Peri-operative Pain Management - a multi-disciplinary team-based approach Dr Steven Wong Chief of Service Department of Anaesthesiology & OT Services Queen Elizabeth Hospital
Outline Development of postoperative pain management Effectiveness of postoperative pain management From postoperative to perioperative pain management
Postoperative pain management Only began in late 80s of the last Century On-demand intramuscular opioids by surgeons
Intramuscular opioids Adopted from: blog.daum.net
Revolution in Postoperative Pain Management in the 20 th Century Epidural analgesia Patient-controlled analgesia device
Epidural analgesia primumn0nn0cere.wordpress.com
Patient-controlled analgesia (PCA) Ferrante & Covino 1990
Acute pain service
How effective is postoperative pain management?
Unfortunately, a reduction in postoperative morbidity and mortality by epidural analgesia has not actually been demonstrated.
Editorial. Anesthesiology 2013;118:780-2 Surprisingly, minor surgical procedures were associated with high pain intensities procedures that have the reputation of being less painful received inadequate pain relief
Does postoperative pain management shorten hospital stay?
Opioid-related adverse effects Nausea and vomiting Pruritus Urinary retention Constipation
Chronic Postsurgical Pain FM Perkins et al. Chronic pain as an outcome of surgery: a review of predictive factors. Anesthesiology 2000 93: 1123-1133.
Injury to the peripheral nerves Central sensitization Loss of descending control Influence from higher centres Genetic predisposition Pathophysiology of chronic postsurgical pain Kehlet et al. Lancet 2006; 367:1618-25
International guidelines on postoperative pain management
Published by NHMRC (Australia) 1 st edition: 1999 2 nd edition: 2005 3 rd edition: 2010 The whole process of acute pain management was reviewed Key messages with level of evidence according to NHMRC designation
Published by NHS in 2004 A designated consultant anaesthetist should be responsible for acute pain management. All nursing staff, and all other healthcare professionals involved in postoperative pain management should have an up-to-date, evidencebased and appropriate understanding of postoperative pain management.
Nurse-led Acute Pain Service Started in some European countries More cost-effective Growing interest in the development of pain management as a nursing specialty Pain as the Fifth Vital Sign has been advocated to have pain assessment for all patients
Published by ASA in 2004 Revised in 2012 Preoperative evaluation - formulation of pain plan Multi-modal techniques for pain management
Working group consisting of anaesthesiologists and surgeons Postoperative pain management should be procedure-specific because the type, level and duration of pain may vary depending on the type of surgery.
www.postoppain.org PROSPECT
ERAS protocol for radical cystectomy Thoracic epidural is superior to systemic opioids in relieving pain. It should be continued for 72h. Multimodal postoperative analgesia, including thoracic analgesia European Urology 2014;65:263-6
Recommendations for acute pain service Include all patients after surgery Include all types of surgery Nurse-led service Perioperative service from preoperative evaluation to postoperative follow-up Collaborate with surgeon Procedure-specific protocols
the acute pain service has to be extended to cover all patients having surgery. In collaboration with the surgeons, postoperative pain management and rehabilitation protocols should be established to facilitate recovery after specific surgical procedures. Editorial. Hong Kong Med J 2008;14:340-1 With more nurses willing to participate in the management of postoperative pain, anaesthesiologists can step back and assume a supervisory role.
What have we done so far?
Nurse-led Acute Pain Service Advanced Practice Nurse (APN) in Pain Management Completed Post Registration Certificate Course (PRCC) in Pain Management Dedicated pain nurses providing full-time service Supervised by the anaesthesiologist Total number in the territory < 20
Nurse-led Acute Pain Service Link nurses Nurses from the operating theatre (OT) and ward Collaborating with the pain nurses Total about 70 from the OT and 380 from various wards (territory-wide) Most of them have not received formal training in pain management
Perioperative pain management Perioperative Care Enhancement Programme Piloted in QEH in July 2014 A team of Pain Nurses and OT nurses, under anaesthesiologists supervision and endorsed by surgeons Pre-operative visit to all elective surgical patients undergoing anaesthesia Intra-operative care Post-operative visit within 48h after surgery
Peri-operative Care Enhancement Programme Algorithm of Peri-operative Care Enhancement Programme Pre-operative Patient Admission No Day Admission Yes Peri-operative Nurses Assess Patients Information Given By Pre-admission Service Intra-operative Operations No Acute Pain Service Yes Pain Nurse Acute Pain Nurse Patient Follow Up + Patient Satisfaction Survey Post-operative No Anaesthetic-related Complications Detected Yes Inform Anaesthesiologist Anaesthesiologist Assesses & Manages Patient Peri-operative Care Case Closed Version July 14
Preliminary results July 2014 February 2015 No of preoperative visits: 1,106 No of postoperative visits: 1,607 Common postoperative problems: Postoperative pain (3%) Severe nausea and vomiting (2.6%)
Preliminary results Other rare postoperative complications: Post-intubation hoarseness of voice (4 cases) Post-dural puncture headache (1 case) Persistent numbness after regional anaesthesia (1 case) Stroke (1 case) All referred to the anaesthesiologists and surgeons for timely management Patient survey Decreased anxiety after preoperative visit (96%) Satisfied with postoperative visit (99%)
Joint Replacement Centre at Hong Kong Buddhist Hospital since 2012 Procedure-specific Perioperative Pain Management Protocol
D1 ambulation (June 2012)
Reduced Length of Stay Primary Total Knee Replacement of HA from Jan 2013 to Oct 2014 and Year 2009 No. of Days 20.0 15.0 10.0 7.2 15.2 10.0 9.2 12.4 5.0 0 0.0 BH QEH HA Average Post-OT LOS (days) 2013 to Oct 2014 Average Post-OT LOS (days) 2009
Reduced Length of Stay No. of Days 18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 Primary Total Hip Replacement of HA from Jan 2013 to Oct 2014 and Year 2009 17.8 14.7 10.8 11.6 8.6 0 QEH HA Average Post-OT LOS (days) 2013 to Oct 2014 Average Post-OT LOS (days) 2009
Patient satisfaction Satisfaction Level with the Anaesthetic Care 70% 64.89% 60% 50% 40% Percentage 30% 28.30% 20% 10% 0.35% 0.59% 5.87% 0% Satisfaction Level Dissatisfed Barely acceptable Acceptable Satisfed Very satisfed
Evolution in perioperative pain management Selective patients Single discipline Single time frame (post-operative) Single modality Single protocol All patients Multi-disciplinary Perioperative (pre- & post-operative) Multi-modal Procedure-specific protocol
Thank you