Presentation is loading. Please wait.

Presentation is loading. Please wait.

Lumbar Spinal Fusion Pain Management Pathways

Published byDenis Cummings Modified over 6 years ago

Similar presentations

Presentation on theme: "Lumbar Spinal Fusion Pain Management Pathways"— Presentation transcript:

1 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.

2 Holding Area Meds All patients should get the following meds unless there is a contraindication: Acetaminophen 1000 mg PO Pregabalin mg or Gabapentin 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.

3 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)

4 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

5 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 ( mg/kg) and Infusion ( mg/kg/hr) Pathway A

6 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 ( mg/kg) and Infusion ( mg/kg/hr) Consider Dexmedetomidine infusion mcg/kg/hr Pathway B

7 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 ( mg/kg) and Infusion ( mg/kg/hr) Consider Dexmedetomidine infusion mcg/kg/hr Pathway C

8 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 ( mg/kg) and Infusion ( mg/kg/hr) Consider Dexmedetomidine infusion mcg/kg/hr. CPS Consults

9 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

10 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

11 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

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

13 1st line Oral drug administration table for Pathway A (Opioid Naïve) patients
Opioid Naïve Pathway A Drug Initial Dose Adjustment Acetaminophen 1000 mg 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 mg mg Q8H Pregabalin 25-75 mg 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

14 1st line Oral drug administration table for Pathway B (Opioid Tolerant) patients
Opioid Tolerant Pathway B Drug Initial Dose Adjustment Acetaminophen 1000 mg 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 mg mg Q8H Pregabalin 25-75 mg 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

15 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 mg Q6min Morphine 1-2 mg IV Up to 4 mg IV Q4H mg Q6min Acetaminophen 1000 mg IV 500 mg Q6H or 1000 mg Q8H Lorazepam 0.5-1 mg IV/IM mg IV Q6-8H Diazepam 5 mg IV/IM Up to 10 mg IV Q6-8H

16 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 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

Download ppt "Lumbar Spinal Fusion Pain Management Pathways"

Similar presentations

Orthopedic Pharmacology: What, When, How, Why and Why not?

Orthopedic Pharmacology: What, When, How, Why and Why not?
Opioid Pharmacology: How to choose and how to use Romayne Gallagher MD, CCFP Division of Palliative Providence Health Care.

Opioid Pharmacology: How to choose and how to use Romayne Gallagher MD, CCFP Division of Palliative Providence Health Care.
New Opioid Formulations: Hope on the Horizon Pamela P. Palmer, MD PhD Professor and Director, UCSF PainCARE Chief Medical Officer, AcelRx Pharmaceuticals,

New Opioid Formulations: Hope on the Horizon Pamela P. Palmer, MD PhD Professor and Director, UCSF PainCARE Chief Medical Officer, AcelRx Pharmaceuticals,
Interaction between MM cells and bone marrow environment critical for tumor growth and propagation osteoclast Myeloma cells Normal bone.

Interaction between MM cells and bone marrow environment critical for tumor growth and propagation osteoclast Myeloma cells Normal bone.
Pain Management In the Palliative Care Setting M. Thomas Beets MD.

Pain Management In the Palliative Care Setting M. Thomas Beets MD.
Suboxone Cheryl Marks, MS, RN-BC, FNP-BC Nurse Practitioner / Coordinator of Inpatient Pain Management Newton-Wellesley Hospital.

Suboxone Cheryl Marks, MS, RN-BC, FNP-BC Nurse Practitioner / Coordinator of Inpatient Pain Management Newton-Wellesley Hospital.
Key dosing points: Begin a bowel regimen when opioid therapy is initiated (senna + docusate). For CHRONIC pain, use a scheduled medication regimen. ( ex:

Key dosing points: Begin a bowel regimen when opioid therapy is initiated (senna + docusate). For CHRONIC pain, use a scheduled medication regimen. ( ex:
Calvin Lui, MD PGY2 February 8, 2014.  Common Opioid Agents and Good Starting Dosages  Opioid Conversion  Use of Patient Controlled Analgesia and Good.

Calvin Lui, MD PGY2 February 8,  Common Opioid Agents and Good Starting Dosages  Opioid Conversion  Use of Patient Controlled Analgesia and Good.
{ Bay Area Prescription Drug Abuse Summit: Pharmacist Perspective Lori Reisner, Pharm.D. Health Sciences Professor of Clinical Pharmacy University of California.

{ Bay Area Prescription Drug Abuse Summit: Pharmacist Perspective Lori Reisner, Pharm.D. Health Sciences Professor of Clinical Pharmacy University of California.
Pain Morning Report Robin Staib, PharmD December 22, 2011.

Pain Morning Report Robin Staib, PharmD December 22, 2011.
Pain Policy Update Opioid Update Stuart Beatty, PharmD, BCPS.

Pain Policy Update Opioid Update Stuart Beatty, PharmD, BCPS.
Pain Management and Sedation Nightfloat Curriculum 2010-2011 LPCH Pediatric Residency Program.

Pain Management and Sedation Nightfloat Curriculum LPCH Pediatric Residency Program.
Presentation TitleDate Anesthesia Manager Training Adding and Documenting Medications.

Presentation TitleDate Anesthesia Manager Training Adding and Documenting Medications.
Prof. Krishna Boddu. MBBS, MD, DNB, FANZCA, MMEd MBBS, MD, DNB, FANZCA, MMEd University of Texas Health Sciences at Houston, Texas, USA University of Western.

Prof. Krishna Boddu. MBBS, MD, DNB, FANZCA, MMEd MBBS, MD, DNB, FANZCA, MMEd University of Texas Health Sciences at Houston, Texas, USA University of Western.
Assessing Pain What is pain? Do you believe that “perception is reality”? What are EB clinical practice guidelines?? What if client non-verbal, or you.

Assessing Pain What is pain? Do you believe that “perception is reality”? What are EB clinical practice guidelines?? What if client non-verbal, or you.
August 16, 2015 Equianalgesia Opioid Calculator: JHH Applications Suzanne A Nesbit, PharmD, CPE Clinical Pharmacy Specialist, Pain Management Department.

August 16, 2015 Equianalgesia Opioid Calculator: JHH Applications Suzanne A Nesbit, PharmD, CPE Clinical Pharmacy Specialist, Pain Management Department.
Narcotic Analgesic Medications Narcotic Analgesics.

Narcotic Analgesic Medications Narcotic Analgesics.
What’s Pain Got to Do With It? PAD Launch Day March 30 th, 2015 Donald Griesdale MD MPH FRCPC Assistant Professor Department of Anesthesiology, Pharmacology.

What’s Pain Got to Do With It? PAD Launch Day March 30 th, 2015 Donald Griesdale MD MPH FRCPC Assistant Professor Department of Anesthesiology, Pharmacology.
Step two: Moderate pain Tramadol Opioid combinations Acetaminophen or aspirin with Codeine Hydrocodone Oxycodone Plus/minus adjuvants Dose limiting toxicity.

Step two: Moderate pain Tramadol Opioid combinations Acetaminophen or aspirin with Codeine Hydrocodone Oxycodone Plus/minus adjuvants Dose limiting toxicity.
A logical method for hospital- based pain treatment Bob Arnold MD Institute to Enhance Palliative Care.

A logical method for hospital- based pain treatment Bob Arnold MD Institute to Enhance Palliative Care.

Similar presentations

Ads by Google