Opioid Safety, Respiratory Compromise

Two Key TakeAways from New American Pain Society Guideline for Post-Surgical Pain Management

By the Physician-Patient Alliance for Health & Safety (PPAHS)

The American Pain Society (APS) recently released Clinical Practice Guideline for Post-Surgical Pain Management sets forth recommendations from an interdisciplinary expert panel. The APS commissioned the panel which received input from the American Society of Anesthesiologists (ASA), and the guideline was approved by the American Society of Regional Anesthesia and Pain Management (ASRA).

Roger Chou, MD, lead author and head of the Oregon Evidence-based Practice Center, says that the guideline targets at all clinicians involved with post-surgical pain:

The intent of the guideline is to provide evidence-based recommendations for better management of postoperative pain, and the target audience is all clinicians who manage pain resulting from surgery,

Here are two key takeaways from the 32 recommendations:

#1 – Use a MultiModal Pain Strategy

The APS guideline asks clinicians to stop and consider the best pain alternatives for each patient. Dr Chou emphasizes the need for a multimodal approach:

The guideline strongly advises use of multimodal anesthesia that target different mechanisms of actions in the peripheral and central nervous systems. Randomized trails have shown that multimodal anesthesia involving simultaneous use of combinations of several medications — acting on different pain receptors or administered through different techniques — are associated with superior pain relief and decreased opioid consumption compared with use of a single medication administered by one technique.

What could that mean for a patient’s outcome?

The decision might mean life or death.

For example, pain-controlled analgesia (PCA) pumps are routinely administered to patients after surgery. John Lachance, who successfully underwent surgery to repair his torn rotator cuff, passed away after receiving opioids from a PCA.

Please click on the picture to view the video about John Lachance.

Please click on the picture to view the video about John Lachance.

John’s wife, Patricia LaChance Knode, believes a more thoughtful pain strategy should have been considered before opioids were automatically administered:

John’s death could have been prevented if he had not been automatically given an opioid, but consideration been given to his sleep apnea and difficulties he had experienced when receiving anesthesia.

Using a #multimodal #pain strategy could mean #life or #death #ptsafety Click To Tweet

The APS guideline indicates these three recommendations graded strong with high-quality evidence:

  • Adults and children can be given acetaminophen and/or non-steroidal anti-inflammatory drugs as part of multimodal analgesia for management of postoperative pain
  • Clinicians should consider surgical site-specific peripheral regional anesthetic techniques with proven efficacy in adults and children for certain procedures
  • Spinal analgesia is appropriate for major thoracic and abdominal procedures, particularly in patients at risk for cardiac and pulmonary complications or prolonged intestinal distress.

#2 – Carefully Monitor All Patients Receiving Pain Medication Particularly Opioids

The APS panel strongly recommends that clinicians continuously assess and monitor their patients receiving pain medication, particularly if it involves opioid administration:

  • Conduct a preoperative evaluation, including assessment of medical and psychiatric comorbidities, concomitant medications, history of chronic pain, and substance abuse;
  • Adjust the pain management plan on the basis of adequacy of pain relief and presence of adverse events;
  • Use a validated pain assessment tool to track response to postoperative pain treatments and adjust treatment plans accordingly;
  • Appropriately monitor sedation, respiratory status, and other adverse events in patients who receive systemic opioids; and
  • Provide appropriate monitoring of patients who have received neuraxial interventions for perioperative analgesia.

The Anesthesia Patient Safety Foundation (APSF) has called for a “paradigm shift” in monitoring patients.. Robert Stoelting, MD (President, APSF) says:

It’s time for a change in how we monitor postoperative patients receiving opioids. We need a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.

How might monitor have changed an outcome?

11 year-old Leah had elective surgery to repair a condition called pectus carinatum, which required the opening of her chest. Leah received epidural anesthesia during surgery, which was left in place to help manage her post-surgical pain.

To view a video about Leah, please click on her image.

To view a video about Leah, please click on her image.

Lenore Alexander believes that had Leah received continuous electronic monitoring, her daughter would still be alive today:

“Would real-time monitoring have saved Leah?

That is one of the many questions that I have asked myself every day since I found my daughter, Leah, dead in her hospital bed.

The answer is yes, it would have.

Yes, continuous electronic monitoring would have saved Leah #ptsafety Click To Tweet

The APS guideline concludes that optimal pain management is a process that starts in the preoperative period and proceeds throughout the continuum of care:

The recommendations are on the basis of the underlying premise that optimal management begins in the preoperative period and is on the basis of an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved, with follow-up assessments as needed.

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