Table Of Content?
Jan Paul Mulier
Departement of Anesthesiology
AZ Sint – Jan AV Brugge
Belgium
Pro: Opioid free general anaesthesia
Square 19 nov 2016 Brussel
Mulier Brussels 2016 1
Poten:al conflicts of interest.
• I have been giving lectures or received research support from
following companies in the last two years:
– Abbvie
– General Electric
– Johnson & Johnson, Ethicon
– Medec
– Merck (MSD)
– Orion (on use of dex only for seda:on in intensive care)
• This lecture on opioid free anesthesia is not supported by any
company.
Jan P Mulier AZ Sint Jan Brugge
Mulier Brussels 2016 2
Pro Opioid for free general
anesthesia?
1. Are opioids a problem?
2. Is opioid free general anesthesia possible?
– Stable anesthesia and painfree recovery for many surgical procedures.
3. Difference in major clinical problems intra- and post-opera:ve?
– Number of events requiring therapy?
4. Outcome difference?
– Theore:cal considera:ons based on drug side effects
– Hard outcome data on clinical important issues
• Mortality, permanent organ dysfunc:on hard to proof except for high risk
• PONV, shivering, sleeping, pain, return to daily live: do you care on ERAS?
• Efficiency, :me and turnover :ll return to work should never stay on first place
– The longer it takes to prove, the more likely the difference is small.
5. Difficulty and complexity
– Intra opera:ve versus post opera:ve
– Training required, next genera:on?
6. Price of the products and total price of treatment :ll return to work
1. Drugs are more expensive intra opera:ve and post opera:ve (mul:modal analgesia drugs
are 10x the price of an opioid).
2. Recovery is faster with less nursing care crea:ng the possibility to return earlier to the
ward, to home and to daily live.
Mulier Brussels 2016 3
TheJournalofPain,Vol7,No4(April),2006:pp225-235
Availableonlineatwww.sciencedirect.com
ORIGINALREPORT/Olsenetal 229
Are opioids a problem?
alsoreceivedeitheratraditionalNSAIDoraCOX-2inhib-
itor.
Opioid Prescriptions by U.S. Primary Care Physicians From 1992 to
2001
Factors Related to Visits With Opioid
Prescriptions
YngvildOlsen,*GailL.Daumit,*,†,‡,§andDanielE.Ford*,†,‡,§
*DivisionofGeneralInternalMedicine,DepartmentofMedicine,JohnsHopkinsUniversitySchoolofMedicine. Inmultivariateanalysesadjustingforclinicallyrelevant
†WelchCenterforPrevention,Epidemiology,andClinicalResearch,JohnsHopkinsUniversitySchoolofMedicine, covariates and year, several independent predictors
BloombergSchoolofPublicHealth,Baltimore,Maryland.
‡DepartmentofHealthPolicyandManagementand§DepartmentofEpidemiology,JohnsHopkinsUniversity, emerged related to having a visit where an opioid was
BloombergSchoolofPublicHealth,Baltimore,Maryland.
prescribed(Table1).Whereasnodifferenceintheodds
of having a visit with an opioid was noted for African
A22b8stract:Littleisknownaboutprimarycarephysicians’(PCPs)presOcpriiboiidngProesfcoripptiiooindss.bWyUe.Sd.ePsrcimribareyCarePhysicians
trendsandfactorsassociatedwithopioidprescribingduringPCPvisitsoverthepastdecade.Usingthe Americans compared to nonhispanic European Ameri-
140
NationalAmbulatoryMedicalCareSurvey,wefoundanopioidprescribedin2,206(5%)PCPvisits Figure2.Spectrumofdiagnosesforwhichprimarycarephysi- cans,patientsofhispanicethnicityhad33%lowerodds
from1992to2001.Theprevalenceofvisitswhereanopioidwasprescribedincreasedfromalowof
4sM1Ne..P66t1.tCmedications per1,000primary carevisitsSa666ehPAb8--pdn11..s-iI88e6802ii.lD2c0000ci45rNaz.i3]]t1ei))(oyd9,O0dhw]0a()(Ra(O;o0n5dthd92Rdhvad.liap2ovs.tst6e7iwhitrn8rposae[g1as9t[ir0ein9i5aono05%1l0dv%[im9Ovidis9inCaRsni2CtnI]2go-Iab1202f.gei9.0.5n00ret902e94wm3--ct-2.[he2e9et90i.eeo0nv505n]ti%13a)nn,)]1sog.)ptp5.cSraeotaaePnaahnntvandkiefieetdaoaiondrerspa3ftedntils5nos6tf(scia3iOmadnecorR.ptieinhfoSen.uerurat6hseatbd01ierilssv0ntvspt[ho0ca9aa(r0clO5nnmea(%tiiaRtCnciaesaIi1)edl1n(CO.d1,9vt1Ie.9uaR6t8.nh8rn52[ia-.e1da-961n2-te5o79..ic6r%4od9es9[0n9dt9]]aoCs)5)(enrPI%oooxgd1fir<rais.rn0MntCmesg.5iI0cze-iie0d1a.tnd5ih0.twvi26icoe1io7-aenp.nf]dr8sgi)oesto1y;ra]nia(((d)nOtOOanromRopdeRRrnpri2rec..dieo77.oss0)c54tci0eohdraii[[fe:n[bv999hrdoii555nnap%r%%tggvaihoicnebaOCNeiCCCdnngyoS/pIIIxiAo2Ii Ddinsshhibitors • v1acii9vasCawT9nithi7sslhraphotbareoneinlesci dccPm,rhCipmb2P roe0asoo0orbswn0eplt,eih o pmoewciadrspoehst;iaeeiNmocnonpc#toiismiodnu2iofn,d 2oontws0re6mnwod.apa efdsitrooie oriipdanplsarrgreoregnesnecsprooccpibhrsrretoreieodpbdn.soeiB rtcitheidnitoatyw tn wsetheoanesf opCAv.b5ifaoems2ritmh-tewe.a9pdrwevi0aceiht]ran)noee.ngdrsnF1eao5oatorannvandhipwnsiiaAdsothptpsiiwat3eiiaeno5nhnsiite,cdsmsr,oewiwhwtnhhaahuaedinosttrees3pomses2,rp%(eiptinOoshrocRiielrdmroiib.wtoa6wieder7edaysdr,s[sc9o(ipOan5dorrc%Rdfeelussr.cvde6Corici8Iifsnbei.htgie5[sv9ad6iN5vnl-ai.%acgn8sott1gimaev]Cnd)ae-I.
prpain escribingisnecessary. Acetaminophen maijnorcrleuadsoendfo rbtahecirkv ipsitawinas, aacchurotneic problemcom- opioidduringthatvisitwere16%higherthanforthose
PpwadthieNumber ofvisits withhftyfirotessu24irrp00cdeeienaecenscceitsavsineva.sdnedt:khTniedhoseiewsnmsltetifieuddedgsiyecaidomteifopsocnorpsrit.iboaSeinedstvsae,grdaeaenolcdguarndpadepue-hblroillciycn-ii,gznregiadncfciaoraceplt/aeioostreihsd,ni-niirnceo-cl,lapuatideonididndgeipnvrrseeeungsrctuasrlni,abcmtieona-rgryyebalcaynotdnUetd.lrSeid.bgpiuafrltfieepmrrteaeonrsysctuehcsreaesrisnee, pnnwaooemhrtsreiepsedruopeawfrssedicbtcsrahciaubrcpikcebladoheptdia(see4,innk35 t%(3wesF%halvieassgovrt3fi en4a2tphg%lo)e ar.;ctt Pvei omid!sinetf.oi0dtnhr0iew1t:h)ph.eoaIifcvthniaiesaisnptntr,asi om’napmdaniroaoydiipnddi oriwaeidagass-- w1.h0P5oa-ts1iee.2nv7itss]i)t.rselsaidstiendglienssththeanno1rt5hmeainstu(tOesR(O.6R01[9.156%[9C5I%.5C1-I
©2006bytheAmericanPainSociety .69]) or midwest (OR .75 [95% CI .66-.85]) had signifi-
sonforthevisitwascodedasachronicproblem(datanot
Keyw0ords:Opioid,primarycare,pain,healthservices,prescribingpatterns. • Cancer diagnoses were noted for cantlyloweroddsofhavingavisitwhereanopioidwas
Year shown).
prescribedthanpatientsinthewest.Geographicregion
1992 -1993 1994 -1995 1996 -1997 1998 -1999 2000 -2001 only 2% of primary care visits in
Althoughpainmedicineasaspecialtyhasgrown Althoughpatientsroutinelypresenttotheirprimary Characteristics of Visits With and did not modify the effect of ethnicity on having a visit
Figure1.Prevalanceofvisitswithpainmedicationsper1,000primarycarevisitsfor1992-2001.P!.0001foroveralltrendofvisits
owviethrothpieoildass.tThdeecya-adxeis,iondnilcyataesfethwenthumoubsearnodfvpisaitisnwithcpaarinemdeodcitcoatriocnosmpeprla1,i0n0i0n0gporifmaprayinca,reprveissitcsr.ibingopioids Wwithhoicuht Oanpi ooipdisoid was prescribed. with an opioid (P " .2 for all geographic region and
specialistshavebeentrained,andtheirnumberis formanyofthesesymptomsoftenengendersdiscom-
race/ethnicityinteractionterms).
sufficienttotreatonlyasmallminorityofthemillionsof fort on the part of PCPs. Fear of addiction, lack of Patients seen during visits where an opioid was pre-
patientswAitllhannoalnycsaenscweerrpeapinercfoomrmpeladinutssin.9g1SMtaotraesotaftteisnt,icalsotrfat-iningc,omprpeasrsiusorenoffro1m998p-1h9a9r9mparceevuatliecnaclemtoar2k0e0t0in-2g0,01).An- PatientswithprivateHMOinsurancehadsignificantly
primarywcaaTrree,phVheyrsesiicoia nnp7s.(0PrC(SPetsa)tvaarCeoaurpslu,eCalolylnlethgeecfiSetrastti tooone,nTfX- ).vainsdictonaslcye zretndosaebp oaPurattCeploy,tPethnestipa rlewlveagleahnlceaenodfrCrOeeXg-u 2laaintohnribyi toorsipn-ioid was prescsricbredibdieddno tidnifcferreinatesrmesdo ffgreondmer, a4ge1, race,rural lower odds (OR .74 [95% CI .66-.84]), whereas patients
counterpatientswithacuteorchronicnoncancerpain. ramificactrieoanssedmsaigkneifitrceaanttilnygfrpoamti9envtissi’tsnpoenrca1n,0c0e0rppraiminarycare or urban residence, private insurance, or presence of a
Results with ovipsiitosidins19a98-1c9o9m9pwlehxendtheecimsioendicaftoiornfimrsatnayppeared withMedicaid(OR2.09[95%CI1.82-2.40])orMedicare
per 1,000 primary cPaCPrs.1e1,o3 1n,v3t9h,4ie0s,m70ai,9rt0kIesnt6r 0eistpono4n5 sve1istiot9sthp9eerd12if,0fi0c-0u1lptriei9msfaar9ycecd3are vtisiots a peak of 6c3om voirsbiidtdsi apgneorsis 1of,0an0xi0ety porrsiumbstaanrcye abusecom- (OR 2.00 [95% CI 1.68-2.39]) had significantly higher
RNeocveeimvebderAP3pr,ri2el02v025a,;2Al0ec0c5ne;pcFteierdstNoroefvviesVmiobniesOri3ctt,so2b0We0r5.7i,t2h005O;Specioondidresvision byPCPsinin2p0r0e0s-c2r0ib0i1ng(Po!pi.o0i0d0s1p).luTsherespeomritasnonfuianlapprpervoa-lenceof pared with patients seen during visits where an opioid
DASMcrdho.donOrouelslmsesoenfrnwePPtMpCarrFesPieconSdsstutirs,cpifarctnpeoheroqSr,eiururtbDiepetyseideaevtesibtsadiiyto8reo s0nan4vYN1to7snR9AfgS9i,aGAv2isgelc-dnBel2ieanid0Orlitac0tlilsam11elI8sonn,r-er,twe6es Je,r5oenaiharyincMnldhesMDeafHeenr oldsltop1i2.icwfik1iTni2sneeh8h9sd,7iep.U1.48no923iEvv0,-e2emrE85rsaaia8tislylt:lv-ips1irtespccvla9traioiln-alyit9cearleu9pvmtcshiroesarai.goticnosunt efigic(idzntehehPogdelwueusts ehiusdt=inhcmethdelhie entadari0enmticscreaeeht,2taaap5i0tmovemenripines0boe,on1edrp4tc0,oho711foem,0nft1aeh0n0epawd)vasatpait.sunrhil di,aem4dy(1bo.ah-l46crei2uys,ot6mo.3vc,ere37ain2r-rete%dvisri)ets- wbearssnooftvpisritesscforirbiendd(ivTiadbulael1o)p.iBoeidcas,uaseborefatkhdeoswmnalolfnsupme-- ocodmdspaorfehdatvoinpgataievnitssitinwphreivraeteanfeoep-fioori-dsewrvaiscepprelasncrsi.bPead-
y1©do5o2l2is:06e10-n056.@91b00jhy01lstm/6et$chh/i3jrn.e.ee2ijMcpbd.A0easuem0iendome.2rfwi0oica0apa5nnrs.1nidPm51au.2i0naa0irlpS6yofiepcricreea1teyvr,0ea0ldev0nisvci tiessritowsef.hOveilvrseeietrsatanthoeosP1pC0ieo-Pyisde awwrdhpaeesreerpittborhhaeldeneee-,inpvpawrseetrDWsiftcietrrahewibngiyicynnahegb oaosOrsosuepyfttsobioosahRprieeidrtloippesiedrsosWst.ara1mtnn6ee-dd1rda8ep,r2sodD2P,ti3z eur7e(ne,r4tas9iMinn,ac8dlr5giarbMpaVReptuiirdsocoDihnatacslhhiSizaeness) made up onlycn i3ofitc%foepa iosoibidfles t.bWhyieende extpaoemntidnaeenld tntvhaueriarmebgleibosnseuaclrhd oaisstfrrie bguitoinonwoasf tCiOenXt-s2sienehnibidtourrsi,ngwevriesitpsreinscrwibheidchhaNdSAhIiDghs,erinocdluddsinogf
havingavisitwhereanopioidwasprescribedcompared
opiooidpwaisopriesdcribsed pincrreaesesdfcrormiabloweodf4.1 per Themostcommondiagnosesreportedduringprimary visits in which an immediate release preparation was
1,000primarycarevisitsin1992-1993toapeakof63 carevisitsinwhichanopioidwasprescribe2d25included prescribed and found similar results to those noted in with visits in which these medications were not pre-
visitsper1,000primarycarevisitsin1998-1999,astatis- backpain,acutemusculoskeletalcoMndiutiolnise,ran Bdhreuads-sels 2016 4 scribed (OR 2.27 [95% CI 2.04-2.53]). In all years from
ticallysignificanttrend(P!.0001).Between1998-1999 ache(Fig2).Cancerdiagnoseswerenotedforonly2%of Table1forallopioids.
and2000-2001,theprevalenceofvisitswhereanopioid primarycarevisitsinwhichanopioidwasprescribed. Inunadjustedanalyses,patientsofhispanicethnicityas 1994to2001,theoddsofhavingavisitwhereanopioid
wasprescribedremainedstable(Fig1).Immediate-re- In64%(1414/2206)ofthevisitsinwhichanopioidwas was prescribed increased significantly compared with
leaseopioidsincontrolledreleaseorMRDSformsmade prescribed,physiciansalsoreportedapain-relateddiag- compared to caucasians (odds ratio [OR] 0.81 [95% CI
uponly3%ofthetotalnumberofopioidsprescribedin nosisastheprimarydiagnosisforthatvisit.Forthissub- .67-.97]),thosecoveredbyHMOsratherthanprivatein- 1992-1993.
visitsbetween1992and2001(datanotshown). setofvisits,therankingofprimarydiagnosesrelatedto In multivariate analyses for the years 1997-2001 only,
thosevisitswasthesameasshowninFigure2. surance (OR .72 [95% CI .64-.82]), and those from the
PrevalenceofVisitsforNonopioidPain Therateofprimarycarevisitsinwhichapain-related, northeast (OR .63 [95% CI .54-.72]) or midwest (OR .81 office characteristics, including type of office and own-
MFerodmic1a9t9i2onthsrough1997,thesemiannualprevalence ptwriemeanry19d9i2aganndos2is00w1afsorreapnoyrotfedthedi8ddniaogtnoinsctriceacasetegboe-- [95%CI.72-.92])regionsofthecountrycomparedwith ership, were not significantly associated with having a
ofvisitstoPCPsinwhichanNSAID,excludingCOX-2 riesincludedinthestudy(backpain,acutemusculoskel- thewesthadloweroddsofreceivinganopioidduringa visitinwhichanopioidwasprescribed(datanotshown).
i(nFihgib1i)t.oVriss,itwswasitphrnesocnri-bCeOdX-r2eminahiinbeitdorrsedlaetcivreealysecdonsisgtnanift- edtisaelasceosn,doittihoenrs,achuetaedadcihseea,seasr,thurnitsisp,ecoifithederpcahinro/unnic- primarycarevisit. Allthefactorsfoundtobesignificantlyassociatedwith
icantly,however,from122per1,000primarycarevisitsin known,cancer)(datanotshown).Thisalsoheldtrue Comorbid depression was infrequently documented odds of having a visit where an opioid was prescribed
1a9n9d6t-h1e9n97toto9160p7epre1r,010,000v0isviitssitisnin2010909-82-0109199(P(P"".0.040f2o)r, wpohretnedadnuarlyinsegstihneclPuCdPedvisaitnsy.pain-relateddiagnosesre- bothinvisitswithandwithoutopioidprescriptions,but remainedsignificantinsensitivityanalysesadjustingfor
patientswiththisdiagnosishadhigheroddsofreceiving pain-relatedprimarydiagnoses(datanotshown).There
an opioid (OR 1.28 [95% CI 1.04-1.59]) compared with werealsonodramaticchangesinthemagnitudeofthese
nondepressed individuals. Patients seen during visits estimates, with the exception of having an NSAID pre-
whereanopioidwasprescribedweremorelikelytohave scribed.Inthesemodels,theoddsofreceivinganopioid
Medicaid (OR 1.93 [95% CI 1.69-2.20]) or Medicare (OR during a visit in which an NSAID was also prescribed
1.92 [95% CI 1.62-2.27]), and longer visits of up to 35 dropped from 2.27 (95% CI 2.04-2.53) to 1.13 (95% CI
minutes(OR1.19[95%CI1.08-1.30]).Inaboutaquarter 1.00-1.27) compared with the odds of having a visit in
of the visits in which an opioid was prescribed patients whichonlyanNSAIDwasprescribed.
the opioid crisis is
drama:c in the
USA
More persons die
from opioids than
Why So Many White American Men Are Dying
from guns or car
WORLD (/WORLD)
BY MIKE MARIANI (/AUTHORS/MIKE-MARIANI)
accidents.
ON 12/23/15 AT 9:41 AM
• The live expectance of middle aged white man
Updated | Not too long after the Soviet flag was hauled down from the Kremlin, a startling number of
Russian men startded deyingc. Ylouinng aned mdiddl e-fageo mern betgahn toe dro wfin, gert srunt ov e:r andm suffeer in the last decade with
asphyxiation and heart attacks in shocking numbers. There were all manner of suspicious, gruesome
deaths, the details oof whnich lsuygges tetd ahlcoheol ab umse and esuicdide. Tihce lifae exlpe ctoancyp for iRuossiain mden wcas onsump:on being the
plummeting; between 1986 and 1996, it dropped
(https://en.wikipedia.org/wiki/Demographics_of_Russia#/media/File:Russian_male_and_female_life_expectancy.PNG)
primary cause.
from 65 to 57.
ADVERTISEMENT
Mulier Brussels 2016 5
Only a USA problem?
• Opioid prescrip:ons increased drama:cally
from the 1990’s to 2004 and have remained
high in subsequent years with nearly 220
million prescrip:ons wrihen in 2011,
compared to 76 million in 1991.
• Simultaneously, a drama:c increase in opioid
addic:on, overdose and death is occurring.
Mulier Brussels 2016 6
Why Opioid crisis in the USA?
1. Opioids are very cheap analgesics
2. Opioids are accepted as treatment for non oncologic chronic pain.
3. Pa:ents request zero pain post opera:ve and will sue the physician if not everything is done to
achieve this.
4. The perscribed dose of opioids postopera:ve at home is very high and never consumed but
also never destroyed.
5. Opioids are the strongest analgesics, but only for a short :me and at an con:nuous increasing
dose (=tolerance)
6. The moment opioids are added hyperalgesia sets in (besides tolerance) making non opioid
analgesics less effec:ve
7. Opioids are given in a very high dose to achieve stable stress free anaesthesia star:ng the
tolerance and hyperalgesia problem when the pa:ent wakes up and need analgesia.
Solu:ons to the crisis ?
1. All solu:ons are focused to the post opera:ve period: awareness, requests to reduce price of
mul:modal drugs, procedure adapted dose perscrip:on, non used drugs disposal
…
2. Stable stress free anaesthesia is also achieved by loco regional anaesthesia or opioid free
general anesthesia and reduces the post op requirements.
Mulier Brussels 2016 7
Canada and
BMJ2014;348:g1251doi:10.1136/bmj.g1251(Published11February2014) Page1of10
ResearcAh cute care hospitals in Ontario, Canada, between 1 April 2003
and 31 March 2010.
Europe
RESEARCH
39 140 opioid naïve pa:ents aged 66 years or older who
had major elec:ve surgery, including cardiac, intrathoracic,
• 40
intra-abdominal, and pelvic procedures.
behind?
Rates and risk factors for prolonged opioid use after
major surgery: population based cohort study
OPENACCESS
HanceClarkeassistantprofessor123,NeileshSonejilecturer24,DennisTKoassociateprofessor567,
LingsongYunanalyst4,DumindaNWijeysunderaassistantprofessor12578
1DepartmentofAnesthesiaandPainManagement,TorontoGeneralHospital,200ElizabethStreet,EatonNorth3EB317,Toronto,ON,Canada,
M5G2C4;2DepartmentofAnesthesia,UniversityofToronto,Canada;3DepartmentofAnesthesia,SunnybrookHealthSciencesCentre,Toronto,
Canada;4DepartmentofAnesthesiaandPainManagement,TorontoWesternHospital,Canada;5InstituteforClinicalEvaluativeSciences,Toronto,
Canada;6DivisionofCardiology,SchulichHeartCentre,SunnybrookHealthSciencesCentre,UniversityofToronto,Canada;7InstituteofHealth
PolicyManagementandEvaluation,UniversityofToronto,Canada;8LiKaShingKnowledgeInstituteofStMichael’sHospital,Toronto,Ontario,
Canada
Abstract withsignificantlylowerrisks(0.73,0.55to0.98and0.45,0.33to0.62,
Ob•je ctive4Tod9esc.r2ibe%rates aondrfis kofactporsifoorpriodlong endpaostoïpveraetive pare:speectivnely)t. s are discharged from hospital with an opioid prescrip:on,
useofopioidsinpatientswhohadnotpreviouslyusedopioidsand ConclusionsApproximately3%ofpreviouslyopioidnaïvepatients
un•de rgoing3ma.jo1re%lectiv ecsuorgenry.:nued to receivconetin ueodtpousieoopiiodidssfor mfooretrha nm90daoysrafeterm tajohrealectnive 90 days amer surgery.
DesignPopulationbasedretrospectivecohortstudy. surgery.Specificpatientandsurgicalcharacteristicswereassociated
withthedevelopmentofprolongedpostoperativeuseofopioids.Our
SettingAcutec•are hospCitalsoinmOntarpio,aCanradea, btetwoee nt1hApreil20 063 .1 % opioid perscrip:ons for chronic non cancer pain.
findingscanhelpbetterinformunderstandingaboutthelongtermrisks
and31March2010.
ofopioidtreatmentforacutepostoperativepainanddefinepatient
Pa•rti cipanPts3a91:40eopionidnta ïvrepeatilenatstageedd66y efaarsocrotldeorwrhos insubcgrlouupsdthaetwadrran tyinteorveuntionnsgtoperevren tparoggresesio,n tolporolowngeed r household income, comorbidi:es
hadmajorelectivesurgery,includingcardiac,intrathoracic, postoperativeopioiduse.
intra-abdominal,andpelvicprocedures.
(diabetes, heart failure, pulImntroodnuacrtiyon disease), and use of specific drugs (benzodiazepines, ).
MainoutcomemeasureProlongedopioiduseafterdischarge,as …
definedbyongoingoutpatientprescriptionsforopioidsformorethan90 Acutepostoperativepainanditstreatmentwithopioidsare
da•ys aftersTurgheryo. racic procedures weirmepo rtaantscosnocerncsifoarttheemdore twhani20t0hmi llsioingpantienitfiswchoantly higher risks.
ResultsOfthe39140patientsintheentirecohort,49.2%(n=19256) undergomajorsurgeryworldwideeveryyear.1Aftersuch
we•re dischMargedafrojmohorsp itaglwyithnanaopieoidcpreoscrlipotiong,anidc3.a1%l prsourgcerey,pdatiuentrsoeftesn ewxpereienrceem oadersatestoosecveiraeptaienthdat with significantly lower risks
(n=1229)continuedtoreceiveopioidsformorethan90daysafter interfereswithpostoperativerehabilitationanddischargefrom
surgery.Followingriskadjustmentwithmultivariablelogisticregression hospital.2Inadequatetreatmentofacutepainmayalsocontribute
modelling,patientrelatedfactorsassociatedwithsignificantlyhigher tothedevelopmentofpersistentpostsurgicalpain,3whichin
risksofprolongedopioiduseincludedyoungerage,lowerhousehold turncanhaveanegativeimpactMonupaltiieenrts B’qruualsityseoflslif e2.40516 8
income,specificcomorbidities(diabetes,heartfailure,pulmonary Opioidsarekeyanalgesicagentsfortreatingmoderatetosevere
disease),anduseofspecificdrugspreoperatively(benzodiazepines, painaftermajorsurgery.6Nonetheless,theyhaveimportant
selectiveserotoninreuptakeinhibitors,angiotensinconvertingenzyme shorttermlimitations,includingsideeffectsandpoorefficacy
inhibitors).Thetypeofsurgicalprocedurewasalsohighlyassociated inmovementassociatedpain.Furthermore,somepatients
withprolongedopioiduse.Comparedwithopenradicalprostatectomies, developlongertermpersistentopioiduse,7whichnegatively
bothopenandminimallyinvasivethoracicprocedureswereassociated impactsonpostsurgicalqualityoflife.45Longtermuseisalso
withsignificantlyhigherrisks(oddsratio2.58,95%confidenceinterval associatedwithincreasedrisksofinjury7andcardiacevents.8
2.03to3.28and1.951.36to2.78,respectively).Conversely,openand
Boththedoctorsdealingwithpatientsperioperativelyandthe
minimallyinvasivemajorgynaecologicalprocedureswereassociated
surgicalpatientsthemselvesthereforefaceanimportantclinical
Correspondence to: H Clarke [email protected]
Extra material supplied by the author (see http://www.bmj.com/content/348/bmj.g1251?tab=related#webextra)
Supplementary tables 1 and 2
No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe:http://www.bmj.com/subscribe
SPECIAL ARTICLES
Practice Guidelines for Acute Pain Management in the
Perioperative Setting
An Updated Report by the American Society of
Anesthesiologists Task Force on Acute Pain Management
° Use the lowest amount
PRACTICEGuidelinesaresystematicallydevelopedrec-
ommendationsthatassistthepractitionerandpatient •Whatotherguidelinestatementsareavailableonthistopic? as possible post-opera:ve
XThesePracticeGuidelinesupdatethe“PracticeGuidelines
inmakingdecisionsabouthealthcare.Theserecommenda- forAcutePainManagementinthePerioperativeSetting,”
tionsmaybeadopted,modified,orrejectedaccordingto adoptedbytheASAin2003andpublishedin2004.*
clinicalneedsandconstraintsandarenotintendedtoreplace •Whywasthisguidelinedeveloped? by using first non opioid
localinstitutionalpolicies.Inaddition,PracticeGuidelinesde- XInOctober2010,theCommitteeonStandardsandPractice
Parameterselectedtocollectnewevidencetodetermine
velopedbytheAmericanSocietyofAnesthesiologists(ASA)are whetherrecommendationsintheexistingPracticeGuide-
notintendedasstandardsorabsoluterequirements,andtheir lineweresupportedbycurrentevidence.
usecannotguaranteeanyspecificoutcome.PracticeGuidelines •Howdoesthisstatementdifferfromexistingguidelines? analgesics and adjunc:ve.
aresubjecttorevisionaswarrantedbytheevolutionofmedical XNewevidencepresentedincludesanupdatedevaluationof
scientificliteratureandfindingsfromsurveysofexpertsand
knowledge,technology,andpractice.Theyprovidebasicrec- randomlyselectedASAmembers.Thenewfindingsdidnot
ommendationsthataresupportedbyasynthesisandanalysisof necessitateachangeinrecommendations.
•Whydoesthisstatementdifferfromexistingguidelines? ° We blame the surgeons
XTheASAguidelinesdifferfromtheexistingguidelinesbe-
UpdatedbytheAmericanSocietyofAnesthesiologists(ASA)Com- causetheyprovidenewevidenceobtainedfromrecentsci-
mitteeonStandardsandPracticeParameters,JeffreyL.Apfelbaum, entificliteratureaswellasfindingsfromnewsurveysof
M.D.(CommitteeChair),Chicago,Illinois;MichaelA.Ashburn,M.D., expertconsultantsandrandomlyselectedASAmembers. and physicians on
M.P.H.(TaskForceChair),Philadelphia,Pennsylvania;RichardT.Con-
nis,Ph.D.,Woodinville,Washington;TongJ.Gan,M.D.,Durham,
NorthCarolina;andDavidG.Nickinovich,Ph.D.,Bellevue,Washing-
ton.ThepreviousupdatewasdevelopedbytheASATaskForceon thecurrentliterature,expertandpractitioneropinion,openfo-
AcutePainManagement:MichaelA.Ashburn,M.D.,M.P.H.(Chair), rumcommentary,andclinicalfeasibilitydata. con:nuing the opioid
SaltLakeCity,Utah;RobertA.Caplan,M.D.,Seattle,Washington; This document updates the “Practice Guidelines for
DanielB.Carr,M.D.,Boston,Massachusetts;RichardT.Connis,Ph.D.,
Woodinville,Washington;BrianGinsberg,M.D.,Durham,NorthCar- AcutePainManagementinthePerioperativeSetting:An
olina;CarmenR.Green,M.D.,AnnArbor,Michigan;MarkJ.Lema, UpdatedReportbytheAmericanSocietyofAnesthesiolo-
M.D.,Ph.D.,Buffalo,NewYork;DavidG.Nickinovich,Ph.D.,Belle- gistsTaskForceonAcutePainManagement,”adoptedby prescrip:ons.
vue,Washington;andLindaJoRice,M.D.,St.Petersburg,Florida.
theASAin2003andpublishedin2004.*
Received from the American Society of Anesthesiologists,
ParkRidge,Illinois.SubmittedforpublicationOctober20,2011.
AcceptedforpublicationOctober20,2011.Supportedbythe
AmericanSocietyofAnesthesiologistsanddevelopedunderthe Methodology ° No change yet in intra
directionoftheCommitteeonStandardsandPracticeParameters,
JeffreyL.Apfelbaum,M.D.(Chair).ApprovedbytheASAHouse A.DefinitionofAcutePainManagementinthe
ofDelegatesonOctober19,2011.Acompletelistofreferences PerioperativeSetting
usedtodeveloptheseupdatedGuidelines,arrangedalphabeti-
callybyauthor,isavailableasSupplementalDigitalContent1, FortheseGuidelines,acutepainisdefinedaspainthatis opera:ve opioid use.
http://links.lww.com/ALN/A780. presentinasurgicalpatientafteraprocedure.Suchpainmay
AddresscorrespondencetotheAmericanSocietyofAnesthesi- betheresultoftraumafromtheprocedureorprocedure-
ologists:520NorthNorthwestHighway,ParkRidge,Illinois60068- relatedcomplications.Painmanagementintheperioperative
2573.ThesePracticeGuidelines,aswellasallpublishedASAPrac-
ticeParameters,maybeobtainedatnocostthroughtheJournal settingreferstoactionsbefore,during,andafteraprocedure
Website,www.anesthesiology.org.
*AmericanSocietyofAnesthesiologistsTaskForceonAcute
PainManagement:Practiceguidelinesforacutepainmanagement !Supplementaldigitalcontentisavailableforthisarticle.Direct
intheperioperativesetting:AnupdatedreportbytheAmerican URLcitationsappearintheprintedtextandareavailablein
SocietyofAnesthesiologistsTaskForceonAcutePainManagement. boththeHTMLandPDFversionsofthisarticle.Linkstothe
ANESTHESIOLOGY2004;100:1573–81. digitalfilesareprovidedintheHTMLtextofthisarticleonthe
Copyright©2012,theAmericanSocietyofAnesthesiologists,Inc.Lippincott Journal’sWebsite(www.anesthesiology.org).
Williams&Wilkins.Anesthesiology2012;116:248–73
Mulier Brussels 2016 9
Anesthesiology,V116•No2 248 February2012
PAIN MEDICINE
Postoperative Opioid-induced Respiratory Depression
A Closed Claims Analysis
(cid:45)(cid:80)(cid:83)(cid:83)(cid:74)(cid:1)(cid:34)(cid:15)(cid:1)(cid:45)(cid:70)(cid:70)(cid:13)(cid:1)(cid:46)(cid:15)(cid:37)(cid:15)(cid:13)(cid:1)(cid:51)(cid:80)(cid:67)(cid:70)(cid:83)(cid:85)(cid:1)(cid:34)(cid:15)(cid:1)(cid:36)(cid:66)(cid:81)(cid:77)(cid:66)(cid:79)(cid:13)(cid:1)(cid:46)(cid:15)(cid:37)(cid:15)(cid:13)(cid:1)(cid:45)(cid:74)(cid:79)(cid:69)(cid:66)(cid:1)(cid:52)(cid:15)(cid:1)(cid:52)(cid:85)(cid:70)(cid:81)(cid:73)(cid:70)(cid:79)(cid:84)(cid:13)(cid:1)(cid:49)(cid:73)(cid:15)(cid:37)(cid:15)(cid:13)(cid:1)(cid:44)(cid:66)(cid:83)(cid:70)(cid:79)(cid:1)(cid:45)(cid:15)(cid:1)(cid:49)(cid:80)(cid:84)(cid:79)(cid:70)(cid:83)(cid:13)(cid:1)(cid:49)(cid:73)(cid:15)(cid:37)(cid:15)(cid:13)(cid:1)
(cid:40)(cid:83)(cid:70)(cid:72)(cid:80)(cid:83)(cid:90)(cid:1)(cid:56)(cid:15)(cid:1)(cid:53)(cid:70)(cid:83)(cid:78)(cid:66)(cid:79)(cid:13)(cid:1)(cid:46)(cid:15)(cid:37)(cid:15)(cid:13)(cid:1)(cid:49)(cid:73)(cid:15)(cid:37)(cid:15)(cid:13)(cid:1)(cid:53)(cid:70)(cid:83)(cid:83)(cid:74)(cid:1)(cid:55)(cid:80)(cid:70)(cid:81)(cid:70)(cid:77)(cid:14)(cid:45)(cid:70)(cid:88)(cid:74)(cid:84)(cid:13)(cid:1)(cid:49)(cid:73)(cid:15)(cid:37)(cid:15)(cid:13)(cid:1)(cid:51)(cid:15)(cid:47)(cid:15)(cid:13)(cid:1)(cid:44)(cid:66)(cid:83)(cid:70)(cid:79)(cid:1)(cid:35)(cid:15)(cid:1)(cid:37)(cid:80)(cid:78)(cid:74)(cid:79)(cid:80)(cid:13)(cid:1)(cid:46)(cid:15)(cid:37)(cid:15)(cid:13)(cid:1)(cid:46)(cid:15)(cid:49)(cid:15)(cid:41)(cid:15)
ABSTRACT
• Postopera:ve opioid-related
Background: Postoperative opioid-induced respiratory depression (RD) is a significant cause of death and brain damage in
the perioperative period. The authors examined anesthesia closed malpractice claims associated with RD to determine whether
patterns of injuries could guide preventative strategies. respiratory depression is an
Methods: From the Anesthesia Closed Claims Project database of 9,799 claims, three authors reviewed 357 acute pain claims
that occurred between 1990 and 2009 for the likelihood of RD using literature-based criteria. Previously cited patient risk fac-
tors for RD, clinical management, nursing assessments, and timing of events were abstracted from claim narratives to identify important cause of iatrogenic
recurrent patterns.
Results: RD was judged as possible, probable, or definite in 92 claims (κ = 0.690) of which 77% resulted in severe brain
injury in the periopera:ve
damage or death. The vast majority of RD events (88%) occurred within 24 h of surgery, and 97% were judged as preventable
with better monitoring and response. Contributing and potentially actionable factors included multiple prescribers (33%),
concurrent administration of nonopioid sedating medications (34%), and inadequate nursing assessments or response (31%). period
The time between the last nursing check and the discovery of a patient with RD was within 2 h in 42% and within 15 min in
16% of claims. Somnolence was noted in 62% of patients before the event.
Conclusions: This claims review supports a growing consensus that opioid-related adverse events are multifactorial and poten-
tially preventable with improvements in assessment of sedation level, monitoring of oxygenation and ventilation, and early • In a review of 357 acute pain
response and intervention, particularly within the first 24 h postoperatively. (ANESTHESIOLOGY 2015; 122:659-65)
claims from the Anesthesia
POSTOPERATIVE opioid-induced respiratory depres-
sion (RD)1 has gained increasing attention as a poten- What We Already Know about This Topic Closed Claims Project database,
tially preventable cause of death and brain damage after (cid:116)(cid:1)(cid:49)(cid:80)(cid:84)(cid:85)(cid:80)(cid:81)(cid:70)(cid:83)(cid:66)(cid:85)(cid:74)(cid:87)(cid:70)(cid:1)(cid:80)(cid:81)(cid:74)(cid:80)(cid:74)(cid:69)(cid:14)(cid:83)(cid:70)(cid:77)(cid:66)(cid:85)(cid:70)(cid:69)(cid:1)(cid:83)(cid:70)(cid:84)(cid:81)(cid:74)(cid:83)(cid:66)(cid:85)(cid:80)(cid:83)(cid:90)(cid:1)(cid:69)(cid:70)(cid:81)(cid:83)(cid:70)(cid:84)(cid:84)(cid:74)(cid:80)(cid:79)(cid:1)(cid:74)(cid:84)(cid:1)(cid:66)(cid:79)(cid:1)(cid:74)(cid:78)(cid:14)
surgery. Cashman and Dolin2 performed a meta-analysis (cid:81)(cid:80)(cid:83)(cid:85)(cid:66)(cid:79)(cid:85)(cid:1)(cid:68)(cid:66)(cid:86)(cid:84)(cid:70)(cid:1)(cid:80)(cid:71)(cid:1)(cid:74)(cid:66)(cid:85)(cid:83)(cid:80)(cid:72)(cid:70)(cid:79)(cid:74)(cid:68)(cid:1)(cid:74)(cid:79)(cid:75)(cid:86)(cid:83)(cid:90)(cid:1)(cid:74)(cid:79)(cid:1)(cid:85)(cid:73)(cid:70)(cid:1)(cid:81)(cid:70)(cid:83)(cid:74)(cid:80)(cid:81)(cid:70)(cid:83)(cid:66)(cid:85)(cid:74)(cid:87)(cid:70)(cid:1)(cid:81)(cid:70)(cid:83)(cid:74)(cid:80)(cid:69)
of 165 articles on postoperative pain management involv- (cid:116)(cid:1)(cid:51)(cid:74)(cid:84)(cid:76)(cid:1)(cid:71)(cid:66)(cid:68)(cid:85)(cid:80)(cid:83)(cid:84)(cid:1)(cid:71)(cid:80)(cid:83)(cid:1)(cid:85)(cid:73)(cid:74)(cid:84)(cid:1)(cid:74)(cid:79)(cid:75)(cid:86)(cid:83)(cid:90)(cid:1)(cid:66)(cid:83)(cid:70)(cid:1)(cid:79)(cid:86)(cid:78)(cid:70)(cid:83)(cid:80)(cid:86)(cid:84)(cid:1)(cid:66)(cid:79)(cid:69)(cid:1)(cid:79)(cid:80)(cid:85)(cid:1)(cid:66)(cid:81)(cid:81)(cid:77)(cid:74)(cid:68)(cid:66)(cid:67)(cid:77)(cid:70)(cid:1)(cid:85)(cid:80)(cid:1) 92 cases involved likely opioid-
(cid:66)(cid:77)(cid:77)(cid:1)(cid:81)(cid:66)(cid:85)(cid:74)(cid:70)(cid:79)(cid:85)(cid:84)(cid:1)(cid:88)(cid:73)(cid:80)(cid:1)(cid:69)(cid:70)(cid:87)(cid:70)(cid:77)(cid:80)(cid:81)(cid:1)(cid:83)(cid:70)(cid:84)(cid:81)(cid:74)(cid:83)(cid:66)(cid:85)(cid:80)(cid:83)(cid:90)(cid:1)(cid:69)(cid:70)(cid:81)(cid:83)(cid:70)(cid:84)(cid:84)(cid:74)(cid:80)(cid:79)
ing almost 20,000 patients who had thoracic, abdominal,
major gynecological, or major orthopedic surgery using a What This Article Tells Us That Is New
single postoperative analgesic technique with observation related respiratory depression
(cid:116)(cid:1)(cid:42)(cid:79)(cid:1)(cid:66)(cid:1)(cid:83)(cid:70)(cid:87)(cid:74)(cid:70)(cid:88)(cid:1)(cid:80)(cid:71)(cid:1)(cid:20)(cid:22)(cid:24)(cid:1)(cid:66)(cid:68)(cid:86)(cid:85)(cid:70)(cid:1)(cid:81)(cid:66)(cid:74)(cid:79)(cid:1)(cid:68)(cid:77)(cid:66)(cid:74)(cid:78)(cid:84)(cid:1)(cid:71)(cid:83)(cid:80)(cid:78)(cid:1)(cid:85)(cid:73)(cid:70)(cid:1)(cid:34)(cid:79)(cid:70)(cid:84)(cid:85)(cid:73)(cid:70)(cid:84)(cid:74)(cid:66)(cid:1)
for adverse events for at least 24 h postoperatively. Based on (cid:36)(cid:77)(cid:80)(cid:84)(cid:70)(cid:69)(cid:1)(cid:36)(cid:77)(cid:66)(cid:74)(cid:78)(cid:84)(cid:1)(cid:49)(cid:83)(cid:80)(cid:75)(cid:70)(cid:68)(cid:85)(cid:1)(cid:69)(cid:66)(cid:85)(cid:66)(cid:67)(cid:66)(cid:84)(cid:70)(cid:13)(cid:1)(cid:26)(cid:19)(cid:1)(cid:68)(cid:66)(cid:84)(cid:70)(cid:84)(cid:1)(cid:74)(cid:79)(cid:87)(cid:80)(cid:77)(cid:87)(cid:70)(cid:69)(cid:1)(cid:77)(cid:74)(cid:76)(cid:70)(cid:77)(cid:90)(cid:1)(cid:80)(cid:81)(cid:74)(cid:14)
their analysis, the authors reported incidence of RD varies (cid:80)(cid:74)(cid:69)(cid:14)(cid:83)(cid:70)(cid:77)(cid:66)(cid:85)(cid:70)(cid:69)(cid:1)(cid:83)(cid:70)(cid:84)(cid:81)(cid:74)(cid:83)(cid:66)(cid:85)(cid:80)(cid:83)(cid:90)(cid:1)(cid:69)(cid:70)(cid:81)(cid:83)(cid:70)(cid:84)(cid:84)(cid:74)(cid:80)(cid:79)
from 0.1 to 37%,2 depending on the route of administration (cid:116)(cid:1)(cid:53)(cid:73)(cid:70)(cid:1)(cid:87)(cid:66)(cid:84)(cid:85)(cid:1)(cid:78)(cid:66)(cid:75)(cid:80)(cid:83)(cid:74)(cid:85)(cid:90)(cid:1)(cid:80)(cid:71)(cid:1)(cid:85)(cid:73)(cid:70)(cid:84)(cid:70)(cid:1)(cid:74)(cid:79)(cid:75)(cid:86)(cid:83)(cid:74)(cid:70)(cid:84)(cid:1)(cid:80)(cid:68)(cid:68)(cid:86)(cid:83)(cid:83)(cid:70)(cid:69)(cid:1)(cid:88)(cid:74)(cid:85)(cid:73)(cid:74)(cid:79)(cid:1)(cid:19)(cid:21)(cid:1)(cid:73)(cid:1)(cid:80)(cid:71)(cid:1)(cid:84)(cid:86)(cid:83)(cid:14) • The vast majority of these
of the opioid, the type of opioid, the definition and method (cid:72)(cid:70)(cid:83)(cid:90)(cid:1)(cid:66)(cid:79)(cid:69)(cid:1)(cid:26)(cid:24)(cid:6)(cid:1)(cid:88)(cid:70)(cid:83)(cid:70)(cid:1)(cid:75)(cid:86)(cid:69)(cid:72)(cid:70)(cid:69)(cid:1)(cid:66)(cid:84)(cid:1)(cid:81)(cid:83)(cid:70)(cid:87)(cid:70)(cid:79)(cid:85)(cid:66)(cid:67)(cid:77)(cid:70)(cid:1)(cid:88)(cid:74)(cid:85)(cid:73)(cid:1)(cid:67)(cid:70)(cid:85)(cid:85)(cid:70)(cid:83)(cid:1)(cid:78)(cid:80)(cid:79)(cid:74)(cid:14)
(cid:85)(cid:80)(cid:83)(cid:74)(cid:79)(cid:72)(cid:1)(cid:66)(cid:79)(cid:69)(cid:1)(cid:83)(cid:70)(cid:84)(cid:81)(cid:80)(cid:79)(cid:84)(cid:70)
of monitoring RD, and the prospective versus retrospective
nature of the study. The lowest estimates were reported when injuries occurred within 24 h of
naloxone administration was used as the criterion for RD, their Sentinel Event Database from 2004 to 2011, wrong
followed sequentially by higher estimates based on respira- dose medication errors were present in half of the events,
tory rate, hypercarbia, and oxygen desaturation.2 In The improper monitoring occurred in almost one third, and surgery and 97% were judged
Joint Commission’s review of opioid-related events from other factors related to medication dosing and interactions
This article is featured in “This Month in Anesthesiology,” page 1A. Corresponding article on page 484. These findings were presented, as preventable
in part, at the American Society of Anesthesiologists 2012 Annual Meeting in Washington, D.C., on October 13, 2012, and in the ASA
Newsletter of May 2013; 77:34–6.
Submitted for publication August 21, 2014. Accepted for publication October 20, 2014. From the Department of Anesthesiology, Vander-
bilt University, Nashville, Tennessee (L.A.L.); Department of Anesthesiology, Virginia Mason Hospital and Seattle Medical Center, Seattle,
Washington (R.A.C.); Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington (L.S.S., K.L.P., G.W.T.,
K.B.D.); and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan (T.V.-L.).
Copyright © 2014, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2015; 122:659-65
Mulier Brussels 2016 10
(cid:34)(cid:79)(cid:70)(cid:84)(cid:85)(cid:73)(cid:70)(cid:84)(cid:74)(cid:80)(cid:77)(cid:80)(cid:72)(cid:90)(cid:13)(cid:1)(cid:55)(cid:1)(cid:18)(cid:19)(cid:19)(cid:1)(cid:116)(cid:1)(cid:47)(cid:80)(cid:1)(cid:20) 659 March 2015
Description:Mulier Brussels 2016. 1 . cally by author, is available as Supplemental Digital Content 1, Supplemental digital content is available for this article.
