Postoperative pain control
What to do after PCA?
Spencer S. Liu, MD
Clinical Professor of Anesthesiology
Director Acute and Recuperative Pain
Services
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.
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
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
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
What can one do?
• Acute Pain Services are popular and
effective
• Typically expensive
• Typically manage PCA modalities
Anesth Analg 2002:95:1361
Anesthesiology. 104(5):1033-1039,2006
13
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
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
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
Patient Education and Pain Management
Preoperative
“Pre-emptive”
medications
Education
Postoperative PCA
APS
Postoperative PO
Pain management
Patient education
Staff education
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
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
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.
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.
Patient Education and Pain Management
Preoperative
“Pre-emptive”
medications
Education
Postoperative PCA
APS
Postoperative PO
Pain management
Patient education
Staff education
RPM Patient Volume
2007
• Since August 2007, the
volume of inpatient
consults has steadily
increased yearly
• Confirming need for
further medical pain
management after
discontinuation of PCA
therapy.
2008
2009
2010
Jan
0
74
107
102
Feb
0
60
92
81
Mar
0
48
76
101
Apr
0
76
100
116
May
0
49
96
107
Jun
0
68
103
90
Jul
0
53
117
83
Aug
0
86
90
108
Sep
16
142
86
128
Oct
56
62
104
154
Nov
56
103
81
106
Dec
24
60
74
156
152
881
1126
Total
1332
Results of RPM Implementation
• Our primary outcome measure
was the Press Ganey
satisfaction survey.
100
•
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).
Percentile Ranking
95
90
85
80
75
2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010
1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd
Quart Quart Quart Quart Quart Quart Quart Quart Quart Quart Quart
91
97
99
97
98
99
99
99
99
99
99
Magnet PG 84
97
99
98
97
99
99
98
99
98
97
92
92
99
90
99
99
99
99
99
99
99
Large PG
HSS PG
RPM HelpLine
Start of RPM/ARJR Pilot
Program (October 2010)
50
45
40
35
30
25
Number of Phonecalls
20
15
10
5
Jan-11
Nov-10
Sep-10
Jul-10
May-10
Mar-10
Jan-10
Nov-09
Sep-09
Jul-09
May-09
Mar-09
Jan-09
0
Staff satisfaction survey
• Returned by
– 81 RNs
– 7 surgical PAs
• 92% rated RPM as extremely helpful
Cost of RPM
• Cost for an NP ~
150,000 USD
• 12.5-15 USD/pt visit
• Could also use a
Physician’s Assistant
Number of PCAs
14000
12000
10000
8000
6000
4000
2000
0
2009
2010
Systemic multimodal analgesia
NSAIDs, COX2, Acetaminophen
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
Gabapentin
Figure 1. Flow diagram of the review
Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556
Copyright restrictions apply.
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
Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556
Copyright restrictions apply.
Figure 3. Effect of preoperative gabapentin on postoperative opioid consumption
Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556
Copyright restrictions apply.
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
Pregabalin
• Laparoscopic hysterectomy
– Opioid sparing
– Increased dizziness
• Laparoscopy
– Better analgesia
– Trend toward increased dizziness
• Laparoscopic cholecystectomy
– Better analgesia
– Opioid sparing
BJA 2008:101:700
Conclusions
• Discussed agents are efficacious
• Modest benefit
• NSAIDs and gabapentanoids have most to
offer
– Reduced opioid consumption
– Reduced side effects
– NSAIDs have more risk
Non-traditional techniques
•
•
•
•
Acupuncture
Music
Static magnet
Massage
Acupuncture
Anesth Analg 2008:106:611
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
Music
Music
• 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
Ambulatory procedures
Intraop
music
4.2
Pain in
PACU
(0-10)
Patient
4
satisfaction
Morphine
14.4
(mg)
Control
3.9
3.9
16.9
Anesth Analg
2010:110:208
Magnet therapy
• Multi-billion dollar
industry
• Mecanisms?
– Increased blood flow
– Altered neuron firing
thresholds
Massage
Summary
• RPM service is efficacious
– Probably cost effective
– Can use different staffing models
• Optimize systemic analgesics
• Role of CAMS?
– Acupuncture has best evidence