10/16/2015 DISCLOSURES WHAT’S NEW IN POST-OP PAIN FOR GYNECOLOGIC SURGERY? October 16, 2015 2015 UCSF Monica W. Harbell, MD What Does � None The Evidence Tell Us? OBJECTIVES PAIN AFTER GYNECOLOGIC SURGERY � Describe the current impact of post-op pain after � 40% of laparoscopic gynecologic surgery patients gynecologic surgery have inadequate pain control after discharge � Provide an overview of options for post-op analgesia � 45-51% of major gynecologic surgery patients � Non-opioid analgesics reported inadequate pain control on POD#3 � Regional anesthesia: � Spinal � After 2 weeks, 23% report inadequate pain control � Epidural � Transversus Abdominus Plane Blocks � By 6 weeks, ~50% feel recovered � Discuss the rationale and benefits of multimodal analgesia and Enhanced Recovery After Surgery (ERAS) pathways Lovatsis D et al. J Obstet Gynaecol Can 2007; 29(8): 664-7. Evenson M. Obstet Gynecol. 2012; 119(4): 780-4. 1
10/16/2015 RISK FACTORS FOR CPSP AFTER ACUTE � CHRONIC PAIN HYSTERECTOMY � 5-32% incidence of chronic pelvic pain 1 year after hysterectomy � Chronic post-surgical pain (CPSP) � Lasts at least 2 months after surgery � Most consistent patient factors are preoperative and postoperative pain Brandsborg B et al . Acta Anaesthesiol Scand 2008; 52: 327-31. Brandsborg B et al. Anesthesiology 2007; 106: 1003-12. Brandsborg B et al. Anesthesiology 2007; 106: 1003-12. CHRONIC PAIN AFTER HYSTERECTOMY OPIOIDS � Surgical approach was not a risk factor � Abdominal, vaginal, laparoscopic Respiratory Respiratory Immuno- Immuno- Depression Depression � Total vs. subtotal abdominal hysterectomy suppresion suppresion � Unclear effect of spinal vs. GA on CPSP � Spinal associated with less pain than GA in a Delay of Delay of nonrandomized study (OR 0.42, CI: 0.21-0.85) early early PONV PONV mobilization mobilization � No difference in pain scores after 12 weeks in one RCT Paralytic ileus Paralytic ileus Brandsborg B et al . Acta Anaesthesiol Scand 2008; 52: 327-31. 2
10/16/2015 HOW OFTEN DO YOUR PATIENTS HAVING MULTIMODAL ANALGESIA GYNECOLOGIC SURGERY RECEIVE POST-OP NSAIDS? � Optimize additive effects of various A. Always agents 93% B. Sometimes � Utilize different modes of analgesia C. Rarely � Non-opioid analgesics D. Never � Regional anesthesia � Minimize side effects 7% 0% 0% � Facilitate patient recovery and Always Sometimes Rarely Never ambulation NSAIDS AND COX2-INHIBITORS � NSAIDS and COX2 inhibitors have opioid-sparing activity � 22-50% in patients undergoing gynecologic surgery Effect of � NSAIDS reduce opioid-related side effects Ketorolac on perioperative � Undesirable side effects include platelet dysfunction, bleeding renal impairment, and GI irritation. � 2.4% surgical-related bleeding vs. 0.4% with placebo � Does ketorolac increase postoperative bleeding? Maund E et al. Br J Anaesth 2011; 106: 292-7. Gobble RM et al. Plast Reconstr Surg. Bauchat JR, Habib AS. Anesthesiology Clin 2015; 33: 173-207. 2014; 133(3): 741-55. 3
10/16/2015 NSAIDS: ACETAMINOPHEN ON DEMAND VS. FIXED INTERVAL � 30-40% opioid-sparing effect in gynecologic surgery with 1g once or twice daily dosing regimen � Max dosing 4g/day � Equal efficacy as NSAIDS Fixed interval NSAID dosing provides more � Improved analgesia and reduced PONV when effective post-operative cesarean analgesia and combined with NSAIDS compared with either drug results in higher patient satisfaction than on- alone demand dosing. Maund E et al. Br J Anaesth 2011; 106: 292-7. Ong CK et al. Anesth Analg 2010; 110: 1170-9. Jakobi P, et al. Am J Obstet Gynecol 187(4):1066-9. 2002 HOW OFTEN DO YOUR PATIENTS HAVING IV VS. PO ACETAMINOPHEN GYNECOLOGIC SURGERY RECEIVE GABAPENTIN? � Higher peak plasma concentrations A. Always 54% B. Sometimes � Increased cost C. Rarely D. Never � No current analgesic outcome benefit 16% 16% 13% E. Don’t know 1% Always Sometimes Rarely Never Don’t know Jibril F et al. Can J Hosp Pharm 2015; 68(3): 238-47. 4
10/16/2015 GABAPENTIN GABAPENTIN � Structural analog to GABA � Side effects: � Sedation (RR 1.65) � Perioperative gabapentin reduces acute postop pain and opioid use. � Dizziness (RR 1.4) � 35% reduction in total opioid use over 1 st 24 hours post-op � Visual disturbances � Reduces preop anxiety, PONV, pruritis � Optimal dose unclear: � Increases patient satisfaction � Most studies: Gabapentin 600-1200mg given 1-2 hours preop � Minimal effective dose of Preop Gabapentin = 600mg Ho et al. Pain 2006; 126(1-3): 91-101. Peng PW et al. Pain Res Manag. 2007: 12(2): 85-92. Doleman B et al. Anaesthesia 2015; 70(10): 1185-204. Alayed N et al. Obstet Gynecol 2014; 123: 1221-9. Alayed N et al. Obstet Gynecol 2014; 123: 1221-9. PREGABALIN GABAPENTINOIDS REDUCE CPSP � Reduced postoperative pain scores and opioid use in 1 st 24 hours � Optimal dose unclear: 100mg-300mg once or q8-12 hours Yao Z et al. Clin Ther 2015; 37(5): 1128-35. Clarke H et al. Anesth Analg. 2012; 115(2): 428-42. 5
10/16/2015 REGIONAL ANESTHESIA SPINAL ANESTHESIA � Spinal anesthesia reduces postop opioid use for 48 hrs � Spinal � Likely due to IT morphine � More cost-effective than GA ($969 savings/patient) � Epidural � Shorter PACU stay (median 282 vs. 234 min) � Improved quality of life scores � Transversus Abdominus Plane (TAP) Block � Unclear effect on hospital length of stay: � No difference for vaginal hysterectomy � Shorter LOS in abdominal hysterectomy (2.2 vs. 3.3 days) Bauchat JR, Habib AS. Anesthesiology Clin 2015; 33: 173-207. Borendal Wodlin et al. Am J Obstet Gynecol 2011; 205(326): e1-7. Sprung et al. Can J Anaesth 2006; 53: 690-700. Massicotte et al. Acta Anaesthesiol Scand 2009; 53: 641-7. INTRATHECAL MORPHINE DOSES FOR EPIDURAL ANALGESIA POST-CESAREAN ANALGESIA Analgesia Pruritus Lower pain scores Did not reduce than with PCA opioids hospital length of stay Reduced opioid use Higher patient satisfaction Faster return of bowel function • Nausea and Vomiting 10% to 50% • Respiratory Depression < 0.25% Ferguson SE et al. Gynecol Oncol 2009; 114: 111-6. Katz J et al. Anesthesiology 2003; 98: 1449-60. Palmer, CM, et al. Anesthesiology 90:437-44. 1999 Jorgenson H et al. Br J Anaesth 2001; 97: 577-83. Palmer, CM, Tech in Reg Anesth & Pain Mgmt 7(4):213-21. 2003 6
10/16/2015 DO EPIDURALS IMPROVE SURVIVAL EPIDURALS AND SURVIVAL AFTER GYN CANCER SURGERY? � GA + Epidural associated with lower rate of ovarian � Epidurals may inhibit tumor spread and growth due to: cancer recurrence vs. GA alone (72 vs. 85%, p= 0.028) � Intrinsic tumor suppression properties of local anesthetics � Longer DFS associated with >48h of epidural use � Minimize opioid induced and surgically induced immunosuppression � Use of Desflurane vs. Sevoflurane associated with lower rate of recurrence (63 vs. 84%, p = 0.01) � Suppression of adrenergic stimulation during surgery � Avoidance of GA, which suppresses NK cell activity � RCT of women for ovarian CA: Patients with combined epidural + GA have higher antitumorigenic cytokines and NK cell cytotoxicity than those with GA alone Hong JY , Lim KT. Reg Anesth Pain Med 2008; 33: 44-51. Dong H et al. J Int Med Res 2012; 40(5): 1822-9. Elias KM et al. Ann Surg Oncol 2015; 22: 1341-8. TRANSVERSUS ABDOMINIS PLANE (TAP) ARE TAP BLOCKS ROUTINELY USED AT YOUR BLOCK INSTITUTION FOR POST-OP ANALGESIA? A. Yes 49% B. No C. Don’t know 29% 22% Yes No Don’t know Figure from Ultrasound For Regional Anesthesia, 2008 7
10/16/2015 TAP BLOCK TECHNIQUE TAP BLOCK: US-GUIDED TECHNIQUE � Placed between subcostal margin and iliac crest � Blind or US guided techniques � 20-30mL of local anesthetic injected incrementally on each side � Complications: � Intravascular injection � Bowel perforation � Liver trauma � Intraperitoneal injection (18% with blind technique) McDonnell et al. Anesth Analg 2008; 106: 186-9. Gray AT et al. Atlas of US-Guided Regional Anesthesia. 2 nd Edition. Elsevier-Saunders, 2013 McDermott G et al. Br J Anesth 2012; 108: 499-502. TAP BLOCKS FOR ABDOMINAL TAP BLOCK: US TECHNIQUE HYSTERECTOMY � 5 RCTs, n = 225 � Reduced pain scores � Reduced opioid use � Limited effect to first 24 hours Champaneria R et al. Eur J Obstet Gray AT et al. Atlas of US-Guided Regional Anesthesia. 2 nd Edition. Elsevier-Saunders, 2013 Gynecol Reprod Biol 2013; 166: 1-9. 8
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