2/5/2016 5:07 PM (last saved)
Anesthesia Acute Pain Service Syllabus
Introduction
The acute pain service is a consult service has been established to provide continuing analgesia for postoperative patients. The comfort and safety of the post-operative patients on service will be the first priority,
with other consults taking second priority. Members of the acute pain service are asked to provide diagnostic or
therapeutic blocks on perioperative patients and to consult on complicated pain management issues, on both
acute and chronic pain patients. In addition, the acute pain service will also provide consultation and blocks for
various hospital services.
Duties of a Resident
The acute pain resident will share responsibilities for
1. Managing the acute pain service
2. Placing peripheral nerve blocks and epidurals in preop. The priority for block placement is:
perineural catheters\blocks > thoracic epidurals > lumbar epidurals
3. Performing consults and (see Consult Coverage below)
4. Evaluating post-block patients, starting epidural infusions, and managing problems in the PACU.
The resident should attend acute pain rounds, both in the morning and in the afternoon, as workload allows. In
addition, they will evaluate any pain consults arising from the ward. All post-op and ward consults should be
seen by an anesthesiologist or APS nurse prior to initiation of service. The resident will contact the acute pain
attending as each patient is referred so that he is aware of all patients and can help in the direction of therapy.
The acute pain resident will be responsible for making sure that all appropriate Epic orders have been initiated
on each patient.
Each resident will be oriented on how to complete the necessary Epic notes/orders. In addition, the acute pain
resident is responsible for updating the census at the end of each day and listing all patients on service. The APS
resident will share responsibility with the APS nurse for ensuring that a note is present on each patient on the
acute pain service daily, and that each patient has been discussed with the acute pain attending. If the acute pain
service resident performs a procedure, s/he will be responsible for writing an appropriate procedure note.
Daily notes on AM rounds are normally written by the APS nurse for proper billing of services. On the
weekends/holidays notes are written by the resident and co-signed by the attending. As appropriate, on PM
rounds document the response to any changes made during or since AM rounds. If there was an intervention
made in the middle of the day or during PM rounds, the attending should be notified. The following are
normally documented in the pain service note:
1. Current pain assessment (VAS resting, movement);
2. Current dose of medication
3. Side effects
4. Complications
5. Catheter site
6. Block sensory level and LE motor function
7. If a catheter is discontinued, whether or not the catheter tip was intact and the site condition
(non-tender, no bleeding).
8. Change in plans or interventions and their effect
9. Communication with primary service as appropriate
10. APS Role (e.g., ordering meds, only making recommendations, following, off service, etc.)
The acute pain resident will take acute pain service call during the month as required by the acute pain call
schedule - generally 2 weekends with some weekday pain call. In addition, the acute pain resident is
responsible for carrying the anesthesia pain pager M-F while in-house. It should be stressed that the acute pain
resident is primarily responsible for all acute pain patients. Calls should be answered as soon as possible. For
problems on current patients or new patients referred in the evening after the call resident has left the hospital,
the call resident will locate an in-house resident to handle the problem. If he cannot, he will need to come in to
see the patient or handle to problem. The best order to contact in-house residents in is 1) SICU resident (if
anesthesia), 2) OB resident 3) C1/R1 resident 4)anesthesia attending on call (85920). Obviously, life will be
smoother if a potential problem is "checked out" with an in house resident prior to leaving.
Acute and Chronic Pain Services Consult Coverage
1. Acute Pain Service (APS) consults may be obtained by calling the APS pager
(303) 266-6493
a. Examples of APS consults include: neuraxial and peripheral blocks for post surgical pain; post surgical
patients with potential complicating factors such as opioid tolerance (opioid exposure of 50 mg per day
of oral morphine equivalent), intolerable side effects or poor response to current pain treatment,
past/present substance abuse, liver or renal dysfunction; patients undergoing traumatic procedures such
as burn wound care; assistance with opioid drug conversions
b. The APS resident will provide initial recommendations over the phone as indicated and notify APS
attending and nurse of any urgent issues
c. If full assessment of pain problem is indicated, within 24 hours, the resident or APS nurse will perform
an evaluation of patient and after discussion with the APS or covering attending leave consult note in
chart with assessment and recommendations with call to referring service.
2. Chronic Pain Service (CPS) consults may be obtained by calling the CPS pager (303) 266-7291
a. Examples of CPS consults include: requests for interventional treatments such as epidural steroid
injection, celiac plexus block, lumbar sympathetic block, epidural or spinal infusion for chronic pain,
intrathecal pump or nerve stimulator refill/adjustments; patients with an established chronic pain
problem; exacerbations or inadequate management of chronic pain problems; chronic pain problem
unrelated to surgical procedure
b. The CPS resident/fellow will provide initial recommendations over the phone as indicated and notify
CPS attending of any urgent issues
c. If full assessment of pain problem is indicated, within 24 hours the CPS resident/fellow will perform an
evaluation of patient and after discussion with the CPS attending leave consult note in chart with
assessment and recommendations with call to referring service.
Pager Forwarding
The Acute Pain Service pager (303-266-6493) can be forwarded to any of the resident's pagers.
Call the pager IT help desk on campus at 303-724-0400 during business hours (M-F 0730-1630) or
USAMobility 877-821-2445 24h/day.
You will need to call again to unforward the pager.
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Phone Calls/Pages for Acute Pain Service at Night and Weekends
Problems Which Can Be Managed By Phone:
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First time call for increasing pain (i.e., handled by bolusing and/or increasing dose/rate/meds)
Clarification of our orders or questions about monitoring, ambulation or orders from other services
Pruritus
Nausea and vomiting
Urinary retention
Patient Must Be Seen For Calls About:
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Severe pain or subsequent calls for additional medication
Before unexpectedly stopping or discontinuing an epidural
Any situation in the acute pain service orders requiring our notification by the patient’s nurse
o Over sedation
o Increasing sedation with slowing of respiratory rate (< 10/min),
o motor block
Sudden increase in density of motor block or sudden change in level of sensory block (suspect epidural
hematoma or intrathecal migration of catheter)
Significant hypotension
Accidental catheter disconnects
Drug errors (pharmacy or nursing) giving patient an overdose relative to pain service orders
Major complications
o Patient falls, drug reactions
The nurses are encouraged to call if they are concerned about their patient. If the nurse’s questions or concerns
cannot be managed by phone, please see the patient along with the nurse.
These suggestions cannot cover all possible eventualities. Let your clinical judgment guide you.
You Will Never Be Faulted For Seeing A Patient Unnecessarily.
APS Nights and Weekends Coverage Resident and Faculty Coverage
1. The APS resident, including any cross-cover resident, MUST consult with the on-call anesthesia
attending regarding any episode of persistent block-induced hemodynamic instability not responsive to
standard measures, persistent unexplained neurologic compromise (not temporary sensory loss/motor
block from local anesthetic bolus), or continuing ineffective pain control after standard response
measures (i.e., bolusing, rate adjustment, mixture adjustment).
2. Any APS patient with the above problems must be seen, the incident documented in the chart, and the
primary service notified.
3. Any decision to abandon or replace a block must be discussed with the on-call anesthesia attending and
the primary service notified.
4. APS patients being managed with only oral or IV medications are included in the above.
5. The APS attending should be contacted M-F 7a-4p and the C1 attending at all other times.
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Acute Pain Service Routines (AKA, the ins & outs of APS)
Preop
 APS Resident: evaluates patients for potential regional block, presents the patient with appropriate
anesthetic choices, and obtains anesthetic/block consent
 OR Resident/CRNA: should complete preanesthesia in Epic and start IV
 If multiple potential blocks for first cases, prioritize peripheral block>thoracic epidural>lumbar epidural and
notify OR anesthesia teams of need to place their own blocks.
 Expedite timely placement of blocks to prevent OR delay. Begin block procedure by 0645-0700.
 After block placed, notify nurse to bring family back. As appropriate, turn over care to OR anesthesia team
or to preop RN for patient monitoring until taken to OR.
 OR Schedule: Each day at ~1330 the next day’s OR schedule is ready for review by APS; mark potential
block candidates and return to preop nursing staff. If multiple blocks expected in AM, notify appropriate
resident/CRNA that (s)he will need to do block. Note if there are any “APS” consults listed under
comments section and discuss with attending/APS RN.
 Preorder Total Joint Pain Protocol/Thoracic Protocol meds for the next day’s patients.
 As workload allows, review patient records of next day’s blocks for medical and pain management history
and contraindications; coagulopathies, abnormal clotting studies, PT, INR, infection, etc.
AM Rounds
 Prior to rounds, use Epic to look up room numbers and gather data for rounding
 Daily patient assessment includes: pain level at rest and with activity, response to PCEA/IVPCA/Nerve
Block, meds, side effects (N/V, numbness, paresthesia, pruritus), dermatome, mobility and strength, LOC,
block catheter site and dressing, and significant events.
 AM Progress Note: APS RN writes notes or resident writes note that attending cosigns.
 OR Pharmacist: Supports the APS by going on AM rounds. Will normally review med record for meds
given for pain, side effects, and for anti-coagulation, and will interrogate PCA pump for amount used. Will
assist in writing orders while APS RN/resident is writing progress note.
 Orders: Notify floor/unit RN before leaving unit when there is an urgent need for changes to a pain infusion
pump or you have removed a block catheter.
PM Rounds
 Briefly document response to changes made on AM rounds.
 Stable patients do not need to be seen, however do not leave lingering problems for cross cover.
 Pre-write orders for next day where appropriate.
PACU
 Nurses can connect and start peripheral nerve block catheters. Anesthesia provider or APS team must
connect and start epidural catheters.
 When APS is writing med orders/managing block infusion, review primary team admit/med recon orders to
ensure pain meds are not double ordered. Reconcile all conflicts before patient leaves PACU.
 If epidural is not working and is d/c’d, notify surgery and ensure that IVPCA (or appropriate meds) are
ordered and sign off case, unless consulted for continued management (chronic pain, opioid tolerance, etc.)
Epidurals
 Epidural Dosing Guide is for average patient of average health. Increase/decrease dosing based on
morbidity, chronic pain, opioid tolerance, etc.
 If adding IVPCA, convert PCEA to basal only infusion
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CT surgery/Thoracic Cases: normally maintain epidural until last chest tube removed, except for
pneumonectomy (no chest tube) – clear with surgery before removing.
Transplant Service: See Transplant Protocol.
Max duration of epidural is 5-6 days. Discuss with attending if going beyond this time limit.
Floor/unit nurses do not d/c catheters; only anesthesia or APS team.
Routine transition to off epidural to PO meds: Normally order short acting PO opioid +/- APAP scheduled x
24h, then prn. Initiate with one dose, then stop epidural 1 hour later. If elderly, consider Vicodin instead of
Percocet. Add APAP/NSAID as appropriate. Order prn IVP opioid as appropriate for BTP.
Anticoagulation: Follow ASRA. Heparin SQ bid/tid OK, if ordered TID, hold one dose and pull cath at
time of held dose (or at least 4h after last dose given). LMWH single daily prophylactic dose is acceptable.
OK to maintain cath with low dose heparin infusion for DVT prophylaxis (PTT 35-45); pull cath in heparin
window: hold gtt x 4h, recheck PTT, pull cath, restart gtt 1h post d/c. Pull cath before start of therapeutic
heparin gtt.
Anytime a catheter is d/c’d or migrates out in a patient with altered coagulation, leave order for RN to
perform Bilateral LE neuro checks for movement and sensation q2h x 24h and stat page primary team/APS
for any new deficits or c/o back pain.
Nerve Blocks
 Ortho Unit RNs can d/c nerve block catheters. Most other units will not be trained to pull cath.
 If any question of NB complication (paresthesia, persistent sensory/motor deficit), follow patient in house,
d/w ortho/APS attending, and, as appropriate, provide APS contact info before d/c home for follow-up.
 Adjust standard TKA nerve block infusion orders as appropriate for other surgeries (i.e., increased dose of
Ropivacaine at increased rate).
Ketamine
 Continuous infusion allowed on stepdown/ICU areas only. See APS order set and hospital policy
 Discuss with attending/APS RN before initiating.
Consults
 Get name and pager of person requesting, including attending. Discuss with APS Attending/APS RN.
 Be clear in note and communication back to primary team if APS is writing orders and managing or is
providing recs only and following/not following.
 It is acceptable to “curb-side” and provide recs over phone/in person.
 All consults should be seen within 24h. If unable to see the day of consult request or consult is not urgent,
provide verbal recs and see the next day.
Chronic Pain/Opioid Tolerant
 Discuss chronic pain patients with APS Attending/APS RN. Make OR anesthesia team aware as
appropriate.
 Anticipate need for ketamine intra and post-op
 Do not initiate long acting opioids or methadone before ensuring outside provider willing to prescribe.
Resources: APS Attending for current clinical, political and interdisciplinary issues and concerns. Robert
Montgomery, CNS and Lynn Hornick, RNC, NP for daily assistance in APS workload and decision-making.
Dr. Matthew Fiegel, APS Medical Director for overall management and policy making. Chronic pain pager
266-7291 for assistance in chronic pain management and to provide AIP chronic pain consults.
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Acute Pain Service Guidelines – Periop Epidural/Intrathecal Analgesia Dosing
I. Thoracic Epidural - Appropriate for all surgeries except lower extremity. See Table VII.
A. Bupivacaine 0.1%. Opioid: 1st Choice Hydromorphone, 2nd choice fentanyl, 3rd morphine.
B. Basal rate: Lower/mid abdominal surgery: T7-12 cath: 8 ml/hr. Upper abdominal and flank surgery:
T6-8 cath: 6 ml/hr. Thoracic surgery, T4-8 cath: 4-6 ml/hr.
II. Lumbar Epidural
A. Bilateral Knee Replacement or occasional hip surgery: 0.0625%-0.1%. Opioid: 1st choice hydromorphone.
Basal rate: 8 ml/hr. Consider decreasing bupivacaine POD#1 AM to facilitate ambulation (0.05-0.08%)
B. Pelvic and Abdominal Surgery
1. Bupivacaine 0.1% w/ morphine or hydromorphone.
2. Basal rate: Lower abdominal and pelvic surgery 8 ml/hr. Mid/upper abd surgery: 10 ml/hr.
3. For occasional Gyn/Onc epidural, consider bupivacaine 0.08% to facilitate ambulation
III. PCEA – Run all epidural infusions as Patient Controlled Epidural Analgesia (except for Dr. Pearlman)
A. Incremental bolus: 3-4 ml. Elderly/debilitated 2 ml. Range 1-5 ml
B. Lock Out: 15 min. Elderly/debilitated 20 min. Range 10-30 minutes.
IV. Surgeon/Service Protocols
A. Transplant Liver Resection: Bupivacaine 0.125-0.15% + Hydro 1-3 g/ml; Load Hydro 0.1-0.3 mg. D/C
catheter within 72h. See separate Liver Resection Protocol.
B. GYN-ONC or GYN: Usually IT morphine only. If epidural placed and is low thoracic or lumbar, ensure
patient is ambulatory POD#1 AM. Start with bupiv. 0.0625-0.08%, or decrease in AM.
C. Dr. Pearlman: All patients get IVPCA and basal only epidural infusion. Always discuss with APS attending
D. Dr. McCarter: do not give FFP/PLTS in liver resection without checking with APS attending
E. Urology: Wilson prefers epidurals for Cystectomies and Radical Nephrectomies. No epidurals for prostates
F. Thoracic: Dr. Meguid desires epidurals for his VATS lobectomies
G. Ortho: No sciatic nerve blocks for TKA with Drs. D’Ambrosia Sr, Lindeque, or Hogan. See Lindeque guide
V. OR Opioid Loading and Postop Infusion Doses - Load epidural in OR with opioid.
Morphine
Load
< 45 yr
45-60 yr
61-70 yr
>70 yr or frail
3-4 mg
3-4 mg
2-3 mg
1-2 mg
Fentanyl
Infusion
30-50 g/ml
20-40 g/ml
20-30 g/ml
10-15 g/ml
Hydromorphone
Load
Infusion
Load
75-100 mcg
50-75 mcg
25-50 mcg
0-25 mcg
4-5 g/ml
3-5 g/ml
3-4 g/ml
1-3 g/ml
0.4-0.6 mg
0.3-0.4 mg
0.2-0.3 mg
0.1-0.2 mg
Infusion
10-20 g/ml
8-10 g/ml
5-7 g/ml
1-5 g/ml
VI. OR Bupivacaine Loading Doses – Load epidural in OR with bupivacaine 0.25%, or 0.125% if low BP
< 45 yr
45-60 yr
61-70 yr
>70 yr or frail
L2-4
Lower
Extremity
OR LOADING: Bupivacaine Injection
L1-4
T7-10
T6-8
Lower
Mid/Lower
Upper Abd./
Abd./Pelvic
Abd.
Flank
10-16 ml
8-14 ml
6-12 ml
5-8 ml
10-14 ml
6-12 ml
5-8 ml
4-6 ml
8-14 ml
6-12 ml
6-10 ml
5-7 ml
8-12 ml
6-8 ml
5-7 ml
3-6 ml
Start Epidural Infusion in PACU
T4-8
Thoracic
5-8 ml
4-6 ml
4-5 ml
3-4 ml
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VII. Epidural Catheter Location – Place catheter as indicated below. If unable to stay within range,
effective epidural analgesia is more likely with a catheter placed higher, rather than lower.
Surgery
General
Thoracic
Colorectal
Urologic
Gynecologic
Vascular
Ortho
Level
Procedure
T6-7
T4-8
T9-10
T10-12
T7-8
T8-10
T10-12
T8-10
T10-12
T9-10
T10-12
L1-2
L2-4
L1-4
T10-12
gastrectomy, esophagectomy, choly, Whipple, hepatic resection
thoracotomy, lung reduction, lung transplant, thymectomy
colectomy, bowel resection, lap choly, A-P resection
low anterior resection
nephrectomy, adrenalectomy
cystectomy
rad. abd. prostatectomy
rad. abd. hysterectomy, TAH and nodes, ovarian cancer debulking
TAH, pelvic exenteration
AAA repair
aorto-bifem repair
bifem-popliteal repair
LE amputation
total hip/bilateral knee replacement, lower extremity reconstruction
hemipelvectomy
VIII. Inadequate Pain Control – Titrating Epidural Infusion Rates
A. Test dose cath to rule out non-working epidural vs. inadequate pain control - See Test Dose Algorithm.
B. With known working epidural:
LUMBAR Infusions
Bolus 1x basal rate and:  basal rate 2-3 ml/hr or 
incremental dose 1-3 ml/hr &  lock out 5 minutes
(MAX. basal rate 15 ml/hr) (MIN. L.O.=10 minute )
THORACIC Infusions
(a) Bolus 1x basal rate and:  basal rate 1-3 ml/hr or 
incremental rate 1-3 ml/hr &  lock out 5 minutes
(MAX. basal rate 15 ml/hr) (MIN. L.O. = 10 minute)
If titration is unsuccessful in managing pain, consider that something has changed with the catheter (migrated, not in
epidural space, etc.). The catheter should be evaluated by the Acute Pain Service resident, nurse, or attending.
IX. Continuous Intrathecal (Spinal) Analgesia – Always discuss with the pain service attending.
Use Fentanyl 1-3 mcg/ml with bupiv. 0.05%-0.08%. Start basal rate of 1-2 ml/hr w/ titration  in 0.5 ml
increments. NO PCA dose. Consider ICU monitoring with high-risk patients. Label pump tubing & cath with
red stickers (in APS file cabinet). Limit manipulation of system - do not pre-order to change infusion bag. Use
Epic order set for IT infusions.
X. Single dose Spinal (Intrathecal) Morphine:
Usual dose is 0.25-0.3 mg. Patients who receive > 0.5 mg spinal morphine should be considered for ICU
monitoring. Use APS specific order set for IT morphine (Non-OB). APS manages all pain for 24h.
XI. Peripheral Nerve Block Catheters
Usual dose is Ropivacaine 0.1% 7 ml/hr for TKA and Ropivacaine 0.2% at 5-10 ml/h for all other catheters.
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Liver Resection Acute Pain Protocol
Mission Statement: To provide satisfactory and safe postoperative analgesia in a multimodal fashion in
our liver resection patients.
1. Wedge Resection:
a. Thoracic Epidural with usual local/opioid combination
b. Scheduled Ketorolac per surgeon preference with their approval
c. Dilaudid/Fentanyl PCA if epidural not effective or transition off of epidural when patient not taking
PO
d. PO Dilaudid and/or Percocet when patient taking PO
2. Large Wedge Resection/Lobectomy (Donor Hepatectomy):
a. Thoracic Epidural with decreased opioid and increased local combination
b. Scheduled Ketorolac per surgeon preference with their approval
c. If epidural not functioning well, or patient refusal, low dose ketamine and fentanyl PCA
combination.
d. Fentanyl PCA when transitioning off of epidural if patient not taking PO
e. PO Dilaudid and/or Percocet when taking PO
f. Do not combine IV and oral pain medications in donor hepatectomy
g. Continuous monitoring (pulse ox and telemetry)
3. Right lobe plus/trisegmentectomy:
a. Same as large wedge resection/lobectomy
*In all liver resection patients, opioid dosing adjustment (due to decreased hepatic metabolic function)
will be considered when ordering IVPCA/PCEAs.
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UCH Total Joint Regional Anesthesia/Analgesia Protocol (9/2013)
Preoperative Holding Area:
1. Oxycodone extended release 20 mg PO if <70 y.o. and 10 mg PO if ≥70 y.o.
2. Celecoxib 400 mg PO or 200 mg po if elderly or relative renal risk. Hold for renal disease.
3. Pregabalin 150 mg PO or 75 mg if elderly
Total Knee:
1. Continuous femoral nerve block catheter and single shot sciatic nerve block
Total Hip:
1. Single shot lumbar plexus nerve block. If unable to perform lumbar plexus, single shot femoral.
Total Shoulder:
1. Single shot interscalene (brachial plexus) nerve block OR continuous interscalene nerve block
catheter.
2. If catheter placed, options are: D/C on POD #1 or #2 OR connect a disposable pump with local
anesthetic at time of discharge that APS will manage for another 2-3 days via phone contact with
patient at home.
Intraoperative:
1. General or spinal anesthetic
2. If spinal anesthetic for THA, consider giving 0.25 mg intrathecal morphine
3. No intraoperative ketorolac
Post Anesthesia Care Unit (PACU):
1. Initiate continuous femoral catheter with ropivacaine 0.1% at 7 ml/h or brachial plexus catheter
with ropivacaine 0.2% at 7 ml/h
2. Preferred sequence for analgesic medication administration is:
a. Ketorolac 15 mg IV x 1 PRN
b. Percocet 5/325 1-2 tabs PO x 1 PRN
c. IVP analgesics as normally ordered on PACU post orders. Start IVPCA before discharge to
floor/unit.
Nursing Unit:
1. Acetaminophen 1000 mg PO TID.
2. Celecoxib 200 mg PO BID PO if <70 y.o. and 100 mg PO if ≥70 y.o. Hold for Crt >1.2 or if unknown
Crt and multiple comorbidities.
3. If <70 years old, Oxycodone extended release 10 mg PO BID.
4. If <70 years old, Oxycodone 5 -10 mg PO every 4h PRN.
5. If ≥70 years old, Oxycodone 2.5-10 mg PO every 4h PRN
6. Discontinue IV PCA POD #1 at 0800
7. For TKA: RN will discontinue femoral nerve block catheter POD #2 at 0600
8. TSA catheter: see above
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Coordination:
1. Patients adhering to the above protocol will be managed by the Acute Pain Service (APS) for the
first 24 hours after THA (expected duration of lumbar plexus single injection block), for the first 48
hours after TKA (while femoral catheter is in place), and for the first 24-48 after TSA (see above).
APS will normally sign off service after these times and turn over pain management to the
Ortho/Hospitalist teams.
2. If a patient refuses a block, the block is contraindicated, or the protocol needs to be modified due
to allergy to protocol meds, the APS will still order and manage all pain meds for the first 24 hours.
After the first 24 hours the APS will usually sign off service or will coordinate with the Ortho and
Hospitalist teams the time frame for sign off and turnover of pain management.
3. If patient surgery (e.g., Bilateral TKA), medical condition, or preference requires an epidural
catheter for post-op pain management, the above protocol will implemented as appropriate and
the APS will manage for 24 hours with the epidural catheter discontinued in the afternoon of POD
#1 (Bilateral TKA: leave catheter in for 48h), and turn over pain management to the
Ortho/Hospitalist teams.
4. The Orthopedic team should order all home meds to continue as appropriate with the exception of
short acting opioids and NSAIDS. These should not be re-ordered as they are included in the
protocol meds. If a patient is on long acting opioids at home, they should most likely be re-ordered
by Ortho as part of Medication Reconciliation. If there is any question about re-ordering home
pain meds, discuss this with the Ortho team prior to placing orders.
References
Hebl JR et al. (2008). A pre-emptive multimodal pathway featuring peripheral nerve block improves
perioperative outcomes after major orthopedic surgery. Regional Anesthesia and Pain Medicine,
Vol 33, 6: pp 510–517.
Hebl JR et al. (2005). A Comprehensive Anesthesia Protocol That Emphasizes Peripheral Nerve
Blockade for Total Knee and Total Hip Arthroplasty. J. Bone Joint Surg. Am. 87:63-70.
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Acute Pain Service (APS) Guidelines for Dr. Lindeque Patients
The APS will discuss the placement of any peripheral nerve block or epidural for post-operative pain with Dr.
Lindeque prior to placing the block for all patients. Exceptions to this are patients undergoing amputation.
Management of Post-operative Pain and Medications
 If the APS provides a catheter as part of the nerve block or provides an epidural catheter, they will
write for all pain medications until signed off service.
 If the APS provides a single injection block and have not been requested by Dr. Lindeque to manage
pain due to chronic pain issues, then his team will order and manage all pain medications.
 If the patient has chronic pain issues and Dr. Lindeque requests the APS to manage their pain, they will
write for all pain medications until signed off service.
Medication Reconciliation at Admission
If the APS is writing pain medications and the patient is on long acting opioids, the Ortho team should discuss
with the APS whether to continue those medications at admission.
Medication Coordination at Discharge
The APS will reinforce to chronic pain patients as appropriate that Dr. Lindeque will only provide pain
medications for up to 30 days after discharge. Patients will be instructed to follow up with their usual
prescriber within 30 days of discharge. The Ortho team will make every effort to copy the discharge summary
to the patient’s usual pain medication prescriber.
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Test-Dose Algorithm For Inadequate Epidural Analgesia
PAIN
Catheter functional?
Test Bolus (Have available: syringe Ephedrine 5 mg/ml)
Monitor vital signs (BP; pulse ox if available) for 30 min., every 5 min x 4.
LUMBAR:
2% lidocaine with epinephrine 1:200,000
6-8 ml x 2 at 5 min. intervals
Maximum volume: 20-30 ml (after 20 ml given, call attending physician)
THORACIC: 2% lidocaine with epinephrine 1:200,000
4-6 ml x 2 at 10 min. intervals
Maximum volume: 10-20 ml (after 10ml given, call attending physician)
(If catheter is known to be functional and patient is c/o of pain, may use 0.25% bupivacaine or bolus with
epidural opioid/local solution from bag, i.e. 5-10 ml)
No dermatomal changes
Unilateral block
Replace catheter or
Start PCA
Reposition patient
Withdraw catheter 1-2 cm and
position patient appropriately
(Check skin depth on record needs to be at least 3cm into
epidural space)
Bilateral functioning block
Increase rate by 2-3 ml/hr
(Consider increasing
concentration of bupiv.
or opioid).
Side effects:
1. Hypotension
a. Treat with Phenylephine/Ephedrine if BP drops > 30% from pre-injection, systolic < 80, or concerned
about adequate perfusion
b. Infuse crystalloid or colloid depending on PMH, CHF, or Intrathoracic surgery.
2. Sedation
a. Decrease, change or eliminate opioid.
b. Nubain 2.5-5 mg IV push every 4 hours prn.
3. Nausea
a. Ondansetron 4 mg IV q 6 hours prn
b. Dramamine 12.5-25 mg IV q 4 hours prn
c. Metoclopramide 10 mg IV q 4 hours prn
d. Transdermal scopolamine 1.5 mg q 72 hours (avoid in patients > 65 years old)
4. If patient unable to ambulate: Decrease or eliminate local anesthetic.
5. Pruritus
a. Decrease, change, or eliminate opioid
b. Nubain 2.5-5 mg IV q 4 hours prn
c. Benadryl 12.5-25 mg IV q 6 hours prn
d. Buprenorphine 0.1-0.2 mg q4h prn
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13
Preop Protocol for Procedures Performed by the Acute Pain Service
on Patients not on the OR Schedule
Inpatient Arriving From Floor/Unit for Procedure
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These procedures will typically consist of epidural catheter, peripheral nerve block, blood patch, or
IV medication infusion (e.g., ketamine, Lidocaine). Medication infusions will usually take one hour
and will be performed and monitored by the APS.
APS to notify Preop Charge nurse of procedure and coordinate arrival time
APS to coordinate with Preop staff to arrange for transport to Preop
Preop nursing to provide support for accepting and prepping patient for procedure
APS paged upon patient arrival
Preop nursing to provide support during procedure as needed and for monitoring vital signs 30-60
minutes post procedure. Post medication infusion monitoring would be needed for 30 minutes,
After clearance by APS, Preop nursing calls for transport and gives report to floor/unit nurse
Outpatient Arriving from Home or Neurology Clinic for Blood Patch Procedure
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Preadmissions scheduling form completed by APS nurse or Preop Charge nurse
Patient instructed to arrive at Surgery check-in at designated time and date (coordinated between
Preop and APS)
Preop nursing to provide support for admitting and prepping patient for procedure
APS paged upon patient arrival
Preop nursing to provide support during procedure as needed and for monitoring vital signs 30-60
minutes post procedure
After clearance by APS, patient discharged home
Outpatient Arriving from Home for APS Evaluation of Potential Post-block complication

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This evaluation would be a brief physical exam by the APS. There would be no procedures
performed or IV needed
Patient instructed to arrive at Surgery check-in at designated time and date (coordinated between
Preop and APS)
Preop nursing to provide support for bringing back the patient, assisting into a gown, and
attending to minor comfort needs
APS paged upon patient arrival
After clearance by APS, patient released to home
Whenever possible, procedures should be performed prior to 1600
due to Preop staffing availability
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Acute Pain Service Clinical Guideline
Perioperative Administration of
Celecoxib (Celebrex®) and Pregabalin (Lyrica®)
Celecoxib
Background
The use of NSAIDs as part of a multimodal analgesic approach for the treatment of perioperative pain has
been shown in numerous studies to decrease postoperative pain, decrease postoperative opioid requirements
(20%-50%), and provide greater patient satisfaction. The newest class of NSAIDs, Cyclooxygenase (COX)-2
inhibitors, have demonstrated comparable analgesic efficacy as conventional NSAIDs, but are associated with
reduced GI side effects and an absence of antiplatelet activity, making them suitable for use in the
perioperative setting.
Controversy exists regarding NSAIDs use on two fronts: 1) bone healing, with fracture and surgery requiring
bone fusion, and 2) Cardiovascular events. Recent reviews of both of these issues, as well as studies of COX-2
in spine fusion surgery, do not show increased risk when the drugs are used for a short time (less than 7 days)
in the immediate postoperative period. Standard recommended precautions should continue to be followed
as outlined below.
Precautions
Contraindicated: CABG surgery; sulfonamide allergy; aspirin or NSAID allergy.
Use with caution in: Cardiovascular disease; renal or hepatic impairment; elderly; GI ulcer/bleed; warfarin use;
high risk of bone non-union (multiple failed implants, smoker),
Dosing Recommendations
Administer in the preop area
 Celebrex 400 mg po x 1 with sip of water 1 hour before surgery
 Reduce dose to 200 mg or avoid in at risk populations
Pregabalin
Background
Pregabalin is an anticonvulsant and neuropathic pain drug approved for use in the treatment of postherpetic
neuralgia and diabetic peripheral neuropathy. Specifically, it is an alpha2-delta (α2-δ) ligand with analgesic,
anxiolytic, and anticonvulsant activity. The compound binds potently to the α2-δ subunit protein of voltagegated calcium channels. Potent binding at this site reduces calcium influx at nerve terminals and reduces the
release of several neurotransmitters, including glutamate, norepinephrine, and substance P, from activated
neurons. Pregabalin’s Tmax is 1 h, its T½ is 6 h, and it exhibits linear pharmacokinetics with low inter-subject
variability. Pregabalin dosing does not require lengthy titration, unlike it’s predecessor gabapentin, and its
starting dosage of 150 mg/day for chronic neuropathic pain significantly relieves pain in many patients.
Pregablin is a successor to gabapentin which has shown in numerous studies of post-operative pain to reduce
opioid requirements and pain scores. Due to the improved pharmacokinetic profile of pregabalin allowing
lowered dosing (less side effects) and quicker therapeutic efficacy, it is preferred for perioperative use over
gabapentin.
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Precautions
Most common side effects are dizziness and somnolence, and peripheral edema. Reduce dose in severe renal
impairment
Contraindications: allergy to pregabalin
Use with caution: pioglitazone/rosiglitazone use; renal impairment, CHF.
Dosing Recommendations
Administer in the preop area
 Pregabalin 150 mg po x 1 with sip of water 1 hour before surgery
 Reduce dose to 50-75 mg or avoid in severe renal impairment and at risk populations
Pregabalin and Celecoxib Combination
There is currently only one study published looking at the combination of pregabalin and celecoxib for
postoperative pain that was done in spinal fusion surgery. The combination reduced morphine use and pain
scores more than either agent alone or compared with placebo.
Acute Pain Service Practice
 As part of a multimodal approach to postoperative management, the APS will consider the use of
pregabalin and celecoxib, in addition to blocks and traditional opioid analgesia, during the
perioperative period when consulted by the surgeon.
 The APS recommends that anesthesia providers consider the use of these medications in their routine
care of the surgical patient.
 The surgical patient with chronic pain and or opioid tolerance presents a special challenge for
postoperative pain management. The use of a multimodal approach including agents like pregabalin
and celecoxib are strongly recommended.
References
Tiippana, EM et al (2007). Do surgical patients benefit from perioperative gabapentin/pregabalin? A
systematic review of efficacy and safety. Anesthesia and Analgesia, 104(6):15451556.
Huang Y.M et al (2008). Perioperative celecoxib administration for pain management after total knee
arthroplasty – A randomized, controlled study. BMC Musculoskeletal Disorders, 9:77-87.
Buvanendran A. (2003). Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor
on pain management and recovery of function after knee replacement. JAMA;290:2411-2418.
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IV PCA Dosing Guide
1. Basal rate is not routinely recommended in opioid-naïve patients.
2. Change the Demand dose for acute pain control (not the basal rate).
3. Increase the Demand dose according to pain level:
a. Mild pain: increase dose by 25%
b. Moderate pain: increase dose by 50%
c. Severe pain: increase dose by 100%
4. Reevaluate pain control about 1 hour after change in Demand dose.
5. For opioid tolerant patients, the Basal rate used initially should be the equianalgesic equivalent of the patient’s
regular 24 hour opioid requirement (see below). The Acute Pain Service, Palliative Care Service, or unit pharmacist
may be consulted for assistance with dose calculations.
6. The Demand dose should normally be half of the Basal rate in opioid-tolerant patient (e.g., if the Basal rate is 2
mg/hr, then the Demand would be 1 mg).
7. Basal rates do not achieve steady state for 10-24 hours. Do NOT increase the basal rate more frequently than this
interval.
8. The RN initiated PRN bolus dose is usually 2 times the Demand dose.
9. Schedule a stimulant laxative for constipation prophylaxis (e.g., Senna).
10. Converting opioid drugs
Equianalgesic Doses
Opioid
IV
PO
Morphine
10 mg
30 mg
Hydromorphone
1.5 mg
7.5 mg
100 mcg
Fentanyl
--(0.1 mg)
Oxycodone
--20 mg
Hydrocodone
--30 mg
Fentanyl patch mcg/hr is approx. equal to the total
24-hour oral morphine dose in mg divided by 2
(Fentanyl 50 mcg/hr patch = Morphine 100 mg po/24hr)
Current opioid (single conversion dose/route) = Total 24 hr dose of current opioid (mg)
New opioid (single conversion dose/route)
Total 24 hr dose of new opioid (mg)
1.
2.
3.
4.
Calculate total 24-hour dose of current opioid.
Convert to 24-hour new opioid equivalent.
If changing drugs, decrease new total 24-hour dose by 25-50% for incomplete cross-tolerance.
Independently verify calculations with someone experienced in opioid conversions.
High Concentration IV PCA Medication
 Morphine 5 mg / ml
 Hydromorphone 1 mg / ml
 Fentanyl 50 mcg / ml
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