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Post by katevaughn on Mar 31, 2019 19:01:17 GMT -5
This month's journal club is presented by Jennifer Pease Moreno. She chose an excellent current review that discusses acute perioperative pain management in the patient with chronic pain. This is a very pertinent article as the number of patients battling chronic pain has increased dramatically over the last ten years. Enjoy! Here is a link JPMcurrentjournal 1.pdf (418.65 KB) to the article. The questions: 1.How can we identify chronic pain patients who are at risk for poor postoperative pain control? 2.What are some of the reasons these patients may experience poor postoperative pain control? 3.What techniques reduce the risk of opioid-related adverse events in chronic pain patients? 4.Discuss techniques to manage perioperative analgesia in the chronic pain patient.
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Post by Lu Lin on Apr 3, 2019 8:28:02 GMT -5
1. From pt's mediacation list, we will see oxycodone or methadone, pt maybe a chronic pain pt. I will normally ask about the dose and frenquency they take the medication. 2. one reason is pt did not take their regular pain medication on the surgical day. 3. Reginal anesthesia is a option for those pt. 4. I think the combination of reginal, give pt appropriate dose are important for chronic pain pt.
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Post by Ben Waldbaum on Apr 8, 2019 10:33:39 GMT -5
1.Patient's with history of opioid substance abuse
2.They are up regulated and hypersensitive to pain from chronic opioid exposure
3.regional anesthesia, multimodal pain control
4. Regional block, multimodal pain control(ketamine, gabapentin, etc)
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kty67
New Member
Posts: 22
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Post by kty67 on Apr 9, 2019 11:58:17 GMT -5
1. We can identify chronic pain patients from their history of opioid use (prescription or illegal), during our conversation to patient if they are very nervous about pain control after surgery (new discoveries). 2. They develop tolerance to opioids from chronic use. 3-4. Multimodal pain control that we already use in our practice with use of regional anesthesia, NSAIDs, Ketamine, LA infusions.
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Post by Jessica Hadley on Apr 16, 2019 10:27:55 GMT -5
1. Reviewing the patient's home medication regimen and inquiring whether the patient has any history of opioid use/misuse. 2. Upregulation of opioid receptors leading to a tolerance of opioid medications and increased dosing requirements. 3. Use of opioid sparing agents, multimodal analgesia, regional anesthesia where appropriate. 4. Use of preoperative po agents (Tylenol, gabapentin), Ketamine, possibly Lidocaine infusions, peripheral nerve blocks if possible, neuraxial anesthesia if appropriate.
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Post by Jennifer Hannon on Apr 19, 2019 9:45:47 GMT -5
1. Reviewing the patient's chart including home meds regimen and whether or not they have a substance use/abuse history. Also time of day the surgery is starting/finishing unfortunately plays a part with regional availability. 2. Upregulation of opioid receptors requiring more needed to achieve same outcomes 3&4. Multimodal anesthesia/analgesia, Lido/Ketamine/Precedex, with regional anesthesia when available. Preop po meds like Gabapentin and Tylenol. Simethicone po in PACU after Laparoscopic insufflation.
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Post by Christine Velarde on Apr 24, 2019 8:10:20 GMT -5
1. We can identify chronic pain patients by identifying them preop by the surgeon listing their medications and creating a pain plan implementing the new pain policy here at JHU. 2. Patients may not get adequate pain control due to poor expectations of pain. If they were not given a proper pain plan they may not try to avoid more opioids post procedure. Other techniques should be tried to help with post op pain (Next question) 3. Chronic pain patients will have a host of different regional blocks to help prevent with post op pain. Preop Tylenol and gabapentin. post op acupuncture/relaxation techniques. 4, Perioperative pain management of the chronic pain patient include: regional blocks preop area. IV Tylenol/iv ibuprofen if available intrrop/ketamine gtt intraop and possible continuance in post op period
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Post by Jackie Howell on Apr 25, 2019 14:25:22 GMT -5
1. Assess patients current medication regimen (drug, dose, frequency) and investigate if they are self medicating with street drugs. 2. Upregulation of receptors, over stimulated pain channel pathways, increasing physical tolerance of drugs without increase in effect 3. Regional anesthesia and PNB when appropriate. Multimodal pain management approach (Magnesium, lidocaine infusions, Tylenol, Toradol, gabapentin, SSRI’s) 4. Continue current dose of methadone if patient is prescribed. Use regional anesthesia when able.
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Post by sarahrollison on Apr 26, 2019 7:17:13 GMT -5
1. As others have said, of course the first line of action is to assess the patient's current medication use. This includes all prescription pain control medications and of course any recreational drug use. Additionally, another suggestion by the article authors is to assess the patient's history of postoperative pain. If available, anesthetic records can be assessed for multimodal pain methods and additional therapies can be added. 2.Multiple factors contribute to poor postoperative pain control for these patients. They may have upregulation of opioid receptors, leading to tolerance and requiring greater doses of opioid/pain medication. They may also have psychological components to their pain and disease states that they make them have an unrealistic expectation of pain control. And depending on their disease state, they may have altered pain sensations such as allodynia or hyperalgesia. In fact, the article discusses the scenario of Opioid-Induced Hyperalgesia,. wherein chronic opioid use leads to an increased sensitivity to pain. 3. Multimodal analgesic techniques should be utilized, which most importantly includes neuraxial or regional anesthesia. These should be used as the primary anesthetic whenever possible or at least in conjunction with general anesthesia to modulate pain. Additional multimodal therapies such as Ketamine, NSAIDs, acetaminophen, gabanoids, and IV lidocaine can be used. 4.I personally like to prescribe preoperative PO tylenol to the majority of my patients to help start pain control early, and if indicated for the procedure or patient, I am not hesitant to order Gabapentin or Lyrica if needed. Methadone should also be given preoperatively based on the patient's current dosage. Additionally, the use of regional anesthetics and continuous nerve blocks should be considered whenever possible. Finally, in the postoperative period I like to ensure that my tylenol can be re-dosed when possible and that the PACU nurse has multiple options for pain control.
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Post by mcesaire on Apr 27, 2019 17:26:39 GMT -5
1. The patients who are most at risk are our pediatric, geriatric, nonverbal, and socioeconomically disadvantaged population. They are at highest risk of not receiving the adequate education, communication, and tapering of their medications. They are the populations that must require a multimodal and multidisciplinary approach in order to avoid untoward side effects from over or under dosing of pain medications. The concern for adequately treating the chronic pain patient during the preoperative period is complex and is ever evolving. This constant evolution is both a blessing ad a curse. We have to learn by trial and error what works best however, its often times frustrating to see how a prior regimen was actually causing harm only to learn the more optimal solution later. In a perfect hospital setting, Surgical teams would have at least a 6 week knowledge of their patients' pain needs and would work with APS or whichever pain team is available to optimize the patient's pain control and titration prior to surgery. A separate preoperative questionnaire should be developed and used when a chronic pain patient is identified and then a subsequent plan set in motion prior to surgery. This plan could be successful if started several weeks before surgery to identify any risk factors for poor pain control and over dosing post surgery. 2. A poor understanding of pharmacology, the patients' needs, and the value of multimodal analgesia are all contributing factors to poor pain control in the preoperative chronic pain patient. The knowledge of receptors and how to choose medications based on a variety of receptors is vitally important. The patient's needs must also be understood. Not just their fear of pain but also their fear of relapse or continued addiction to medications they have discontinued. I recently heard on NPR that once drug abusers succeed to 5 years of remission from drug addition, their odds of relapse are less than 15%. Understanding the specific fears and concerns of the chronic pain patient would allow us to include all of the possibilities in pain control including non conventional therapies and adjuncts. 3. The techniques used to reduce the risk of opioids during the preoperative period are; 1. titrating the patients opioids prior to surgery 2. utilizing multimodal analgesia during the perioperative period and 3. developing a pain management plan with the patient and educating them on the plan in order to garner compliance. Each of these actions will best support a successful pain management plan for a chronic pain patient. 4. One of the techniques mentioned in the article that I valued was the use of alpha agonists during the perioperative period. I think the benefits of mitigating the withdrawal effects, the decrease in opioid requirements, and the respiratory depression sparing effects make the use of alpha 2 agonists very attractive. Of course using APAP and NSAIDs are also very helpful considering that these medications will also add to pain control without increasing the dependence on opioids. Education on scheduling is important but it is also important to explain the value of these medications to these patients. I've had the experience of patients thinking I was undertreating their loved one's pain because I ordered tylenol. Many people assume that because it is an over the counter medication it does not have value, this is the same concern with NSAIDS, however, when they are educated on how these medications work and how they work well with opioids, its been helpful. In conclusiion, I appreciated the comparison of chronic pain to a comorbidity like any other. The same way in which we regard and assess patients with cardiovascular, respiratory, and other comorbidities we should thoroughly and adequately evaluate the patients with chronic pain needs and challenges. Maintaining our education on new pain management modalities is vital, and continuously educating or nursing and surgical colleagues is necessary to have a well rounded pain team.
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Post by angie brooks on Apr 29, 2019 19:50:05 GMT -5
1. Chronic pain patients that are at risk for poor pain control post op can be identified in a thorough pre op evaluation. Knowing their current pain diagnosis, and typical pain scores, as well as, their current regimen for pain control. That would include knowing the pain meds, dosage, and prescription schedules. Also determining their past experiences with pain management and expectations. 2. Patients can potentially have many reasons that they may experience increased pain post op. They probably have an opioid tolerance and are at risk for opioid withdrawal. The may have unrealistic expectations about pain control. They have an increased pain response if the surgical site is the source of their chronic pain. They may overreport their pain score if they fear not getting enough pain meds. they may have untreated psychiatric disorders. There may be a failure to use other analgesic modalities. 3. In order to reduce the risk of opioid related adverse events there are techniques that can be employed. Avoid over reliance on pain scores and focus more on functional indicators of pain. Usage of regional techniques whenever possible. No usage of 2 or more continuous release long acting opioids. Do not use sliding scale opioid administration. Make sure the patient has continuous pulse oximetry on the floor. Confirm preop doses with primary care provider. If possible avoid coadministration of opioids and benzodiazepines. 4.There are several techniques to improve perioperative analgesia in chronic pain patients. The use of regional anesthetics whenever possible. Extensive preoperative education will help with setting goals and mitigating expectations. Potentially weaning opioids in the weeks prior to surgery. Set the treatment plan with the patient regarding opioids, use of multimodal analgesia.
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Post by mary clothier on Apr 29, 2019 21:00:20 GMT -5
No questions one of our challenging patient populations to manage are the know chronic pain folks, with pain medication included in their medication list, arguably our most challenging patients are those who are not known, use pain meds daily, narcotic and/or non narcotics to manage their chronic pain.
Pain tolerance is a unique and individual phenomenon, potential higher requirements needed for those who take pain medication on fairly regular schedule, also there is the "want vs need", the toughest read of all!
Good pre-op history, what pain medication(s) have worked best in the past to control your pain? Multimodal, Alternative techniques ( blocks, regional, Lidocaine drips, Ofirmev, PO Tylenol) pre-op meds! Discussion with patient pre-op, laying ground work, "covering all basis for managing your pain pre, intra, and post op"!
Pre-op pain meds, intra op multimodal, alternative techniques, post op meds that have worked in the past for patient, discussion with patient, doing all to control your pain pre, intra, and post op!
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nanci
Junior Member
Posts: 57
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Post by nanci on Apr 30, 2019 12:48:43 GMT -5
We can help to identify chronic pain patients by speaking with them about their perception of pain, their experiences, and current medication regimen, alternative medication regimen and comorbidites- all as part of the preoperative evaluation.
Some reasons the chronic pain patients may experience poor postoperative pain control include that they have either opioid tolerance or withdrawal, started off with unrealistic expectations of pain control, untreated comorbidites, and having a poor past history of pain control.
In chronic pain patients some techniques that can reduce the risk of opioid-related adverse events include, but are not limited to, using regional techniques when possible, avoiding over-reliance on pain scores and look to functional indicators of pain, do not use 2 or more long acting continuous release opioids at the same time and no use of sliding scale opioid administration, and using pulse oximetry and bedside capnography in areas outside of the operating rooms.
Techniques to manage chronic pain patients that can improve preoperative analgesia include multimodal techniques and medications. Examples include NSAID use, Regional anesthesia techniques, Anti-spasmodics, topical local anesthetics, and even the use of Precedex.
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Post by Jocelyn Datud on Apr 30, 2019 15:23:52 GMT -5
1. History taking is important. If possible, this should be done prior to the day of surgery. All opioids currently being taken must be identified including the dosages, dosing schedules, and whether a long-acting sustained-release medication is used. Logging on to the appropriate State Controlled Substances mon- itoring website is also a good source. The total average daily opioid consumption should be noted in the patient's record. Aberrant behaviors such as frequent early refills, multiple practitioners prescribing opioid medications, or multiple opioid prescriptions from emergency department visits should be noted and taken into account. 2. Some of the reasons why chronic pain patients experience poor pain control includes opioid tolerance, opioid withdrawal, Unrealistic expectations, over-reporting of pain for fear of not receiving sufficient pain medication, and increased pain response when the surgical site is the source of chronic pain. 3. Avoid over-reliance on pain score and focus on functional indicators of pain; Utilize regional anesthesia; Avoid using two or more long-acting continuous release opioids simultaneously; continuous pulse oximetry and etco2 monitoring. 4. As anesthesia providers, regional technique will be beneficial. Also we should educate the patient about the goals and expectations in terms of managing pain. If seen earlier, discuss about weaning opioids days/weeks prior to surgery. Recognize the increased analgesia needs of these patients, and plan for an escalation of 30-50% above baseline postoperatively. Also, use of multimodal analgesia perioperatively.
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