POST-OP MULTIMODAL PAIN

MANAGEMENT

Maripat Welz-Bosna

Reading Hospital Medical Center

Department of Medicine Hospitalist Services/Pain Management

Objectives

• Understand the basic neurobiology of the pain pathway

• Understand whet "Multimodal" pain management means and why it is effective

• List 3 medical co morbidities that need to be addressed and can affect both pre/post operative care

• Describe conservative management options for the post-surgical joint replacement patient who is not progressing well

Relieving Pain in America (IOM)

• $560-635 Billion per year financial costs

• 30 Million cases of acute & post operative pain

• 4 Billion work days lost per year due to pain

• 22 Million adults use prescription pain medication

• Increased numbers of misuse of Opioids/Addiction

• 2006 Estimated 53.3 Million Surgical/Non-Surgical procedures performed in

the US

• 1 in 200 patients who had out patient surgical procedure end up being

hospitalized due to inadequate pain control

• Ambulatory surgical procedures make up 70% of the volume of hospital based

elective surgical procedures

"The major difference between

iatrogenic pain and other types of

pain is iatrogenic pain is anticipated.

Therefore, the provider has an

excellent opportunity to deal with

such pain in a planned and

expeditious manner".

Brian Goldman MD

Prevalence of Post Operative PainStannard, Kalso, & Ballantyne, 2010

• Caesarean Section 4-6%

• Inguinal Hernia Repair 12%

• Vasectomy 15%

• Laparoscopic Cholecystectomy 23%

• Hysterectomy 32%

• Colectomy 28%

• Sternotomy 32%

• Radical Prostatectomy 32%

• Thoracotomy 50%

• Mastectomy & Axillary Node Surgery 50%

• Lower Extremity Amputation (Stump Pain 62%) (Phantom Pain 70%)

What's the easiest pain to bear?

Components of Acute Pain:

The Heart of Multimodal Analgesia

Nociceptive

Visceral

Neuropathic

Inflammatory

Myofascial (Muscle Spasm)

Multimodal Analgesia

• Balanced

Involves the selected use of specific drugs in combination

• Use of multiple analgesic drugs with different modes of action

Non-Opioid with an Opioid

• Local Anesthetic Block combined with systemic analgesic

Improve analgesia through synergy

Preemptive Pain Management"Stop the pain before it Starts"

PreSurgical or PreRehabilitation Program

• Educate the patient about surgical

procedure, pre/post operative care and

Rehabilitation

• Discuss with the patient that "providers"

will do everything to help control pain

• Find out what the patients most

"prominent fears" are prior to Joint

Surgery

• Change the Focus from "Post Surgical"

paradigm of injury management to

"Healing Advancement"

Importance of Pain Education

• The nervous system will be in a "Hyper" protective mode

• As a result of the nervous system being hyper protective, pain

will occur well before tissue damage occurs: Not just as tissue

damage is happening

• Pain is no longer an indicator of tissue injury or danger

• The sensitized post surgical nervous system can produce

pain in the absence of tissue danger

• Knowledge can be utilized to control pain

Language is Important

• Move from: "Reactive" to "Proactive"

"From the time you wake from surgery the focus will be

about healing, your injury will be a past process".

• Educate the patient that swelling, inflammation,

and pain help to facilitate healing

Multimodal Perioperative

Preemptive Analgesia

• Analgesic Medication or Intervention prior to

surgical tissue injury MAY produce greater pain

relief then the same medication/intervention

administered following surgical tissue injury

• Has been shown effective in some animal studies,

but collecting data from post-operative patients is

more difficult

• Based on "Wind-Up" Theory (Hyperalgesic

Response)

Main Goals

Preemptive Analgesia

Decrease pain after tissue injury

Prevent Spinal Sensitization

Reduce the incidence of inflammatory

or chronic pain

Senturk, 2002

Injection of 10 MG Morphine ( NNT 2.9) is roughly equivalent

to an oral 200 MG dose of Ibuprofen (NNT 2.7)

Bandolier, 2007

Table comparing efficacy of many different

oral and injectable medications for pain

Drugs in Post/Preoperative Pain

Management

• Opioids

• Tramadol

• Nonopioids

NSAIDS & Cox-2

Alpha-2 adrenergic agonists

N-methyl-D-aspartate antagonists (Ketamine,

Magnesium, Dextramethorphan, Methadone)

Gabapentin, Pregabalin & Carbamazepine

Glucocorticoids

Capsaicin

• Local Anesthetics (Sodium Channel

Blocking)

Pre-Operative Intradermal

Accupuncture

• 50 % reduction in post-operative

morphine requirement

• 20-30% reduction in

post-operative nausea

• 30-50% reduction in plasma

cortisol and epinephrine

Kotani N., Hashimoto H; Anesthesiology 2001;95

Factors that have been associated with Poor

Outcomes in Joint Replacement Surgeries

• Sex- Female

• General Health Complications

• BMI

• Past Post Surgical Complications

• Anxiety

• Depression (Untreated)

• Fear Avoidance Behaviors

• Propensity to Catastrophize

• Externalization of Locus of Control

• High Presurgical Pain Levels

• Genetic or Epigenetic determined sensitivity to heightened sensory or noxious input

Factors NOT associated with

Poor Outcomes

• ROM or Strength Limitations

• Imaging Findings

• Level of Disability

–Johnny Appleseed

The factors that are most responsible for

poor outcomes are produced by the

nervous system NOT the Musculoskeletal

System

Management of Continued

Post-Operative Pain

• R/O Post surgical complications

• Assess for concurrent pathology

• Maximize Therapeutic Intervention: Both Pharmacologic & Non pharmacologic

Mindfulness and Guided Imagery

Both help with control of "Fight / Flight"

Heat, Cold, Message, & TENS Unit

• Look at medication options

• Biopsychosocial Model

• Support emotionally and clinically

• Do not automatically assume that Psychiatric issues are the cause of struggles

• Coordination and Communication

• Healthcare team

• Patient, Family, Stakeholders

Take Home Points

• Multimodal analgesia can help improve pain control and minimize side

effects

• Persistent post surgical pain may be influenced by improved acute pain

control

• Order routine pain medications initially for moderate to sever pain (Rather

than PRN)

• Patient specific factors need to be considered in prescribing the BEST post-

operative analgesic regime

• Around the clock NSAIDS + Acetaminophen are effective in minimizing

opioid use

• Patient Education, Mindfulness, and Guided Imagery have been used

successfully to address Psychosocial Risk Factors

Questions & Comments?