Lumbar Spinal Fusion Pain Management Pathways Lisa Kunze If this presentation did not open in Slideshow mode, please switch to slideshow mode first. By clicking the “screen” icon on the bottom right of this window. This presentation uses action arrow or home buttons. The choice of pathway you choose will decide what slides will be visible. Please click on the action buttons or hyperlinks to advance the presentation. Using your keyboard will not result in a logical slide sequence.

Holding Area Meds All patients should get the following meds unless there is a contraindication: Acetaminophen 1000 mg PO Pregabalin 75-150 mg or Gabapentin 300-600 mg PO (or the patient’s usual dose) Celecoxib 400 mg PO (except Dr. Glazer’s patients) Oxycontin 10 mg PO, or the patient takes his/her usual dose if already on Oxycontin.

Holding Area Discussion Discuss with the spine team and confirm the following. Is neuromonitoring being planned? Is an intraoperative epidural being planned? If YES call APS (Page 3PAIN) Discuss the Pathway (A, B, C) the patient falls under (see next slide) Is a CPS consult required for any patient? If YES call CPS (Page 3OUCH) (See next slide)

Decide which pathway the patient falls under and click the title Patient taking LESS than 60 mg of morphine equivalents/day for 2 weeks Pathway A: Opioid Naïve Patient taking MORE than 60 mg of morphine equivalents/day for > 2 weeks Pathway B: Opioid Tolerant Patients strictly NPO or unable to get comfortable in the PACU on PO meds Pathway C: IV Analgesia Patients on opioid agonist/antagonists Examples: Naltrexone, Suboxone, Methadone, Subutrex, Buprenorphine CPS Consult Required Morphine Equivalents in mg/Day IV PO Morphine 20 mg 60 mg Oxycodone n/a 40 mg Hydromorphone 4 mg Oxycontin MS Contin Oxymorphone 50 mg

Intraoperative pain management for Pathway A (Opioid Naïve) patients Administer antibiotics as per ID recommendations as posted in the OR and Anesthesia intranet Minimize or omit intraoperative Fentanyl use Use one of these per clinical judgment: Hydromorphone or Morphine boluses Consider Ketamine bolus (0.1-0.2 mg/kg) and Infusion (0.1-0.2 mg/kg/hr) Pathway A

Intraoperative pain management for Pathway B (Opioid Tolerant) patients Administer antibiotics as per ID recommendations as posted in the OR and Anesthesia intranet Minimize or omit intraoperative Fentanyl use Use one of these per clinical judgment: Hydromorphone or Morphine Consider Ketamine bolus (0.1-0.2 mg/kg) and Infusion (0.1-0.2 mg/kg/hr) Consider Dexmedetomidine infusion 0.2-0.7 mcg/kg/hr Pathway B

Intraoperative pain management for Pathway C (IV Analgesia) patients Administer antibiotics as per ID recommendations as posted in the OR and Anesthesia intranet Minimize Fentanyl use Use one of these per clinical judgment: Hydromorphone or Morphine Consider Ketamine bolus (0.1-0.2 mg/kg) and Infusion (0.1-0.2 mg/kg/hr) Consider Dexmedetomidine infusion 0.2-0.7 mcg/kg/hr Pathway C

Intraoperative pain management for CPS Consult Required patients Please discuss the intraoperative analgesic management with CPS if appropriate. Administer antibiotics as per ID recommendations as posted in the OR and Anesthesia intranet Minimize or omit intraoperative Fentanyl use Use one of these per clinical judgment: Hydromorphone or Morphine Consider Ketamine bolus (0.1-0.2 mg/kg) and Infusion (0.1-0.2 mg/kg/hr) Consider Dexmedetomidine infusion 0.2-0.7 mcg/kg/hr. CPS Consults

PACU pain management for Pathway A (Opioid Naïve) patients The goal of PACU pain management is to try to keep patients on PO pain medications as far as possible and resort to IV pain medications in exceptional cases. Acetaminophen Opioid (Choose one): Oxycodone PO Hydromorphone PO Morphine PO Anticonvulsants Oral spinal cord skeletal muscle relaxants Oxycontin or MS Contin Ketamine infusion (with APS consult) Celecoxib (if not administered previously) Pathway A

PACU pain management for Pathway B (Opioid Tolerant) patients The goal of PACU pain management is to try to keep patients on PO pain medications as far as possible and resort to IV pain medications in exceptional cases. Acetaminophen Opioid (Choose one): Oxycodone PO Hydromorphone PO Morphine PO Anticonvulsants Oral spinal cord muscle relaxants Oxycontin or MS Contin Clonidine patch or tablet (with APS consult) Ketamine infusion (with APS consult) Celecoxib (if not administered previously) Pathway B

PACU pain management for Pathway C (IV Analgesia) patients The goal of PACU pain management is to try to keep patients on PO pain medications as far as possible and resort to IV pain medications in exceptional cases. Opioid (Choose one): PCA Hydromorphone PCA Morphine Acetaminophen IV Oral spinal cord muscle relaxants Pathway C

PACU Pain management for CPS Consult Required patients Please discuss the PACU analgesic management with CPS (see tables for suggestions). CPS Consults

1st line Oral drug administration table for Pathway A (Opioid Naïve) patients Opioid Naïve Pathway A Drug Initial Dose Adjustment Acetaminophen 1000 mg 500-1000 mg Q6-8H Oxycodone 5- 10 mg 10-15 mg Q4H Hydromorphone 2-4 mg 4-6 mg Q3-4H Morphine 15 mg 15 mg Q4H Oxycontin 10 mg 10mg Q12H (check with APS) MS Contin 15 mg Q8-12H (check with APS) Gabapentin 100-300 mg 300-900 mg Q8H Pregabalin 25-75 mg 75-300 mg Q12H Topiramate Use patient’s regimen Diazepam 5 mg 5-10 mg QD-BID Lorazepam 0.5-1 mg 0.5-2 mg BID-TID Cyclobenzaprine 5-10 mg Q8H

1st line Oral drug administration table for Pathway B (Opioid Tolerant) patients Opioid Tolerant Pathway B Drug Initial Dose Adjustment Acetaminophen 1000 mg 500-1000 mg Q6-8H Oxycodone 10-15 mg 20 mg Q4H Hydromorphone 4-6 mg 4-8 mg Q3-4H Morphine 15-30 mg 30 mg Q4H Oxycontin 10 mg or patient's dose 10 mg Q12H (check with APS/CPS) MS Contin 15 mg or patients dose 15 mg Q8-12H (check with APS) Gabapentin 300-600 mg 300-900 mg Q8H Pregabalin 25-75 mg 75-300 mg Q12H Topiramate Use patient’s regimen Diazepam 5 mg 5-10 mg QD-BID Lorazepam 0.5-1 mg 0.5-2 mg BID-TID Cyclobenzaprine 5-10 mg Q8H

Drug administration table for Pathway C (IV Analgesia) patients IV Analgesia Pathway C Drug Initial Dose Adjustment PCA Hydromorphone 0.5 to 1 mg IV Q4H, 0.25mg if >70 years old 0.12-0.36 mg Q6min Morphine 1-2 mg IV Up to 4 mg IV Q4H 0.5-2.0 mg Q6min Acetaminophen 1000 mg IV 500 mg Q6H or 1000 mg Q8H Lorazepam 0.5-1 mg IV/IM 0.25-2 mg IV Q6-8H Diazepam 5 mg IV/IM Up to 10 mg IV Q6-8H

Drugs that should be initiated or adjusted with CPS consult only Initial Dose Adjustment Metaxalone 800 mg Q8H to Q6H Methocarbamol 500 mg Q4H Up to 1500 mg Q8H Meperidine 25-100 mg PO/IV/IM Q6H Baclofen PO 5 mg Q8H Up to 15 mg Q8H Baclofen pump Consult CPS interrogation preop and postop Clonidine 0.1 mg Q12H Up to 0.2 mg Q12H Clonidine transdermal 0.1 mg Q 7 days None Tizanidine 2-4 mg PO Q8H 4 mg Q8H after several days Topiramate 25-50 mg Q12H Up to 200 mg/day