Transcript Pain Management

Surgical Site Pain
Management
Improving Outcomes
February 2007
Objectives
At the end of the presentation, you will be able to:






Discuss current pain theories.
Differentiate various types of pain.
List key components of a pain management
program.
Review the TJC pain standards.
Describe the role of a surgical site pain
management system.
Describe outcomes related to surgical site
pain management systems.
What is Pain?
Pain is a complex
phenomenon derived
from sensory stimuli or
neurologic injury and
modified by individual
memory, expectations,
and emotions.
Sternbach RA, ed. The
Psychology of Pain. 1978. p
223-39.
Pain: Subjective Component
“whatever the experiencing person
says it is and exists whenever he
says it does.”
McCaffery, M. Nursing practice
theories related to cognition, bodily
pain, and man-environment
interactions. 1968, Pg 95.
Understanding Pain
Pain is different for every person.
 Pain is part of a historical and cultural
framework.
 Everyone’s experience and perceptions of
pain will differ.

Neurophysiology Of Pain
Stimulation of nerve receptors for pain
(nociceptors) - free nerve endings in
almost all tissue types
 Mechanical, chemical, thermal sources
 Once stimulated, impulse travels to
spinal cord and brain
 Impulse becomes experience of pain

February 2007
Classification Of Pain
Acute
Chronic
Referred
Acute Pain

One-dimensional


Underlying cause
Acute injury, disease or
surgery.
Sudden onset, defined
area, quick response
 Treatment goal:



Eradication of
underlying disease
Analgesics used as
adjunctive therapy
Chronic Pain




Multidimensional
Persists at least one month beyond usual course
Worsened by physical, psychological, social factors
Types:




Chronic condition
 Osteoarthritis
 Cancer
Chronic pain from acute source
 Post-mastectomy chronic pain syndrome (PMCPS)
 Post-thoracotomy chronic pain syndrome (PTCPS)
Acute injury that results in chronic pain (back injury)
No discernable cause
Referred Pain

Referred pain occurs when pain
affecting one of the visceral
organs is referred to the
external body, not necessarily
in the same location.
Are We Undertreating Pain?


217 adults in a university teaching hospital
 61% pain of 7-10 during past 24 hours
 49% pain of 4-10 “right now”
 20% pain of 4-10 despite analgesics
Despite efforts to improve pain management,
no change in patients pain ratings
Ward SE, Gordon D. Application of the American Pain
Society quality assurance standards Pain 1994
Mar;56(3):299-306
Postoperative Pain Experience
80% of patients experienced acute pain
after surgery
 Most patients had moderate, severe or
extreme pain
 Ambulatory patients experienced more
pain after discharge than when they were
in facilities

Apfelbaum JS, et al. Postoperative pain experience: results from
a national survey suggest postoperative pain continues to be
undermanaged. Anesth Analg 2003;97:534-40.
When Treatment Fails,
Pain is Imprinted


Noxious stimuli can
sensitize the
nervous system
response to
subsequent stimuli.
Would “pre-emptive
analgesia” make a
difference?
Under-Treated Acute Pain
Side Effects


Increased risk of thromboembolism
Catecholamine secretion





Vasoconstriction, Increased heart rate
Increased myocardial oxygen
consumption
Decreased oxygen delivery
Increased cardiac morbidity
Potential increased risk of infection
Potentially
Serious
Complications
Tetzlaff JE. Cardiovascular consequences of severe
acute pain. Practical pain management Mar/Apr
2004;11-13.
American Pain Society
Guidelines for Assessment
PAIN – The Fifth Vital Sign
In 1995 the American Pain Society (APS)
created this phrase to elevate awareness
of pain treatment among health care
professionals.
TJC Standards

Addresses the assessment and
management of pain



Recognize the right of patients to appropriate
assessment and management of pain
Screen patients for pain during their initial
assessment and, when critically required,
during outgoing periodic re-assessments
Educate patients suffering from pain & their
families about pain management
Establish Institutional Nursing
Protocol







Acknowledge pain is real.
Respect patient’s reactions and attitudes.
Inform patients about pain and therapies.
Administer pain medication appropriately.
Explain actions and side effects.
Decrease noxious stimuli.
Document treatment and patient response.
Assessing Pain



VAS = Visual Analogue Scale
VRS = Visual Response Scale
0-10 scale 10 = worst pain imaginable
0-100 scale
Wong-Baker Faces Scale
Assessment of Pain

Location


Pattern


Where? Does it radiate?
Does it occur at a special time?
Onset

When did it begin?
Was it sudden or gradual?
Assessment of Pain








Type
Dull, sharp, aching, stabbing, burning
Intensity:
How strong?
How long does it last?
Does it vary?
Causative Factors:
What brings on the pain? What makes it worse?
Evolution of Pain Control
Opioids
General Anesthesia
Epidural/
Spinal
anesthesia
Regional
Anesthesia
Local
Anesthesia
Acute Pain - Control Methods

Pharmacological




Opioid
Non-Opioid
Local anesthetics
Non-Pharmacological







Change/Adjust Position
Diversion Activities
Relaxation Techniques
Meditation
Acupuncture/Acupressure
Heat, cold, massage
Hypnosis
Opioids
Mainstay of pain management
 Morphine
 Dilaudid
 Fentanyl (IV, Transdermal)
 Demerol
 Oral opioids


Percocet, Vicodin, Lortab, Oxycontin
PCA vs
intermittent
injection
Opioid Side Effects









Nausea and vomiting
Ileus/Constipation
Urinary retention
Respiratory depression
Apnea
Sedation
Confusion
Tolerance
Restricted Ambulation
Longer
Hospital
Stays
&
Increased
Costs
Opioids and Surgical Infections


Is there a link?
Maybe

Two studies in particular
Horn
et al Surgical Infections
2002;3(2):109-18.
Alverdy et al Surgical Infection Society
Annual Meeting, La Jolla, CA 2006
PCA and SSI
Chart review of 515 randomly selected
patients who had major rectal or intestinal
surgery.
 214 had PCA
 Results: Use of PCA significantly
associated with increased in-hospital
surgical site infection (10.7% vs 4.0%)
 Possibly due to suppression of natural
killer cells causing immune compromise.

Horn SD et al. Association between patient-controlled
analgesia pump use and postoperative surgical site
infection in intestinal surgery patients. Surgical Infections
2002;3(2):109-18.
Non-Opioid Analgesics

NSAIDs



Aspirin, ibuprofen, naproxen, acetominophen
Toradol® ketorolac (injection)
 Side Effects: Gastrointestinal distress, clotting
disorders, dependence, kidney failure (ibuprofen)
liver failure (acetominophen)
COX-2 Inhibitors



Vioxx® - rofecoxib
Not Available
Bextra® - valdecoxib
Celebrex® - celecoxib
 Less gastrointestinal and bleeding issues
Regional-Local Anesthesia



The abolition of painful impulses
from any region or regions of
the body by temporarily
interrupting the sensory nerve
conductivity with local
anesthetics.
Motor function may or may not
be involved.
The patient does not lose
consciousness.
Types of Regional Anesthesia

Peripheral nerve block

Types of Procedures







Ortho: Upper, Lower & Spine (including trauma Rib & Hip
Fractures)
General: Mastectomy & Abdominal Procedures
CV/CT & Cath Lab: VATs, Thoracotomies, TAVR
OB/GYN: C-Sections
Single injection or continuous infusion of local
anesthetic near nerve
Performed by anesthesiologist
Surgical site



Can be used for multiple types of surgery
Catheter placed by surgeon
Can be incisional or near incision
Surgical Site

Pain Management




A continuous, regulated flow of local anesthetic
through a fenestrated antimicrobial Soaker®
catheter directly into or near an intra-operative
site
Soaker® catheters provide wider, more even
distribution of local to incisional area
Portable, easy-to-use, disposable for
outpatient or inpatient
Therapy continues up to five days
Surgical Site Pain Management
Procedure Landscape



Spine
 ALIF, PILF, TLIF
 Iliac Crest
General
 Colectomy/Ventral
Hernia
 Hemorrhoidectomy
CV/CT
 Thoracotomy
 Open Heart/AAA
 Vascular
 Amputation




Bariatric
 Open/Laparoscopic
Plastic Surgery
 Breast Surgery
 Abdominoplasty
Urology
 Prostatectomy
 Nephrectomy/Kidney
transplants
OB/GYN
 Hysterectomy/Oncology
 C-Section
Local Anesthetics

Bupivacaine (Marcaine®, Sensorcaine®)


Lidocaine (Xylocaine®)


0.2%, 0.1% or 0.5%
Levobupivacaine (Chirocaine®)


0.5% or 1%
Ropivacaine (Naropin™)


0.25% or 0.5%
0.25% or 0.5%
Avoid local with epinephrine!!!
Filling the Pump

USP 797 Pharmaceutical
Compounding – Sterile
Preparations

Prior January 2008: Pumps
were filled anywhere &
everywhere, most common
was the Back Table in the OR


HIGH RISK
Post January 2008:Filled in
Pharmacy under a hood by a
trained Personnel OR by a
Third Party Vendor and
shipped to the Hospital’s
Pharmacy

LOW RISK
Surgical Site Pumps
Benefits of a Soaker™
Catheter for Surgical Site



Infuses local
anesthetic over a
broader area
compared to pointsource catheters
Greater versatility in
catheter placement
More even
distribution of
medication
5”
24 holes
2.5”
11 holes
Standard
3 holes
Soaker Catheter
New Techniques: Tunneling
Benefits:









Catheter(s)are placed deeper and closer to key nerves
May eliminate the need to close a separate layer –
peritoneum
Minimizes risk of nerve damage and bleeding
Blunt tunneling minimizes needle stick risk to the
surgeon
Less leakage
Better pain results because of proximity to
innervations
Catheter are placed further away from the incision
(fear of fluid build up or infection)
Catheters can now be placed pre-incision
Tunneler
Tunneling Through Rectus Sheath


The catheter is
placed in the
pre-peritoneal
space using a
tunneler.
This places the
catheter near
larger nerves
and away from
the incision.
Demonstrated Clinical Evidence


Many published and presented studies
Typical Results
 1 to 3 day length of stay reduction
 40-70% reduction in narcotics
 8-30% reduction in treatment costs
 90%+ patient satisfaction
 Infection rates less than national averages
 Substantial reductions in pain scores
Clinical Research Results

CV/CT Surgeries:








Decrease in PCA requirements by 63%
Length of stay reduced
PACU time reduced 12%
Significant decrease in pain
No infections
Serum levels <30% of toxicity
Decrease in costs by 8%
Increase in lung volume – spirometry
White PF, et al. Anesthesiology 2003; 99(4): 918-23
Dowling R, et al. J Thoracic CV Surgery 2003;
126(5): 1271-8.
Paravertebral Approach
Can be
approached
either
Anterior or
Posterior
Extrapleural Placement
Mastectomy
Narcotic Use
80
70
% of Patients
60
50
40
30
20
10
0
No Post op Narcotics
No Narcotics > Day 1
Placebo
ON Q
Morrison JE, Jacobs VR. Zentralblatt fur Gynakologie
2003;125:17-22.
Mastectomy
Lumbar Laminectomy & Fusion

Paraspinal Muscle of the
back




Multifidus
Longissimu
Interspinous
Intertransverse
Lumbar Results

Without Local Infusion
With Local Infusion
Meta-analysis Surgery Types
Surgery
Number of
Trials
Number of
Patients
Cardiothoracic
14
565
General
11
602
7
412
12
562
Gynecology-urology
Orthopedics
Meta-analysis of Wound Catheters






Meta-analysis of 44 randomized
controlled trials (RCTs)
Published in peer-reviewed journal.
2141 patients
Studies used a variety of infusion devices
and methods.
Studies covered multiple types of
surgeries.
Studies published during 1983 - 2006
Liu SS, Richman JM, Thirlby RC, Wu CL. J Am Coll Surg 2006; 203(6):
914-32.
Clinical Research Results

Orthopedic Surgery

Total Joint Replacement
 Decreased
length of stay
 Decreased
nausea and vomiting
 Earlier
 More

return to physical therapy
abmulatory
Rotator Cuff-ACL Repair
 Earlier
return to physical therapy
 Decreased
narcotic use
Gottschalk A et al. Anesth Analg 2003;97:1086-91.
Ford PJ, Slavagno RT, Pianta T, Dine A. Presented
at NAON 2004
Total Joint Replacement
Postop Nausea and Vomiting
2.5
Mean days
2
1.5
Began using therapy
1
0.5
0
1997
1998
1999
2000
2001
2002
2003
Year
p<0.05 Years 2001-2003 compared to previous
Ford PJ, Slavagno RT, Pianta T, Dine A. Presented at NAON 2004.
Meta-analysis Results

Pain scores at rest: lower in all groups
combined (p< 0.001)


Pain scores with activity: lower in all groups
combined (p < 0.001)


22 mm reduction
Opioid rescue medication: Fewer patients
required in all groups (p< 0.001)


10mm reduction
41% vs. 66%
Total opioid required: less in all groups
combined (p< 0.001)

reduction of 11 mg/day
Results continued

Postoperative nausea and vomiting (PONV):
less in all groups combined (p< 0.001)


Patient satisfaction better in all groups
combined (p< 0.007)



24% vs. 40%
43% vs. 13% had excellent satisfaction
No local anesthetic toxicity
Infection rates 0.7% in active group and
1.2% in control group
Potential Cost Savings

Narcotic reduction savings



50% on average reduction in narcotics
Pharmacy charges to fill PCA orders
Narcotic complication treatments


Anti-emetic medications reduction
Elimination of foley catheter



Decrease UTI
Reduction in Benadryl
Minimized ICU and PACU times

$800 per hour
Potential Cost Savings



Minimize or eliminate electronic pump usage
 $20-50/day with supplies and labor to
maintain
Minimize nurse labor to teach, monitor and
maintain narcotic delivery
Viscusi Study
 $1240 cost for 3 days of PCA
 Cost Drivers are time spent – not drugs or
devices
Viscusi E, et al. A multidimensional model for evaluating
the key cost drivers associated with perioperative pain.
Postop Nursing Care

Assess surgical site pain.








Distinguish from other sources of pain. Provide adjunct
analgesia prn.- THIS IS A MULTIMODAL THERAPY
Check that clamps are open and tubing not
kinked.
Verify label(s)
Verify flow rate are set properly OR secure flow
restrictor (if present) to skin.
Check pump for remaining drug.
Check site for redness, drainage, intact dressing.
Observe for signs of local anesthetic toxicity.
When removed, check for intact tip.
REMEMBER…Safety is Key!

Assessment

Fall Risk


Pts who have lower extremity surgery are High Fall
Risk (with or without a RA)
Do pts have the proper precautions (knee
stabilizers)?
Does It Make A Difference??
Reduced time in PACU
 Reduced time to discharge readiness
 Reduced PONV
 Reduced concerns for opioid induced
respiratory depression
 Better pain management w/ fewer side
effects
 Improved pain scores
 Great satisfaction

HCAHPS
HCAHPS
HCAHPS
Why Regional Anesthesia???

Patient







Decreased narcotic
usage = less side
effects
Earlier ambulation
Shortened recovery
time
Less incidence of
breakthrough pain
Decreased length of
stay
Better patient
outcomes
Higher patient
satisfaction

Hospital





Decreased PONV
Increase through put
Controlled pain =
happier pts = better
experience
Higher HCAHP Scores
Lower readmissions
rates
Summary
 Undertreatment of acute pain
persists despite decades of efforts to
improve clinician knowledge.

New modalities exist that improve
traditional pain management by
providing site-specific, nonnarcotic relief of pain.
Thanks for your
attention!
Questions?