DEPENDENCY AND ANESTHESIA CARE
From the Mayo Clinic Symposium on Anesthesia and Perioperative Medicine, sponsored by Mayo College of Medicine,
School of Continuing Medical Education
Educational Objectives
| The goals of this program are to help patients quit smoking (at least during the perioperative period) and to improve
perioperative management of the opioid-dependent patient. After hearing and assimilating this program, the clinician
will be better able to:
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 | 1. Explain the 2 main reasons for patients to stop smoking before surgery and to maintain tobacco abstinence after
surgery.
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| 2. Discuss false barriers to perioperative smoking cessation and review the recommended approach to helping
patients quit smoking.
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| 3. Identify patients at risk for difficult perioperative pain management related to long-term opioid use.
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| 4. List factors that put patients at risk for complications of perioperative opioid use.
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| 5. Utilize the multimodal, multidisciplinary approach to pain management.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning
committee reported nothing to disclose.
Acknowledgements
Drs. Warner and Trentman spoke in Phoenix, AZ, at the Mayo Clinic Symposium on Anesthesia and Perioperative Medicine
2008, held February 20-23, 2008, and sponsored by the Mayo College of Medicine, School of Continuing Medical
Education, Scottsdale, AZ. The Audio-Digest Foundation thanks the speakers and the sponsor for their
cooperation in the production of this program.
| SMOKING DURING THE PERIOPERATIVE PERIOD —David O. Warner, MD, Professor of Anesthesiology, Mayo
College of Medicine, Rochester, MN
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| Reasons to stop smoking: 1) improve perioperative outcome; 2) increase likelihood that patient able to stop smoking
permanently; smoking cessation improves surgical outcomes by reducing severity and frequency of cardiovascular complications,
respiratory complications (eg, pneumonia), and wound-related complications (eg, infection, dehiscence)
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| Short-term cardiovascular benefits of smoking cessation: half-life of nicotine ≈1 hr; relatively brief duration
of abstinence can significantly reduce concentration of nicotine in plasma; decreases seen in heart rate (HR) and systolic
blood pressure within 12 hr; carbon monoxide half-life ≈4 hr; carboxyhemoglobin level near normal at 12 hr; net effect of
smoking cessation is improvement in exercise capacity (measure of overall cardiovascular and pulmonary function)
within ≈12 hr; studies indicate even overnight abstinence reduces level of myocardial ischemia observed in intraoperative
period; ischemia can be correlated with level of carbon monoxide as marker of recent cigarette smoke; in study, orthopedic
surgery patients undergoing major hip and knee replacements randomized to tobacco intervention or control, 6 to 8
wk before surgery; ≈80% of intervention patients able to quit or reduce smoking; rates of overall complications >50% in
control group and ≈18% in intervention group; “most of that was because their wounds did a lot better”; tendency toward
improvement in cardiac outcome, but numbers too small to tell for sure
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| Surgery promotes smoking cessation: opportunity to intervene; forced abstinence in health care facility; goal to extend
period of perioperative abstinence beyond time spent in surgical facility; major medical interventions improve quit
rates; may also improve efficacy of tobacco interventions; if cessation attempted alone on self-help basis, success rate
only 5% to 10% for any given attempt; when outpatient cessation clinic utilized, success rate 25% for any single attempt;
rate of spontaneous abstinence 1 yr after major noncardiac surgery double that seen with self-help attempt; if surgery directly
related to smoking (eg, coronary artery bypass grafting [CABG], lung cancer resection), rates of spontaneous abstinence
can be high (although, even after lung resection for cancer, ≈20% of patients still cannot quit smoking)
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| False barriers to perioperative smoking cessation
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| Myth 1: quitting immediately before surgery increases pulmonary complications—if smoking stopped before surgery,
takes several weeks or months before rate of pulmonary complications decreases; quitting within a few weeks of surgery
does not increase pulmonary complications
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| Myth 2: nicotine replacement therapy dangerous to surgical patient—nicotine not one of substances responsible for problems
with wound-related complications after surgery; adding nicotine replacement therapy does not negate benefit of
reducing or eliminating smoking to decrease rate of wound-related complications
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| Myth 3: surgical patients already too stressed (most consider cigarettes stress-management tool)—smoking status does
not affect changes in perceived stress; no evidence that during perioperative period, smoking abstinence stressful for
these patients
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| Myth 4: patients do not want to hear about their smoking —essentially all smokers know about health hazards; most not
aware how smoking might affect their surgery and want to know; patients want information and options; almost all will
not be offended if you discuss their smoking, but they do not want sermon (≈75% of current smokers looking for opportunity
to quit); patients expect health care professional to give best advice about health improvement
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| Role of anesthesia personnel in helping smokers quit: only ≈30% of anesthesiologists and certified registered
nurse anesthetists report almost always advising patient to quit smoking; real barriers to intervention include, “I don’t
know how,” “I don’t have time,” and “It’s not my job”
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| American Society of Anesthesiologists’ (ASA) smoking cessation initiative: every smoker cared for by anesthesiologist
will receive assistance in quitting as integral part of care; ASA members becoming more involved in smoking
cessation efforts, thus increasing abstinence rates during perioperative period
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| Recommended approach: ask—assess tobacco use at every visit; advise—strongly urge all tobacco users to quit
smoking; refer—to resources that can help users quit smoking
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| “Quitlines”: free via telephone to all residents of United States; staffed by trained counselors; 4 to 6 personalized sessions;
many offer free nicotine-replacement therapy; ≈30% success rates for patients who complete sessions; most providers
and patients know little about quitlines
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| Ask: every patient about tobacco use, even if you already know answer; reinforces message that you as anesthesia provider
think patient’s tobacco use important
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| Advise: all smokers to quit for as long as possible before and after surgery (speaker targets ≈1 wk after surgery for those
patients who do not want to quit permanently); day of surgery especially important; “fast” from both food and cigarettes;
benefits include improved wound healing, cardiovascular function, and pulmonary function; great opportunity to quit
permanently (many people do not have cravings at time of surgery)
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| Refer: if time available, talk about Quitlines (free; talk with specialist, not recording; free stop-smoking medications may
be available; can call any time, even after surgery; can help patient stay off cigarettes even if he or she has already quit);
proactive fax referral system can be used in preoperative clinic; telephone number 1-800-QUIT-NOW
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| Other resources: ASA Quitcard—contains national quitline number, information about importance of quitting, and also
Web site for further information; helps patient get connected with experts and counselors who can provide necessary
help; brochures and other patient education material; tobacco treatment specialist; government Web site—
www.smokefree.gov; insurers—many have programs to help patients stop smoking; ASA Web sites—for patients
www.asahq.org/patientEducation/smoking_cessation.htm; for providers www.asawebapps. org/docs/SmokeCessation.htm
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| Centers for Medicare and Medicaid Services (CMS) reimbursement for tobacco interventions:
Healthcare Common Procedure Coding System codes can be used to bill above and beyond anesthesia fee to provide
these services; covers patient with tobacco-related disease in Medicare population; specific codes for short-term and
long-term counseling that can be used to bill separately
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| PERIOPERATIVE CARE OF THE OPIOID-DEPENDENT PATIENT —Terrence L. Trentman, MD, Assistant Professor
of Anesthesiology, Mayo College of Medicine, and Staff Anesthesiologist, Mayo Clinic, Scottsdale, AZ
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| Hospital pain case: obese man; undergoing major orthopedic surgery; preoperative opioid use includes oxycodone extended-release,
80 mg bid, for low back pain; patient snores loudly; diagnosed with hypertension, diabetes, and coronary
artery disease; postoperative pain management difficult (high pain scores; poor participation in rehabilitation); multiple
opioids tried (intravenous [IV] morphine, then patient-controlled analgesia [PCA]; changed to PCA hydromorphone);
promethazine (Phenergan) given for nausea; by third postoperative day, night nurse notes patient hypoventilating and difficult
to arouse; pulse oximetry indicates low O2 saturation; naloxone (Narcan) given with supplemental O2 ; patient
transferred to intermediate care; has prolonged hospital stay; not satisfying for patient, surgeon, or hospital administrators
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| Pain management goals: relieve pain (may not be realistic in opioid-tolerant patient with long-term pain); optimize rehabilitation
(increase function; prevent further injury)
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| Postoperative pain management issues: types of pain; regulatory factors (eg, Joint Commission); options for pain
management; opioids; other classes of medications; nerve blocks; alternative approaches to pain management (eg, transcutaneous
electrical nerve stimulation [TENS] units; acupuncture); multimodal multidisciplinary approach
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| Postoperative pain management deficiencies: pain common in hospitalized patients; opioids in postoperative patients
associated with side effects, including nausea and vomiting, ileus, and respiratory depression
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| Sequelae of poorly controlled acute pain: include higher risk for development of long-term pain, increased sympathetic
activity, splinting, and impaired immune response; eventually leads to myocardial ischemia, impaired rehabilitation,
pneumonia, infection, and sepsis
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| Joint Commission pain initiative: assess pain, repeat assessment, and intervene effectively; initiative does not indicate
pain must be relieved; many organizations responded by distributing pain scales, numeric pain ratings, and pain thermometers
to help health care providers understand “where our patients are at and how they’re responding to our therapy”;
health care provider cannot just treat number (must look at other things, including functional outcomes)
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| Types of pain: acute vs long-term—everyone has experience with acute pain, but long-term pain does not act like acute
pain; other ways to classify pain include nociceptive, neuropathic, visceral, cancer, and somatic; acute pain inflicted on
patient already experiencing long-term pain can be extremely difficult to manage, especially when patient opioid-tolerant
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| Preoperative management: ask surgeon for advance notice when patient on high-dose narcotics who has history of
difficult pain management scheduled for surgery; continue all preoperative medications, particularly narcotics; consider
changing nonsteroidal anti-inflammatory drugs (NSAIDs) to cyclooxygenase-2 (COX-2) inhibitors, if appropriate; consider
use of neuraxial block
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| Preemptive analgesia: meta-analysis concluded that epidurals, NSAIDs, and wound infiltration with local anesthetic
provided significant benefit (eg, improved pain scores, less supplemental analgesic consumption, greater time to first analgesic
consumption in first 1 to 2 days)
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| Nonopioid analgesic “pile-on”: includes local anesthetics (eg, nerve blocks, epidurals), acetaminophen (eg, Tylenol),
NSAIDs or COX-2 inhibitors, N-methyl-D-aspartate (NMDA) receptor blockers (eg, ketamine), anticonvulsants (eg,
gabapentin, pregabalin), and α2 -adrenergic agonists (eg, dexmedetomidine)
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| Gabapentin: used as anticonvulsant; also approved by Food and Drug Administration (FDA) for postherpetic neuralgia;
one study showed significant decrease in movement-related pain scores and morphine consumption; another study concluded
gabapentin has analgesic and opioid-sparing effect in acute postoperative pain when used in conjunction with opioids;
another systematic review found significant reduction in pain scores and opioid consumption, significant increase in
sedation and anxiolysis, and no difference in dizziness or nausea and vomiting
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| Ketamine: used as induction agent and sometimes in small doses for analgesic purposes; systematic review found low-
dose ketamine had reduced morphine requirements, less nausea and vomiting, and minimal side effects; most authors described
using ketamine as bolus before incision and then at low dose (eg, 25-30 mg for 70-kg patient) for ≈1 day in infusion
delivery form
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| Dexmedetomidine: centrally acting, α2 -agonist, administered IV; FDA-approved for use post-CABG in intensive care
unit as sedative; tried for perioperative pain management; study of abdominal and orthopedic surgery found less morphine
consumption, better pain control, and lower HR in postanesthesia care unit (PACU); no difference in morphine
consumption or pain control at 24 hr; another similar study found less morphine use in PACU and on hospital floor and
less nausea and pruritus for ≤48 hr
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| IV lidocaine: study of lidocaine infusion in patients undergoing laparoscopic colectomy showed time to bowel function
and hospital discharge significantly shorter; opioid consumption also less; requires discussion with surgeon and nursing
staff before sending patient with lidocaine infusion or ketamine to hospital floor
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| Tips for early postoperative period: assess patient early in postoperative period (do not let pain get “wound up”); give
prophylactic O2 and continuous pulse oximetry to high-risk patient on high-dose opioids; avoid other nonanalgesic sedatives
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| Reasons for difficulty with opioid-tolerant patient: long-term pain associated with anxiety and depression; analgesics
do not help; pain scores often high, no matter what clinician does; focus on functional outcomes and activity; long-
term opioid users seem hyperalgesic to experimental painful stimuli; goal to minimize opioids yet provide good pain relief
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| Fentanyl: available as transdermal system (ie, patch; recent recall by some manufacturers due to leaking of gel); Actiq
lollipop provides large dose to opioid-tolerant cancer patient; Fentora (buccal tablet) similar idea
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| Patch: recent warnings; communication key; protocol may be better; be cautious with scheduled doses or infusions of
opioids as adjuncts to fentanyl patch (changes in body temperature can increase blood levels); do not start opioid-naive
patients on patch perioperatively
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| Meperidine (Demerol): active metabolite (normeperidine) can cause seizure and accumulate in patients with renal failure;
atropine-like effect; contributes to tachydysrhythmias; shorter half-life than morphine; meta-analysis showed meperidine
consistently associated with risk for delirium in elderly; speaker’s institution has limited use to routine postoperative
pain management only
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| Perioperative management of patients with long-term pain plus opioid dependence: multimodal approach;
includes local anesthetic blocks, epidural opioids, acetaminophen, gabapentin, and COX-2 inhibitors; danger of
polypharmacy and oversedation, especially if receiving other drugs, eg, nausea medication
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| Alternative approaches to pain management: include TENS units, biofeedback and relaxation, and acupuncture;
set realistic expectations; anesthesia provider able to work with patient to manage pain, but not cure it; TENS units—
study in postoperative abdominal surgery showed less pain during walking and vital capacity activities, and no significant
change at rest; meta-analysis of 1350 patients, with TENS in incisional area, set at maximal tolerable subnoxious
level, showed ≈27% reduction in analgesic consumption, compared to placebo; acupuncture—pain scores similar, but
less analgesic use with auricular acupuncture than sham acupuncture; another study showed less pain and less analgesic
use, with greater range of motion in shoulder and higher patient satisfaction
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Suggested Reading
Arain SR et al: The efficacy of dexmedetomidine versus morphine for postoperative analgesia after major inpatient surgery.
Anesth Analg 98:153, 2004; Barrera R et al: Smoking and timing of cessation: impact on pulmonary complications after thoracotomy.
Chest 127:1977, 2005; Bell RF et al: Perioperative ketamine for acute postoperative pain. Cochrane Database Syst
Rev: CD004603, 2006; Brill S et al: Perioperative management of chronic pain patients with opioid dependency. Curr Opin Anaesthesiol
19:325, 2006; Compton P et al: Pain responses in methadone-maintained opioid abusers. J Pain Symptom Manage
20:237, 2000; Dirks J et al: A randomized study of the effects of single-dose gabapentin versus placebo on postoperative pain and
morphine consumption after mastectomy. Anesthesiology 97:560, 2002; Doverty M et al: Methadone maintenance patients are
cross-tolerant to the antinociceptive effects of morphine. Pain 93:155, 2001; Gilron I: Is gabapentin a "Broad-spectrum" analgesic?
Anesthesiology 97:537, 2002; Gurbet A et al: Intraoperative infusion of dexmedetomidine reduces perioperative analgesic
requirements. Can J Anaesth 53:646, 2006; Hurley RW et al: The analgesic effects of perioperative gabapentin on postoperative
pain: a meta-analysis. Reg Anesth Pain Med 31:237, 2006; Møller AM et al: Effect of preoperative smoking intervention
on postoperative complications: a randomised clinical trial. Lancet 359:114, 2002; Ong CK et al: The efficacy of preemptive analgesia
for acute postoperative pain management: a meta-analysis. Anesth Analg 100:757, 2005; Sorensen LT et al: Abstinence
from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg 238:1, 2003; Strassels SA et al:
Postoperative pain management: a practical review, part 2. Am J Health Syst Pharm 62:2019, 2005; Strassels SA et al: Postoperative
pain management: a practical review, part 1. Am J Health Syst Pharm 62:1904, 2005; Warner DO et al: Anesthesiologists,
general surgeons, and tobacco interventions in the perioperative period. Anesth Analg 99:1766, 2004; Warner DO et al:
Smoking behavior and perceived stress in cigarette smokers undergoing elective surgery. Anesthesiology 100:1125, 2004.
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