Multimodal Pain Management
35. W.W., a 36-year-old male, arrives at the ambulatory surgery center for an inguinal hernia repair. This procedure will be performed under local anesthesia, with sedation as needed, and is expected to be completed within 30 minutes. His medical and surgical histories are unremarkable. He is not currently taking any medication and reports no drug allergies. Following discharge from the ambulatory surgery center, how should W.W.'s postoperative pain be managed?
In general, one would expect that the greater the magnitude of the surgical trauma, the greater the patient's postoperative pain.145 For minor surgical procedures (e.g., inguinal hernia repair, breast biopsy), there is minimal surgical trauma, and the patient goes home shortly after surgery. For intermediate surgical procedures (e.g., total abdominal hysterectomy, laparoscopic cholecystectomy), short-term hospitalization is often necessary to observe the patient's recovery and manage his or her pain. Patients undergoing major surgery (e.g., bowel resection, thoracotomy) experience a significant surgical stress response that can significantly increase postoperative morbidity. Effective pain management is essential.
If pain is mild in intensity, a nonopioid analgesic such as acetaminophen or an NSAID is appropriate. If pain is moderate in intensity or not controlled with acetaminophen or an NSAID, a low-potency opioid combination (e.g., acetaminophen with hydrocodone or codeine) is used. When pain is moderate to severe in intensity, a more potent opioid (e.g., morphine, oxycodone) is necessary. If a fixed combination of opioid and nonopioid is used, the total daily dose administered to the patient is limited by the maximum allowable daily dose of the nonopioid (e.g., acetaminophen, ibuprofen).
Multimodal or “balanced” analgesia is often used to provide postoperative analgesia. It is difficult to optimize postoperative pain relief, to the point of achieving normal function, by using one drug or route of administration. By using two or more drugs that work at different points in the pain pathway, additive or synergistic analgesia can be achieved and adverse effects reduced because doses are lower and side effect profiles are different. Opioids are a mainstay of analgesic therapy for moderate-to-severe pain. However, opioids are often associated with intolerable adverse effects (e.g., nausea, vomiting, constipation, itching, sedation). Maximizing the use of nonopioid analgesics generally results in less need for opioids and improved analgesia (Table 9-20).145,146,169-172 When compared to morphine alone, the addition of an NSAID following major surgery reduces pain intensity and 24-hour morphine consumption. As a result, the incidence of morphine-related adverse effects of nausea, vomiting, and sedation is also reduced. Although the risk of surgical bleeding from nonselective NSAIDs is low, the risk can be increased in certain settings (e.g., after tonsillectomy).169
| Table 9-20 Commonly Used Analgesic Drugs and Nonpharmacologic Techniques for Postoperative Pain Management | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| |||||||||||||||||||||||||||||||||
For W.W., the anticipated surgical trauma is minor, and he will recover at home. The surgeon will inject a long-acting local anesthetic (e.g., bupivacaine) into the tissues surrounding the surgical field. This will provide intraoperative anesthesia at the surgical site and postoperative analgesia until the effects of bupivacaine wear off. Then, W.W. will likely require a less potent opioid (e.g., hydrocodone, codeine) combined with acetaminophen for pain control. If his pain is not controlled or his pain is mild in intensity, W.W. may take an NSAID (e.g., ibuprofen 200 or 400 mg Q 4–6 hr PRN or naproxen 220 mg Q 12 hr PRN).
Economic Issues
It is still common to find several anesthesia-related medications (e.g., sevoflurane, rocuronium) on an institution's top 25 expenditure list. Because of this, these medications are often targeted for cost-containment activities (e.g., appropriate flow rate for sevoflurane, use of vecuronium in place of rocuronium when appropriate).173-177 Although many anesthetic agents do not appear to be excessively expensive when looking at individual patient use, large dollar savings can be realized because of the thousands of patients that are anesthetized per year in a hospital.
Value-Based Anesthesia Care
When trying to reduce costs in the perioperative setting, one should not focus solely on using the least expensive technology, piece of equipment, or drug. This strategy can lead to unacceptable patient outcomes and higher total costs. The importance of looking at the “big picture” has been recognized by the anesthesiology profession since the early 1990s when they put forth the concept of value-based anesthesia care, which seeks the best patient outcomes at the most reasonable costs. The advantages and disadvantages of the technique or drug are balanced against all costs associated with the surgical experience.178
Total Costs of Surgical Stay
In one study, anesthesia costs, including medication use, accounted for 6% of the total costs for inpatient surgery, with approximately 50% being variable. Hence, modifying medication selection can impact, at most, 3% of the total costs associated with surgery. However, OR costs, including the costs of the PACU, accounted for 37% of the total costs of surgery, with approximately 44% being variable. Therefore, modifying practices that influence these costs can impact total cost by up to 16%.179 In another study, labor costs were estimated to be two orders of magnitude greater than anesthesia maintenance costs for a 60-minute outpatient procedure; therefore, a major component of cost-containment efforts should be directed at the reduction of labor costs by streamlining OR time and shortening PACU discharge time.180 Methods to reduce a patient's PACU stay may allow personnel reductions and/or reassignment of staff during slow periods. These studies highlight the opportunity for cost reduction in the perioperative setting by focusing on nonmedication costs and support the concept of fast-track anesthesia.
Fast-Track Anesthesia
Throughput is a major issue in most hospitals today. The perioperative setting is often targeted as needing improvement. Fast-track anesthesia, if successfully implemented, can help with throughput issues. The goal of fast tracking is to accelerate the movement of the patient through the perioperative experience (OR, PACU, and/or ICU). It has been promoted to improve patient satisfaction, to improve OR and PACU efficiency, and to lower the costs of the surgical experience. Several developments have facilitated the fast-track process and include the wide-scale use of less invasive surgical procedures (e.g., laparoscopy), the incorporation of new monitoring techniques to allow better titration of anesthesia (e.g., “consciousness” monitors),181 and the use of short-acting, fast-emergence anesthetic agents to reduce wake-up times and drug hangovers. Although medication costs may be higher with fast-track anesthesia, fast tracking can improve clinical and financial outcomes in both inpatient and outpatient settings. Fast tracking cardiac surgery patients has resulted in quicker extubation, reduced length of stay, reduced ICU readmission rate, and a 25% cost reduction.182,183 Furthermore, fast-track cardiac surgery patients have a decreased health care resource usage for at least 1 year following discharge.184 In a landmark outpatient study, fast tracking was implemented in five surgical centers and resulted in annual net savings from $50,000 to $160,000, with no significant differences in patient outcomes.185,186 In this study, outpatients meeting a well-defined set of criteria were allowed to skip phase I recovery and proceed directly to phase II from the OR. Phase I recovery can be considered an ICU-type environment. Patients are taken here from the OR to recover hemodynamically and fully regain consciousness; this requires intensive nursing care (usually one nurse to two patients). Once patients are awake, hemodynamically stable, and able to sit upright, they are moved to phase II recovery to finish the recovery process. In this setting, the nurse-patient ratio is 1:3, or greater if nurse assistants are employed. The low-solubility, volatile inhalation agents (desflurane, sevoflurane) are ideally suited for fast tracking in the outpatient setting.181,187
Thus, the goal for the cost-effective use of medications in the perioperative setting is a net reduction in the cost of surgical procedures (either the result of a lower overall medication cost or process modifications such as fast tracking) by taking advantage of the medications' properties and keeping in mind that patients' outcomes should not be negatively impacted and, ideally, should be improved.
0 comments:
Post a Comment