Acute Pain Management
Acute Pain Management / Regional Anesthesia
Faculty:
| Dr. David Goldstein |
Dr. Richard Henry |
Dr Melanie Jaeger
Director APMS |
| Dr. Michael McMullen |
Dr. John Murdoch |
Dr. Rachel Rooney |
| Dr. Tarit Saha |
Dr. Vidur Shyam |
Dr. Brian Simchison |
Rosemary Wilson,
Nurse Practitioner |
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APMS Helpful Hints Heparin 5000usc q8h:
Gynecologic oncology and general surgery patients are often placed on q8h heparin post operatively for DVT prophylaxis as per ACCP guidelines. If using epidural analgesia in these patients, avoid concurrent use of other medications affecting clotting such as ASA and NSAIDs. If the epidural is functioning, there is little need for NSAIDs. They may be used once the epidural is removed.
Liver Resections: Liver resection patients often have a high INR on POD #1 and 2. This usually resolves without treatment by POD #4-5. The surgeons use the trends of the INR in assessing and evaluating liver function. If you feel FFP or Vitamin K is indicated for your patient, please discuss with Dr. Jalink or Nanji prior to ordering. They should be aware of your concerns and they need to alter their evaluation of liver function if exogenous products have been given.
Orthopedics: All THA and TKA patients are aiming to go home on POD #3. In order to meet that goal, the surgeons would like THA pts to have the PCA stopped in morning of POD #1 and TKA pts to have the PCA stopped in the afternoon of POD #1. If you feel it is in the patients’ best interest and if they are able to manage adequately on po opioids, then we should strive to follow this timeline. The nurses are extremely stretched and are unlikely to be able to help mobilize the patient who is hindered by a PCA. These patients must mobilize and are more likely to manage it without an IV and PCA attached to them.
The orthopedic surgeons are all in agreement with NSAID use in total joint arthroplasty patients if there are no contraindications.
Consider decreasing ropivacaine in the PAI for those <60kg and/or >80yrs old.
Splitting the PAI for bilateral TKAs is ineffective and prevents other strategies. Better to do nothing and then we can do a FNB in PACU.
Epidurals: Please don’t send patients from the PACU to the floor with a motor block from an epidural. This should be resolved before leaving the PACU. In most cases, if a patient cannot walk, the epidural is doing them no benefit and should be replaced. More importantly, epidural hematomas CANNOT be ruled out if they have a motor block
Epidurals for most patients should not inhibit their ability to walk. If they cannot get out of bed due to leg weakness, then this should be addressed immediately.
If your patients has a neurological abnormality and you fee an MRI is indicated to rule out a hematoma,
1. Attending APMS/Anesthesiologist to discuss concerns with Attending Surgeon or MRP covering
2. Surgeon and Anesthesiologist must agree that risks of potential clip movement is acceptable compared to risk of neuraxial hematoma. Note: All internal clips in KGH are titanium, therefore MRI compatible
3. Anesthesiologist to discuss with neuroradiologist and request MRI.
4. MRI will ensure that all internal staples and clips are properly documented by nursing on the OR record
5. Epidural to be removed by anesthesiologist as it is not MRI compatible. Coagulation profile must be taken into consideration and treated appropriately.
6. All skin staples are stainless steel (although they are MRI compatible, there is concern that they may heat initially) therefore must be removed by the surgical service and replaced with steristrips or sutures without delaying MRI.
7. MRI will be interpreted by neuroradiologist immediately upon completion of scan and neurosurgeon consulted depending on result. Neuroradiologist should review MRI with APMS/Anesthesiology Attending Staff
Fluids:
Consider type of bowel prep used in your fluid management. Keep in mind, TKA patients can lose 500-800ml from their drain in the first 24 hours.
Foley Catheters: Foley catheters are not needed just because they have an epidural. If the patient can walk, they can probably void.
Vaginal hysterectomy and lumbar discectomy patients often go home the evening of POD#1, so in these cases an IV PCA is rarely indicated.
Chronic Opioid Use: Please document (actual dose, not tablets) and order preoperative opioids, especially long acting ones. When discontinuing APMS, please ensure that long acting opioids (including methadone) are continued.
Baclofen: Withdrawal is life-threatening. This medication must be ordered if patient is on it pre-operatively. When discontinuing APMS, please order for it to be continued.
Educational Resources:
Objectives for Regional Anesthesia and Acute Pain Management (APMS) Rotation2010 Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy, ASRA and Pain Medicine Evidence-Based Guidelines (3rd Edition)
Reg Anesth Pain Med 2010;35: 64-101. APMS/ Regional Rotation Discussion Forum (internal use)Acute Pain Management: Scientific Evidence: Australian and New Zealand College of Anaesthetists Faculty of Pain Medicine, Third Edition 2010Oral Opioid Preparations - KGH/HDHLinks:
American Society of Regional Anesthesia and Pain Medicine (ASRA)
New York School of Regional Anesthesia (NYSORA)
Ultrasound for Regional Anesthesia (extensive reference section) ---------------------------------
To order methadone for patients post op on methadone preop:1. Call 1 866 358 0453
2. Leave your name, phone number and CPSO number
3. Leave patients full name and address
4. Leave dose and frequency of methadone and reason for use, analgesia or addiction.
