This document discusses strategies for postoperative pain management and preventing postoperative nausea and vomiting (PONV). It emphasizes developing inpatient pain protocols using a multimodal approach with minimized opioids and continuous monitoring to safely manage pain. It identifies patient risk factors for opioid adverse events and PONV. The use of electronic order sets can help standardize care and provide clinical decision support. Developing protocols requires establishing committees and an educational process.

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Update on Postoperative Pain
Management and Nausea and
Vomiting
Viet Nam
2016
Paul Carns, MD
Mayo Clinic
USA
Rochester, MN

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Nothing to Disclose

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Objectives
• Describe the importance of opioid use
assessment
• Recognize that opioids are often sources for
sentinel events
• Determine ways to develop inpatient pain
protocols
• Identify patients at risk for Postoperative
Nausea and Vomiting (PONV)
• Discuss treatment of PONV

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Pain Medication Orders
• Patient populations are now older and heavier
• Pain/Sedation mismatch may lead to
overdosing of opioids
• Failure to preempt known side effects may
affect morbidity
• Order errors can be catastrophic

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Medication Errors in the Hospital
Sentinel Events
• Opioids
• Heparin
• Insulin
(Incidence of respiratory depression in post-
operative patients is 0.5%)
Davies EC et al: Plos ONE, Feb 2009;4(2):e4439

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Opioid Adverse Events
• Lack of knowledge
• Potency differences
• Conversion errors
• Administration
• Multiple opioid use
• Multiple routes
• Inadequate monitoring
USFDA report: April 18, 2012

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Opioid Risk Assessment
• Sleep apnea/snoring
• Morbid obesity
• Age
• 2.8 X higher 61-70
• 5.4 X higher 71-80
• 8.7 X higher over 80
• Opioid naïve
• Postop abdominal/thoracic
• Surgical time
• Combined use of other
sedating meds
• Benzodiazepines
• Antihistamines
• CNS depressants
• Smokers
Jarzyna D et al; Pain Mgt Nurs 2011;12(3):118-145e10

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Pain Control Goals
• Treat adequately and ensure safety
• Minimize opioids
• Multimodal approach
• Assure continuous proper assessment and
monitoring
• Plan for side effect management
• Streamline the process (giản hóa)

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Advantages of Opioid Protocols
• Consistent dosing (real time, evidence based
prompts)
• Cost effective, improves clinician efficiency
• Integrate with Smart Pumps
• Assures Multimodal program
• Monitoring standards
• Nothing missed/forgotten
• Easy to update
• But, no protocol is substitute for common sense

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Advantages of CPOE
Computerized Provider Order Entry
Paper
• Difficult to find
• Unaware of availability
• Difficult to change
• Old sets hang around
• May need more than one
• ?evidence based
Electronic
• Available everywhere
• Real time prompts
• Updated easily
• No old versions
• Link to other order sets
• Clinical Decision Support
programming
J Am Med Inform Assoc. 2007 Jan-Feb; 14(1): 41–47

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Disadvantages of Protocols?
• Typically not mandatory
• Increased legal risk if order set not used?
• Need educational process for awareness.
• May need outside vendor. $?
• Committees needed to develop and agree
• Takes time
J Am Med Inform Assoc 2005;12:561-567

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Annual Review
• Mandatory Review Cycle
• Change is inevitable
• Order sets must have proponent identified
• Enhance Innovation
• Pharmacy and Therapeutics committee vital in
coordination

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Example: IV PCA Protocol

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Antibiotics, DVT prophylaxis, Bowel Care, Diet, IV fluids, Anti-emetics,
Activity, Respiratory
Integrate within other order sets

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Pain Protocols
• IV PCA
• Oral
• Epidural infusions
• Peripheral Nerve Infusions
• “Service Specific”

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How to accomplish:
• Establish physician leader
• Get key players together as a committee
• Anesthesia/Pain
• Surgeon
• Medicine
• Nursing
• Pharmacy
• IT
• Develop protocol
• Begin education of staff
• Start with only one unit and adjust via feedback

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Postoperative Nausea and Vomiting

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PONV
• Common
• 50% incidence for nausea
• 30% incidence for vomiting
• 80% in high risk
• Prolongs recovery
• May lead to admission to hospital
• Increased costs
• Adequate prophylaxis required
Anesth Analg 2014;118:85–113

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Patients at Risk
• **Younger age (<50)
• Type of operation
• Abdominal (laproscopic), eye, ear, gyne
• Female
• Non-smokers
• Previous History of PONV
• Opioids used for post op pain

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Anesth Analg 2014;118:85–113

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Reduction in Risk
• Avoid Volatile General Anesthesia
• Use regional anesthesia
• Use propofol induction and infusion (TIVA)
• Avoid Nitrous Oxide
• Minimize perioperative opioids
• Adequate hydration

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Strategies thought not to work
• Reduction in neostigmine dose
• Supplemental Oxygen

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Q-T prolongation
• Droperidol
• Ondansetron

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NK-1 antagonists
• Used in controlling side effects with
chemotherapy
• Aprepitant (po) / Fosaprepitant (iv)
• First approved in USA
• Casopitant
• Netupitant
• Rolapitant (160 hr half-life)

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Other Options
• Scopolamine patch
• History of motion sickness
• Need reminder order to remove
• May cause mental status change in elderly
• Phenothiazines
• May cause significant drowsiness
• Corticosteroids
• Sub-hypnotic doses of propofol
• Acupuncture

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Thank you

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Questions & Discussion