization (Dynamic) Nociceptive stimuli amplified ( Primary and Secondary Hyperalgesia) Non painful stimuli produce PAIN (Allodynia)
  • 7. Preemptive PainManagement:PreventSensitization ( duration andIntensity) Reduce the Nociceptive input (Minimally invasive surgery,LA, NSAIDS, Opioids) Attenuate Transmission ( Blocks, Spinal, Epidural) Modulate mechanisms that underlie sensitization ( NMDA blockade, Opioids)
  • 8. Multimodal Pain Management Pain Neurobiology is a complex of Dynamic Interrelated systems Unimodal Analgesia cannot be sufficient to provide optimal pain management Additive & Synergistic effects of Multiple modes should improve outcome
  • 9. 4 principles of Multimodal PainManagement Multiple Mechanisms/ Sites of action Avoid Opioid Dominance Opioid Sparing vs side effects Multimodal / Lower Doses / Reduce adverse effects Treat and Prevent Toxicity / Side effects i.e PONV /Delirium/Pruritis
  • 10. VA Quality ImprovementStudy N=300 ~ 40 % of joint arthroplasty have PONV if untreated Joint Arthroplasty patients are at high risk of PONV ~ 10 % of have PONV if Risk Reduction Strategy and Prophylaxis ( combination therapy)
  • 11. Consensus Guidelines forManaging PONV Evaluate Risk ( Patient, Anesthetic Surgical) Strategies to reduce baseline risk (Modify Anesthetic Technique) Antiemetic prophylaxis Moderate Risk: Monotherapy 5 HT3 Receptor antagonist High risk: Combination therapy Gan A&A 2003
  • 12. art64_fig11.gif
  • 13. Acetaminophen Synergy with Opioids / Opioid sparing Synergy with NSAID’s Inexpensive Routes PO / PR Use 3-4 g/24 hr short term<2 wks
  • 14. Model for Post surgical Chronic Pain Physiological Preop Maintaining Psychological Factors factors Acute pain Chronic PainPhysiological ( Nociceptive andFactors Affective Components) Acute injury Psycho/social (Surgery) Maintaining Factors
  • 15. Multimodal pain managementand Outcomes Multiple PRCT’s in 10 yrs Improved Pain Scores and Patient Satisfaction Decreased use of PCA and Parenteral Analgesia BUT no change in LOS/Outcome
  • 16. Beyond Multimodal PainManagement: A MultimodalStrategy to EnhancePostoperative Recovery Multimodal Rehabilitation model Integrated (Patient, Nurse,PT/OT.Pharmacist, Surgeon, Anesthesiologist) Use the Improved pain management to accelerate recovery discharge & Really Improve outcome
  • 17. Multimodal Recovery Wellness model Perioperative model ( seamless) Architecture from Bed oriented wards to Activity Oriented Units “Postoperative Rehabilitation Unit” Now lets look at Outcome
  • 18. Opioid Tolerance:Reality Check Increasing incidence of Opioid Tolerant Patients presenting for Surgery CPS & APS approve the use of Opioids for Chronic Non malignant Pain i.e Osteoarthritis
  • 19. Opioid Tolerance(Chronic Pain) Morphine equivalence > 30 mg/ day for > I monthCentral sensitization ; afferent nociceptive facilitatation Primary and secondary hyperalgesia Allodynia Opioid mu receptor down regulation
  • 20. Opioid Tolerance : Features Tolerance to:pain management,respiratory depressionSedation Non Nociceptive Suffering ( anxiety) Renders Perioperative Pain Management Challenging
  • 21. Opioid Tolerance in thePerioperative Period Its too late postop ( in the PACU ) Start preop ( identify , plan , preop Opioid , Acetaminophen, NSAID, +/- Clonidine Continue Intraop ( Opioid , Local, Regional , Ketamine) Extend strategy Postop (Opioid , Regional , +/- Ketamine, NSAIDs, Acetaminophen
  • 22. Opioid Tolerance: MultimodalStrategies Use Neuraxial Blockade/ Regional Anesthesia/Analgesia with LA NSAID’s Acetaminophen at max dose ( 1.5-2 g load and 4 g/day) Low dose Ketamine intra +/- postop Treat Non Nociceptive Suffering
  • 23. Opioid Tolerance Identify Discuss Complexity and Potential Toxicity with Patients Resume PO Opioid asap at higher dose and provide breakthrough
  • 24. Strategy and Goals Integrated Pre, Intra & post operative Care Seamless Multimodal pain management Treat Pain with activity Avoidance of routine PCA Opioid Improve pain management and outcomes
  • 25. Perioperative vs Postoperative Preop: Recognition, Assessment, Discussion, Plan, Pre emptive Intraop: Modification of Surgical approach Anesthesia and Pain Management Strategy Post Op: Multimodal Pain Management and Intervention
  • 26. VA Approach: Preop Consultation and preparation Identify Risk of Difficult to manage pain High dose Acetaminophen +/- NSAID Low dose long acting Opioid (Oxycodone CR 10 mg)
  • 27. VA Approach:”Intraop” Intrathecal LA(Spinal) and low dose Opioid( PF Morphine 100 ug) +/- GA or Epidural for Revisions or Opioid Tolerance Preincision LA LA in capsule and closure PONV prophylaxis Fast track PACU
  • 28. VA Approach:”Post op” Full reg dose Acetaminophen +/- NSAID Reg low dose long acting Opioid (Oxycodone CR) plus breaktrough prn opioid ( Oxycodone IR) PCA only for unsatisfactory pain control “Fast track” early mobilization
  • 29. Rehabilitation / Recovery Achieve best pain control with minimal side effects Use that pain control to achieve early : Recovery Mobilization Function
  • 30. Ambulatory or Short stay HipReplacement Minimally Invasive approach 85 % with same day DC N= 100 Duwelius JBJS 2000
  • 31. Short Stay Total KneeArthroplasty Spinal Anesthesia Multimodal pain management Femoral Nerve LA Catheter Infusion Anesthesia and Analgesia Jan 2006
  • 32. MIS Surgery:PurportedBenefits Surgical Invasiveness Better Pain Management Improved Rehabilitation Protocols ?Higher Complication rate with MIS Woolson JBJS 2004, Ogonda JBJS 2005 Wright J.Artroplasty 2004
  • 33. Periop Pain Management Talk about it “Can and should focus on pain” Work on Periop Strategies and utilize them to enhance satisfaction /outcome Manage PONV
  • 34. The Future Perioperative infusion of Continuos Regional Anesthesia(PICRA) PCOA Antineuropathic agents ( gabapentin/pre gabalin) Microsphere impregnated Local anesthetic agents
  • 35. A Multimodal Strategy toEnhance PostoperativeRecovery: Conclusions Integrated Perioperative approach Enhanced Perioperative Pain management Perioperative stress response and Organ Dysfunction reduction ( eg blood loss, PONV ) Utilize to achieve Fast Track Recovery and Enhance Outcome
  • 36. Divinum est sedare dolorumBlessed are those who treat pain.-Galen
  • 37. COX 2 Inhibiters : Background Inducible vs Constitutive enzymes No apparent GI or Renal Sparing Platelet Aggregation Sparing ( Thromboxane inhibition)
  • 38. Cyclooxygenase Isoforms Cox-1 Cox-2Constitutive, and found in Predominately induciblemost tissues - enzyme in many tissues -“housekeeping”. Inducible 10- to 20-fold by inflam2- to 4-fold by inflammatory stimuli or cancerstimuli Stimulates PGI2 production in endotheliumOnly isoform present inplatelets TxA2Main isoform in gastric Constitutive in CNS, fem.mucosa Cytoprotective reproductive tract, and kidneyPG’s
  • 39. COX 2 Inhibiters : When ? Pain Management Challenging and Intraop Bleeding an Issue Pain Management responsive to NSAIDS (Bone, Gyne etc and potential for intraop /post op bleeding) Concurrent Anticoagulation or LMW Heparin Epidural insitu and pain outside covered dermatomes
  • 40. Cardiovascular and Platelet EffectsPlatelets: - ASA: irreversibly acetylates Cox-1, selectively inhibits TxA2 formation - Nonselective NSAIDs: Inhibit TxA2 and PGI2 to a similar degree. Effect is reversible during the dosing interval - COXIBS: Inhibit (reversibly) Prostacyclin formation which mediates platelet inhibition
  • 41. CLASS and VIGOR studiesCLASS: - Celebrex Long-term Arthritis Safety StudyVIGOR: - VIoxx Gastrointestinal Outcomes ResearchVery large (n = >4,000 and >8,000), multicenter, double-blind, randomized trials (no placebo arm) examining efficacy and safety of Celecoxib and Rofecoxib
  • 42. CLASS VIGOR- 28% with RA, 72% OA - 100% with RA- compared coxib Vs - compared coxib (2x max ibuprofen & diclofenac dose) Vs naproxen- ASA allowed for Cardiac - ASA not allowed prophylaxis (21%) - sig lower rates of upper GI- no difference in ulcer events and GI bleeding frequency,but fewer with vioxx symptomatic ulcers - sig higher rates of- no sig difference in MI thrombotic events and MI frequency with Rofecoxib, altho’ CV mortality rates similar
  • 43. Why do Cox-2s IncreaseSAEs?? Not completely explained by the trials Increase of thrombotic CV events more than cancels reduction in complicated ulcer risk
  • 44. COX 2 Inhibiters : Cost COX 2 $ 1.25/day Rofecoxib and Valdecoxib once daily dosing Nonselective po nonselective COXIB $30-60 cents (eg Diclofenac) IV nonselective COXIB (~$ 8.00 day) (eg Ketorolac)
  • 45. COX 2 Inhibiters : Add toformulary ? Minimal cost Selective Use When Indicated Avoid use when known or risk factors for CAD Platelet sparing really only benefit
  • 46. The Future IV Acetaminophen = “Propacetamol will be available in Canada “soon” IV Parecoxib immediately converted to Valdecoxib Nitric Oxide-donating NSAIDs NO functions as an endogenous mediator of gastric mucosal health and defence
  • 47. Multimodal Perioperative PainManagement and MultimodalStrategies to Enhance PostOperative Outcomes Hamed Umedaly MD FRCPC Anesthesiologist Medical Director POPS Vancouver Acute