A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/295392
A3 [MAY 2014, SUPPLEMENT A] Bariatric Times HOT TOPICS IN SURGICAL PAIN MANAGEMENT Introduction Effective pain management is a nationwide priority f or healthcare organizations, practitioners, and policy makers. Over the past two decades, the suboptimal treatment of acute pain has become an important issue in healthcare, specifically in the postoperative setting. 1,2 For example, The Joint Commission i nstituted pain management standards for the assessment and management of acute pain in 2001. 3 The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, also known as the CAHPS ® , is the first national, standardized, publicly reported survey of patients' perspectives on hospital care. Included in the HCAHPS survey are questions regarding pain management. The scores are available to the public and allow patients to compare hospitals in a meaningful manner. 4 Patient satisfaction is an increasingly important outcome when considering perioperative analgesic regimens. Unmet Need in Pain Management Despite the increased focus on pain management and the availability of effective analgesics and new mechanisms for delivering pain medications in the immediate postoperative period over the past two decades, the incidence of postoperative pain remains high. In a 2012 survey, approximately 85 percent of patients reported postoperative pain; of those, 65 percent of patients reported moderate to extreme pain. 5 These data are similar to those from a survey conducted in 1995 (65% versus 63% of patients reported moderate to extreme postoperative pain, respectively). 1,5 Postoperative pain is associated with various complications and poor outcomes. Postoperative pain is also one of the most common reasons for hospital readmission following discharge. 6 Traditionally as well as currently in the United States, monotherapy with opioids is used as the mainstay to treat postoperative pain. In a 2012 study analyzing data from 1,665,418 hospital patients, 72 percent of inpatients treated with intravenous (IV) pain medication received IV narcotic monotherapy. 7 By their nature of being morbidly obese, bariatric patients are at a high risk for respiratory depression. Factors such as obstructive sleep apnea and postoperative atelectasis are common in patients with morbid obesity. 8,9 These patients also suffer frequently from postoperative nausea and vomiting (PONV) despite triple PONV prophylaxis. 10 These factors make postoperative pain management challenging in these patients. In 2012, The Joint Commission published a Sentinel Event Alert that underscored the need for judicious and safe use of opioids in hospitals. Included in The Joint Commission's recommendations were measures aimed a t reducing the overall use of opioids, such as implementing a multimodal approach to perioperative analgesia. 11 Multimodal Approach to Pain Management Acute postoperative pain is complex and multifactorial and may be optimally treated via a multimodal approach in the perioperative setting. With this approach, two or more analgesics acting by different mechanisms are administered when providing analgesia. 12 Using different classes of analgesics, each with different pathways and receptors, multimodal analgesia can optimize analgesic efficacy by using lower doses of each of the respective agents, with the aim to reduce the risk of dose-related adverse events (AEs). 13 Multimodal analgesia may be implemented via a stepwise approach with non-opioids serving as the foundational agents given perioperatively for the management of pain with adjunctive opioids added as needed for moderate to severe pain. 12,13 Over the past decade, multimodal analgesia has gained recognition as an effective strategy for the management of acute pain in the perioperative setting, and the concept is supported by numerous professional organizations. The American Society of Anesthesiologists (ASA), 12 the American Society for Pain Management Nursing (ASPMN), 1 4 the Agency for Healthcare Research and Quality (AHRQ), 15 and The Joint Commission 11 encourage a multimodal approach to perioperative analgesia. Current ASA Guidelines recommend that unless contraindicated, all surgical patients should receive an around-the-clock regimen of a non-opioid agent, such as acetaminophen, a nonsteroidal anti-inflammatory drug (NSAID), or a COX-2 selective NSAID (COXIB). OFIRMEV ® (acetaminophen) Injection Acetaminophen is a non-salicylate, non-NSAID, non- opioid analgesic and antipyretic agent. The precise mechanism(s) of the analgesic and antipyretic properties of acetaminophen is not established, but is thought to primarily involve central actions. 16 OFIRMEV is the first and only IV formulation of acetaminophen available in the United States. OFIRMEV is indicated for the management of mild to moderate pain, the management of moderate to severe pain with adjunctive opioid analgesics, and the reduction of fever. OFIRMEV is approved for use in patients two years of age and older. 16 EDITED-Cadence Ofirmez Suppl copy 2_Layout 1 4/14/14 10:13 AM Page A3