Postoperative pain management

[mikeGR]

Guys,
I was wondering if anyone could point towards specific literature on the differences between the commonly used IV narcotics (morphine, hydromorphone, fentanyl) and the clinical implications of those differences. Uptodate is rather poor in this regard and the surgery textbooks even worse. In my understanding, the main differences are the PK/PD and the histamine effects of morphine (vasodilation etc).

Do you know of any relevant clinical evidence? Where do you base your decisions on postop pain management?

Thanks in advance!
M

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[dpmd]

Honestly, I never really researched it that much. Fentanyl is short acting enough that I only use it for particularly painful dressing changes (or as a drip in the ICU) or other times where short is good. Morphine is my go to drug mostly because there seems to be less eupohoria with it than dilaudid and I like to reserve dilaudid for when morphine isn't working or there is an allergy or side effect that is an issue. I think I am biased by having to deal with drug seekers though.

I am a strong believer in multi modal approach to pain control and am generous with NSAIDs and muscle relaxants in addition to narcotics in an effort to reduce the amount of narcotics they need. I also like to make the switch to po over IV narcotics as soon as possible and do scheduled po narcotics frequently (one of the thing that often gets me a phone call from pharmacy is when I give norco q4 around the clock and let the patient keep their PCA for a day or so, but really it is the same as having a prn breakthrough morphine order without the pt having to wait for a nurse to give it).

 

[armybound]

On an unrelated note, I really like IV tylenol but feel like PO tylenol in Percocet/Norco is nothing more than a hindrance to my ability to medicate my patients. I feel like the PO tylenol adds very little to pain control, and I usually base my orders on the amount and strength of the opioid being delivered while trying to avoid my tylenol max.

Do you guys have an opinion on how useful PO tylenol is? I have absolutely no evidence to back up my feelings on tylenol and think I could learn a thing or two regarding how I give pain medication.

 

[dpmd]

On an unrelated note, I really like IV tylenol but feel like PO tylenol in Percocet/Norco is nothing more than a hindrance to my ability to medicate my patients. I feel like the PO tylenol adds very little to pain control, and I usually base my orders on the amount and strength of the opioid being delivered while trying to avoid my tylenol max.

Do you guys have an opinion on how useful PO tylenol is? I have absolutely no evidence to back up my feelings on tylenol and think I could learn a thing or two regarding how I give pain medication.

I think it adds a little something, but reaching the max is an issue with those with higher narcotic needs. I will usually still give tylenol when I do something like IR and SR morphine, but then again I am a big fan of using multiple agents. At the very least it gives the pt another pill to take, potentially at a different time, so the placebo effect may be helping.

 

[Dr.LeoSpaceman]

On an unrelated note, I really like IV tylenol but feel like PO tylenol in Percocet/Norco is nothing more than a hindrance to my ability to medicate my patients. I feel like the PO tylenol adds very little to pain control, and I usually base my orders on the amount and strength of the opioid being delivered while trying to avoid my tylenol max.

Do you guys have an opinion on how useful PO tylenol is? I have absolutely no evidence to back up my feelings on tylenol and think I could learn a thing or two regarding how I give pain medication.

I've always found PO tylenol to be worthless. IV acetaminophen does seem to work quite well, though. I'm a big fan of postop Toradol.

As for opiates, my anecdotal experience is that it's dealer's choice between morphine and dilaudid unless there's a specific reason for one or the other. I won't use a fentanyl PCA just because it's fairly uncommon on the surgical floors, which is a setup for someone incorrectly programming the PCA.

 

[mikeGR]

Honestly, I never really researched it that much. Fentanyl is short acting enough that I only use it for particularly painful dressing changes (or as a drip in the ICU) or other times where short is good. Morphine is my go to drug mostly because there seems to be less eupohoria with it than dilaudid and I like to reserve dilaudid for when morphine isn't working or there is an allergy or side effect that is an issue. I think I am biased by having to deal with drug seekers though.

I am a strong believer in multi modal approach to pain control and am generous with NSAIDs and muscle relaxants in addition to narcotics in an effort to reduce the amount of narcotics they need. I also like to make the switch to po over IV narcotics as soon as possible and do scheduled po narcotics frequently (one of the thing that often gets me a phone call from pharmacy is when I give norco q4 around the clock and let the patient keep their PCA for a day or so, but really it is the same as having a prn breakthrough morphine order without the pt having to wait for a nurse to give it).

My thoughts exactly. There have been several studies (including a Cochrane review) showing that addition of PO NSAID/tylenol decrease narcotic requirements, and I like to believe that the placebo effect of an additional 'pain medicine' works just as much as the med itself. I sometimes do ibuprofen + tylenol + narcotic (sometimes all scheduled) in harder to control cases. It also works when you think that the patient really is not in such extreme pain that you need to increase the narcotics, yet you have to do something for the 9/10 pain they have while texting/sleeping/eating etc. PR tylenol works in this regard as well

I also think toradol works wonders, however I have heard some horror stories for postop bleeding and AKI, and some of my attendings hate it.

 

[armybound]

we do a lot of scheduled tylenol and ibuprofen, but all IV.

toradol makes me nervous. seems like all of the urology residents are concerned about AKI in stone/renal colic patients. seems like it works well, though.

 

[anonperson]

Guys,
I was wondering if anyone could point towards specific literature on the differences between the commonly used IV narcotics (morphine, hydromorphone, fentanyl) and the clinical implications of those differences. Uptodate is rather poor in this regard and the surgery textbooks even worse. In my understanding, the main differences are the PK/PD and the histamine effects of morphine (vasodilation etc).

Do you know of any relevant clinical evidence? Where do you base your decisions on postop pain management?

Thanks in advance!
M

Premedicate with IV acetaminophen prior to surgery.

Post operatively:
For major cases: Dilaudid PCA with a loading dose and a 10 minute demand dose. With history of chronic narcotic use, will use a basal rate. Scheduled post operative acetaminophen, like others have stated, I feel that IV acetaminophen works well but try to transition to PO in a reasonable amount of time as well also. Scheduled toradol use (this is attending dependent, some ENT literature indicates increased bleeding when used I think pre op for tonsillectomy cases) usually 30mg Q6-8 hours, if very old will use 15mg scheduled.

Transition to oral medications around 12-24 hours post operatively. Usually scheduled acetaminophen, ibuprofen, and PRN oxycodone or just use percocet/ibuprofen.

I think a couple of factors play a role:
Patient perception and their understanding of pain and what to expect. Some patients are very unrealistic with their expectation or are chronic pain patients and nothing will help other than time.
Scheduled acetominphen/NSAID use is helpful as well with breakthrough narcotic use.

As far as using dilaudid vs morphine vs fentanyl. I avoid morphine just due to increased complaints of nausea/pruritus etc. Never really used fentanyl. Not that common among our department.

There is more research coming out on post operative pain/recovery. You can do a literature search on enhanced recovery pathways. One of the articles I remember reading recently was out of Mayo. But it includes a fairly detailed approach at pain management starting from before the actual surgery to post op to have better pain control, reduce narotic need etc.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3913481/?report=classic

 

[rigid]

Is there any evidence that IV tylenol > PO because my understanding is that there isn't any

 

[anonperson]

Is there any evidence that IV tylenol > PO because my understanding is that there isn't any

I don't think there is anything firm out there. Some of the company studies comment on decreased absorption in an NPO patient if given pre operatively but I think that is only for a few hours. Sometimes anesthesia will balk at giving a patient something po pre op (depends on the anesthesia personnel).

 

[rigid]

Oh yeah intra/pre-op then definitely IV but i mean for post op.

 

[Dwindlin]

Is there any evidence that IV tylenol > PO because my understanding is that there isn't any

There are some reasonable studies that show higher sustained plasma and CSF acetaminophen levels with the IV, there is one small randomized study I know of that showed a trend (didn't reach statistical significance, though it wasn't what they originally set out to show anyways) towards better pain control. Several efficacy trials listed on clinicaltrials.gov right now for IV acetaminophen so hopefully we'll have some better answers in the near future.