The Obese Surgical Patient: A Need for a Strong Multimodal Analgesia Approach

Chris Pasero, MS, RN-BC

Disclosures

March 20, 2014

Goals of Care for Postoperative Pain Management

The current recommended approach for the management of postoperative pain is multimodal analgesia.[1,2,6,12,13,14,15] The importance of implementing this approach in patients with risk factors for respiratory depression cannot be overemphasized. The rationale for using multimodal analgesia as opposed to unimodal approaches is that using a single analgesic rarely achieves optimal (both effective and safe) pain relief.[2]

The multimodal approach combines analgesics that work on different mechanisms along the pain pathway to produce additive or synergistic analgesic effects.[16] A multimodal postoperative pain treatment plan may include acetaminophen, a nonsteroidal anti-inflammatory drug (NSAID), an opioid, and a local anesthetic, or combinations thereof.[2,15,17] A major benefit is that pain relief is usually achieved with lower doses of analgesics, particularly lower opioid doses, which is a primary goal of pain treatment in all patients and is critical in patients with multiple risk factors, such as the patient in this scenario. Lower opioid doses result in fewer clinically significant adverse effects, such as postoperative nausea and vomiting, excessive sedation, and respiratory depression. Multimodal analgesia includes the addition of practical nonpharmacologic approaches as well.[6,18] Whenever possible, the initiation of the multimodal treatment plan should begin preoperatively.[2,13]

Nurses play a key role in ensuring multimodal therapy and improving the safety of pain management by promptly contacting the prescriber to obtain orders for nonopioid analgesics in patients with opioid-only treatment plans.[19] Table 2 provides an example of a multimodal analgesia order set that includes options for scheduled nonopioid analgesics as the foundation of pain treatment and opioids that can be administered if needed for pain that is unrelieved by the scheduled nonopioids.

Table 2. Multimodal Pain Control Order Set for Opioid-Naive Adults

Scheduled for mild pain (1/10 -3/10)

Note: May order acetaminophen + one NSAID (staggered doses not necessary). Do not order more than one NSAID.
  • Acetaminophen 650 mg PO q6h

  • Acetaminophen 1000 mg PO q6h

  • Acetaminophen 1000 mg IV q6h × 4 doses (excluding perioperative dose), then switch to acetaminophen 1000 mg PO q6h. Call MD if unable to take PO meds.

  • Ibuprofen 400 mg PO q6h

  • Ibuprofen 400 mg IV q6h × 4 doses (excluding perioperative dose), then switch to ibuprofen 400 mg PO q6h. Call MD if unable to take PO meds.

  • Ketorolac 7.5 mg IV q6h × 4 doses (excluding perioperative dose), then switch to ibuprofen 400 mg PO q6h. Call MD if unable to take PO meds.

  • Ketorolac 15 mg IV q6h × 4 doses (excluding perioperative dose), then switch to ibuprofen 400 mg PO q 6 h. Call MD if unable to take PO meds.

Scheduled for moderate-severe pain (4/10 -10/10)

Note: Unless contraindicated, order both acetaminophen + one NSAID (staggered doses not necessary). Do not order more than one NSAID.
  • Acetaminophen 1000 mg PO q 6h

  • Acetaminophen 1000 mg IV q6h × 4 doses (excluding perioperative dose), then switch to acetaminophen 1000 mg PO q6h. Call MD if unable to take PO meds.

  • Ibuprofen 400 mg PO q6h

  • Ibuprofen 800 mg PO q6h

  • Ibuprofen 400 mg IV q6h × 4 doses (excluding perioperative dose), then switch to ibuprofen 400 mg PO q6h. Call MD if unable to take PO meds.

  • Ketorolac 7.5 mg IV q6h × 4 doses (excluding perioperative dose), then switch to ibuprofen 400 mg PO q6h. Call MD if unable to take PO meds.

  • Ketorolac 15 mg IV q6h × 4 doses (excluding perioperative dose), then switch to ibuprofen 400 mg PO q6h. Call MD if unable to take PO meds.

  • Ketorolac 30 mg IV q6h × 4 doses (excluding perioperative dose), then switch to ibuprofen 400 mg PO q6h. Call MD if unable to take PO meds.

PRN for moderate pain (4/10 -6/10)

Note: Order one.

  • Oxycodone IR 5-10 mg PO q4h PRN

  • Morphine IR 10-15 mg PO q4h PRN

PRN for severe pain (7/10 -10/10)

Note: Order one.
  • Oxycodone IR 10-30 mg PO q4h PRN

  • Morphine IR 15-45 mg PO q4h PRN

  • Morphine 2-4 mg IV q2h PRN

  • Hydromorphone 0.5-1 mg IV q2h PRN

NOTES:
  1. Maximum dose from all sources per 24- h period: acetaminophen: 4000 mg; ibuprofen: 3200 mg; ketorolac: 120 mg (60 mg in patients > 65 years old)

  2. Call MD if Cr ≥ 1.0 before giving NSAID.

  3. Do not give NSAID if serum Cr ≥ 1.0 mg/dL or if Cr increases > 2× baseline. Call MD.

  4. Do not give NSAID if platelet count < 70,000/µL. Call MD.

  5. Administer opioids in accordance with opioid dose range policy and procedure

  6. If POSS level is > 2, respiratory rate is ≤ 8 breaths/min, or patient has any other signs/symptoms of opioid-induced respiratory depression:

    1. Do not give opioid.

    2. Give 0.5 mL dilute naloxone (Narcan, 0.4 mg/10mL normal saline) IV very slowly over 2 min; repeat until POSS level is < 3 and respiratory rate > 12 breaths/min.

    3. Initiate continuous pulse oximetry and capnography.

    4. Contact primary MD for further orders.

Cr = creatinine; IR = instant release; IV = intravenous; NSAID = nonsteroidal anti-inflammatory drug; POSS = Pasero Opioid Sedation Scale; PRN = as needed; q = every

Copyright 2014, Chris Pasero. From Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St. Louis: Mosby/Elsevier; 2011. Format developed by Pam DeVellis, Cape Cod Health. Used with permission.

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