1. Surviving Surgery’s Aftermath Judith Handley MD Assistant Professor OUHSC October 5, 2012

2. Disclosures I have no disclosures

3. Objectives Discuss basic pathophysiology of acute pain Identify options in treatment of acute post operative pain Discuss a multi-modal approach to pain management in the post operative patient

4. Pain: Definition The IASP defines pain as “Unpleasant sensory and emotional experience associated with real or perceived tissue injury” “Whatever the person says it is, wherever the person says it is”

5. Impact on Healthcare Pain is the most common reason a patient seeks healthcare The cost in healthcare dollars in significant annually

6. Acute Pain Sudden onset Usually lasts < 6months Has a known cause/circumstance – Surgery – Burns/cuts – Broken bones, pulled muscles – Labor and childbirth

7. Post-Operative Pain You wake up from surgery hurting, why? -Skin/Incision Pain -Muscle Pain -Bone Pain -Tendon/Ligament Pain -Movement Pain -Throat Pain

8. Pathophysiology

10. Why is it so important to control and treat Post-Op pain?  Good Post-Op Pain Control = › Faster recovery and discharge › Ability to utilize deep breathing exercises  Decrease post-op pneumonia/collapsed lung  Decrease O2 requirements › Ability to sit up, get out of bed, walk sooner  Decreases decubitis ulcers and blood clot formation › Active participation in Physical Therapy › Comfortable and satisfied patient

11. Unrelieved Post-Op Pain Poor Post Op Pain Control = – Increases risk of post operative morbidity and mortality Pneumonia Decubitis Ulcers Blood Clots – Increases hospitalization and costs of care – Can develop into chronic pain – Unnecessary patient suffering, unsatisfied patient

12. Other Thoughts To control pain post-operatively, you need to know information pre-operatively. – Allergies – Does the patient take any pain medication at home regularly or intermittently? – Where is current pain? – Introduce and educate about pain scales

13. Post-Op Pain Control Options  Regional Anesthesia/Analgesia › Peripheral Nerve Blocks › Single Injection Intrathecal/Caudal Analgesia › Epidural Analgesia  Non-Opioids  Opioids › IV vs. PO › PRN vs. PCA  Adjuvants

14. Regional/Neuraxial Anesthesia  Administration of local anesthetics (often with other drugs) into the epidural space, around a peripheral nerve plexus, or into the intrathecal space to block pain transmission.  Types: 1. Peripheral Nerve Blocks 2. Epidural Analgesia 3. Single Injection Intrathecal/Caudal Analgesia

15. Regional Anesthesia: Nerve Blocks  Commonly used for surgery involving the upper or lower extremities › Types: Interscalene, Axillary, Femoral, Sciatic, Caudal  Typically used for outpatient procedures (although can be used inpatient and as a continuous infusion)  Nerve stimulators and ultrasound guided  Typically lasts 4-24 hours

16. Regional Anesthesia: Nerve Blocks Advantages: – Reduced amount of additional systemic opioids – Reduction of side effects Nausea/vomiting Puritis Drowsiness

17. A thin catheter that is threaded into the epidural space which provides anesthesia by continuous infusion via an epidural pump Indications: Thoracic/heart surgeries, abdominal surgeries, limb amputation, thoracotomies, urology surgeries

18. Epidural Analgesia Drugs infused through an epidural catheter – Local Anesthetics (Bupivacaine, Ropivacaine…) – Opioids (fentanyl, hydromorphone…) – All are preservative free

19. Advantages of Epidural Analgesia  Local Anesthetics via Epidural= can prevent the pain response with minimal physiologic alterations  Opioids via Epidural= can provide prolonged analgesia at low doses  Systemic Opioids= modify perception of nociceptive input so patients are better able to tolerate pain  GOAL: Reduction of systemic opioids, better pulmonary profile, better OOB and PT profile

20. Single Injection Analgesia Caudal Intrathecal Duramorph – Extended Release morphine – Peaks in 6 hrs and lasts 18-24

21. Single Injection Analgesia Intrathecal Duramorph – 3:1 ratio or PICU admit Caudal Duramorph Dosing: – Less than 15mcg/kg – discharge home – 15-45mcg/kg – admitted, 3:1 ratio or PICU – Greater than 45mcg/kg – automatic PICU

22. Opioids Drug options – Morphine – Fentanyl – Hydromorphone PRN Bolus or PCA

23. Patient Controlled Analgesia (PCA) Common agents used – Morphine – Hydromorphone – Fentanyl PCA demand dose Basal Rate

24. Non-Opioids and Adjuvants Drug Options – Ketoralac – Acetaminophen – Ibuprofen Route of administration options Other adjuvants

25. Post-Op Pain Management Care Plans Individualized Tailored to the specific surgical procedure Perioperative pain control optimized Utilize a multi-modal approach

26. Multi-Modal Approach Outpatient – Cyst removal right elbow Regional, opioid with adjuvant medications Inpatient – Posterior Spinal Fusion

27. Thank You Questions