Anesthesia Acute Pain ServiceSyllabus

Introduction

The acute pain service is a consult service has been established to provide continuing analgesia for post-operative patients. The comfort and safety of the post-operative patients on service will be the first priority, with other consults taking second priority. Members of the acute pain service are asked to provide diagnostic or therapeutic blocks on perioperative patients and to consult on complicated pain management issues, on both acute and chronic pain patients. In addition, the acute pain service will also provide consultation and blocks for various hospital services.

Duties of a Resident

The acute pain resident will share responsibilities for

  1. Managing the acute pain service
  2. Placing peripheral nerve blocks and epidurals in preop. The priority for block placement is: perineural catheters\blocks > thoracic epidurals > lumbarepidurals
  3. Performing consults and (see Consult Coverage below)
  4. Evaluating post-block patients, starting epidural infusions, and managing problems in the PACU.

The resident should attend acute pain rounds, both in the morning and in the afternoon, as workload allows. In addition, they will evaluate any pain consults arising from the ward. All post-op and ward consults should be seen by an anesthesiologist or APS nurse prior to initiation of service. The resident will contact the acute pain attending as each patient is referred so that he is aware of all patients and can help in the direction of therapy. The acute pain resident will be responsible for making sure that all appropriate Epic orders have been initiated on each patient.

Each resident will be oriented on how to complete the necessary Epic notes/orders. In addition, the acute pain resident is responsible for updating the census at the end of each day and listing all patients on service. The APS resident will share responsibility with the APS nurse for ensuring that a note is present on each patient on the acute pain service daily, and that each patient has been discussed with the acute pain attending. If the acute pain service resident performs a procedure, s/he will be responsible for writing an appropriate procedure note.

Daily notes on AM rounds are normally written by the APS nurse for proper billing of services. On the weekends/holidays notes are written by the resident and co-signed by the attending. As appropriate, on PM rounds document the response to any changes made during or since AM rounds. If there was an intervention made in the middle of the day or during PM rounds, the attending should be notified. The following are normally documented in the pain service note:

  1. Current pain assessment (VAS resting, movement);
  2. Current dose of medication
  3. Side effects
  4. Complications
  5. Catheter site
  6. Block sensory level and LE motor function
  7. If a catheter is discontinued, whether or not the catheter tip was intact and the site condition (non-tender, no bleeding).
  8. Change in plans or interventions and their effect
  9. Communication with primary service as appropriate
  10. APS Role (e.g., ordering meds, only making recommendations, following, off service, etc.)

The acute pain resident will take acute pain service call during the month as required by the acute pain call schedule - generally 2 weekends with some weekday pain call. In addition, the acute pain resident is responsible for carrying the anesthesia pain pager M-F while in-house. It should be stressed that the acute pain resident is primarily responsible for all acute pain patients. Calls should be answered as soon as possible. For problems on current patients or new patients referred in the evening after the call resident has left the hospital, the call resident will locate an in-house resident to handle the problem. If he cannot, he will need to come in to see the patient or handle to problem. The best order to contact in-house residents in is 1) SICU resident (if anesthesia), 2) OB resident 3) C1/R1 resident 4)anesthesia attending on call (85920). Obviously, life will be smoother if a potential problem is "checked out" with an in house resident prior to leaving.

Acute and Chronic Pain Services Consult Coverage

  1. Acute Pain Service (APS) consults may be obtained by calling the APS pager (303) 266-6493
  1. Examples of APS consults include: neuraxial and peripheral blocks for post surgical pain; post surgical patients with potential complicating factors such as opioid tolerance (opioid exposure of 50 mg per day of oral morphine equivalent), intolerable side effects or poor response to current pain treatment, past/present substance abuse, liver or renal dysfunction; patients undergoing traumatic procedures such as burn wound care; assistance with opioid drug conversions
  2. The APS resident will provide initial recommendations over the phone as indicated and notify APS attending and nurse of any urgent issues
  3. If full assessment of pain problem is indicated, within 24 hours, the resident or APS nurse will perform an evaluation of patient and after discussion with the APSor covering attendingleave consult note in chart with assessment and recommendations with call to referring service.
  1. Chronic Pain Service (CPS) consults may be obtained by calling the CPS pager (303) 266-7291
  1. Examples of CPS consults include: requests for interventional treatments such as epidural steroid injection, celiac plexus block, lumbar sympathetic block, epidural or spinal infusion for chronic pain, intrathecal pump or nerve stimulator refill/adjustments; patients with an established chronic pain problem; exacerbations or inadequate management of chronic pain problems; chronic pain problem unrelated to surgical procedure
  2. The CPS resident/fellow will provide initial recommendations over the phone as indicated and notify CPS attending of any urgent issues
  3. If full assessment of pain problem is indicated, within 24 hours the CPS resident/fellow will perform an evaluation of patient and after discussion with the CPSattending leave consult note in chart with assessment and recommendations with call to referring service.

Pager Forwarding

The Acute Pain Service pager (303-266-6493) can be forwarded to any of the resident's pagers.

Call the pager IT help desk on campus at 303-724-0400 during business hours (M-F 0730-1630) or USAMobility 877-821-2445 24h/day.

You will need to call again to unforward the pager.

Phone Calls/Pages for Acute Pain Service at Night and Weekends

Problems Which Can Be Managed By Phone:

  • First time call for increasing pain (i.e., handled by bolusing and/or increasing dose/rate/meds)
  • Clarification of our orders or questions about monitoring, ambulation or orders from other services
  • Pruritus
  • Nausea and vomiting
  • Urinary retention

Patient Must Be Seen For Calls About:

  • Severe pain or subsequent calls for additional medication
  • Before unexpectedly stopping or discontinuing an epidural
  • Any situation in the acute pain service orders requiring our notification by the patient’s nurse
  • Over sedation
  • Increasing sedation with slowing of respiratory rate (< 10/min),
  • motor block
  • Sudden increase in density of motor block or sudden change in level of sensory block (suspect epidural hematoma or intrathecal migration of catheter)
  • Significant hypotension
  • Accidental catheter disconnects
  • Drug errors (pharmacy or nursing) giving patient an overdose relative to pain service orders
  • Major complications
  • Patient falls, drug reactions

The nurses are encouraged to call if they are concerned about their patient. If the nurse’s questions or concerns cannot be managed by phone, please see the patient along with the nurse.

These suggestions cannot cover all possible eventualities. Let your clinical judgment guide you.

You Will Never Be Faulted For Seeing A Patient Unnecessarily.

APS Nights and Weekends Coverage Resident and Faculty Coverage

  1. The APS resident, including any cross-cover resident, MUST consult with the on-call anesthesia attending regarding any episode of persistent block-induced hemodynamic instability not responsive to standard measures, persistent unexplained neurologic compromise (not temporary sensory loss/motor block from local anesthetic bolus), or continuing ineffective pain control after standard response measures (i.e., bolusing, rate adjustment, mixture adjustment).
  2. Any APS patient with the above problems must be seen, the incident documented in the chart, and the primary service notified.
  3. Any decision to abandon or replace a block must be discussed with the on-call anesthesia attending and the primary service notified.
  4. APS patients being managed with only oral or IV medications are included in the above.
  5. The APS attending should be contacted M-F 7a-4p and the C1 attending at all other times.

Acute Pain Service Routines (AKA, the ins & outs of APS)

Preop

  • APS Resident:evaluates patients for potential regional block, presents the patient with appropriate anesthetic choices, and obtains anesthetic/block consent
  • OR Resident/CRNA: should complete preanesthesia in Epic and start IV
  • If multiple potential blocks for first cases, prioritize peripheral block>thoracic epidural>lumbar epidural and notify OR anesthesia teams of need to place their own blocks.
  • Expedite timely placement of blocks to prevent OR delay. Begin block procedure by 0645-0700.
  • After block placed, notify nurse to bring family back. As appropriate, turn over care to OR anesthesia team or to preop RN forpatient monitoring until taken to OR.
  • OR Schedule: Each day at ~1330 the next day’s OR schedule is ready for review by APS; mark potential block candidates and return to preop nursing staff. If multiple blocks expected in AM, notify appropriate resident/CRNA that (s)he will need to do block. Note if there are any “APS” consults listed under comments section and discuss with attending/APS RN.
  • Preorder Total Joint Pain Protocol/Thoracic Protocol meds for the next day’s patients.
  • As workload allows, review patient records of next day’s blocks for medical and pain management history and contraindications; coagulopathies, abnormal clotting studies, PT, INR, infection, etc.

AM Rounds

  • Prior to rounds, use Epic to look up room numbers and gather data for rounding
  • Daily patient assessment includes: pain level at rest and with activity, response to PCEA/IVPCA/Nerve Block, meds, side effects (N/V, numbness, paresthesia, pruritus), dermatome, mobility and strength, LOC, block catheter site and dressing, and significant events.
  • AM Progress Note: APS RN writes notes or resident writes note that attending cosigns.
  • OR Pharmacist: Supports the APS by going on AM rounds. Will normally review med record for meds given for pain, side effects, and for anti-coagulation, and will interrogate PCA pump for amount used. Will assist in writing orders while APS RN/resident is writing progress note.
  • Orders: Notify floor/unit RN before leaving unit when there is an urgent need for changes to a pain infusion pump or you have removed a block catheter.

PM Rounds

  • Briefly document response to changes made on AM rounds.
  • Stable patients do not need to be seen, however do not leave lingering problems for cross cover.
  • Pre-write orders for next day where appropriate.

PACU

  • Nurses can connect and start peripheral nerve block catheters. Anesthesia provider or APS team must connect and start epidural catheters.
  • When APS is writing med orders/managing block infusion, review primary team admit/med recon orders to ensure pain meds are not double ordered. Reconcile all conflicts before patient leaves PACU.
  • If epidural is not working and is d/c’d, notify surgery and ensure that IVPCA (or appropriate meds) are ordered and sign off case, unless consulted for continued management (chronic pain, opioid tolerance, etc.)

Epidurals

  • Epidural Dosing Guide is for average patient of average health. Increase/decrease dosing based on morbidity, chronic pain, opioid tolerance, etc.
  • If adding IVPCA, convert PCEA to basal only infusion
  • CT surgery/Thoracic Cases: normally maintain epidural until last chest tube removed, except for pneumonectomy (no chest tube) – clear with surgery before removing.
  • Transplant Service: See Transplant Protocol.
  • Max duration of epidural is 5-6 days. Discuss with attending if going beyond this time limit.
  • Floor/unit nurses do not d/c catheters; only anesthesia or APS team.
  • Routine transition to off epidural to PO meds: Normally order short acting PO opioid +/- APAP scheduled x 24h, then prn. Initiate with one dose, then stop epidural 1 hour later. If elderly, consider Vicodin instead of Percocet. Add APAP/NSAID as appropriate. Order prn IVP opioid as appropriate for BTP.
  • Anticoagulation: Follow ASRA. Heparin SQ bid/tid OK, if ordered TID, hold one dose and pull cath at time of held dose (or at least 4h after last dose given). LMWH single daily prophylactic dose is acceptable. OK to maintain cath with low dose heparin infusion for DVT prophylaxis (PTT 35-45); pull cath in heparin window: hold gtt x 4h, recheck PTT, pull cath, restart gtt 1h post d/c. Pull cath before start of therapeutic heparin gtt.
  • Anytime a catheter is d/c’d or migrates out in a patient with altered coagulation, leave order for RN to perform Bilateral LE neuro checks for movement and sensation q2h x 24h and stat page primary team/APS for any new deficits or c/o back pain.

Nerve Blocks

  • Ortho Unit RNs can d/c nerve block catheters. Most other units will not be trained to pull cath.
  • If any question of NB complication (paresthesia, persistent sensory/motor deficit), follow patient in house, d/w ortho/APS attending, and, as appropriate, provide APS contact info before d/c home for follow-up.
  • Adjust standard TKA nerve block infusion orders as appropriate for other surgeries (i.e., increased dose of Ropivacaine at increased rate).

Ketamine

  • Continuous infusion allowed on stepdown/ICU areas only. See APS order set and hospital policy
  • Discuss with attending/APS RN before initiating.

Consults

  • Get name and pager of person requesting, including attending. Discuss with APS Attending/APS RN.
  • Be clear in note and communication back to primary team if APS is writing orders and managing or is providing recs only and following/not following.
  • It is acceptable to “curb-side” and provide recs over phone/in person.
  • All consults should be seen within 24h. If unable to see the day of consult request or consult is not urgent, provide verbal recs and see the next day.

Chronic Pain/Opioid Tolerant

  • Discuss chronic pain patients with APS Attending/APS RN. Make OR anesthesia team aware as appropriate.
  • Anticipate need for ketamine intra and post-op
  • Do not initiate long acting opioids or methadone before ensuring outside provider willing to prescribe.

Resources: APS Attending for current clinical, political and interdisciplinary issues and concerns. Robert Montgomery, CNS and Lynn Hornick, RNC, NP for daily assistance in APS workload and decision-making. Dr. Matthew Fiegel, APS Medical Director for overall management and policy making. Chronic pain pager 266-7291 for assistance in chronic pain management and to provide AIP chronic pain consults.

Acute Pain Service Guidelines – Periop Epidural/Intrathecal Analgesia Dosing

I. Thoracic Epidural - Appropriate for all surgeries except lower extremity. See Table VII.

  1. Bupivacaine 0.1%. Opioid: 1st Choice Hydromorphone, 2nd choice fentanyl, 3rd morphine.
  2. Basal rate: Lower/mid abdominal surgery: T7-12 cath: 8 ml/hr. Upper abdominal and flank surgery:

T6-8 cath: 6 ml/hr. Thoracic surgery, T4-8 cath: 4-6 ml/hr.

II. Lumbar Epidural

  1. Bilateral Knee Replacement or occasional hip surgery: 0.0625%-0.1%. Opioid: 1st choice hydromorphone.

Basal rate: 8 ml/hr. Consider decreasing bupivacaine POD#1 AM to facilitate ambulation (0.05-0.08%)

  1. Pelvic and Abdominal Surgery
  1. Bupivacaine 0.1% w/ morphine or hydromorphone.
  2. Basal rate: Lower abdominal and pelvic surgery 8 ml/hr. Mid/upper abd surgery: 10 ml/hr.
  3. For occasional Gyn/Onc epidural, consider bupivacaine 0.08%to facilitate ambulation
III. PCEA – Run all epidural infusions as Patient Controlled Epidural Analgesia (except for Dr. Pearlman)
  1. Incremental bolus: 3-4 ml. Elderly/debilitated 2 ml. Range 1-5 ml

B. Lock Out: 15 min. Elderly/debilitated 20 min. Range 10-30 minutes.

IV. Surgeon/Service Protocols

A. Transplant Liver Resection: Bupivacaine 0.125-0.15% + Hydro 1-3 g/ml; Load Hydro 0.1-0.3 mg. D/C catheter within 72h. See separate Liver Resection Protocol.

B. GYN-ONC or GYN: Usually IT morphine only. If epidural placed and is low thoracic or lumbar, ensure patient is ambulatory POD#1 AM. Start with bupiv. 0.0625-0.08%, or decrease in AM.

C. Dr. Pearlman: All patients get IVPCA and basal only epidural infusion. Always discuss with APS attending

D. Dr. McCarter: do not give FFP/PLTS in liver resection without checking with APS attending

E. Urology: Wilson prefers epidurals for Cystectomies and Radical Nephrectomies. No epidurals for prostates

F. Thoracic: Dr. Meguid desires epidurals for his VATS lobectomies

G. Ortho: No sciatic nerve blocks for TKA with Drs. D’Ambrosia Sr, Lindeque, or Hogan. See Lindeque guide

V. OR Opioid Loading and Postop Infusion Doses - Load epidural in OR with opioid.

VI. OR Bupivacaine Loading Doses – Load epidural in OR with bupivacaine 0.25%, or 0.125% if low BP

VII.Epidural Catheter Location – Place catheter as indicated below. If unable to stay within range, effective epidural analgesia is more likely with a catheter placed higher, rather than lower.

Surgery LevelProcedure
General T6-7gastrectomy, esophagectomy, choly, Whipple, hepatic resection Thoracic T4-8 thoracotomy, lung reduction, lung transplant, thymectomy Colorectal T9-10 colectomy, bowel resection, lap choly, A-P resection T10-12 low anterior resection Urologic T7-8 nephrectomy, adrenalectomy T8-10 cystectomy T10-12 rad. abd. prostatectomy

GynecologicT8-10rad. abd. hysterectomy, TAH and nodes, ovarian cancer debulking