SCOAP Community Speaks Up: Advanced Pain Control

Surgeons at Sacred Heart in Spokane have asked “Is pain control getting in the way of recovery?”

Over the last five years, SCOAP has collected data to signal hospitals about their use of advanced pain control. One frequent question our patients ask when preparing for an elective surgery is, “How much pain will I have?” SCOAP recognizes that effective pain control requires giving patients active participation and control of their pain management and is the standard of care.  Evidence suggests that effective pain control reduces complications, decreases length of stay and improves patient comfort, satisfaction and outcome.  Effective pain control has included the element of advanced pain management, defined as a pain control method that is patient-controlled either through Patient Controlled Analgesia (PCA) or Patient Controlled Epidural Analgesia (PCEA).  SCOAP measures and benchmarks whether bariatric and colorectal patients receive advanced pain control (Patient-Controlled Analgesia or Epidural) following their operation.

Which method is preferable?
A meta-analysis[1] of 100 RCTs of randomized patients (abdominal surgery-36%, thoracic-24%, and lower extremity-12%) who received postoperative analgesia-either epidural analgesia or parenteral opioids found that for abdominal surgery, all epidural regimens were better postoperative analgesia than parenteral opioids.  Another meta-analysis of sixteen studies of only patients having colorectal surgery determined that although systemic opioids are effective for pain, they delay recovery of colonic mobility and prolong postoperative ileus.[2]

Do epidurals delay or help recovery?
Emerging evidence from multimodal “enhanced” recovery programs[3] – implementation of a perioperative patient care paradigm that reduces the time to discharge home and resumption of activities of daily living after surgical procedures – indicates that pain control, while an important aspect of patient care, needs to be considered not as a separate intervention but as one crucial component in a bundled care path.  

A key component of enhanced recovery programs is early ambulation. This is made possible by eliminating barriers such as the “two point restraint” of the Foley catheter and PCA, and the “three point restraint” when a routine NG tube is also in place.  In a recent SCOAP data review comparing length of stay (LOS) data from Q3 2008 through Q4 2009, hospitals in Washington State with lower LOS provided PCA’s to 90% of elective open colon/rectal patients and epidurals to 10%.   Hospitals with higher LOS used PCAs for 83% of these patients and epidurals for 28%.  In exploring this interesting finding it became apparent that we needed to get more information to better understand the reasons for prolonged length of stay.

As of January 2010 we are measuring how soon the patient is able to ambulate through the measure of the “voiding epidural” which is calculated using the date the patient’s Foley catheter is removed in patients who have epidurals. The recently issued Q1 2010 SCOAP report reflects these changes with new metrics. As more hospitals develop enhanced recovery protocols with multi-modal approaches, postoperative pain management is addressed in increasingly detailed and specific ways and SCOAP is evolving in response.

Is there evidence for the “voiding” epidural approach to pain control?
In a randomized trial of 54 patients[4] undergoing partial colectomy surgery, thoracic epidural analgesia (TEA) with bupivacaine and morphine inserted at the T8-T10 vertebral interspace was shown to provide the best balance of analgesia and side effects while accelerating postoperative recovery of gastrointestinal function and time to fulfillment of discharge criteria after colon surgery in relatively healthy patients within the context of a multimodal recovery program. The so-called “Walking/Voiding” epidurals provide pain relief and also allow patients to be up and out of bed sooner and more comfortably.  In another recent study,[5] sixty patients undergoing thoracic or thoraco-abdominal surgery were studied prospectively. Patients were randomly assigned   to receive either TEA or patient-controlled  i.v. opiate analgesia (PCA) after their operation. Visual analogue pain and sedation scores were recorded for the period of the study. The authors concluded that epidural analgesia with local anesthetic and opioid improved quality of life and delivered better analgesia compared with PCA.

There is also evidence that the practice of keeping a urinary catheter in place postoperatively when a patient has a thoracic epidural to avoid urinary retention may not be necessary.  A recent randomized study[6] of patients scheduled for thoracic and abdominal surgery and receiving continuous thoracic epidural analgesia found that leaving the bladder catheter as long as the epidural analgesia is maintained results in a higher incidence of UTI and prolonged hospital stay. Removal of the bladder catheter on the morning after surgery does not lead to higher rate of catheterizations.

Surgeons at Southwest asked “Are there special considerations for pain control with bariatric patients? We are concerned about using PCAs for these patients.”
For patients with clinically severe obesity (BMI≥35 kg/m2) who present for bariatric surgery, the incidence of obstructive sleep apnea (OSA) ranges from 71% to 77%. Postoperatively, patients with OSA present the anesthesiologist, surgeon, and nursing staff with a difficult situation. Although diminution of pain is the goal of every caregiver, the use of narcotics is especially dangerous in patients with OSA. After the use of any general anesthetic, the patient with OSA will exhibit a propensity for rapid eye movement (REM) sleep during the first several days after surgery.  In the patient with OSA, the genioglossus muscle is virtually paralyzed during REM sleep, allowing the tongue to fall posteriorly to the retroglossal space. Normally, such patients would arouse and terminate REM sleep, but this reflex is diminished with the administration of narcotics or sedatives.

For patients with severe pain and the need for opiates, the risk of over-sedation and airway compromise is clearly increased. In patients with OSA, respiratory depression culminating in respiratory arrest has been reported after an intravenous “push” of opioid analgesics, an epidural infusion of opioid analgesia  and with the use of patient-controlled opioid analgesia. Proper patient positioning (e.g., HOB to 30°), the administration of CPAP, nursing monitoring and limited use of narcotic analgesics have been recommended to address these risks.  Some hospitals admit these patients to the ICU for a brief period to provide more nursing support and assessment of the patient’s needs. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used as an adjunct for postoperative pain control as the use of NSAIDs can decrease opioid use by 20% to 35%.[7]  There is no literature that indicates a clear contraindication to use of a PCA or PCEA.

What about laparoscopic surgery?
Pain control following laparoscopic surgery is related to the size of incisions. Some colorectal surgeries that are hand-assisted may have a significant incision.  A retrospective analysis[8] of hospital records was performed for 16 patients undergoing laparoscopic colorectal surgery. Thoracic epidural in this study offered optimal analgesia and quality of care.  Other considerations for pain control in laparoscopic colorectal surgery have focused on decreasing length of stay. A randomized clinical trial[9] of patients undergoing segmental laparoscopic colectomy compared PCA vs. TEA and found that TEA significantly improved early analgesia following laparoscopic colectomy but did not affect the length of hospital stay.

What are best-performing SCOAP hospitals doing to ensure patients have optimal pain control and recovery?
SCOAP hospitals that are successfully addressing postoperative pain control have developed strategies and guidelines to standardize all aspects of care during the entire perioperative period.   They have formed teams that include key players such as anesthesia staff, nursing staff and other clinicians to address ongoing quality improvement activities and are providing training and coaching to staff so they understand and are supportive of the organization’s approach to postoperative recovery,  and the need to provide effective pain management that optimizes patient outcome.  They also use SCOAP data to figure out whether or not strategies like epidurals are helping or restricting their patients.  Evidence suggests that patients with open bariatric or colorectal operations should receive a thoracic epidural that is properly positioned to allow ambulation and voiding, and that pain control be considered as part of the multi-modal approach to surgical recovery. Patients with large laparoscopic incisions may also benefit from thoracic epidurals. Bariatric patients with OSA require careful monitoring and limited use of narcotic analgesics.  Only by tracking on the effectiveness and impact of advanced pain control will we balance the benefits and drawbacks of this powerful technology.

Thanks for all you do as a part of SCOAP.

[1] Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290(18):2455-2463

[2] Marret E, Remy C, Bonnet F, Postoperative Pain Forum Group. Meta-analysis of epidural analgesia vs. parenteral opioid analgesia after colorectal surgery. Br J Surg. 2007; 94(6):665-673.

[3] Lassen K, Soop M, Nygren J, Cox PBW, Hendry PO, Spies C et al.  Consensus review of optimal perioperative care in colorectal surgery. Arch Surg 2009; 144: 961–969.

[4] Liu SS, Carpenter RL, Mackey DC, Thirlby RC, Rupp SM, Shine TS, Feinglass NG, Metzger PP, Fulmer JT, Smith SL: Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 1995; 83:757-65

[5] Ali, M, Winter DC , Hanly AM, O’Hagan C,  Keaveny J, Broe P.  Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life. Br. J. Anaesth. 2010 104: 292-297.

[6] Zaouter C, Kaneva P, Carli F. Less Urinary Tract Infection by Earlier Removal of Bladder Catheter in Surgical Patients Receiving Thoracic Epidural Analgesia Regional Anesthesia & Pain Medicine: November/December 2009 – Volume 34 – Issue 6 – pp 542-548

[7] Bell R, Rosenbaum S. Postoperative considerations for patients with obesity and sleep apnea. Anesthesiol Clin N Am 23 (2005), pp. 493–500.

[8] Dennis, RJ, Mills, P. Thoracic Epidural versus Morphine Patient Controlled Analgesia After Laparoscopic Colectomy World Journal of Laparoscopic Surgery, September-December 2008.

[9] Senagore AJ, Delaney CP, Mekhail N, Dugan A, Fazio VW. Randomised clinical trial comparing epidural anaesthesia and patient controlled analgesia after laparoscopic segmental colectomy. Br.J.Surg 2003; 90: 1195–9.


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