Event 2: Mrs. Smith's Surgery

Surgical Team Unit Meeting

The surgical team discusses Mrs. Smith's refusal of an epidural for surgery.

After watching the video, you may wonder about the depth of knowledge needed about medications. Jenny addresses this subject:

Test Your Knowledge

How else could Jenny have described Carol so that she was more respectful?

Incorrect. Interprofessional patient focused collaboration is a team effort, reaching out to team members is equal in importance to seeking guidance.

Incorrect. Professional hierarchies can result in dysfunctional communication among team members, it is important to be conscious of this and capitalize on opportunities to improve communication when possible.

Incorrect. Patient centered care is dependent on interprofessional collaboration. Interprofessional collaboration is achieved through team training and evaluating/redesigning current systems.

Correct. Interprofessional collaboration that is patient-focused should be outcome driven and relationship focused. In this case the preferred outcome is appropriate and adequate pain management for Mrs. Smith, keeping focused on the outcome is important. Assigning blame to Carol during a team meeting is counterproductive to relationship building.

Strategies to Reduce Medication Errors

Strategies to implement
- Education programs
- Written information on medications available on all patient care units
- Detailed policies and procedures for prescribing
- Standardized concentration for all opioids
- Independent double-checks on initiation of therapy and with all setting changes

Reference

Moss J. Joint Commission Journal on Quality and Patient Safety. 2010;36(8):359-364

Surgical Unit Team Meeting: Erin

Erin will be the patient’s clinical nurse. She is prepared to report on Mrs. Smith’s comprehensive monitoring plan of care based on evidence-based practice guidelines.

Pain During Hospitalization Predicts Long-Term Pain at 6 Months

Line chart shows the incidence of pain at six months post op based on pain during hospitalization. — Pain during hospitalization predicts long-term pain at 6 months

Reference

Ochroch EA, et al. Anesthesiology. 2002;97:1234-1244.

Multimodal Pain Therapy

Multimodal pain therapy decreases the chances of chronic pain.

Regional analgesic techniques can impact the pain experience for weeks to months following major surgery.

Thoracotomy
Prostatectomy

Health care provider administers a regional analgesic technique. — Multimodal pain therapy

Pre-operative administration of gabapentin or pregabalin to help limit the development of central sensitization and:

Lower postoperative pain intensity
Lower the chances of developing chronic pain

Note: Gabapentin and pregabalin are not FDA approved for this purpose but are supported by strong clinical trial evidence. See Clarke, H et al. Anesthesia & Analgesia. 2012;115(2):428-442.

Postoperative Pain Predicts Chronic Post-Thoracotomy Pain (CPTP)

Reference

Pluijms WA, et al. Acta Anaesthesiologica Scandinavica. 2006;50:804-808.

Pain Therapy is the Responsibility of All Team Members

Health care team provides care to patient on a gurney. — Pain therapy is the responsibility of all team members.

Pre-operative screening and planning
Pre-operative medication administration
Pre-operative pain procedures
Postoperative multimodal medication therapy
Ongoing patient and family education
Ongoing patient assessment

Pain Management Strategies

Spinal opioids ± local anesthetics
- Epidural opioid and/or local anesthetics [Patient Controlled Epidural Analgesia (PCEA)]
- Intrathecal opioid administration
Regional anesthetic techniques
Systemic opioids
- Intravenous Patient- Controlled Analgesia (IV PCA or PCA)
Non-opioid analgesics
- Acetaminophen and NSAIDs
Adjuvant agents
- Gabapentin and pregabalin

Patient Controlled Epidural Anesthesia (PCEA): Basic Principles

The catheter (of course) has to actually be where we want it for the technique to work
- Thoracic T6 – T9
- Upper Abdomen T7 – T10
- Lower Abdomen T9 – L1
- Hip / Knee L1 – L4
Pain relief is better when both local anesthetics and opioids are used
- think before you use a local anesthetic alone
Patients receiving PCEA do not always require an indwelling urinary catheter

Does Patient Controlled Epidural Anesthesia (PCEA) Improve Outcomes?

Three healthcare providers can been seen setting up patient controlled epidural analgesia. — Patient controlled epidural analgesia

Compared to systemic opioids, PCEA appears to lower risk of perioperative complications, thus possibly improving surgical outcomes
PCEA may also have an impact on long-term survival following cancer surgery

Reference

Gottschalk A, et al. European Critical Care & Emergency Medicine. 2011;3:16-24.

Long-Term Survival and Epidural Analgesia

Healthcare provider provides epidural analgesia to a patient — Epidural analgesia

Recent epidemiologic study evaluating survival in patients over age 66 who underwent colectomy for non-metastatic colorectal cancer
- 42,151 patients included in review
There was a significant association between epidural use and improved survival (adjusted Cox model hazard ratio = 0.91, 95% CI 0.87-0.94)

Reference

Cummings KC, et al. Anesthesiology 2012;116:797-806.

Patient Controlled Epidural Analgesia: Medication-Related Adverse Events

The risk of harm is real
- opioids can lead to sedation and respiratory depression / arrest
- the most common opioid used is fentanyl and it is important to know the concentration per ml, and dose per hour
- local Anesthetics can lead to hypotension and neurological dysfunction
Don’t forget about the risk of epidural failure

Reference

American Society of Anesthesiologists Task Force on Neuraxial Opioids. Anesthesiology 2009;110:1–13.

Pain Following Major Thoracotomy (with PCEA)

Bar chart showing pain following a major thoracotomy (with PCEA) over the first five days following surgery. — Pain following major thoracotomy (with PCEA)

Reference

Ochroch EA, et al. Anesthesiology. 2002;97:1234-1244.

Next: Post-Operative