Improving the Management of Postoperative Pain - PowerPoint Presentation

Slide1

Improving the Management of Postoperative Pain

:

Multimodal

Approaches

in

Clinical PracticeSlide2

Acute Pain – Epidemiology

Acute pain is very common

51.4 million surgical in-patient procedures were performed in 2010 in the United States

Centers for Disease Control and Prevention. National Center for Health Statistics. www.cdc.gov/nchs/faststats/inpatient-surgery. Accessed July 8, 2015.Slide3

Acute Pain – Scope of the

Problem

Almost all patients experience pain after surgery, procedure, or injurySurvey of 300 US adults undergoing surgery:86% experienced pain post surgery75% had moderate to extreme pain in the immediate postsurgical period74% still had pain post discharge

Gan

TJ et al.

Curr

Med Res

Opin

. 2014;30(1):149-160.Slide4

Acute Pain – Scope of the

Problem

Studies suggest that after orthopedic, general, or cardiac surgery, 63% of patients experience pain resolution within 6 days

That means that 37% of

patients

continued to have pain problems beyond discharge from the hospital

However

, in 25% of patients, the pain did not

change, and in 12% the pain worsened in this period of time

Chapman CR et al.

J Pain.

2011;12(2):257-262.

Chapman CR et al.

Pain Res Treat.

2012;2012:608359

.Slide5

Current Problems With the Assessment of Acute Pain

Current taxonomies for postoperative pain

do not adequately describe an individual patient’s pain profile

Harstall

C,

Ospina

M.

Pain:

American Association for Marriage and Family Therapy

Clinical Updates.

2003;11(2):1-4.

World Health Organization. WHO guidelines on the pharmacological treatment of persisting pain in children with medical

illnesses. http

://www.who.int/medicines/areas/quality_safety/children_persisting_pain/en/.

Accessed July 8, 2015.Slide6

Current Problems With the Assessment of Acute Pain

When used alone, these

taxonomies do not capture the multidimensionality of pain or the dynamics of pain over the course of a 24-hour day in an individual patientThis approach may result in inadequate individualization of

pharmacologic pain

management

Somatic vs neuropathic

Pitfalls in the implementation of therapy to treat these patients:

Multimodal therapy

Opioid metabolismDrug-drug interactions

Psychological issues: catastrophizing, anxiety, depression,

etc

History of opioid use preoperatively

Preexisting pain

Genetics: gene polymorphismSlide7

Making the Differential Diagnosis

Is there an early neuropathic pain component

present?Suspect in individuals who are still receiving high doses of opioids + adjuvants 4-5 days post surgeryMust rule out opioid tolerance from preoperative opioid use

or abuseSlide8

Challenges in the Management of Acute Pain

Variable response to analgesics

Older age = more sensitivity to opioidsEthnicityPsychological issuesType of surgical procedureThe use of pre-emptive analgesic techniques

Intraoperative anesthetic techniques:

Regional anesthetic procedures vs general

Ketamine use

Genetics: gene polymorphismSlide9

Making the Differential Diagnosis

Is there an early neuropathic pain component

present?Suspect in individuals who are still receiving high doses of opioids + adjuvants 4-5 days post surgery

Must rule out opioid tolerance from preoperative opioid use

or

abuseSlide10

Neuropathic Pain (NP) Diagnosis

LANSS PAIN SCALE

Leeds Assessment of Neuropathic Symptoms

and

Signs

Bennett M.

Pain

. 2001;92(1-2):147-157.

PAIN QUESTIONNAIRE

5 Questions

SENSORY TESTING

2 Questions

Maximum

score = 24. If

< 12

, NP unlikelySlide11

Leeds Assessment of

Neuropathic

Symptoms and SignsWould you describe your pain as strange unpleasant sensations in your skin? (eg, pricking, tingling, pins and needles)

Yes

= 5/No= 0

Does the skin in the painful areas look different to normal? (

eg

,

mottled, more red/pink than usual)

Yes

= 5 /No= 0

Is the skin in the affected area abnormally sensitive to touch? (

eg

,

unpleasant sensations if lightly stroked, painful to wear tight clothes)

Yes

= 3/No= 0

Does your pain come on suddenly in bursts for no apparent reason when you are still?

(

eg

,

like electric shocks, 'bursting' or 'jumping' sensations)

Yes= 2/No= 0Do you feel that skin temperature in the painful area has changed (eg,

hot, burning)

Yes

= 1/No= 0 Does stroking the affected area of skin with a piece of cotton wool produce an unpleasant painful sensation? Yes= 5/No= 0 Does touching the affected area of skin with a sharp needle feel sharper or duller when compared to an area of normal skin? Yes= 3/No= 0

Bennett M.

Pain

. 2001;92(1-2):147-157.Slide12

Challenges in the Management of Acute Pain

Variable response to analgesics

Older age = more sensitivity to opioidsEthnicityPsychological issuesType of surgical procedureThe use of pre-emptive analgesic techniques

Intraoperative anesthetic techniques:

Regional anesthetic procedures vs general

Ketamine use

Genetics: gene polymorphismSlide13

Acute Pain Impacts

Patients’ Lives

Negative effects of inadequate acute pain management include:Increased hospital stay or more frequent readmissionsReduced quality of life (QOL)

Impaired physical function

Decreased functional recovery

Increased complications

Impaired

sleep

McCarberg

BH

et al.

Am J

Ther

.

2008;15(4):312-320.

Pavlin

DJ

et al.

J

Clin

Anesth

.

2004;16(3):200-206.

Sinatra

R.

Pain Med.

2010;11(12):1859-1871.

Morrison RS

et al.

J Am

Geriatr

Soc.

2009;57(1):1-10

.Slide14

Chronic pain

may

develop

after

surgery

as a result

of complex biochemical and pathophysiological

mechanisms

Clinically meaningful, severe acute postoperative

pain

may be a

risk

factor for the development of chronic

pain

Up to 50%

of patients reportedly suffer from chronic

pain following common

surgery

Effectively managing

acute

pain can reduce the risk for pain

progression

Inadequate Acute

Pain Management

Can

Have

Consequences

Sinatra

R.

Pain Med.

2010;11(12):1859-1871

.

Morrison RS

et al.

J Am

Geriatr

Soc.

2009;57(1):1-10

.

Voscopoulos

C,

Lema

M.

Br J

Anaesth

.

2010;105(

s

uppl

1

):i69-i85.Slide15

S

tudies suggest that individualization

of pain evaluations are important to determine:Preoperative risk factorsThe pattern of resolution for each patientThe therapeutic approach to implement

Chapman CR et al.

J Pain.

2011;12(2):257-262.

Chapman CR et al.

Pain Res Treat.

2012;2012:608359

.

Improving postoperative pain managementSlide16

Multimodal Therapy

Synchronous administration of ≥ 2 pharmacological agents or approaches, each with a distinct mechanism of action

American Society of Anesthesiologists Task Force on Acute Pain Management.

Anesthesiology

. 2012;116(2):248-273.

American Society of Anesthesiologists Task Force on Acute Pain Management. Practice Guidelines for Acute Pain Management in the Perioperative

Setting.

Anesthesiology

. 2012;116:248-273.Slide17

Multimodal Therapy

Key Practice Guidelines Recommendations

American Society of Anesthesiologists Task Force on Acute Pain Management.

Anesthesiology

. 2012;116(2):248-273.

Whenever possible, anesthesiologists should use

multimodal

pain management therapy.Slide18

Multimodal Therapy

Rationale:

Targeting of different pathwaysSynergism of multiple agentsAllows for dose reduction of individual agents, reducing the risk for adverse effectsSlide19

Multimodal Therapy

Key Practice Guidelines Recommendations

American Society of Anesthesiologists Task Force on Acute Pain Management.

Anesthesiology

. 2012;116(2):248-273.

Anesthesiologists who manage perioperative pain should, after thoughtfully considering the risks and benefits for the individual patient, use therapeutic options such as:

Epidural or intrathecal opioids

Systemic opioid

patient-controlled analgesia (PCA)

Regional techniquesSlide20

Key Practice Guidelines Recommendations

Unless contraindicated, patients should receive an around-the-clock regimen of nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors, or acetaminophen.

Dosing regimens should be administered to optimize efficacy while minimizing the risk for adverse events.

The choice of medication, dose, route, and duration of therapy should be individualized.

American Society of Anesthesiologists Task Force on Acute Pain Management.

Anesthesiology

. 2012;116(2):248-273.

Multimodal TherapySlide21

Perioperative Techniques

in Pain Management

Technique

Examples

Advantages

Disadvantages

Central

Regional Analgesia

Intrathecal or epidural

opioid

a

Improved pain relief

Increased

frequency of pruritus

Epidural

opioid

a

+ local

anesthetic

b

Improved

pain scores

Increased motor weakness

Epidural

opioid

a

+ clonidine

None noted

None noted

a

Examples of opioids include morphine, fentanyl,

sufentanil

b

Examples of local anesthetics include bupivacaine,

ropivacaineAmerican Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-273.Slide22

Technique

Examples

Advantages

Disadvantages

Systemic

opioids

a

Staff

-administered intramuscular (IM) injections

None noted

Pain on injection

Tissue

damage

Staff

-administered intravenous injections

Similar pain control to PCA

Peak

/ trough opioid adverse drug reactions (ADRs)

PCA without

background infusion

Improved

pain scores vs IM

None noted

PCA with background infusion

Improved pain scores vs IM

Increased analgesic use vs

no background

a

Examples of opioids include morphine, fentanyl, hydromorphone

American Society of Anesthesiologists Task Force on Acute Pain Management.

Anesthesiology

. 2012;116(2):248-273.

Perioperative Techniques

in Pain ManagementSlide23

Technique

Examples

Advantages

Disadvantages

Peripheral

Regional Analgesia

Peripheral nerve

blocks

b

Generally, improved pain relief

and l

ower analgesic

consumption compared with saline

None noted

Intra-articular

blocks

b

or

opioids

a

None noted compared

with saline

None noted

Infiltration of

incisions

b

Generally, improved pain relief

and l

ower analgesic

consumption compared with saline

None noted

a

Examples of opioids include morphine, fentanyl,

sufentanil

b

Examples of local anesthetics include bupivacaine, ropivacaineAmerican Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-273.Perioperative Techniques in Pain ManagementSlide24

Technique

Examples

Advantages

Disadvantages

Nonopioid

systemic

analgesics

Acetaminophen

(oral, rectal, injectable)

Similar benefit to

intravenous (IV) PCA opioid

Fewer ADRs

None noted

Injectable

NSAIDs

Improved

pain scores

Reduced analgesic use

NSAID

risks / ADRs

Oral

NSAIDs (both non- and selective

None noted

NSAID

risks / ADRs

Gabapentinoids

(both

gabapentin and

pregabalin

)

When combined w/

opioids

Improved pain scores

Reduced

analgesic use

None

noted

American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-273.

Perioperative Techniques in Pain ManagementSlide25

Dual Ascending Pathways

Spinal Cord

Mid Brain

Thalamus

Sensory Cortex

Limbic Cortex

Ascending

Pathways

Peripheral

Nociceptor

Dorsal

Horn

Sensory

Fiber

Efferent

Fiber

Descending

Pathways

Slide courtesy of Raymond Sinatra, MDSlide26

Physiological Pain

Spinal Cord

Mid Brain

Thalamus

Sensory Cortex

Limbic Cortex

Ascending

Pathways

Nociceptor

Dorsal

Horn

Sensory

Fiber

Efferent

Fiber

Slide courtesy of Raymond Sinatra, MDSlide27

Postoperative Pain

Treatment

Multi

m

odal

Therapy

Local anesthetics (LA)

infiltration

Acetaminophen

Anti-inflammatory agents,

COX-2 inhibitor

LA

via peripheral

nerve catheters

Local anesthetics

Opioids



2

-Agonists

NMDA antagonists

COX-2 Inhibitors

Opioids



2

-Agonists

Acetaminophen

N

-methyl-

d

-aspartate

(NMDA) antagonists

Slide courtesy of Raymond Sinatra, MD and modified for educational purposes Slide28

Multimodal Approaches:

Evidence-based Summary

Acetaminophen (APAP) – oral, single doseCochrane review151 studies, 5762 patients, 3277 active, 2425 placebo50%



in pain with 50% APAP group, 20% placebo group

for 4 hours

Number needed to treat (NNT) based on dose:

APAP 500 mg: 3.5

APAP 650 mg: 4.6

APAP 1000 mg: 3.6

50% of APAP and 70% of placebo needed additional analgesia

A systematic

review

2

identified 21 studies

comparing APAP alone

or in combination with

NSAIDs and

reported increased efficacy with the combination of

2 agents

than with either

alone

1

Toms L et al.

Cochrane Database

Syst

Rev

. 2008;(4):CD004602.

2

Ong CK et al.

Anesth

Analg

.

2010;110(4):

1170-1179.Slide29

Acetaminophen – Parenteral

Studied single dose, multiple dose over 24 hours compared with placebo

Orthopedic surgery, laminectomy, abdominal, gynecological, cardiac, and thyroidectomyDosing: 1 gram IV, either single dose or every 6 hoursSummary APAP patients:Statistically significant shortened time to meaningful pain relief and in total relief compared with placeboImproved patient satisfaction with pain control, lower morphine consumption (up to 61%) and decreased incidence of vomitingNo statistical significant difference in the rates of adverse events including liver function abnormalities compared with placebo

Wininger

SJ et al.

Clin

Ther

.

2010;32(14):2348-2369.

Cakan

T et al.

J

Neurosurg

Anesthesiol

.

2008;20(3):169-173.

Memis

D et al.

J

Crit

Care

. 2010;25(3):458-462.

Macario

A, Royal MA.

Pain

Pract

. 2011;11(3):290-296.

Multimodal Approaches:

Evidence-based SummarySlide30

Acetaminophen

(

Paracetamol or APAP)Produces a central analgesic effect, but unknown mechanism of action (MoA) for years

New evidence for

MoA

from extensive research

MoA

evidence now suggests that the analgesic

effect of APAP

is

partly due

to the indirect activation of cannabinoid CB(1)

receptors

APAP primary

amine

(

p-aminophenol

) is

conjugated

to form N

-

arachidonoylphenolamine

,

an

endogenous cannabinoid N-arachidonoylphenolamine is an agonist at TrpV-1

receptors and an inhibitor of cellular

anandamide

uptake,  increased levels of endogenous cannabinoidsAPAP may also work through inhibition of prostaglandin (PG) synthesis via prostaglandin H(2)

synthetase

,

particularly in areas of the brain with high concentrations of fatty acid amide

hydrolase

Thus,

acetaminophen may have multiple

MoAs

, one of which ultimately

acts as a pro-drug, the active one being a cannabinoid Dual effect may be both a direct analgesic effect and modulation effectBertolini

A et al. CNS Drug Rev. 2006;12(3-4):250-275.Graham GG et al. Inflammopharmacology. 2013;21(3):201-232.Anderson BJ. Paediatr

Anaesth. 2008;18(10):915-921.Slide31

Nonselective NSAIDs

Single dose oral ibuprofen

1 – Summary 72 randomized clinical trials (RCTs), 9168 patients 50% pain relief in approximately half of patients with moderate to severe postoperative pain, and adverse events were similar to placebo Single dose oral aspirin2 – Summary



50

% or greater reduction in pain in 39% of those with moderate to severe pain, compared with 15% of those in the placebo

group

The

efficacy of aspirin was considered equivalent to that of acetaminophenAdverse

events were statistically similar for those taking a lower

aspirin

dose, 600 mg to 650 mg, compared with placebo. However, patients who took

900

mg to 1000

mg

experienced

adverse events at more than twice the rate of patients receiving placebo (26%

vs

12%). The most common events in the aspirin group were drowsiness, dizziness, nausea, vomiting, and gastric

irritation

1

Derry C

et al.

Cochrane

Database

Syst

Rev

. 2009;(1):CD004234.

2

Derry C et al.

Cochrane

Database

Syst

Rev.

Published Online Jan 2012Multimodal Approaches: Evidence-based SummarySlide32

S

elective NSAIDs – Single dose Celecoxib

Cochrane review - 10 studies, 1785 patientsNNT for  50% decrease in pain over 4 to 6 hours:Celecoxib 200 mg: 4.8Celecoxib 400 mg: 3.5Median time for rescue medication use:Celecoxib 200 mg:

6.6 hours

Celecoxib

400 mg:

8.4 hours

Placebo: 2.3 hours

Proportion of patients requiring rescue medications:Celecoxib

200

mg: 74%

Celecoxib

400 mg:

63%

Placebo:

91%

Adverse events mild to moderate in all groups with no difference

in frequency

Derry S

et al.

Cochrane Database

Syst

Rev

. Published Online:

22

OCT

2013

Multimodal Approaches:

Evidence-based SummarySlide33

Injectable NSAIDs

Ketorolac and ibuprofen studied in United States

Indicated for short-term moderate to severe acute pain that requires analgesia at the opioid levelStudies (variety of surgery types) with ketorolac1,2 compared with placebo suggest patients who received ketorolac:Significant reduction in painReduction in opioid consumption (~30%)Facilitation of quicker recovery and rehabilitation

Studies with ibuprofen in orthopedic and abdominal surgery

3

At 800-mg dose, reduced morphine use by 22% in first 24 hours

Significant reductions in pain at rest and with movement

No significant increases compared with placebo in ADRs

1.

Cassinelli

EH et al.

Spine (

Phila

Pa 1976).

2008;33(12):1313-1317.

2. Wong HY et al.

Anesthesiology

. 1993;78(1):6-14.

3.

Southworth

S et al.

Clin

Ther

.

2009;31(9):1922-1935.

Multimodal Approaches:

Evidence-based

SummarySlide34

Parenteral Opioids – Patient-controlled Analgesia

Cochrane review

55 studies with 2023 patients receiving PCA and 1838 patients assigned to a control group (nurse-administered opioid)PCA provided better pain control and greater patient satisfaction than conventional parenteral 'as-needed' analgesiaPatients using PCA:Consumed

higher amounts of opioids than the

controls

Had higher

incidence of pruritus (itching

),

but similar incidence of other adverse effects There

was no difference in the length of hospital

stay

Hudcova

et al.

Cochrane Database

Syst

Rev.

2006;(4):CD003348.

Multimodal Approaches:

Evidence-based SummarySlide35

Parenteral Opioids – Patient-

c

ontrolled AnalgesiaPCA vs nurse-controlled (NCA) after cardiac surgery10 randomized trials, 666 patientsCompared with NCA:PCA significantly reduced visual analogue scale (VAS) at 48 hours, not at 24 hoursPCA groups showed significantly increased cumulative morphine equivalents consumed at 24 hoursNo difference with ventilation times, length of ICU stay, length of

hospital stay, patient satisfaction scores, sedation scores, incidence

of postoperative nausea and vomiting (PONV), respiratory depression, severe pain, discontinuations, and death

Bainbridge D et al.

Can J

Anaesth

. 2006;53(5):492-499.

Multimodal Approaches:

Evidence-based SummarySlide36

Epidural Opioids

Cochrane Review

Abdominal aortic surgery15 trials with 1297 patients (633 received epidural analgesia and 664 received systemic opioid analgesia)The epidural analgesia group showed significantly lower visual analogue scale scores for pain on movement (up to postoperative day 3) Conclusions:

Compared with systemic opioids:

Regardless

of the site of the epidural catheter and epidural

formulation, epidural

analgesia provides better pain

relief (especially during movement) in the period up to 3 postoperative days

D

uration

of postoperative tracheal

intubation is reduced

by roughly

half with epidural

The occurrence of prolonged postoperative mechanical ventilation, myocardial infarction, gastric

complications,

and renal complications

was

reduced by epidural

analgesia

Nishimori

M et al.

Cochrane Database

Syst

Rev

. 2012;(7):CD005059.

Multimodal Approaches:

Evidence-based SummarySlide37

Epidural Local Anesthetics vs

O

pioid-based Regimens (systemic or epidural)Cochrane ReviewAbdominal surgery, 8 studies, small numbers of patientsKey outcome analysis: Postoperative: Gastrointestinal (GI) function, pain, PONV, and complicationsConclusions:

Epidural local anesthetics:

Reduced time of GI functioning, slight reduction in VAS pain scores on the first postoperative day

No significant differences in PONV or complications

Jorgensen H et al.

Cochrane Database

Syst

Rev.

Published Online:

22 JAN 2001

Multimodal Approaches:

Evidence-based SummarySlide38

Continuous Epidural Analgesia

Cochrane

database review1: 9 RCT comparing IV PCA and continuous epidural analgesia (CEA) CEA had better pain control in the first 72 hours after abdominal surgeryThere was no difference in length of

hospital stay

and adverse events between the

2 routes

Patients

with CEA had a higher incidence of pruritus related to opioidsC

omparing PCA vs CEA in colorectal surgery

2

showed that CEA significantly reduced

postoperative

pain

and ileus, but was associated with pruritus, hypotension,

and urinary retention

1

Werawatganon T,

Charuluxanun

S.

Cochrane

Database

Syst

Rev

. 2005;(1):CD004088.

2

Marret E

et

al; Postoperative Pain Forum Group.

Br J

Surg.

2007;94(6):665-673.

Multimodal Approaches:

Evidence-based SummarySlide39

Intrathecal (IT) Morphine + PCA Morphine vs PCA Morphine Alone

Major abdominal surgery, 60 patients

SummaryAnalgesia at rest and while coughing was significantly better in the IT+PCA morphine group on the first postoperative day only Morphine consumption was lower in the IT+PCA morphine group during first postoperative dayNo difference was found in pain relief and morphine consumption between the groups on the second postoperative

day

Nausea

and vomiting were more frequent with IT+PCA morphine

on

the first postoperative

day No respiratory depression occurred in either

group

Satisfaction

was high in both

groups

Devys

JM et al.

Can J

Anaesth

. 2003;50(4):

355-361.

Multimodal Approaches:

Evidence-based SummarySlide40

Local Anesthetics – Wound Infiltration

Useful in a variety of surgeries

Cardiothoracic, abdominal, gynecological, colorectal, head and neck, orthopedicGeneral conclusions from studies:Effective in a variety of surgical sitesNeither infection nor toxicity appears to be a significant clinical issuePreoperative blockage superior to postoperativePain is reduced both at rest and on mobilizationOpioid requirements are less

Decreased occurrence of acute and chronic pain 3 and 6 months after surgery shown in 1 study with breast cancer surgery

Scott NB.

Anaesthesia

. 2010;65(

suppl

1):67-75.

Multimodal Approaches:

Evidence-based SummarySlide41

Intravenous

Lidocaine

Meta-analysis after abdominal surgery8 trials, 161 patients received lidocaine (active arm), 159 saline (placebo arm) Both arms could receive as-needed opioidsLidocaine IV groups showed:Decreased duration of ileusLength of hospital stay

Postoperative pain intensity

Incidence of PONV

30%–50% reduction in opioid consumption

Marret

E et al.

Br J Surg

. 2008;95(11):1331-1338.

Multimodal Approaches:

Evidence-based SummarySlide42

Intravenous

Lidocaine

Systematic review (various surgeries, including: abdominal, tonsillectomy, total hip, coronary bypass)16 trials, 395 patients received lidocaine (active arm), 369 saline (placebo arm)All could receive as-needed opioidsIn patients who received IV lidocaine IV:Pain scores were reduced at rest and with cough or movement for

up

to 48 hours postoperatively

in abdominal surgery patients

N

o

impact on postoperative analgesia in patients undergoing tonsillectomy, total hip arthroplasty,

or coronary artery bypass surgery

Decreased duration of ileus

Length of hospital stay shortened

Postoperative pain intensity lessened

Incidence of PONV decreased

Up to 85% reduction in opioid consumption

McCarthy GC et al.

Drugs

. 2010;70(9):1149-1163.

Multimodal Approaches:

Evidence-based SummarySlide43

Ketamine Intravenous – Systematic Review

70 studies, 4701 patients (2652 ketamine, 2049 placebo)

SummaryPatients receiving ketamine reported a reduction in total opioid consumption and an increase in the time to first analgesic dose needed across all studies

(

P

< .001

).

The

greatest

efficacy of ketamine

was found for thoracic, upper abdominal,

and

major orthopedic surgical

subgroups

Despite

using less opioid, 25 out of 32 treatment groups (78%) experienced less pain than the placebo groups

Hallucinations and nightmares were more common

with patients receiving ketamine,

but

there was no association with increased sedation

In patients in whom ketamine was reported as

efficacious for pain, postoperative nausea and vomiting was less frequent in

those patients who received ketamine

The analgesic effect of ketamine was independent of the type of intraoperative opioid administered,

the timing

of ketamine administration, and

the ketamine dose administered

Laskowski

K et al.

Can

J

Anaesth

.

2011;58(10):911-23.

Multimodal Approaches:

Evidence-based SummarySlide44

Gabapentinoids

- Systematic Review of RCTs

Gabapentin: 22 trials, 1640 patientsPregabalin: 8 trials, 707 patientsSummary:

Gabapentin provided better

postoperative

analgesia

and in sparing

rescue analgesics

than placebo in the 6/10

RCTs that

administered gabapentin as preemptive analgesia only

14 RCTs

suggested that gabapentin did not reduce PONV when compared with placebo

Pregabalin

provided better

postoperative

analgesia

and in sparing

rescue analgesics

than

placebo in

2/3 RCTs

that evaluated the effects of

pregabalin

alone vs placebo4 studies

reported no

pregabalin

effects on preventing PONVBoth agents reduced opioid consumption by ~30%

Dauri

M et al.

Curr

Drug Targets

. 2009;10(8):71633.26

Multimodal Approaches:

Evidence-based SummarySlide45

Systemic



2 Agonist – Meta-analysis of RCTsSummaryModerate analgesic benefit—probably better than paracetamol, but less than that of ketamine and NSAIDs

as inferred from

nonsystematic

indirect

comparison

Adverse reactions may be significant (hypotension

and bradycardia

)

Provides extra

analgesic benefits such as sedation,

anxiolysis

, analgesia, postoperative shivering

, decreased PONV

, agitation, mitigation of stress response to surgery and tracheal intubation,

anaesthetic

-sparing effect, and as supplement to

neuraxial

and peripheral nerve

blocks

Decreased perioperative mortality and myocardial

infarction,

especially in high-risk vascular

surgeries

Blaudszun

G et al. Anesthesiology. 2012;116(6):1312-1322.

Multimodal Approaches:

Evidence-based SummarySlide46

Perioperative Pain –

Analgesic Adjuvants

Drug

Pain Intensity

Analgesic Opioid Consumption

Opioid-related Side Effects

Prevention

of Chronic

Postsurgical

Pain

Side Effects

Ketamine







Inconsistent

Psychomimetic

(hallucinations, dreams)

Pregabalin







Yes

Sedation,

dizziness

Gabapentin







Yes

Sedation, dizziness

IV

Lidocaine







Possible

None noted,

but monitorSystemic α2 agonistNo dataHypotension, bradycardia

Shankar R et al.

Anaesth

Crit

Care

Pain

. 

2013;13(5):152-157. Slide47

Systemic Multimodal Medications – Common Adverse Drug Reactions

Class

Examples

ADR Risks

Comments

Opioids

Morphine

Hydromorphone

Fentanyl

Sedation

Constipation

Nausea / Vomiting

Dizziness

Sedation

may impair postoperative rehabilitation

Constipation may affect time to discharge

NSAIDs

(injectable)

Ketorolac

Ibuprofen

GI bleeds

Nephrotoxicity

May affect wound / bone healing

NSAIDs

(oral, nonselective)

Ibuprofen

Naproxen

Diclofenac

GI

bleeds

Nephrotoxicity

Nausea / Vomiting

May affect wound / bone healing

NSAIDs

(oral, selective)

Celecoxib

Nephrotoxicity

Nausea / VomitingMay affect wound / bone healingAcetaminophenAcetaminophen(oral and injectable)

Hepatotoxicity at high dosesNo effect on bleeding timesWell toleratedGabapentinoidsGabapentin PregabalinDizzinessSedation

Helpful with neuropathic painSlide48

Multimodal Analgesia

The state-of-the-art is multimodal therapy with:

Opioids IV Intraspinal

(IS)

O

ral route

NSAIDs

APAP

Local anesthetics

Wound site infiltration or perfusion

Peripheral nerve infusions via catheters

Epidural

IV

Preperitoneal

catheters

American Society of Anesthesiologists Task Force on Acute Pain Management.

Anesthesiology.

2012;116(2):248-273. Slide49

Temporal Pain Intensity

Differences Between Acute and

Chronic Pain

Step 4 (interventional

)

Step 3 (potent

opioids

)

Increasing Pain Intensity

Step 2 (weak

opioids

)

Step 1 (

nonopioids

)

Decreasing Pain Intensity

No

analgesics

Chronic Pain “Ladder”

Acute Surgical PainSlide50

Transition From Acute Surgical Pain and the Development of Chronic Pain

interventional

potent opioids

weak opioids

non-

opioids

Decreasing

Pain Intensity

Surgery

Increasing Pain

Intensity

no medications

Time

Nerve Injury

v

s Central

Sensitization

interventional

potent opioids

adjuvantsSlide51

Transition From Acute Surgical Pain to Subacute (Persistent) Pain

interventional

potent opioids

weak opioids

non-

opioids

Decreasing

Pain Intensity

Surgery

Pain Intensity Remains High

no medications

Time 1 to 12 weeks

potent opioids

adjuvantsSlide52

Multimodal Pain Management:

Step Therapy

Crews JC.

JAMA.

2002;288(5):629-632.

Severe Postoperative Pain

Step 1 and Step 2 Strategies

AND

Local Anesthetic Peripheral Neural Blockade

(with or without catheter)

AND

Use of Sustained-release Opioid Analgesics

Nonopioid

Analgesic

Acetaminophen, NSAIDs, or COX-2 Selective Inhibitors

AND

Local Anesthetic Infiltration

Moderate Postoperative Pain

Mild Postoperative Pain

Step 1 Strategy

AND

Intermittent Doses of Opioid Analgesics

Step 3

Step 2

Step 1

Reprinted with permission. Copyright © 2002

American Medical Association. All rights reserved.Slide53

Pharmacoeconomics

Consequences of side effects

Consequences of inadequate pain control

Consequences of postoperative complications

ReadmissionsSlide54

Transition From Acute Surgical Pain to Subacute (Persistent) Pain

interventional

potent opioids

weak opioids

non-

opioids

Decreasing

Pain Intensity

Surgery

Pain Intensity Remains High

no medications

Time 1 to 12 weeks

potent opioids

adjuvantsSlide55

Clinical PearlsSlide56

Thank you!