Download Pancreatectomy and Islet Cell AutoTransplant APS Acute Pain Pathway UNMC 2016

Pancreatectomy & Islet Cell AutoTransplant
APS Acute Pain Pathway
University of Nebraska Medical Center
Department of Anesthesiology
1) Early Preoperative
a) Surgery to initiate APS consult to be done concurrently during preoperative
surgical appointment (preferred) or at PASC appointment.
i) Routine APS consult will be performed in usual fashion.
(1) Emphasis on verification of current opioid regimen.
ii) Patient will be informed of pain pathway.
iii) Patient/provider pain management expectations to be established.
iv) APS recommendations for post-operative pain control will be included in consult
note
(1) Hydromorphone or morphine PCA dosing to be specified.
(a) Total daily opioid dosing should be 3X the baseline morphine equivalents.
(2) Dosing of intra/postoperative ketamine infusion will be specified.
1) Immediate Preoperative
a) APS consult and the above recommendations will be completed if not already
done.
b) A bilateral dual TAP block (subcostal x2, lateral x2) will be performed using a
mixture of Exparel 20cc+bupivicaine0.25% 30cc+ 10cc 0.9NS.
2) Early Postoperative
a) APS to provide immediate assistance and rapid medication titration to manage
uncontrolled pain.
i) Patient PCA dosing may require dosing to be escalated 5X baseline morphine
equivalents.
ii) Rapid escalation may require APS to direct nurse loading at bedside.
b) Ketamine infusion will be continued at 10mg/hr for 24 to 72 hrs depending on
patient’s status and presence of side effects.
Reviewed T.Nicholas MD 4/18/2016
Pancreatectomy & Islet Cell AutoTransplant
APS Acute Pain Pathway
University of Nebraska Medical Center
Department of Anesthesiology
1) Late Postoperative
a) De-escalation of opioids:
i) No de-escalation of opioids will occur within the first 48 hrs unless the patient has
negative side effects or clinical condition warrants.
ii) Oral conversion:
(1) If the patient is taking orals, de-escalation will occur in a suggested stepwise fashion, as
follows:
(2) Basal dosing will be replaced with long acting oral opioid.
(a) Dose of long acting oral opioid will be based upon a 25 to 30% reduction of previous
basal 24 hr. morphine equivalents total dose.
(3) Dose of short acting opioid upon a 25 to 30% reduction of previous demand 24 hr.
morphine equivalents total dose
(4) Rescue IV opioids will be available for breakthrough pain.
iii) APS will document a suggested oral titration regimen for the rest of the hospital stay
dependent on patient clinical status.
(1) Suggested further titration will not exceed a 25% reduction in morphine equivalents per
week until the patient achieve presurgical opioid requirements.
iv) Scheduled oral multi-modal adjuncts medications will be ordered when patient
tolerating PO.
2) These recommendations are to be used in conjunction with the
“Pancreatectomy & Islet Cell AutoTransplant-Anesthetic Pathway”
Reviewed T.Nicholas MD 4/18/2016