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Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services
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Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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Page 1: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Postoperative pain controlWhat to do after PCA?

Spencer S. Liu, MD

Clinical Professor of Anesthesiology

Director Acute and Recuperative Pain Services

Page 2: 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.

Page 3: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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

Page 4: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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

Page 5: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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 2007:104:689Anesth Analg 2007:105:789

Page 6: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

What can one do?

• Acute Pain Services are popular and effective

• Typically expensive

• Typically manage PCA modalities

Anesth Analg 2002:95:1361

Page 7: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 8: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 9: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 10: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 11: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 12: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 13: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

13

Anesthesiology. 104(5):1033-1039,2006

Page 14: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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

Page 15: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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

Page 16: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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

Page 17: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Patient Education and Pain Management

Preoperative

Postoperative PCA

Postoperative PO

APS

Education“Pre-emptive” medications

Pain management Patient education Staff education

Page 18: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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

Page 19: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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

Page 20: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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.

Page 21: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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.

Page 22: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Patient Education and Pain Management

Preoperative

Postoperative PCA

Postoperative PO

APS

Education“Pre-emptive” medications

Pain management Patient education Staff education

Page 23: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

RPM Patient Volume

• Since August 2007, the volume of inpatient consults has steadily increased yearly

• Confirming need for further medical pain management after discontinuation of PCA therapy.

2007 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

Total 152 881 1126 1332

Page 24: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Results of RPM Implementation

• Our primary outcome measure was the Press Ganey satisfaction survey.

• 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).

75

80

85

90

95

100

Perc

entil

e Ra

nkin

g

Large PG 91 97 99 97 98 99 99 99 99 99 99

Magnet PG 84 97 99 98 97 99 99 98 99 98 97

HSS PG 92 92 99 90 99 99 99 99 99 99 99

2008 1st

Quart

2008 2nd

Quart

2008 3rd

Quart

2008 4th

Quart

2009 1st

Quart

2009 2nd

Quart

2009 3rd

Quart

2009 4th

Quart

2010 1st

Quart

2010 2nd

Quart

2010 3rd

Quart

Page 25: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

RPM HelpLine

0

5

10

15

20

25

30

35

40

45

50

Jan-0

9

Mar-

09

May-0

9

Jul-09

Sep-0

9

Nov-0

9

Jan-1

0

Mar-

10

May-1

0

Jul-10

Sep-1

0

Nov-1

0

Jan-1

1

Number of Phonecalls

Start of RPM/ARJR Pilot Program (October 2010)

Page 26: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Staff satisfaction survey

• Returned by– 81 RNs– 7 surgical PAs

• 92% rated RPM as extremely helpful

Page 27: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Cost of RPM

• Cost for an NP ~ 150,000 USD

• 12.5-15 USD/pt visit• Could also use a

Physician’s Assistant

0

2000

4000

6000

8000

10000

12000

14000

2009 2010

Number of PCAs

Page 28: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Systemic multimodal analgesia

Page 29: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

NSAIDs, COX2, Acetaminophen

Page 30: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 31: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 32: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 33: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 34: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 35: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 36: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 37: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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

Page 38: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 39: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Gabapentin

Page 40: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Copyright restrictions apply.

Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556

Figure 1. Flow diagram of the review

Page 41: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Copyright restrictions apply.

Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556

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

Page 42: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Copyright restrictions apply.

Tiippana, E. M. et al. Anesth Analg 2007;104:1545-1556

Figure 3. Effect of preoperative gabapentin on postoperative opioid consumption

Page 43: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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

Page 44: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Pregabalin

• Laparoscopic hysterectomy– Opioid sparing– Increased dizziness

• Laparoscopy– Better analgesia– Trend toward increased dizziness

• Laparoscopic cholecystectomy– Better analgesia– Opioid sparing BJA 2008:101:700

Page 45: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Conclusions

• Discussed agents are efficacious

• Modest benefit

• NSAIDs and gabapentanoids have most to offer– Reduced opioid consumption– Reduced side effects– NSAIDs have more risk

Page 46: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Non-traditional techniques

• Acupuncture• Music• Static magnet• Massage

Page 47: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Acupuncture

Page 48: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 49: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Anesth Analg 2008:106:611

Page 50: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 51: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 52: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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

Page 53: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Music

Page 54: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

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, 812Eur J Anaesthesiol 2005:22, 96

Page 55: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Ambulatory procedures

Intraop

music

Control

Pain in PACU

(0-10)

4.2 3.9

Patient satisfaction

4 3.9

Morphine

(mg)

14.4 16.9 Anesth Analg 2010:110:208

Page 56: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Magnet therapy

• Multi-billion dollar industry

• Mecanisms?– Increased blood flow– Altered neuron firing

thresholds

Page 57: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 58: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Massage

Page 59: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 60: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 61: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 62: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.
Page 63: Postoperative pain control What to do after PCA? Spencer S. Liu, MD Clinical Professor of Anesthesiology Director Acute and Recuperative Pain Services.

Summary

• RPM service is efficacious– Probably cost effective– Can use different staffing models

• Optimize systemic analgesics

• Role of CAMS?– Acupuncture has best evidence


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