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Ziconotide provided effective relief of intractable facial pain
S84
Abstracts
The Journal of Pain
(432) Impact of IV acetaminophen in a post-operative orthopedic population: a retrospective review
(434) Managing post-operative pain in the obese patient: treatment and monitoring challenges
J Pawasauskas, P Houlihan, and M Kelley; Kent Hospital, Warwick, RI
M Fennessy-Cooney and D Sullivan; Westchester Medical Center, Valhalla, NY
Intravenous acetaminophen is becoming more commonly utilized as an approach for peri-operative pain management. Some studies have demonstrated decreases in post-anesthesia care unit (PACU) length of stay (LOS), however none have found this outcome in an orthopedic surgical population. The objective of this study was to determine the impact of IV acetaminophen on time to discharge readiness from PACU and the financial impact of any significant findings. Primary outcomes evaluated included time to PACU discharge readiness, use of opioid analgesics, and time to first oral medication. Secondary outcomes included total hospital LOS and treatments for opioid-related adverse drug events. Study protocol was approved by the institutional review board of the facility. This retrospective review evaluated adult patients who were admitted for orthopedic procedures between March and August of 2012 in a 359-bed community hospital. Of the 442 surgical cases during the specified dates, 109 were included in this analysis. Fifty-five patients received intravenous acetaminophen and 54 served as controls. Patients who received intravenous acetaminophen demonstrated readiness for PACU discharge significantly sooner than controls, 111.7 vs. 149.4 minutes, respectively (p=0.0007). Based on the institution’s cost per PACU admission, this corresponds with potential annual cost savings of approximately $377K if the medication were used in all orthopedic cases. Time to discharge, as defined by time from PACU admission to hospital discharge, was not significantly different between groups (p=0.22). Time to first oral medication was earlier in patients who received intravenous acetaminophen, although this finding did not reach statistical significance (p=0.31). There were no significant differences between groups with regard to treatment of constipation or pruritis, (p=0.25 and p=0.24, respectively), although anti-emetics were used more frequently in patients who received acetaminophen (p=0.059).
It has been estimated that 65% of Americans are overweight or obese, and the most rapidly growing segment of this population are the severely obese or super-obese. As the health risks associated with obesity have gained wider recognition, there has been a corresponding increase in the number of patients undergoing bariatric surgery. Additionally, complications associated with obesity contribute to the development of conditions often associated with the need for other surgical interventions. Nurses are encountering an increasing number of obese patients in the perioperative setting who pose multiple challenges for safe and effective pain management. The need for effective pain management in these patients is critical for the prevention of postoperative complications such as atelectasis and deep venous thrombosis. However, obesity poses increased risk for adverse outcomes associated with the use of common postoperative analgesics such as opioids. The need for a balance between analgesia and adverse effects is essential for all patients, but among severely obese postoperative patients, the margin for error is significantly smaller. There are numerous respiratory co-morbidities associated with obesity, including sleep-disordered breathing, which may complicate postoperative management of these patients. An understanding of the unique opioid pharmacokinetics and pharmacodynamics in this patient population is necessary to provide safe and effective analgesia. In striving to provide effective analgesia while preventing opioid related complications, a variety of monitoring techniques may be employed to assist in the recognition of hypoventilation. Most importantly, it is essential for nurses to utilize assessment skills which enable them to promptly recognize signs of opioid related complications such as hypoventilation. The use of multimodal analgesic approach is recommended to optimize comfort and reduce the risks associated with opioid administration. This presentation will include a case presentation to illustrate the key points in the management of acute postoperative pain in this challenging patient population.
F19 Perioperative Pain - Other
F21 Spinal Analgesia
(433) Treatment of postoperative pain in shoulder surgery with SABER-Bupivacaine
(435) Ziconotide provided effective relief of intractable facial pain
D Ellis, N Verity, D Cupertino, CA
Wendicke-Lophaven; Durect Corp.,
D Souzdalnitski, L Wells, E Gaitour, D Bracho, A Beshai, and N Lokesh; Cleveland Clinic, Cleveland, OH
SABER-Bupivacaine (SB) is a long-acting depot formulation designed to deliver bupivacaine to surgical wounds over a 72 hour period to effectively control postoperative pain. SB is administered directly into the surgical wound in a 5 mL volume containing 660 mg of bupivacaine. SB was evaluated in a multicenter, double-blind, placebo and active controlled trial of 107 patients undergoing laparoscopic subacromial decompression surgery under general anesthesia. Efficacy co-primary endpoints were 1.) Pain intensity (PI) on shoulder movement assessed with a NRS at scheduled time points over 1-72 hours post-surgery expressed as time normalized AUC and 2.) Total rescue opioid use over 0-72 hours expressed as IV morphine equivalents. Patients were randomized in a 2:1:1 ratio to 5 mL SB (53 pts.), to bupivacaine-HCl, 20 mL of 0.25% (BUP) (29 pts.), or to SABER-Placebo, 5 mL (SP) (25 pts.). In addition to prn opioid rescue, all patients were given acetaminophen as preemptive analgesia (2-4 gm/ day depending on body weight). The mean (SD) PI AUC1-72 was 5.16 (1.94) for SB, 5.16 (2.38) for BUP, and 6.43 (1.77) for SP (ANOVA p=0.012 SB vs. SP). SB significantly reduced PI AUC on post-operative days 1 and 2 compared to SP. In a repeated measures analysis, SB was statistically superior to BUP over the first 12 hours (p=0.01) and trended significant at 24 hours (p=0.07). Median morphine equivalents taken over 0-72 hours were 4.0 mg for SB, 8.0 mg for BUP, and 12.0 mg for SP (Wilcoxon p=0.013 SB vs. SP). All patients completed the trial normally and incidence of AEs was similar between treatment groups. The most frequent AEs were headache, nausea and musculoskeletal pain. Study supported by Nycomed and abstract by Durect.
Intractable neuropathic pain is a common and difficult to treat condition. A 71year-old woman, a retired nurse, reported sustained pain relief with intermittent intrathecal injections of Ziconotide for treatment of intractable face pain. She has history of multiple facial fractures involving her right orbit, bilateral maxillary bones, and nose followed by a surgical reduction and hardware fixation 7 years prior to this encounter. The patient experienced the onset of sharp bifacial pain and burning pain, across her lips and midface, within two weeks after this trauma. The hardware was removed 6 years prior to treatment. Numerous healthcare providers, several medications, and many interventional procedures (right maxillary, trigeminal ganglion and sphenopalatine blocks) were experienced without any effect. Additionally, scar tissue removal from her jaw bone was performed 4 and 5 years before the encounter with no relief. Gamma knife treatment of her Gasserian ganglion 3 years prior to this encounter yielded no relief. The patient has undergone a trail of intrathecal Ziconotide which has completely resolved her left facial pain in the maxillary region and transiently improved her right sided facial pain. Seven intrathecal injections of Ziconotide 8-10 mcg, were administered over 10 months yielding a decrease in her right facial pain down to a minimum; each lasting 2-3 weeks. The left sided pain did not return after the first injection. She reported dizziness that lasted up to 2 days after some of the respective injections, but no nausea, no change of mental status, or any other side effects. Since the patient is out of state, she preferred to undergo intrathecal pump implantation, which has been recently approved. The mechanism of sustained effect of intermittent injections of Ziconotide is unexplained and will need to be explored further as it may open new perspectives in treatment of intractable facial pain.
Lissin, and K
Abstracts
The Journal of Pain
(432) Impact of IV acetaminophen in a post-operative orthopedic population: a retrospective review
(434) Managing post-operative pain in the obese patient: treatment and monitoring challenges
J Pawasauskas, P Houlihan, and M Kelley; Kent Hospital, Warwick, RI
M Fennessy-Cooney and D Sullivan; Westchester Medical Center, Valhalla, NY
Intravenous acetaminophen is becoming more commonly utilized as an approach for peri-operative pain management. Some studies have demonstrated decreases in post-anesthesia care unit (PACU) length of stay (LOS), however none have found this outcome in an orthopedic surgical population. The objective of this study was to determine the impact of IV acetaminophen on time to discharge readiness from PACU and the financial impact of any significant findings. Primary outcomes evaluated included time to PACU discharge readiness, use of opioid analgesics, and time to first oral medication. Secondary outcomes included total hospital LOS and treatments for opioid-related adverse drug events. Study protocol was approved by the institutional review board of the facility. This retrospective review evaluated adult patients who were admitted for orthopedic procedures between March and August of 2012 in a 359-bed community hospital. Of the 442 surgical cases during the specified dates, 109 were included in this analysis. Fifty-five patients received intravenous acetaminophen and 54 served as controls. Patients who received intravenous acetaminophen demonstrated readiness for PACU discharge significantly sooner than controls, 111.7 vs. 149.4 minutes, respectively (p=0.0007). Based on the institution’s cost per PACU admission, this corresponds with potential annual cost savings of approximately $377K if the medication were used in all orthopedic cases. Time to discharge, as defined by time from PACU admission to hospital discharge, was not significantly different between groups (p=0.22). Time to first oral medication was earlier in patients who received intravenous acetaminophen, although this finding did not reach statistical significance (p=0.31). There were no significant differences between groups with regard to treatment of constipation or pruritis, (p=0.25 and p=0.24, respectively), although anti-emetics were used more frequently in patients who received acetaminophen (p=0.059).
It has been estimated that 65% of Americans are overweight or obese, and the most rapidly growing segment of this population are the severely obese or super-obese. As the health risks associated with obesity have gained wider recognition, there has been a corresponding increase in the number of patients undergoing bariatric surgery. Additionally, complications associated with obesity contribute to the development of conditions often associated with the need for other surgical interventions. Nurses are encountering an increasing number of obese patients in the perioperative setting who pose multiple challenges for safe and effective pain management. The need for effective pain management in these patients is critical for the prevention of postoperative complications such as atelectasis and deep venous thrombosis. However, obesity poses increased risk for adverse outcomes associated with the use of common postoperative analgesics such as opioids. The need for a balance between analgesia and adverse effects is essential for all patients, but among severely obese postoperative patients, the margin for error is significantly smaller. There are numerous respiratory co-morbidities associated with obesity, including sleep-disordered breathing, which may complicate postoperative management of these patients. An understanding of the unique opioid pharmacokinetics and pharmacodynamics in this patient population is necessary to provide safe and effective analgesia. In striving to provide effective analgesia while preventing opioid related complications, a variety of monitoring techniques may be employed to assist in the recognition of hypoventilation. Most importantly, it is essential for nurses to utilize assessment skills which enable them to promptly recognize signs of opioid related complications such as hypoventilation. The use of multimodal analgesic approach is recommended to optimize comfort and reduce the risks associated with opioid administration. This presentation will include a case presentation to illustrate the key points in the management of acute postoperative pain in this challenging patient population.
F19 Perioperative Pain - Other
F21 Spinal Analgesia
(433) Treatment of postoperative pain in shoulder surgery with SABER-Bupivacaine
(435) Ziconotide provided effective relief of intractable facial pain
D Ellis, N Verity, D Cupertino, CA
Wendicke-Lophaven; Durect Corp.,
D Souzdalnitski, L Wells, E Gaitour, D Bracho, A Beshai, and N Lokesh; Cleveland Clinic, Cleveland, OH
SABER-Bupivacaine (SB) is a long-acting depot formulation designed to deliver bupivacaine to surgical wounds over a 72 hour period to effectively control postoperative pain. SB is administered directly into the surgical wound in a 5 mL volume containing 660 mg of bupivacaine. SB was evaluated in a multicenter, double-blind, placebo and active controlled trial of 107 patients undergoing laparoscopic subacromial decompression surgery under general anesthesia. Efficacy co-primary endpoints were 1.) Pain intensity (PI) on shoulder movement assessed with a NRS at scheduled time points over 1-72 hours post-surgery expressed as time normalized AUC and 2.) Total rescue opioid use over 0-72 hours expressed as IV morphine equivalents. Patients were randomized in a 2:1:1 ratio to 5 mL SB (53 pts.), to bupivacaine-HCl, 20 mL of 0.25% (BUP) (29 pts.), or to SABER-Placebo, 5 mL (SP) (25 pts.). In addition to prn opioid rescue, all patients were given acetaminophen as preemptive analgesia (2-4 gm/ day depending on body weight). The mean (SD) PI AUC1-72 was 5.16 (1.94) for SB, 5.16 (2.38) for BUP, and 6.43 (1.77) for SP (ANOVA p=0.012 SB vs. SP). SB significantly reduced PI AUC on post-operative days 1 and 2 compared to SP. In a repeated measures analysis, SB was statistically superior to BUP over the first 12 hours (p=0.01) and trended significant at 24 hours (p=0.07). Median morphine equivalents taken over 0-72 hours were 4.0 mg for SB, 8.0 mg for BUP, and 12.0 mg for SP (Wilcoxon p=0.013 SB vs. SP). All patients completed the trial normally and incidence of AEs was similar between treatment groups. The most frequent AEs were headache, nausea and musculoskeletal pain. Study supported by Nycomed and abstract by Durect.
Intractable neuropathic pain is a common and difficult to treat condition. A 71year-old woman, a retired nurse, reported sustained pain relief with intermittent intrathecal injections of Ziconotide for treatment of intractable face pain. She has history of multiple facial fractures involving her right orbit, bilateral maxillary bones, and nose followed by a surgical reduction and hardware fixation 7 years prior to this encounter. The patient experienced the onset of sharp bifacial pain and burning pain, across her lips and midface, within two weeks after this trauma. The hardware was removed 6 years prior to treatment. Numerous healthcare providers, several medications, and many interventional procedures (right maxillary, trigeminal ganglion and sphenopalatine blocks) were experienced without any effect. Additionally, scar tissue removal from her jaw bone was performed 4 and 5 years before the encounter with no relief. Gamma knife treatment of her Gasserian ganglion 3 years prior to this encounter yielded no relief. The patient has undergone a trail of intrathecal Ziconotide which has completely resolved her left facial pain in the maxillary region and transiently improved her right sided facial pain. Seven intrathecal injections of Ziconotide 8-10 mcg, were administered over 10 months yielding a decrease in her right facial pain down to a minimum; each lasting 2-3 weeks. The left sided pain did not return after the first injection. She reported dizziness that lasted up to 2 days after some of the respective injections, but no nausea, no change of mental status, or any other side effects. Since the patient is out of state, she preferred to undergo intrathecal pump implantation, which has been recently approved. The mechanism of sustained effect of intermittent injections of Ziconotide is unexplained and will need to be explored further as it may open new perspectives in treatment of intractable facial pain.
Lissin, and K