Multimodal Perioperative Pain Management and Multimodal Strategies to Enhance Post Operative Outcomes

Hamed Umedaly MD FRCPCAnesthesiologist Medical Director POPSVancouver AcuteUniversity of British Columbia

Why ? What's wrong with the status quo ?

Improved Anesthesia & Pain management can be achieved !Improved potential for Recovery ?Unidimensional approaches limit outcomeImprovements not realizing optimal patient outcome ?

4 A’s of Changing Physician 4 A’s of Changing Physician Behavior ( Pathman model)Behavior ( Pathman model)AwareAgree

AdoptAdhere

For every complex problem there is an answer that is simple, neat and wrong

H.L Menken 1880-1956

Concept of Perioperative Pain Management and Acute Rehabilitation

Pre- Op Education Preparation & PlanningPre & Intraop Pain Management & Physiological StabilizationPost-op pain management and Acute Rehabilitation

Kehlet 1995-2005

Preemptive Pain Management: Neurobiology

Noxious stimuli initiate cascade of events peripherally and centrally to produce PAINSensitization (Dynamic) Nociceptive stimuli amplified ( Primary and Secondary Hyperalgesia)Non painful stimuli produce PAIN (Allodynia)

Preemptive Pain Management:Prevent Sensitization ( duration and Intensity)

Reduce the Nociceptive input (Minimally invasive surgery,LA, NSAIDS, Opioids)Attenuate Transmission ( Blocks, Spinal, Epidural)Modulate mechanisms that underlie sensitization ( NMDA blockade, Opioids)

Multimodal Pain Management

Pain Neurobiology is a complex of Dynamic Interrelated systemsUnimodal Analgesia cannot be sufficient to provide optimal pain managementAdditive & Synergistic effects of Multiple modes should improve outcome

4 principles of Multimodal Pain Management

Multiple Mechanisms/ Sites of actionAvoid Opioid Dominance Opioid Sparing vs side effectsMultimodal / Lower Doses / Reduce adverse effectsTreat and Prevent Toxicity / Side effectsi.e PONV /Delirium/Pruritis

VA Quality Improvement Study N=300

~ 40 % of joint arthroplasty have PONV if untreated Joint Arthroplasty patients are at high risk of PONV

~ 10 % of have PONV if Risk Reduction Strategy and Prophylaxis ( combination therapy)

Consensus Guidelines for Managing PONV

Evaluate Risk ( Patient, Anesthetic Surgical)Strategies to reduce baseline risk (Modify Anesthetic Technique)Antiemetic prophylaxis Moderate Risk: Monotherapy 5 HT3 Receptor antagonistHigh risk: Combination therapy

Gan A&A 2003

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Acetaminophen

Synergy with Opioids / Opioid sparingSynergy with NSAID’sInexpensive

Routes PO / PRUse 3-4 g/24 hr short term<2 wks

Model for Post surgical Chronic Pain

Acute pain ( Nociceptive and Affective Components)

Preop Psychological factors

Acute injury (Surgery)

Physiological Factors

Chronic Pain

Physiological Maintaining Factors

Psycho/social Maintaining Factors

Multimodal pain management and Outcomes

Multiple PRCT’s in 10 yrsImproved Pain Scores and Patient SatisfactionDecreased use of PCA and Parenteral AnalgesiaBUT no change in LOS/Outcome

Beyond Multimodal Pain Management: A Multimodal Strategy to Enhance Postoperative Recovery

Multimodal Rehabilitation modelIntegrated (Patient, Nurse,PT/OT.Pharmacist, Surgeon, Anesthesiologist)Use the Improved pain management to accelerate recovery discharge & Really Improve outcome

Multimodal Recovery

Wellness modelPerioperative model ( seamless)Architecture from Bed oriented wards to Activity Oriented Units“Postoperative Rehabilitation Unit”Now lets look at Outcome

Opioid Tolerance: Reality Check

Increasing incidence of Opioid Tolerant Patients presenting for Surgery

CPS & APS approve the use of Opioids for Chronic Non malignant Paini.e Osteoarthritis

Opioid Tolerance (Chronic Pain)

Morphine equivalence > 30 mg/ day for > I month

Central sensitization ; afferent nociceptive facilitatationPrimary and secondary hyperalgesia Allodynia

Opioid mu receptor down regulation

Opioid Tolerance : Features

Tolerance to: pain management, respiratory depression Sedation

Non Nociceptive Suffering ( anxiety)Renders Perioperative Pain Management Challenging

Opioid Tolerance in the Perioperative Period

Its too late postop ( in the PACU )Start preop ( identify , plan , preop Opioid , Acetaminophen, NSAID, +/- Clonidine Continue Intraop ( Opioid , Local, Regional , Ketamine)Extend strategy Postop (Opioid , Regional , +/- Ketamine, NSAIDs, Acetaminophen

Opioid Tolerance: Multimodal Strategies

Use Neuraxial Blockade/ Regional Anesthesia/Analgesia with LANSAID’sAcetaminophen at max dose ( 1.5-2 g load and 4 g/day)Low dose Ketamine intra +/- postopTreat Non Nociceptive Suffering

Opioid Tolerance

IdentifyDiscuss Complexity and Potential Toxicity with Patients Resume PO Opioid asap at higher dose and provide breakthrough

Strategy and Goals

IntegratedPre, Intra & post operative CareSeamlessMultimodal pain management Treat Pain with activityAvoidance of routine PCA OpioidImprove pain management and outcomes

Perioperative vs Postoperative

Preop: Recognition, Assessment, Discussion, Plan, Pre emptive

Intraop: Modification of Surgical approach Anesthesia and Pain Management Strategy

Post Op: Multimodal Pain Management and Intervention

VA Approach: Preop

Consultation and preparationIdentify Risk of Difficult to manage painHigh dose Acetaminophen+/- NSAID Low dose long acting Opioid (Oxycodone CR 10 mg)

VA Approach:”Intraop”

Intrathecal LA(Spinal) and low dose Opioid( PF Morphine 100 ug)+/- GA or Epidural for Revisions or Opioid TolerancePreincision LALA in capsule and closurePONV prophylaxisFast track PACU

VA Approach:”Post op”

Full reg dose Acetaminophen+/- NSAID Reg low dose long acting Opioid (Oxycodone CR) plus breaktrough prn opioid ( Oxycodone IR)PCA only for unsatisfactory pain control“Fast track” early mobilization

Rehabilitation / Recovery

Achieve best pain control with minimal side effectsUse that pain control to achieve early :RecoveryMobilizationFunction

Ambulatory or Short stay Hip Replacement

Minimally Invasive approach85 % with same day DC N= 100

Duwelius JBJS 2000

Short Stay Total Knee Arthroplasty

Spinal AnesthesiaMultimodal pain managementFemoral Nerve LA Catheter Infusion

Anesthesia and Analgesia Jan 2006

MIS Surgery:Purported Benefits

Surgical InvasivenessBetter Pain ManagementImproved Rehabilitation Protocols

?Higher Complication rate with MIS

Woolson JBJS 2004, Ogonda JBJS 2005Wright J.Artroplasty 2004

Periop Pain Management

Talk about it “Can and should focus on pain”

Work on Periop Strategies and utilize them to enhance satisfaction /outcome

Manage PONV

The Future

Perioperative infusion of ContinuosRegional Anesthesia(PICRA)PCOAAntineuropathic agents ( gabapentin/pre gabalin)Microsphere impregnated Local anesthetic agents

A Multimodal Strategy to Enhance Postoperative Recovery: Conclusions

Integrated Perioperative approachEnhanced Perioperative Pain managementPerioperative stress response and Organ Dysfunction reduction ( eg blood loss, PONV )Utilize to achieve Fast Track Recovery and Enhance Outcome

Divinum est sedare dolorum

Blessed are those who treat pain.-Galen

COX 2 Inhibiters : Background

Inducible vs Constitutive enzymesNo apparent GI or Renal SparingPlatelet Aggregation Sparing ( Thromboxane inhibition)

Cyclooxygenase Isoforms

Cox-1 Cox-2Constitutive, and found in most tissues -“housekeeping”. Inducible 2- to 4-fold by inflammatory stimuli

Only isoform present in platelets TxA2

Main isoform in gastric mucosa CytoprotectivePG’s

Predominately inducible enzyme in many tissues -10- to 20-fold by inflamstimuli or cancer

Stimulates PGI2 production in endothelium

Constitutive in CNS, fem. reproductive tract, and kidney

COX 2 Inhibiters : When ?

Pain Management Challenging and Intraop Bleeding an Issue Pain Management responsive to NSAIDS (Bone, Gyne etc and potential for intraop /post op bleeding)Concurrent Anticoagulation or LMW HeparinEpidural insitu and pain outside covered dermatomes

Cardiovascular and Platelet Effects

Platelets:- ASA: irreversibly acetylates Cox-1,

selectively inhibits TxA2 formation

- Nonselective NSAIDs: Inhibit TxA2 and PGI2 to a similar degree. Effect is reversible

during the dosing interval

- COXIBS: Inhibit (reversibly) Prostacyclinformation which mediates platelet inhibition

CLASS and VIGOR studiesCLASS:

- Celebrex Long-term Arthritis Safety StudyVIGOR:

- VIoxx Gastrointestinal Outcomes Research

Very large (n = >4,000 and >8,000), multicenter, double-blind, randomized trials (no placebo arm) examining efficacy and safety of Celecoxib and Rofecoxib

CLASS- 28% with RA, 72% OA

- compared coxib Vs ibuprofen & diclofenac

- ASA allowed for Cardiac prophylaxis (21%)

- no difference in ulcer frequency,but fewer symptomatic ulcers

- no sig difference in MI frequency

VIGOR- 100% with RA

- compared coxib (2x max dose) Vs naproxen

- ASA not allowed

- sig lower rates of upper GI events and GI bleeding with vioxx

- sig higher rates of thrombotic events and MI with Rofecoxib, altho’ CV mortality rates similar

Why do Cox-2s Increase SAEs??

Not completely explained by the trials

Increase of thrombotic CV events more than cancels reduction in complicated ulcer risk

COX 2 Inhibiters : Cost

COX 2 $ 1.25/dayRofecoxib and Valdecoxib once daily dosing

Nonselective po nonselective COXIB $30-60 cents (eg Diclofenac)IV nonselective COXIB (~$ 8.00 day)

(eg Ketorolac)

COX 2 Inhibiters : Add to formulary ?

Minimal cost

Selective Use When IndicatedAvoid use when known or risk factors for CAD

Platelet sparing really only benefit

The FutureIV Acetaminophen = “Propacetamol

will be available in Canada “soon”

IV Parecoxibimmediately converted to Valdecoxib

Nitric Oxide-donating NSAIDsNO functions as an endogenous mediator of gastric mucosal health and defence

Multimodal Perioperative Pain Management and Multimodal Strategies to Enhance Post Operative Outcomes

Hamed Umedaly MD FRCPCAnesthesiologist Medical Director POPSVancouver Acute