1. Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services

2. Disclosure HSS educational activities are carried out in a manner that serves the educational component of our Mission. As faculty we are committed to providing transparency in any/all external relationships prior to giving an academic presentation. Spencer S. Liu, MD Hospital for Special Surgery Disclosure: I do not have a financial relationship with any commercial interest.

3. Background Postoperative pain is a key issue for patients Large surveys indicate patients are more concerned about pain (59%) than surgical outcome (51%) Unfortunately, this concern remains justified Anesth Analg 2003:97:534

4. Background Multiple surveys report continued poor postoperative pain control Most recently in 2003 –250 adults –Mix of in-patient and ambulatory –75% reported experiencing pain during or after surgery –73% reported moderate to severe pain

5. Is postoperative pain that bad? Inherently, who wants pain –Guidelines from: WHO APS ASA Regulatory requirement: JCAHO Key patient satisfaction surveys: Press Ganey Pain can create bad outcomes –Morbidity –HRQOL –Development of chronic pain Anesth Analg 2007:104:689 Anesth Analg 2007:105:789

6. What can one do? Acute Pain Services are popular and effective Typically expensive Typically manage PCA modalities Anesth Analg 2002:95:1361

13. 13 Anesthesiology. 104(5):1033-1039,2006

14. How well is pain controlled after the APS signs off? What happens after the APS signs off? Typically, the surgeons alone manage postoperative pain with po analgesia and write the home prescriptions Not so good per patient surveys Same here at HSS In March 2007 –Negative patient letters

15. Recuperative Pain Medicine RPM rolled out in August 2007 –Recurrent negative themes in patient letters, comments, and New York Times editorials Post-PCA patients experienced inadequate pain management with oral analgesics Post-PCA patients did not have easy access to a pain management expert

16. Based on these reports, a plan was formed Multidisciplinary team –Surgeon in Chief –Anesthesiologist in Chief –Executive Leadership –Director of Risk Management –Director of APS –Director of CPS –CAMS –Director of Patient education

17. Patient Education and Pain Management Preoperative Education “Pre-emptive” medications Postoperative PCA APS Postoperative PO Pain management Patient educationStaff education

18. How to measure impact? No currently standardized, validated tools We chose 3 outcome measure for before and after implementation measurement –Press Ganey Survey Administered to all postoperative patients to assess satisfaction Has specific questions on pain management Benchmarked against similar institutions –Staff satisfaction survey –Number of calls to Helpline Less is better Do all the work upfront

19. Preoperative educational role of RPM Worked with Patient education to update and expand sections on perioperative analgesia for pre-operative patient education classes for total joint replacement and spine surgery

20. Clinical role of RPM Designed to fill identified gaps Provide a seamless transition from the IV/Epidural PCA to oral medications Continued pain management monitoring thru to discharge. The RPM service collaborates with both the Acute Pain Service and Chronic Pain Service.

21. Administrative and Educational Role of RPM for postoperative care Created discharge medication policy –Correct meds –Enough pain meds until first FU visit Created discharge booklet –Written resource for patients on basic pain management information. Expectations for pain control Common pain medications Common expected side effects –All inpatients receive at discharge.

22. Patient Education and Pain Management Preoperative Education “Pre-emptive” medications Postoperative PCA APS Postoperative PO Pain management Patient educationStaff education

23. RPM Patient Volume Since August 2007, the volume of inpatient consults has steadily increased yearly Confirming need for further medical pain management after discontinuation of PCA therapy. 2007200820092010 Jan074107102 Feb0609281 Mar04876101 Apr076100116 May04996107 Jun06810390 Jul05311783 Aug08690108 Sep1614286128 Oct5662104154 Nov5610381 106 Dec246074 156 Total15288111261332

24. Results of RPM Implementation Our primary outcome measure was the Press Ganey satisfaction survey. Philips, B., Liu, S., et al. “Creation of a Novel Recuperative Pain Medicine Service to Optimize Postoperative Analgesia and Enhance Patient Satisfaction”,HSS Journal (February 2010).

25. RPM HelpLine Start of RPM/ARJR Pilot Program (October 2010)

26. Staff satisfaction survey Returned by –81 RNs –7 surgical PAs 92% rated RPM as extremely helpful

27. Cost of RPM Cost for an NP ~ 150,000 USD 12.5-15 USD/pt visit Could also use a Physician’s Assistant

28. Systemic multimodal analgesia

29. NSAIDs, COX2, Acetaminophen

37. Impact of Reuben retractions NSAIDs –No effect as no RCT retracted COX2 –Only 1 RCT with 60 patients retracted –One additional RCT demonstrating analgesic benefit with celecoxib in TKR BMC Musculoskelet Disord 2008;9:77. Acetaminophen –No effect as no RCT retracted

39. Gabapentin

40. Copyright restrictions apply. Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556 Figure 1. Flow diagram of the review

41. Copyright restrictions apply. Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556 Figure 2. Pain intensity difference between the control and gabapentin groups (PIDc-g) at rest (panel A) and on movement (panel B) on VAS 0-100 during 24 h observation after a single 1200 mg dose 1-2 h before surgery

42. Copyright restrictions apply. Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556 Figure 3. Effect of preoperative gabapentin on postoperative opioid consumption

43. Side effects Reduction in opioid related side effects –Nausea: NNT=25 –Vomiting: NNT=6 –Urinary retention: NNT=7 Adverse effects –Sedation: NNH=35 –Dizziness: NNH=12

44. Pregabalin Laparoscopic hysterectomy –Opioid sparing –Increased dizziness Laparoscopy –Better analgesia –Trend toward increased dizziness Laparoscopic cholecystectomy –Better analgesia –Opioid sparing BJA 2008:101:700

45. Conclusions Discussed agents are efficacious Modest benefit NSAIDs and gabapentanoids have most to offer –Reduced opioid consumption –Reduced side effects –NSAIDs have more risk

46. Non-traditional techniques Acupuncture Music Static magnet Massage

47. Acupuncture

49. Anesth Analg 2008:106:611

52. Acupuncture May also depend on belief system 47/47 studies from China, Japan, and Taiwan found efficacy 53/96 studies from US, UK, and Sweden found efficacy

53. Music

54. Several RCTs Soft, relaxing music vs none during general anesthesia –Open inguinal hernia repair –Varicose vein stripping –Hysterectomy Very modest and short lived benefit from music Acta Anaesthesiol Scand 2003:47, 278 Acta Anaesthesiol Scand 2001:45, 812 Eur J Anaesthesiol 2005:22, 96

55. Ambulatory procedures Intraop music Control Pain in PACU (0-10) 4.23.9 Patient satisfaction 43.9 Morphine (mg) 14.416.9 Anesth Analg 2010:110:208

56. Magnet therapy Multi-billion dollar industry Mecanisms? –Increased blood flow –Altered neuron firing thresholds

58. Massage

63. Summary RPM service is efficacious –Probably cost effective –Can use different staffing models Optimize systemic analgesics Role of CAMS? –Acupuncture has best evidence