ADE and Harm Collaborative: Reducing ADEs and harm associated with opioids - Safer post-operative pain management
March 21, 2013
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Agenda, March 21, 2013
• Welcome • Collaborative education overview • Post-operative Pain Management: Challenges and New
Directions • T.J. Gan, M.D., MHS, F.R.C.A FFARCS(I) • Professor and Vice Chair for Clinical Research,
Department of Anesthesiology, Duke University Medical Center
• Q & A • Monthly Progress Reports • Next Steps
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Collaborative Objectives
• Safer post-operative pain management that reduces both ADEs and Harm
• Address three focus areas: • Identification (screening patients for risk)
»Webinar 1 and 2 • Standardization of monitoring post-operative
patients on opioids (tools/technology/processes) »Webinar 3 and 4
• Education and communication (at transitions of care and discharge)
»Webinar 5 and 6
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What do we want to accomplish?
Goal:
To reduce ADEs and Harm associated with opioids use among surgical inpatients by implementing evidence-based strategies and processes to make pain management safer • By the end of 2013, reduce opioid related ADEs and Harm
by 40% compared to 2010
• For pilot population, by 6.30.2013: 100% elective surgery patients screened preoperatively
for OSA and opioid tolerance
100% elective surgery patients’ pain assessed using a standardized tool
100% elective surgery patients discharged to home on an opioid will have documentation of written/verbal discharge instructions to include: the name, purpose, action, side effects, monitoring and “what to do if this happens” for the opioid discharge medication.
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Focus 2: Safe communication and monitoring during the perioperative period
• A standardized hand-off/transition communication process is in place for all patients receiving opioids, which includes, at minimum: 1) history of snoring, obesity or OSA and 2) drug and dose history for previous shift;
• Standardization of pain assessment tools for patients on opioids post-operatively house-wide;
• Continuous oximetry is used in all post-operative patients receiving IV narcotics/ opioids; and,
• Continuous capnography is used on all post-operative patients receiving supplemental oxygen and receiving IV narcotics/opioids, epidural, or PCA (patient controlled analgesia)
Post-operative Pain Management. Challenges
and New Directions T. J. Gan, M.D., MHS, F.R.C.A. FFARCS(I)
Professor and Vice Chair for Clinical Research Department of Anesthesiology Duke University Medical Center
Incidence and Severity of Postoperative Pain
1. Apfelbaum, Gan et al. Anesth Analg. 2003 2. Warfield, et al. Anesthesiology 1993 3. Gan TJ. ASRA 2012 abstract.
Readmissions from Same-day Surgeries: Pain Is Most Common Reason (US)
Mean charges for patients readmitted due to pain were $1,869 ± $4,553 per visit
38% of patients readmitted for pain had undergone orthopedic procedures
Inadequate Acute Pain Management Has Consequences
Delayed ambulation1 Increased CV and pulmonary pathophysiology Shortened or missed rehabilitation sessions1 Decreased quality of life2 Increased cost of care3 Potential for progression from acute to
chronic pain4
1. Morrison et al. Pain. 2003;103:303-311; 2. Wu et al. Anesth Analg. 2003;97:1078-1085; 3. Coley et al. J Clin Anesth. 2002;14:349-353; 4. Pluijms et al. Acta Anaesthesiol Scand. 2006;50:804-808.
Long-Term Consequences of Acute Pain: Potential for Progression to Chronic Pain
Woolf. Ann Intern Med. 2004;140:441; Petersen-Felix. Swiss Med Weekly. 2002;132:273-278; Woolf. Nature.1983;306:686-688; Woolf et al. Nature. 1992;355:75-8.
Acute Postoperative Pain Has Been Associated With Chronic Pain After Common Procedures
Incidence of Chronic Post-Surgical Pain
US Surgical Volumes (1000s)1
Amputation 57-62%2 159
Breast surgery 27-48%3,4 479
Thoracotomy 52-61%5,6 110
Inguinal hernia repair 19-40%7,8 609
Coronary artery bypass 23-39%9-11 598
Caesarean section 12%12 220
Factors correlated with the development of post-surgical chronic pain1:
1.Nerve injury 2.Inflammation 3.Intense acute postoperative pain
1. Kehlet et al. Lancet. 2006;367:1618-1625; 2. Hanley et al. J Pain. 2007;8:102-10; 3. Carpenter et al. Cancer Prac. 1999;7:66-70; 4. Poleschuk et al. J Pain. 2006;7:626-634; 5. Katz et al. Clin J Pain. 1996;12:50-55; 6. Perttunen et al. Acta Anaesthesiol Scand. 1999;43:563-567; 7.Massaron et al. Hernia. 2007;11:517-525; 8. O’Dwyer et al. Br J Surg. 2005;92:166-170; 9. Steegers et al. J Pain. 2007;8:667-673; 10. Taillefer et al. J Thorac Cardiovasc Surg. 2006;131:1274-1280; 11. Bruce et al. Pain. 2003;104:265-273; 12. Nikolajsen et al. Acta Anaesthesiol Scand. 2004;48:111-116.
The Severity of Post-Operative Pain is Associated With Development of Chronic Pain In a long term evaluation of thoracotomy patients
(N=149), Those who developed chronic post-thoracotomy pain syndrome were: – Those who experienced severe acute pain: 67% vs
38% (P = 0.0001) – Those who experienced a prolonged duration
(1month) of severe acute pain (P = 0.02)
*Chronic pain assessed 6 months to 3.5 years post-surgery Pluijms et al. Acta Anaesthesiol Scand. 2006;50:804-808.
Patient’s Perspectives on Hospital Pain Management
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is the first national, standardized, publicly reported survey measuring and comparing patients’ perceptions of their hospital experiences – In two 1-year, nationwide HCAHPS surveys of 3765
reporting hospitals conducted in 2008 and 2009, pain management received an average score of 68 (out of a possible 100), revealing room for improvement in pain management
Results of the HCAHPS will soon be one of the measures used to calculate institutional incentive payments
HCAHPS in Pain Management : July 2009 – June 2010
Hospital Consumer Assessment of Health Plans Survey
Opioids – Main Strong Analgesic
Bind to opioid receptors in spinal cord, brainstem and limbic cortex
Good Efficacy: dose dependent pain relief with no ceiling effect
Good Safety Profile: No cardiovascular, hepatic or renal effects
Multiple agents: Morphine, hydromorphone, fentanyl, sufentanil, oxycodone, oxymorphone
Multiple delivery systems: oral, parenteral, transdermal, epidural, spinal
Morphine or Incision Length Correlation With Bowel Function Return?
Colectomy patients (40) ● Primarily left colon and
rectal procedures
Return of bowel function? ● Correlation between
morphine PCA dose and first bowel sounds (P = 0.001), flatus (P = 0.003), and first bowel movement (shown; P = 0.002)
● No correlation between incision length and morphine dose
PCA = patient-controlled analgesia.
Adapted with permission from Cali RL, et al. Dis Colon Rectum. 2000;43:163-168.
“Trade-offs” in Pain Management: Patients Have Concerns That May Hinder Treatment
Gan et al. Brit J Anaesthesia. 2004;92:681-68
Recent Joint Commission Sentinel Event Alert Reinforces the Severity of the Opioid Problem
• Opioid analgesics rank among the drugs most frequently associated with adverse drug events
• A number of safety measures, including education and monitoring, may reduce the risks of opioid-related adverse events
• Key patients warrant multimodal opioid sparing approaches; including non-opioid pain medications
Patients at the Highest Risk for Oversedation and Respiratory Depression Sleep apnea or sleep disorder Morbid obesity Snoring Older age No recent opioid use Post-surgery, especially after upper
abdominal or thoracic surgery Increased opioid dose requirement Longer time receiving general
anesthesia during surgery Concomitant use of other sedating
drugs Smoker
Outcomes: Cost and Length of Stay (LOS) Regional
ADE=adverse drug event.
Oderda, Gan et al. J Pain & Palliative Care Pharmacotherapy 2012
What are we trying to achieve?
Effective and consistent analgesia
Minimal adverse events
Patient satisfaction
Multimodal or balanced analgesia
⇓ doses of each analgesic
Improved anti-nociception due to synergistic/ additive effects
May ⇓ severity of side effects of each drug
Kehlet H, et al. Anesth Analg 1993;77:1048–56 Playford RJ, et al. Digestion 1991;49:198–203
Monotherapy vs Multimodal Analgesia
Give More
Opioids!
Potent Opioids
Weak Opioids
Breakthrough Pain
Moderate to Severe Pain
Mild to Moderate
Pain
Weak Opioids,
Tapentadol
Neural Blockade, Ketamine
Acetaminophen, NSAIDs, Coxibs, Gabapentanoids,
Anesthesiology
“Whenever possible, anesthesiologists should employ multimodal pain management therapy.
Unless contraindicated, all patients should receive an around-the-clock regimen of NSAIDs,
coxibs, or acetaminophen.”
ASA Task Force on Acute Pain Management. Anesthesiology. 2012;116:248–73
Adjunctive Analgesics NSAIDs and COX-2 selective inhibitors (coxibs)
Acetaminophen
Local anesthetics
Ketamine
Gabapentin / pregabalin
Clonidine / dexmedetomidine
Magnesium, neostigmine, adenosine, naloxone
Non pharmacological techniques
New Analgesics and Novel Delivery Systems
New Analgesics – Cannabinoids: Dronabinol, Ajulemic acid – TRP-V1 receptor agonist: Capsaicin,
Resiniferatoxin – Anti-nerve growth factor- NGF Antibodies – LOX Inhibitors- Powerful anti-inflamatories that
have less side effects Novel Delivery System
– Depobupivacaine – Fentanyl iontopheresis – Sufentanil Nanotap
Enhanced Recovery After Surgery (ERAS)
“An interdisciplinary multimodal concept to accelerate postoperative convalescence and reduce general morbidity (including POI) by simultaneously applying several interventions”
What are the appropriate choices in constructing ERAS, multimodal protocols?
Mattei P. World J Surg. 2006;30:1382-1391. Person B, Wexner S. Curr Probl Surg. 2006;43:6-65.
Reduction in length of stay and complications
Traditional ERAS p-value
LOS – all procedures (days) 9.6 ± 8.4; 7 (5.5-10)* 5.8 ± 3.9; 5 (3-7)* < 0.0001
LOS – open (days) 11.8 ± 9.9; 7 (6-14)* 7.1 ± 3.9; 6 (4.5-8.5)* 0.004
LOS – laparoscopic (days) 6.5 ± 3.8; 6 (4.25-7)* 4.9 ± 3.7; 4(3-5.5)* 0.005
Urinary Tract Infection (UTI) 26.5% 13.4% 0.03
Mean ± SD; Median (IQR)
Miller and Gan et al. Anesthesiology ASA abstract 2011
Pain Score and Morphine Consumption Traditional Care vs. ERAS
Miller and Gan et al. Anesthesiology Abstract 2011
Ketamine in Opioid Dependent Patients Undergoing Spine Surgery
Ketamine Placebo P Value %
PACU Morphine (mg) 18 ± 14 22 ± 20 0.21 ↓ 18.0
PACU VAS 4.1 ± 3.1 5.6 ± 3.0 0.03 ↓ 26.7
24 h Morphine (mg) 142 ± 82 202 ± 176 0.03 ↓ 30
48 h Morphine (mg) 203 ± 109 323 ± 347 0.04 ↓ 37
48 VAS 5.4 ± 2.1 5.3 ± 2.2 0.83 ↑ 1.0
6 week Morphine mg/hr equivalents
0.8 ± 1.1 2.8 ± 6.9 0.04 ↓ 71
6 week VAS 3.1 ± 2.4 4.2 ± 2.4 0.02 ↓ 26.2
Hospital Discharge (min) 4,364 4571 0.73 ↓ 3.45 hour
Loftus R, et al. Anesthesiology 2010;113:639-46
Conclusions Pain is still poorly managed
Acute pain can lead to long-term chronic pain
Opioid analgesics, while effective, can result in significant side effects
Multimodal analgesic regimen improves both short- and long-term pain management
Moving from opioid based to opioid sparing regimen
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Q&A
T.J. Gan, M.D., MHS, F.R.C.A. FFARC S (I) Professor and Vice Chair for Clinical
Research Department of Anesthesiology
Duke University Medical Center
Leslie Schultz, RN, PhD, CPHQ Clinical Consultant
Premier Safety Institute
Jeff Vawter, MHA Director, Partnership for Patients
Collaborative Education & Delivery
Cristina Wilhelm, RN, BSN Manager, QUEST
Collaborative Education & Delivery
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Thank you for participating in today’s Webinar!
Questions after today’s presentation? Please contact us:
Cristina Wilhelm, Manager, QUEST Collaborative Education & Delivery [email protected]
Jeff Vawter, Director, PFP Collaborative Education & Delivery [email protected]