Pain Medicine 2015; 16: 1666–1672 Wiley Periodicals, Inc.
PERSPECTIVE & COMMENTARY Commentary Perioperative Surgical Home and the Integral Role of Pain Medicine
Disclosures: The authors have no conflicts of interest to disclose.
Introduction Many criticisms surround the current management of the surgical experience. These include the fragmented nature of care delivered perioperatively with multiple transitions, the high costs of many common procedures, and the sometimes disappointing outcomes given the monetary and human investments made in surgical care [1,2]. Modeled in some ways after the concept of the patientcentered medical home, the American society of anesthesiologists has articulated a definition of the perioperative surgical home (PSH) as “a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience” [3]. Though, we do not yet fully understand the potential benefits of the PSH model, a recent review suggests that the quality of care is often improved, and costs are reduced [4]. At the core of the PSH concept is the notion that various groups of health care specialists should work together to provide optimal care. Complementary to that notion, and particularly relevant to reducing fragmented treatment as well as improving the patient’s experience, is the recognition that the seamless longitudinal management of specific aspects of care may facilitate optimal outcomes. Pain management in the immediate postoperative period is already one of the better developed components of the PSH, and one on which further expansion of the model can be based [5]. As our understanding of factors predisposing patients to excessive acute postoperative pain, persistent postoperative pain, poor functional outcomes, and the prolonged use of opioids grows, so too will our ability to contribute to the 1666
perioperative management of surgical patients. Figure 1 displays a roadmap of key goals for comprehensive pain management in the perioperative setting. Discussion Preoperative Pain Assessment and Treatment Optimization A fundamental tenet of the PSH is that involvement begins at the time a patient is deemed a candidate for surgery. This involvement may be through phone, video, electronic consultation using the electronic health record (EHR), or in-person evaluation, such as in a preanesthetic evaluation clinic. Preoperative pain assessment and treatment optimization has three fundamental principles: evaluation, education, and optimization. Patient Evaluation The fundamental objectives of pain-related patient preoperative assessment include: 1) the identification of chronic pain conditions that may complicate surgical, postoperative, or rehabilitative efforts; 2) the use of medications that may impact management, such as opioids and anticoagulants; 3) active or historical abuse of substances that might require preoperative evaluation and treatment; 4) the presence of physiological factors limiting analgesic choices or making certain options advantageous, for example, coagulopathy, severe pulmonary disease, and sleep apnea; and 5) the presence of psychological factors linked to more severe or more persistent postoperative pain, such as anxiety, depression, or catastrophizing. An important issue regarding preoperative pain assessment is who does the assessment and how the assessment is actually performed. Most of the required information can be obtained from the medical record, particularly a complete EHR, and through focused patient interview. Telephone, video-assisted telemedicine, and inperson preoperative clinic-based evaluations are all feasible approaches to collecting additional information. In most cases, a physician-supervised nurse practitioner or physician assistant can accomplish the required aims. Patients identified as posing particular challenges because of relatively severe physiological or psychological disease
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Reprint requests to: David J. Clark, MD, PhD, Anesthesiology and Perioperative Care Service, 112A VAPAHCS 3801 Miranda Ave., Palo Alto, CA 94304, USA. Tel: 650-493-5000 ext 60479; Fax: 650-852-3423; E-mail: [email protected].
Evidence-Based Pain Medicine for Patients
may require the direct involvement of a physician. The preoperative psychological evaluation of patients is a relatively new concept, and brief but validated psychological questionnaires available to assist in these efforts include the beck depression inventory-short form shortened versions of the state-trait anxiety inventory, shortened pain catastrophizing scale, and similar instruments. Education Concerning Pain and Pain Management Options The education of patients and their families concerning postoperative pain and management options may help set expectations as well as reduce postoperative pain levels and health care expenditures [6,7]. Postoperative pain is a major fear among surgical candidates. One goal is to describe the typical course of pain in the postoperative period. For example, minor surgeries may require only a few days of mild analgesic use while spine and joint replacement procedures may require from one to several weeks of opioid management. Who will be managing their pain postoperatively? When will their primary care provider resume control of their pain management? This is also an opportunity to manage expectations surrounding pain control. Having no pain for the entire period of convalescence is often not achievable, but reassurance that very good levels of control with progressive improvement are expected for most patients may be a simple but welcomed message.
A very closely related goal is to address options for pain management. The concept that intravenous and oral medications will be available may not be unexpected, but the concepts of using local and regional analgesic techniques are likely to be less familiar. Patients in this model become active partners and not passive subjects in pain management. Preoperatively, we can describe to patients how nerve block procedures work, and why we may insert catheters to provide target-specific analgesia. Preventative strategies and their rationales can be introduced to patients. Video-based educational materials could be provided to reduce perioperative anxiety for patients having procedures under regional anesthesia [8]. If an acute pain specialist or team will be involved, the patient should know this in advance to build patient confidence in our abilities. Importantly, the patient should be engaged in describing previous experiences with postoperative pain control: which measures were helpful in the past; which techniques were not effective; and which medications had unacceptable side effects? Verbal, printed, video, and increasingly, Web-based information are all possible approaches to providing information on perioperative pain management. Preoperative Medication Optimization In some cases, it is appropriate to manage pain medications preoperatively. This is particularly important for chronic pain patients using high doses of opioids or when 1667
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Figure 1 A roadmap of pain management in perioperative pain care. In this model pain management issues are addressed at several points in the PSH process. The goals of evaluation and treatment are different at each point, and may involve different team members. Ultimately this process emphasizes the comfort and safety of the patient while optimizing efficiency and supporting optimal outcomes.
Walters et al.
Another common perioperative pain medicine issue surrounds the use of anticoagulants. Use of such agents may influence the use of regional anesthetic and analgesic techniques [17]. Therefore, understanding the need for anticoagulation and coordinating with the prescribing physician the most appropriate cessation timing, bridging therapy if necessary, and planning the resumption of those drugs in the context of regional catheter placement and removal are important preoperative goals. Preoperative Psychological Optimization Psychological factors are important and potentially modifiable modulators of postoperative pain. Rapidly implemented psychological interventions have been described. In one approach, patients receive a 2 hour cognitive behavioral therapy training session with additional homework assignments [18]. This form of therapy has been shown to be very effective in reducing pain catastrophizing, a psychological characteristic linked to acute and persistent postoperative pain. Training in the use of imagery, relaxation, and other coping strategies may be alternative and more easily implemented approaches that can be introduced shortly before surgery [19]. Preoperative Physical Optimization Though not pain management strategies per se, physical “prehabilitation” programs have been developed for both joint replacement, spine, and other surgeries, and may improve outcomes as well as reduce costs [20–22]. Pain and physical activity limitations are closely related issues for many chronic pain patients. The hope in these approaches is that strengthening muscles and reducing kinesiophobia (fear of movement related to pain) will enhance participation in postoperative rehabilitation ultimately reducing pain and improving functional outcomes. Improved physical status may improve the 1668
patient’s ability to withstand the overall surgical process as well. Thus, it seems reasonable to consider building prehabilitation expertise and capabilities into our preoperative pain management offerings. Anesthetic Management Care of the patient during surgery and in the early postoperative time frame is at the core of an anesthesiologist’s traditional scope of practice. This does not mean, however, that this core area of practice does not need to evolve to best fit overall perioperative management. Selection of the Optimal Anesthetic Technique Much has been studied and reported concerning selection of optimal anesthetic techniques for specific types of procedures. Generally pain-related outcomes have focused on relatively short term parameters, such as such as postanesthesia care unit times and analgesic requirements in the first 24 hours or so. We have a growing literature, however, regarding interventions to prevent persistent postoperative pain. Additional studies have addressed questions, such as whether regional analgesic techniques help patients reach rehabilitative milestones more quickly than traditional care, for example, general anesthesia and opioid management, that may be more expedient for an anesthesiologist to perform [23]. Very recent work has emphasized the role of anesthetic technique as a critical component of surgical clinical pathways. Not surprisingly, these studies have largely focused on high volume joint replacement procedures, although abdominal surgery outcomes have also been studied, and the fundamental considerations can be applied to the evaluation of specific anesthetic approaches to nearly any type of surgery [24]. The key point is that investigators, and hopefully soon practicing anesthesiologists, are emphasizing outcomes, such as hospital costs, length of stay, postoperative functional status, and other indices beyond our more traditional concerns. Anesthetic Selection and Challenging Patient Populations While it is appropriate to work toward understanding the best overall anesthetic pathways for typical patients, it is the challenging patient that absorbs the greater proportion of time and other resources. Anesthesiologists have the opportunity to show high value though the selection of the best anesthetic techniques to address the individual patient’s challenges intraoperatively as well as positioning the patient for optimal recovery through personalized medicine. Examples of such considerations are the use of epidural catheters for thoracic surgical cases in patients with compromised respiratory status, continuous regional analgesic techniques for patients with severe cardiovascular disease and the tailored use
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a preventative strategy will be implemented. Chronic opioid users, for example, tend to experience more intense and longer duration postoperative pain [9,10]. They also have poorer outcomes from spine and joint replacement surgeries [11,12] and require supplemental opioids longer than opioid na€ıve patients [13]. Studies have shown that 15% to more than 50% of patients presenting for surgery, in the United States, consume opioids chronically [11,14]. For such chronic opioid users, consolidation of the medications, elimination of concurrent sedating agents, for example, benzodiazepines and muscle relaxants, and even attempts at opioid use reduction are all potential goals. Conversely, introducing new medications, such as gabapentin or a COX-II inhibitor may be considered, that is, preventive analgesia, and, if appropriate, prescriptions and specific instructions provided [15]. The use of buprenorphine for pain or addiction represents one particularly challenging scenario well-suited to PSH management. Use of this drug can greatly complicate perioperative pain management due to its partial agonist properties and long effective half-life [16].
Evidence-Based Pain Medicine for Patients of multimodal analgesia for patients with significant opioid use histories. Postoperative Acute and Transitional Management Models of acute postoperative pain management range from individual providers following their own patients to multidisciplinary groups following large panels of complex patients to the time of discharge and beyond. Consistent with the PSH model, we are now challenged to offer more than simple recommendations from a single postoperative visit, at least for some patients. Interventional Acute Pain Management (Regional Anesthesia)
Complex Perioperative Pain Medicine The in-hospital management of more challenging pain patients expands our traditional roles and is one where help is critically needed as patients with psychiatric disease, chronic opioid use, and other persistent conditions can experience poor pain control and have expensive lengthy postoperative stays [26]. Here, our expanded involvement may take various forms. For example, the effective use of opioids for acute pain control in opioid tolerant patients can be challenging as pain scores are higher and side effects from these pain medications are more frequent [10]. The conversion of large doses of intravenous opioids to oral equivalent dosing requires experience beyond what is typical for most physicians and other providers. Additionally issues like the use of supplemental monitoring continuous positive airway pressure for patients with obstructive sleep apnea or the informed use of opioids and nonopioid adjuncts in patients with significant organ system dysfunction may require our expertise. The use of intravenous adjuvants such as ketamine, dexmedetomidine, lidocaine, and others outside of the operating room requires the availability of qualified staff, but these agents may offer specific advantages in complex patients [27]. In designing and presenting these approaches to patients, we may focus on helping the patient meet functional milestones used with increasing frequency as outcome metrics.
A common place for care to become uncoordinated is when patients are being readied for discharge even if all medications are being given orally. Most patients do well, but surgical teams are frequently uncomfortable designing taper plans for opioids and adjuvants after surgery. These are roles we are well-suited to assume. Additional responsibilities include instructions on the removal of catheters connected to ambulatory infusion devices, and communicating with the primary care provider regarding the plan for analgesic management. These efforts should be coordinated with the rehabilitative components of care that may also be supervised by an anesthesiologist-led group familiar with recovery from specific types of surgery. As it is not uncommon for the taper from opioid and other analgesics to require over a month, particularly in patients with psychiatric or opioid use histories [13], our teams need to maintain the ability to follow patients by phone, secure e-mail, or even in a clinic setting for up to a few months with the goal of stabilizing analgesic use. Long-Term Postoperative Follow-Up Typically chronic pain clinics have operated independently of acute pain services. This is changing as we recognize more and more that recovery from surgery can be an extended process and that acute and chronic pain after surgery exists on the same continuum. In fact persistent pain after surgery can be found in up to 50% of some patient cohorts, and may require ongoing treatment [28]. Planning ahead to be able to provide ready referrals of patients unable to taper from analgesics, those developing signs of complex regional pain syndrome after limb surgery, and those developing neuropathic pain after thoracotomy, herniorrhaphy, or other high-risk surgeries may prevent undue delays in treating patients for surgery-related persistent pain states. For some patients, pain clinics operated by pain medicine specialists may establish long-term pain management relationships. Joint replacement and spine surgeries, for example, reduce but often do not eliminate pain. Repeat spine and joint replacement surgery is not uncommon, and these surgeries are often performed because of recurrent pain complaints [29,30]. It is our hope that longterm coordinated pain management will reduce the need for these procedures, thereby reducing the costs and risks of care as well as improving patient satisfaction. Addressing Major Knowledge Gaps Above, we have outlined many of the opportunities within perioperative pain medicine available to expand the PSH model. Table 1 provides a summary of those recommendations. We do, however, face major challenges in demonstrating that these measures can achieve the goals we seek. It is through research 1669
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To this point, acute perioperative pain services have mostly focused on the management of routine patients having some form of regional anesthesia or analgesia, and this is likely to remain central to our postoperative interactions. Either physicians or trained supervised personnel will need to manage catheters until the time of their removal and block resolution as well as initiate and manage intravenous or oral analgesic regimes. Adjustment of analgesic medications and interventions will need to be made to facilitate ambulation, resumption of normal activities, and to participate in rehabilitative efforts. Regional analgesic techniques are often at the core of surgery related clinical pathways and enhanced recovery strategies suggesting this role may become even more important [25].
Transitional Planning
Walters et al.
Table 1
The primary goals of the three stages of perioperative pain management
Preoperative Optimization
Intraoperative Management
Postoperative and Transitional Management
Optimize adverse patient factors Medication use, opioids, anticoagulants Anxiety, depression, catastrophizing Poor physical functional status
Choice of technique Regional, general, combined One-shot vs. continuous neural blockade
Regional techniques Catheter management Home infusions
Patient education Anesthetic and analgesic options Outline postoperative transition plan Expectations surrounding pain relief Expectations surrounding rehabilitation
Opioid dependent patients Maintenance requirements Supplemental opioids Buprenorphine
Preemptive/preventative strategies
Opioid management IV to PO conversions Complex dosing for dependent patients Management of buprenorphine Contact with primary provider Follow-up in pain clinic
The PSH model of care supports pain management intervention throughout the perioperative period. Preoperatively, the fundamental goals are to prepare the patient for safe and effective pain control while setting reasonable expectations for pain relief and progress towards functional milestones. Intraoperative management emphasizes not only optimizing the analgesic component of the anesthetic, but organizing management to provide optimal postoperative pain control as well. Postoperatively, a range of goals face pain management personnel. Excellent pain control must be maintained while transitioning a patient from intravenous and catheter-based therapies to oral regimes. Some patients, such as those dependent on opioids, will have complex management needs. Finally, planning medication tapers and arranging appropriate follow-up with either the patient’s primary provider or pain clinic are important pre-discharge tasks.
focused both on individual components of the proposed approaches and analysis of the success of the overall processes from a health services perspective that we may understand the impact of our efforts. Perhaps the most approachable type of research related to PSH management involves the evaluation of the efficacy of its individual components. For example, does the use of adductor canal block enhance long-term functional outcomes of total knee arthroplasty? Studies like these are oriented around understanding how one intervention, for example, opioid taper or anesthetic blockade, impacts a very specific aspect of surgical outcome. It seems likely that we will more often see economic endpoints as the primary outcomes of many future perioperative pain studies. The results of these focused studies will remain important as they help to establish or refute the hypothesis that a specific maneuver can achieve a specific endpoint. Conversely, establishing the efficacy of component processes is not the only challenge facing the implementation of the PSH. The concept of comparative-effectiveness research is fundamental to evaluating the success of various PSH models [2]. This is a substantial task as we consider the permutations of the available options for each perioperative stage, the diversity of surgeries performed and the diversity of patient populations. Furthermore, the outcomes we select need to take into account the priorities of patients, hospitals, insurers, and medical providers. In this regard, we need to compare viable but alternative approaches to care with individual pre-, intra-, and postoperative components assembled based on their anticipated individual contributions to overall care. 1670
Our challenge is made greater by the rapid advancements in pain management techniques. Just as pain specialists were early proponents of patient controlled analgesia devices and perineural catheters, so too will we be the specialists testing novel drugs, new devices, and innovative preventative strategies both for acute and persistent postoperative pain. Involvement in the entire perioperative process rather than the in-hospital component alone is critical to our making high-value contributions. The expansion of regional anesthesiology and acute pain medicine fellowships and rising stature of these programs toward accreditation is testimony to the rapid growth in this field. Academic programs need to be early adopters of innovative PSH programs as it is from training programs that the next generation of perioperative care specialists will arise. Admittedly our first experiences in performing these analyses may be somewhat confusing. However, as we embrace the multifaceted PHS approach to care, so too must we embrace a multifaceted approach to its evaluation. TESSA L. WALTERS, MD,*,† EDWARD R. MARIANO MD, MAS,*,† and J. DAVID CLARK, MD, PhD*,† *Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA; †Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA References 1 Vetter TR, Goeddel LA, Boudreaux AM, et al. The perioperative surgical home: How can it make the case so everyone wins? BMC Anesthesiol 2013;13:6.
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Adjuvant techniques Ketamine Dexmedetomidine
Adjuvant medications
Evidence-Based Pain Medicine for Patients 2 Vetter TR, Ivankova NV, Goeddel LA, et al. An analysis of methodologies that can be used to validate if a perioperative surgical home improves the patient-centeredness, evidence-based practice, quality, safety, and value of patient care. Anesthesiology 2013;119:1261–74. 3 Schweitzer M, Fahy B, Leib M, Rosenquist R, Merrick S. The perioperative surgical home model. Am Soc Anesthesiol News Lett 2013;77:58–9. 4 Kash BA, Zhang Y, Cline KM, Menser T, Miller TR. The perioperative surgical home (PSH): A comprehensive review of US and non-US studies shows predominantly positive quality and cost outcomes. Milbank Q 2014;92:796–821.
6 Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: A multicenter randomized controlled trial with 1-year follow-up. Spine 2014;39: 1449–57. 7 McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement. Cochrane Database Syst Rev 2014;5: CD003526. doi: 10.1002/14651858.CD003526.pub3. 8 Jlala HA, French JL, Foxall GL, Hardman JG, Bedforth NM. Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. Br J Anaesth 2010;104:369–74. 9 Chapman CR, Davis J, Donaldson GW, Naylor J, Winchester D. Postoperative pain trajectories in chronic pain patients undergoing surgery: The effects of chronic opioid pharmacotherapy on acute pain. J Pain 2011;12:1240–6.
14 VanDenKerkhof EG, Hopman WM, Goldstein DH, et al. Impact of perioperative pain intensity, pain qualities, and opioid use on chronic pain after surgery: A prospective cohort study. Reg Anesth Pain Med 2012;37:19–27. 15 Rosero EB, Joshi GP. Preemptive, preventive, multimodal analgesia: What do they really mean? Plast Reconstr Surg 2014;134:85S–93S. 16 Vadivelu N, Mitra S, Kaye AD, Urman RD. Perioperative analgesia and challenges in the drug-addicted and drug-dependent patient. Best Pract Res Clin Anaesthesiol 2014;28:91–101. 17 Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American society of regional anesthesia and pain medicine evidencebased guidelines (third edition). Reg Anesth Pain Med 2010;35:64–101. 18 Darnall BD, Sturgeon JA, Kao MC, Hah JM, Mackey SC. From catastrophizing to recovery: A pilot study of a single-session treatment for pain catastrophizing. J Pain Res 2014;7:219–26. 19 Lin PC. An evaluation of the effectiveness of relaxation therapy for patients receiving joint replacement surgery. J Clin Nurs 2012;21:601–8. 20 Gillis C, Li C, Lee L, et al. Prehabilitation versus rehabilitation: A randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology 2014;121:937–47. 21 McKay C, Prapavessis H, Doherty T. The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: A randomized controlled pilot study. PM R 2012;4:647–56.
10 Rapp SE, Ready LB, Nessly ML. Acute pain management in patients with prior opioid consumption: A case-controlled retrospective review. Pain 1995; 61:195–201.
22 Nielsen PR, Jorgensen LD, Dahl B, Pedersen T, Tonnesen H. Prehabilitation and early rehabilitation after spinal surgery: Randomized clinical trial. Clin Rehabil 2010;24:137–48.
11 Lee D, Armaghani S, Archer KR, et al. Preoperative opioid use as a predictor of adverse postoperative self-reported outcomes in patients undergoing spine surgery. J Bone Joint Surg Am 2014;96:e89
23 Paul JE, Arya A, Hurlburt L, et al. Femoral nerve block improves analgesia outcomes after total knee arthroplasty: A meta-analysis of randomized controlled trials. Anesthesiology 2010;113:1144–62.
12 Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am 2011;93:1988–93.
24 Memtsoudis SG, Sun X, Chiu YL, et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology 2013;118:1046–58. 1671
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5 Cyriac J, Cannesson M, Kain Z. Pain management and the perioperative surgical home: Getting the desired outcome right. Reg Anesth Pain Med 2015; 40:1–2.
13 Carroll I, Barelka P, Wang CK, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg 2012;115:694–702.
Walters et al. 25 Hebl JR, Dilger JA, Byer DE, et al. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med 2008;33:510–7. 26 Stundner O, Kirksey M, Chiu YL, et al. Demographics and perioperative outcome in patients with depression and anxiety undergoing total joint arthroplasty: A population-based study. Psychosomatics 2013;54:149–57. 27 Loftus RW, Yeager MP, Clark JA, et al. Intraoperative ketamine reduces perioperative opiate consumption in opiate-dependent patients with chronic
back pain undergoing back surgery. Anesthesiology 2010;113:639–46. 28 Reddi D, Curran N. Chronic pain after surgery: Pathophysiology, risk factors and prevention. Postgrad Med J 2014;90:222–7; quiz 6. 29 Dy CJ, Marx RG, Bozic KJ, et al. Risk factors for revision within 10 years of total knee arthroplasty. Clin Orthop Relat Res 2014;472:1198–207. 30 Xu R, Bydon M, Macki M, et al. Adjacent segment disease after anterior cervical discectomy and fusion: Clinical outcomes after first repeat surgery versus second repeat surgery. Spine 2014;39:120–6. Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 8, 2016
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PERSPECTIVE & COMMENTARY Commentary Perioperative Surgical Home and the Integral Role of Pain Medicine
Disclosures: The authors have no conflicts of interest to disclose.
Introduction Many criticisms surround the current management of the surgical experience. These include the fragmented nature of care delivered perioperatively with multiple transitions, the high costs of many common procedures, and the sometimes disappointing outcomes given the monetary and human investments made in surgical care [1,2]. Modeled in some ways after the concept of the patientcentered medical home, the American society of anesthesiologists has articulated a definition of the perioperative surgical home (PSH) as “a patient-centered and physician-led multidisciplinary and team-based system of coordinated care that guides the patient throughout the entire surgical experience” [3]. Though, we do not yet fully understand the potential benefits of the PSH model, a recent review suggests that the quality of care is often improved, and costs are reduced [4]. At the core of the PSH concept is the notion that various groups of health care specialists should work together to provide optimal care. Complementary to that notion, and particularly relevant to reducing fragmented treatment as well as improving the patient’s experience, is the recognition that the seamless longitudinal management of specific aspects of care may facilitate optimal outcomes. Pain management in the immediate postoperative period is already one of the better developed components of the PSH, and one on which further expansion of the model can be based [5]. As our understanding of factors predisposing patients to excessive acute postoperative pain, persistent postoperative pain, poor functional outcomes, and the prolonged use of opioids grows, so too will our ability to contribute to the 1666
perioperative management of surgical patients. Figure 1 displays a roadmap of key goals for comprehensive pain management in the perioperative setting. Discussion Preoperative Pain Assessment and Treatment Optimization A fundamental tenet of the PSH is that involvement begins at the time a patient is deemed a candidate for surgery. This involvement may be through phone, video, electronic consultation using the electronic health record (EHR), or in-person evaluation, such as in a preanesthetic evaluation clinic. Preoperative pain assessment and treatment optimization has three fundamental principles: evaluation, education, and optimization. Patient Evaluation The fundamental objectives of pain-related patient preoperative assessment include: 1) the identification of chronic pain conditions that may complicate surgical, postoperative, or rehabilitative efforts; 2) the use of medications that may impact management, such as opioids and anticoagulants; 3) active or historical abuse of substances that might require preoperative evaluation and treatment; 4) the presence of physiological factors limiting analgesic choices or making certain options advantageous, for example, coagulopathy, severe pulmonary disease, and sleep apnea; and 5) the presence of psychological factors linked to more severe or more persistent postoperative pain, such as anxiety, depression, or catastrophizing. An important issue regarding preoperative pain assessment is who does the assessment and how the assessment is actually performed. Most of the required information can be obtained from the medical record, particularly a complete EHR, and through focused patient interview. Telephone, video-assisted telemedicine, and inperson preoperative clinic-based evaluations are all feasible approaches to collecting additional information. In most cases, a physician-supervised nurse practitioner or physician assistant can accomplish the required aims. Patients identified as posing particular challenges because of relatively severe physiological or psychological disease
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 8, 2016
Reprint requests to: David J. Clark, MD, PhD, Anesthesiology and Perioperative Care Service, 112A VAPAHCS 3801 Miranda Ave., Palo Alto, CA 94304, USA. Tel: 650-493-5000 ext 60479; Fax: 650-852-3423; E-mail: [email protected].
Evidence-Based Pain Medicine for Patients
may require the direct involvement of a physician. The preoperative psychological evaluation of patients is a relatively new concept, and brief but validated psychological questionnaires available to assist in these efforts include the beck depression inventory-short form shortened versions of the state-trait anxiety inventory, shortened pain catastrophizing scale, and similar instruments. Education Concerning Pain and Pain Management Options The education of patients and their families concerning postoperative pain and management options may help set expectations as well as reduce postoperative pain levels and health care expenditures [6,7]. Postoperative pain is a major fear among surgical candidates. One goal is to describe the typical course of pain in the postoperative period. For example, minor surgeries may require only a few days of mild analgesic use while spine and joint replacement procedures may require from one to several weeks of opioid management. Who will be managing their pain postoperatively? When will their primary care provider resume control of their pain management? This is also an opportunity to manage expectations surrounding pain control. Having no pain for the entire period of convalescence is often not achievable, but reassurance that very good levels of control with progressive improvement are expected for most patients may be a simple but welcomed message.
A very closely related goal is to address options for pain management. The concept that intravenous and oral medications will be available may not be unexpected, but the concepts of using local and regional analgesic techniques are likely to be less familiar. Patients in this model become active partners and not passive subjects in pain management. Preoperatively, we can describe to patients how nerve block procedures work, and why we may insert catheters to provide target-specific analgesia. Preventative strategies and their rationales can be introduced to patients. Video-based educational materials could be provided to reduce perioperative anxiety for patients having procedures under regional anesthesia [8]. If an acute pain specialist or team will be involved, the patient should know this in advance to build patient confidence in our abilities. Importantly, the patient should be engaged in describing previous experiences with postoperative pain control: which measures were helpful in the past; which techniques were not effective; and which medications had unacceptable side effects? Verbal, printed, video, and increasingly, Web-based information are all possible approaches to providing information on perioperative pain management. Preoperative Medication Optimization In some cases, it is appropriate to manage pain medications preoperatively. This is particularly important for chronic pain patients using high doses of opioids or when 1667
Downloaded from http://painmedicine.oxfordjournals.org/ by guest on June 8, 2016
Figure 1 A roadmap of pain management in perioperative pain care. In this model pain management issues are addressed at several points in the PSH process. The goals of evaluation and treatment are different at each point, and may involve different team members. Ultimately this process emphasizes the comfort and safety of the patient while optimizing efficiency and supporting optimal outcomes.
Walters et al.
Another common perioperative pain medicine issue surrounds the use of anticoagulants. Use of such agents may influence the use of regional anesthetic and analgesic techniques [17]. Therefore, understanding the need for anticoagulation and coordinating with the prescribing physician the most appropriate cessation timing, bridging therapy if necessary, and planning the resumption of those drugs in the context of regional catheter placement and removal are important preoperative goals. Preoperative Psychological Optimization Psychological factors are important and potentially modifiable modulators of postoperative pain. Rapidly implemented psychological interventions have been described. In one approach, patients receive a 2 hour cognitive behavioral therapy training session with additional homework assignments [18]. This form of therapy has been shown to be very effective in reducing pain catastrophizing, a psychological characteristic linked to acute and persistent postoperative pain. Training in the use of imagery, relaxation, and other coping strategies may be alternative and more easily implemented approaches that can be introduced shortly before surgery [19]. Preoperative Physical Optimization Though not pain management strategies per se, physical “prehabilitation” programs have been developed for both joint replacement, spine, and other surgeries, and may improve outcomes as well as reduce costs [20–22]. Pain and physical activity limitations are closely related issues for many chronic pain patients. The hope in these approaches is that strengthening muscles and reducing kinesiophobia (fear of movement related to pain) will enhance participation in postoperative rehabilitation ultimately reducing pain and improving functional outcomes. Improved physical status may improve the 1668
patient’s ability to withstand the overall surgical process as well. Thus, it seems reasonable to consider building prehabilitation expertise and capabilities into our preoperative pain management offerings. Anesthetic Management Care of the patient during surgery and in the early postoperative time frame is at the core of an anesthesiologist’s traditional scope of practice. This does not mean, however, that this core area of practice does not need to evolve to best fit overall perioperative management. Selection of the Optimal Anesthetic Technique Much has been studied and reported concerning selection of optimal anesthetic techniques for specific types of procedures. Generally pain-related outcomes have focused on relatively short term parameters, such as such as postanesthesia care unit times and analgesic requirements in the first 24 hours or so. We have a growing literature, however, regarding interventions to prevent persistent postoperative pain. Additional studies have addressed questions, such as whether regional analgesic techniques help patients reach rehabilitative milestones more quickly than traditional care, for example, general anesthesia and opioid management, that may be more expedient for an anesthesiologist to perform [23]. Very recent work has emphasized the role of anesthetic technique as a critical component of surgical clinical pathways. Not surprisingly, these studies have largely focused on high volume joint replacement procedures, although abdominal surgery outcomes have also been studied, and the fundamental considerations can be applied to the evaluation of specific anesthetic approaches to nearly any type of surgery [24]. The key point is that investigators, and hopefully soon practicing anesthesiologists, are emphasizing outcomes, such as hospital costs, length of stay, postoperative functional status, and other indices beyond our more traditional concerns. Anesthetic Selection and Challenging Patient Populations While it is appropriate to work toward understanding the best overall anesthetic pathways for typical patients, it is the challenging patient that absorbs the greater proportion of time and other resources. Anesthesiologists have the opportunity to show high value though the selection of the best anesthetic techniques to address the individual patient’s challenges intraoperatively as well as positioning the patient for optimal recovery through personalized medicine. Examples of such considerations are the use of epidural catheters for thoracic surgical cases in patients with compromised respiratory status, continuous regional analgesic techniques for patients with severe cardiovascular disease and the tailored use
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a preventative strategy will be implemented. Chronic opioid users, for example, tend to experience more intense and longer duration postoperative pain [9,10]. They also have poorer outcomes from spine and joint replacement surgeries [11,12] and require supplemental opioids longer than opioid na€ıve patients [13]. Studies have shown that 15% to more than 50% of patients presenting for surgery, in the United States, consume opioids chronically [11,14]. For such chronic opioid users, consolidation of the medications, elimination of concurrent sedating agents, for example, benzodiazepines and muscle relaxants, and even attempts at opioid use reduction are all potential goals. Conversely, introducing new medications, such as gabapentin or a COX-II inhibitor may be considered, that is, preventive analgesia, and, if appropriate, prescriptions and specific instructions provided [15]. The use of buprenorphine for pain or addiction represents one particularly challenging scenario well-suited to PSH management. Use of this drug can greatly complicate perioperative pain management due to its partial agonist properties and long effective half-life [16].
Evidence-Based Pain Medicine for Patients of multimodal analgesia for patients with significant opioid use histories. Postoperative Acute and Transitional Management Models of acute postoperative pain management range from individual providers following their own patients to multidisciplinary groups following large panels of complex patients to the time of discharge and beyond. Consistent with the PSH model, we are now challenged to offer more than simple recommendations from a single postoperative visit, at least for some patients. Interventional Acute Pain Management (Regional Anesthesia)
Complex Perioperative Pain Medicine The in-hospital management of more challenging pain patients expands our traditional roles and is one where help is critically needed as patients with psychiatric disease, chronic opioid use, and other persistent conditions can experience poor pain control and have expensive lengthy postoperative stays [26]. Here, our expanded involvement may take various forms. For example, the effective use of opioids for acute pain control in opioid tolerant patients can be challenging as pain scores are higher and side effects from these pain medications are more frequent [10]. The conversion of large doses of intravenous opioids to oral equivalent dosing requires experience beyond what is typical for most physicians and other providers. Additionally issues like the use of supplemental monitoring continuous positive airway pressure for patients with obstructive sleep apnea or the informed use of opioids and nonopioid adjuncts in patients with significant organ system dysfunction may require our expertise. The use of intravenous adjuvants such as ketamine, dexmedetomidine, lidocaine, and others outside of the operating room requires the availability of qualified staff, but these agents may offer specific advantages in complex patients [27]. In designing and presenting these approaches to patients, we may focus on helping the patient meet functional milestones used with increasing frequency as outcome metrics.
A common place for care to become uncoordinated is when patients are being readied for discharge even if all medications are being given orally. Most patients do well, but surgical teams are frequently uncomfortable designing taper plans for opioids and adjuvants after surgery. These are roles we are well-suited to assume. Additional responsibilities include instructions on the removal of catheters connected to ambulatory infusion devices, and communicating with the primary care provider regarding the plan for analgesic management. These efforts should be coordinated with the rehabilitative components of care that may also be supervised by an anesthesiologist-led group familiar with recovery from specific types of surgery. As it is not uncommon for the taper from opioid and other analgesics to require over a month, particularly in patients with psychiatric or opioid use histories [13], our teams need to maintain the ability to follow patients by phone, secure e-mail, or even in a clinic setting for up to a few months with the goal of stabilizing analgesic use. Long-Term Postoperative Follow-Up Typically chronic pain clinics have operated independently of acute pain services. This is changing as we recognize more and more that recovery from surgery can be an extended process and that acute and chronic pain after surgery exists on the same continuum. In fact persistent pain after surgery can be found in up to 50% of some patient cohorts, and may require ongoing treatment [28]. Planning ahead to be able to provide ready referrals of patients unable to taper from analgesics, those developing signs of complex regional pain syndrome after limb surgery, and those developing neuropathic pain after thoracotomy, herniorrhaphy, or other high-risk surgeries may prevent undue delays in treating patients for surgery-related persistent pain states. For some patients, pain clinics operated by pain medicine specialists may establish long-term pain management relationships. Joint replacement and spine surgeries, for example, reduce but often do not eliminate pain. Repeat spine and joint replacement surgery is not uncommon, and these surgeries are often performed because of recurrent pain complaints [29,30]. It is our hope that longterm coordinated pain management will reduce the need for these procedures, thereby reducing the costs and risks of care as well as improving patient satisfaction. Addressing Major Knowledge Gaps Above, we have outlined many of the opportunities within perioperative pain medicine available to expand the PSH model. Table 1 provides a summary of those recommendations. We do, however, face major challenges in demonstrating that these measures can achieve the goals we seek. It is through research 1669
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To this point, acute perioperative pain services have mostly focused on the management of routine patients having some form of regional anesthesia or analgesia, and this is likely to remain central to our postoperative interactions. Either physicians or trained supervised personnel will need to manage catheters until the time of their removal and block resolution as well as initiate and manage intravenous or oral analgesic regimes. Adjustment of analgesic medications and interventions will need to be made to facilitate ambulation, resumption of normal activities, and to participate in rehabilitative efforts. Regional analgesic techniques are often at the core of surgery related clinical pathways and enhanced recovery strategies suggesting this role may become even more important [25].
Transitional Planning
Walters et al.
Table 1
The primary goals of the three stages of perioperative pain management
Preoperative Optimization
Intraoperative Management
Postoperative and Transitional Management
Optimize adverse patient factors Medication use, opioids, anticoagulants Anxiety, depression, catastrophizing Poor physical functional status
Choice of technique Regional, general, combined One-shot vs. continuous neural blockade
Regional techniques Catheter management Home infusions
Patient education Anesthetic and analgesic options Outline postoperative transition plan Expectations surrounding pain relief Expectations surrounding rehabilitation
Opioid dependent patients Maintenance requirements Supplemental opioids Buprenorphine
Preemptive/preventative strategies
Opioid management IV to PO conversions Complex dosing for dependent patients Management of buprenorphine Contact with primary provider Follow-up in pain clinic
The PSH model of care supports pain management intervention throughout the perioperative period. Preoperatively, the fundamental goals are to prepare the patient for safe and effective pain control while setting reasonable expectations for pain relief and progress towards functional milestones. Intraoperative management emphasizes not only optimizing the analgesic component of the anesthetic, but organizing management to provide optimal postoperative pain control as well. Postoperatively, a range of goals face pain management personnel. Excellent pain control must be maintained while transitioning a patient from intravenous and catheter-based therapies to oral regimes. Some patients, such as those dependent on opioids, will have complex management needs. Finally, planning medication tapers and arranging appropriate follow-up with either the patient’s primary provider or pain clinic are important pre-discharge tasks.
focused both on individual components of the proposed approaches and analysis of the success of the overall processes from a health services perspective that we may understand the impact of our efforts. Perhaps the most approachable type of research related to PSH management involves the evaluation of the efficacy of its individual components. For example, does the use of adductor canal block enhance long-term functional outcomes of total knee arthroplasty? Studies like these are oriented around understanding how one intervention, for example, opioid taper or anesthetic blockade, impacts a very specific aspect of surgical outcome. It seems likely that we will more often see economic endpoints as the primary outcomes of many future perioperative pain studies. The results of these focused studies will remain important as they help to establish or refute the hypothesis that a specific maneuver can achieve a specific endpoint. Conversely, establishing the efficacy of component processes is not the only challenge facing the implementation of the PSH. The concept of comparative-effectiveness research is fundamental to evaluating the success of various PSH models [2]. This is a substantial task as we consider the permutations of the available options for each perioperative stage, the diversity of surgeries performed and the diversity of patient populations. Furthermore, the outcomes we select need to take into account the priorities of patients, hospitals, insurers, and medical providers. In this regard, we need to compare viable but alternative approaches to care with individual pre-, intra-, and postoperative components assembled based on their anticipated individual contributions to overall care. 1670
Our challenge is made greater by the rapid advancements in pain management techniques. Just as pain specialists were early proponents of patient controlled analgesia devices and perineural catheters, so too will we be the specialists testing novel drugs, new devices, and innovative preventative strategies both for acute and persistent postoperative pain. Involvement in the entire perioperative process rather than the in-hospital component alone is critical to our making high-value contributions. The expansion of regional anesthesiology and acute pain medicine fellowships and rising stature of these programs toward accreditation is testimony to the rapid growth in this field. Academic programs need to be early adopters of innovative PSH programs as it is from training programs that the next generation of perioperative care specialists will arise. Admittedly our first experiences in performing these analyses may be somewhat confusing. However, as we embrace the multifaceted PHS approach to care, so too must we embrace a multifaceted approach to its evaluation. TESSA L. WALTERS, MD,*,† EDWARD R. MARIANO MD, MAS,*,† and J. DAVID CLARK, MD, PhD*,† *Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA; †Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA References 1 Vetter TR, Goeddel LA, Boudreaux AM, et al. The perioperative surgical home: How can it make the case so everyone wins? BMC Anesthesiol 2013;13:6.
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Adjuvant techniques Ketamine Dexmedetomidine
Adjuvant medications
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