Volume 5 - No. 3 2017 Educated Hand Publishing LLC “The Science Behind the Art” Volume 5 - No. 3 2017 Anesthesia eJournal - Online ISSN 2333-2611 Page 14 Anesthesia Related Outcomes in Patients Receiving Regional Anesthesia for Shoulder Surgery in a CRNA-Only Practice In the Rural Setting Gregory Bozimowski DNP, CRNA1 Peter Skellenger MS, CRNA2 Affiliation: 1 University of Detroit Mercy 2 Peter Skellenger was a student at University of Detroit Mercy at the time of writing the manuscript. He is now a practicing CRNA in MI Funding/Conflict of Interest Disclosure: The authors have no funding or conflicts of interest to report. INTRODUCTION As the population in the United States ages and the demands on the healthcare system increase, so too does the pressure to provide superior anesthesia services that include safe, effective, efficient care with improved outcomes, greater patient satisfac- tion, and lower cost. This is particularly the case in rural areas of the United States, which account for nearly 72 million Ameri- cans who may have limited access to providers, where the drive to provide high quality care while reducing costs is paramount.1 Regional anesthesia (RA) for shoulder surgery is a commonly used technique. The benefits have been studied and are well documented. One commonly used technique is the administration of an interscalene block (ISB) to supplement the adminis- tration of general anesthesia (GA) in combination with sedation, or even as a sole anesthetic, has gained favor. The avoidance or reduction of the hemodynamic instability and other adverse effects that may occur as a result of GA is one appeal to that practice.2 In addition, regional anesthesia has been shown to provide postoperative pain relief for patients undergoing shoulder procedures. While single shot ISB has been shown to provide significant postoperative pain relief, it is of a short duration and is not without adverse effects.3 A review of the literature was conducted to examine the potential benefits of RA as compared to GA for shoulder surgery with a secondary intent to evaluate the presence of data collected in rural settings. Abstract The purpose of this retrospective chart review was to characterize the complication rate and outcomes among a group of patients receiving regional anesthesia (RA) undergoing shoulder surgery in the rural setting utilizing a Certified Registered Nurse Anesthetist (CRNA) only model. Demographic information was obtained. Patients were primarily ASA 2 and 3 classifications and were outpatients with a mean age of 52.6 years. The most common preoperative diagnosis was rotator cuff tear. The recorded procedure was most often shoulder arthroscopy. RA was performed on 70 patients (92.1%) with 6 (7.9%) patients receiving no RA. General anesthesia (GA) was administered with RA to 68 (89.5%) patients with the re- mainder receiving sedation with RA. Pain scores as measured by visual analogue scale (VAS) reflected effective analgesia. The mean VAS score reported on arrival to PACU was 1.27, after one hour 1.69, and 0.38 upon discharge from PACU. Postoperative analgesics were required for 26 (34.2%) patients. The incidence of postoperative nausea or vomiting was 6.6% of patients reporting nausea and 2.6% patients experiencing emesis. The mean anesthesia time was 127.3 minutes with mean operating room time of 121.2 minutes. Mean time in PACU was 134.6 minutes. The descriptive data attained in the analysis demonstrate RA as a safe and effective supplement to GA administered by CRNAs in a rural setting. Future research is needed specific to CRNA-only practice models and rural settings and should include controlled randomized trials to evaluate outcomes in groups consisting of GA, GA+RA, RA + sedation and even RA alone in select populations. AEJ Anesthesia eJournal www.anesthesiaejournal.com Volume 5 - No. 3 2017 Page 15 BACKGROUND The electronic based search of the literature review was completed using the following databases: PubMed, Cochrane, INFOTRAC, MEDLINE, Ovid Medline, and CINAHL. The following sub- ject headings and combinations were used: “interscalene + shoul- der surgery”, “regional anesthesia vs. general anesthesia”, “regional anesthesia + shoulder surgery”, “regional anesthesia”, “ambulatory surgery”, “rural anesthesia”, “rural + anesthesia”. The search revealed many articles that compared RA with GA; however, there is a lack of articles with specificity to the rural setting. (See Table 1- Data-Extraction) A meta-analysis by Ab- dallah and colleagues4 reviewed randomized and quasi-random- ized controlled trials that compared ISB to GA and combined techniques. The authors examined studies conducted between 1994 and 2013 and represented 1090 patients over 23 trials. They reported reduced pain at rest and in motion at various intervals postoperatively in patients who received an ISB. The analysis also revealed decreased opioid consumption in the first 24 hours and longer time to request opioids in the ISB group. Other reported benefits of ISB included increased patient satisfaction, decreased time of stay in the post anesthesia care unit (PACU) and hospi- tal admission and a lower incidence of postoperative nausea and vomiting (PONV). The authors concluded that ISB provided effective analgesia during the first 6 postoperative hours and reduced opioid related side effects. Hadzic and colleagues5 conducted a randomized, blinded, prospective study comparing the techniques of ISB to GA with respect to the recovery profiles and patient satisfaction in patients having outpatient shoulder surgery. Data were collected from a total of 50 patients placed equally into 2 groups consisting of those receiving an ISB and those receiving GA. Primary outcome measures included: patients eligible for bypass of phase I PACU instead going directly to phase II, hospital admission rates, and time to discharge. Secondary outcome measurements included: reports of moderate/severe pain, treatment of pain, nausea, vomit- ing, sore throat, ambulation, oral intake, and time to home readi- ness. The authors reported that more patients receiving ISB (76%) were eligible to bypass phase I of PACU than patients receiving GA (16%). No patients receiving ISB were admitted to the hos- pital, while 16% of the GA group was admitted overnight due to intractable pain. Time to discharge of ISB patients was found to be 2.5 hours less than patients receiving GA. No patients in the ISB group reported moderate to severe pain as compared to 80% of those in the GA group. Pain score values and analgesic use differences between the two groups were not statistically signif- icant; however, the authors report these findings as “statistically underpowered”. The authors report that patient satisfaction with anesthesia was higher in the ISB group with 79% reporting that they would choose the same anesthetic again while 36% of the patients in the GA group stated they would choose GA again. Lehmann and colleagues6 conducted a randomized controlled study of 120 subjects that evaluated the use of ISB versus GA, or a combined ISB + GA for patients undergoing shoulder arthros- copy. The primary outcome variable measured was opioid con- sumption on the day of surgery with secondary outcomes being post-op monitoring times, anesthesia times, patient satisfaction, and the ability to bypass the recovery room. In addition, subjec- tive outcomes such as perceived pain and nausea were measured. Following surgery, the authors found that 27 of 40 subjects receiving ISB only were able to bypass the PACU completely and had the shortest monitoring time necessary in the PACU compared to GA or GA + ISB. On the day of surgery, opioid consumption was significantly reduced in the patients receiving ISB but they found no significant difference in opioid consump- tion between the ISB and ISB + GA groups. Patient satisfaction scores in the ISB and ISB + GA groups were significantly higher than scores reported by GA only patients. Patients in the ISB group reported less nausea and vomiting as compared to the other groups and reported their experience as “better than expected” more frequently than patients in both the GA and the GA + ISB groups. In a retrospective chart review, Yauger and colleagues7 compared outcomes between patients undergoing either shoulder arthros- copy or knee arthroscopy receiving GA or RA in a military same day surgery unit (SDSU) in a certified registered nurse anesthe- tist (CRNA) only practice model. The study reviewed 342 cases, with 161 GA and 181 RA. Combined GA and RA procedures were excluded. Regional anesthetic techniques included inter- scalene block (ISB) for shoulder arthroscopy or femoral nerve block (FNB) for knee arthroscopy. Results included a 13 minutes longer pre-op time for GA patients than the RA group, with a slightly less intra-operative time. The GA group also utilized 25.9 minutes less anesthesia provider time. The RA group spent 20.3 minutes less time in PACU than did the GA group and SDSU. Pain scores post-operatively were significantly increased in the GA group, with increased morphine equivalent opioid use by the GA group relative to the RA group. This study suggests that CRNA-administered regional anesthesia provided a safe and effective alternative anesthetic for outpatient shoulder and knee arthroscopy, with improved quality indicators such as a reduction of PONV, pain, and opioid consumption as compared to GA. Gonano and colleagues8 evaluated the differences between ultrasound (US) guided ISB and GA for arthroscopic shoulder surgery. The total sample size was 40 patients with equal distribu- tion into each group. Researchers recorded all drugs and dispos- able equipment used and evaluated each method in terms of cost. Other costs were calculated considering anesthesia-related work- flow and total anesthesia time, total time in PACU, and readiness for discharge. A decreased total cost for patients receiving ISB (33 +/- 9 €) was reported as compared to the GA group (41 +/- 7 €). The authors found that anesthesia time was significantly less in the ISB group [12 (+/- 4) minutes] versus the GA group [23 (+/- 6) minutes]. PACU time was significantly reduced in the ISB group (45 +/- 17 min) versus the GA group (70 +/- 20) minutes. The review of the literature suggests that RA not only allows for excellent surgical anesthesia, but also reduces length of patient stay, intra and post-operative opioid requirements, post-operative pain, PONV, and overall cost, while simultaneously improving patient satisfaction scores. The review also demonstrates a need for research to explore best practices specific to rural anesthesia practice. PURPOSE OF THE STUDY Although there is a significant body of literature comparing regional anesthesia to general anesthesia, there are few studies looking at these techniques for shoulder surgery specifically in the Anesthesia eJournal www.anesthesiaejournal.com Volume 5 - No. 3 2017 Page 16 rural population. The purpose of this retrospective chart review was to characterize the complication rate and outcomes among a group of patients receiving regional anesthesia in patients undergoing shoulder surgery in the rural setting utilizing a Cer- tified Registered Nurse Anesthetist only model. Complications measured in this review included nausea, vomiting, and delayed discharge. Need for opioid analgesia was also measured. MATERIALS AND METHODS DESIGN The Institutional Review Board at the University of Detroit Mercy approved the project through expedited review. It is a retrospective chart review of patients undergoing shoulder surgery at Hillsdale Community Health Center (HCHC) during 2014. HCHC utilizes a CRNA only anesthesia practice model. It has 47 acute care beds and is located in Southwestern Michigan, 112 miles from Detroit, in a county of approximately 47,000 people. The project was also approved by the administration of HCHC who granted access to the patient electronic records. DATA COLLECTION The authors developed the data collection sheet used to gather patient information. (Appendix 1) Inclusion criteria included all patients undergoing shoulder surgery. The hospitals electron- ic medical system was utilized to retrieve records of patients through coding indicating they met inclusion criteria during the identified time period. To maintain confidentiality and anonymity, patient identifiers were not collected. Collected data included patient demographics of gender, age, ASA status, height, weight, and BMI. In addition preoperative diagnosis, surgical approach (open versus arthroscopic), surgical procedure, and type of anesthetic administered were recorded. Times were measured reflecting anesthesia time, operating room time, and PACU time in minutes. The occurrence of nausea or vomiting was recorded as was prophylactic and rescue agents administered. Pain measure- ments upon arrival to PACU, one hour later, and upon discharge from PACU were also recorded using the VAS. Opioid and other analgesic administration was recorded for pre, intra, and postop- erative periods. RESULTS Seventy nine patient records were reviewed. Three patient records were excluded because of incompleteness of crucial data in the records leaving a sample population of 76 patients. Descriptive analysis of the data was performed. Demographic data is summa- rized in table 2. The most common preoperative diagnosis was rotator cuff tear (47.4%) followed by impingement syndrome (14.5%) and an- kylosis (6.6%) with a variety of other diagnoses comprising the remainder in near equal numbers. The recorded procedure was most often shoulder arthroscopy (76.3%). A combined RA with GA technique was performed on nearly all patients so compari- sons between RA and GA were not attainable. (Table 3) Bupiv- icaine 0.5% was utilized in 65 (85.5%) of the RA procedures with ropivicaine 0.5% utilized in the remainder. Only 3 patients (3.9%) received preoperative analgesia. Pain scores as measured by VAS reflected effective analgesia. (Table 4) The overall rate of PONV as well as rescue medication for PONV was low. Prophylaxis for PONV was administered to most patients with ondansetron 4 mg alone or in combinations with dexamethasone 4mg or metaclopromide 10mg most often utilized. (Table 5) The mean anesthesia time was 127.3 minutes with mean OR time of 121.2 minutes. Mean time in PACU was 134.6 minutes. Blocks were administered in the preoperative holding area so that OR time was not prolonged. Two blocks were deemed to be ineffective in PACU and were re-administered. One patient was admitted unplanned for intractable pain. No other adverse events were reported. DISCUSSION This analysis provided current data related to demographics and outcomes in patients undergoing shoulder surgery in a CRNA-only rural practice setting. Quality outcomes data are crucial to continuously provide supportive data speaking to the safety and efficacy of CRNA solo practice. The descriptive data attained demonstrates effective RA as a supplement to GA. As a result, a decrease in Mean Alveolar Concentration (MAC) of inhaled agent can be assumed and small intraoperative doses of opioid were required allowing a reasonable assumption of a cor- relation to reduced opioid side effects. A very low incidence of PONV occurred suggesting that low opioid use, inhalation agent, and/or prophylactic antiemetic administration was effective. The PONV incidence was lower than reported in the studies reviewed here and lower than the incidence reported by Gohl and colleagues9 in a 2001 study com- paring ISB to GA techniques in which they found 66% of GA patients experienced nausea and 25% for those receiving ISB and GA combined. The measured mean anesthesia time represented only 6.1 minutes longer than OR time. So the institutional practice of performing the regional technique in the preoperative holding area did not significantly increase valuable time in the OR. This study is not without limitations. Foremost, a randomized prospective design comparing GA to RA or a longer retrospective study period to mine data from patients who underwent shoul- der surgery prior to the predominate practice of most frequently employing RA would provide better comparative data. Since the target population was a rural setting with CRNA-only practice the findings cannot be generalized to larger facilities with other anesthesia care models. This study provides supportive data that RA added to the anes- thesia plan for shoulder surgery in a rural, CRNA-only practice is safe, effective and efficient. Although questions could not be answered through comparison of groups in this study, the data revealed low incidences of postoperative adverse events, effective analgesia during the postoperative period, and minimal anesthesia time beyond operating room time needed. Implications for Clinical Practice and Future Research The current trends in healthcare in the United States point towards increasing patient satisfaction and quality while reduc- ing costs. Regional anesthesia has long been recognized as a safe alternative or adjunct to general anesthesia in select patient populations and surgical procedures. As the reviewed literature Anesthesia eJournal www.anesthesiaejournal.com Volume 5 - No. 3 2017 Page 17 suggests, a regional approach to outpatient shoulder surgery can reduce costs and improved outcomes, with the added benefit of improved patient satisfaction. Future research is needed specific to CRNA-only practice models and rural settings and should in- clude controlled randomized trials to evaluate outcomes in groups consisting of GA, GA+RA, RA + sedation and even RA alone in select populations. Research exploring the potential benefits of the use of ultrasound-guided blocks versus more traditional approaches and the use of lower doses of local anesthetics and optimization of outcome measures need also to be conducted. Further, it may prove beneficial to evaluate the effectiveness of continuous infiltration of local anesthetic in the outpatient setting. An additional area of future research should include a focus on rural anesthesia and the costs associated with providing anesthetic care in this setting. This review of the current litera- ture as well as the descriptive evaluation of this practice points to promising reduction of costs and increased efficiency, both areas that could drastically impact the bottom line in the often budget-compromised rural healthcare setting. Table 1-Data Extraction Authors/Study Design, Purpose and Sample Results and Conclusions Critique of Strengths and Weakness Hadzic A, Williams BA, Karaca PE. et al. For Outpatient Rotator Cuff Surgery, Nerve Block Anesthesia Provides Superior Same-day Recovery over General Anesthesia. Anesthesiology. 2005; 102:1001–1007. Design: Prospective, randomized study comparing the use of ISB to GA for outpatient shoulder surgery. Purpose: To compare which technique (nerve block vs. GA) provides more efficient recovery and greater patient satisfaction. Sample: 50 patients Result: * 76% of ISB patients and 16%of GA patients bypassed PACU * 0 ISB patients and16% of GA patients were admitted * 0 (0 %) ISB patients and 20 (80 %) GA patients were treated for pain in PACU * Discharge time for ISB was 123 +/- 57 min and 286 +/- 100 min for GA patients Conclusions: The authors conclude that ISB increased PACU bypass, faster same-day recovery, better analgesia, and fewer adverse events following outpatient rotator cuff surgery as compared to GA. Strengths: Randomized, blinded study Aldrete scoring used on all patients initially to assess ability to bypass PACU Follow-up was through 2 week period Weaknesses: Small sample size GA patients received PONV prophylaxis, ISB patients did not GA patients received nitrous oxide 50%, an agent known to produce PONV Authors/Study Design, Purpose and Sample Results and Conclusions Critique of Strengths and Weakness Lehmann L, Loosen G, Weiss C, Schmittner M. Interscalene plexus block versus general anaesthesia for shoulder surgery: A randomized controlled study. Eur J Orthop Surg Traumatol. 2015; 25(2) 255-61. doi: 10.1007/s00590-014-1483-3. Epub 2014 May 15. Accessed June 4th, 2015 Design: Randomized, controlled, clinical trial Purpose: Evaluates the post-op opioid consumption in patients receiving ISB, ISB + GA, or GA alone for shoulder arthroscopy Sample: 120 patients total. ISB: N= 40 ISB + GA: N= 40 GA: N= 40 Result: * Opioid requirements of ISB and ISB + GA were similar and less than GA alone. * ISB had significantly higher patient satisfaction scores * ISB led to significantly less PONV and lower pain scores than GA or GA + ISB * ISB had increased rate of bypassing PACU and discharge from the recovery room than ISB or ISB + GA Conclusions: When compared to GA, patients receiving ISB or ISB + GA had a reduction in post-op opioid consumption, time to oral intake and Strengths: • Randomized, blinded study • Large sample sizes Weaknesses: • The authors cite their choice of LA and volume of dos- ing as a weakness of the study Anesthesia eJournal www.anesthesiaejournal.com Volume 5 - No. 3 2017 Page 18 Authors/Study Design, Purpose and Sample Results and Conclusions Critique of Strengths and Weakness Gonano C, Kettner SC, Ernstbrunner M, Schebasta K, Chiari A, Marhofer P. Comparison of economical aspects of interscalene brachial plexus blockade and general anesthesia for arthroscopic shoulder surgery. British Journal of Anaesthesia. 2009; 103 (3): 428–33 (2009) doi:10.1093/ bja/aep173. Accessed June 4th, 2015. Design: Randomized clinical trial Purpose: This study was designed to evaluate the potential economic advantage of US- guided ISB vs. GA for arthroscopic shoulder surgery. The emphasis in this study is placed on the use of ultrasound for block placement and the economic impact vs. GA. Sample: 40 patients total ISB group: N= 20 GA group: N= 20 Result: * Costs are minimally lower in the ISB group compared to the GA group. Cost savings seen in faster turnover time when ISB performed in block room. * PACU time, opioid use, PONV rates all reduced in the ISB group. * 10% of ISB patients needed vasopressor and fluid therapy vs. 60% of GA patients. Conclusions: ISB is a cost-effective method of providing anesthesia for arthroscopic shoulder surgery. ISB is associated with less total anesthesia related cost and improved time efficacy. Strengths: • Looked specifically at costs • Looked at US-guided blocks Weaknesses: • Small sample size • Australian study- may not be able to extrapolate to US Anesthesia eJournal www.anesthesiaejournal.com Volume 5 - No. 3 2017 Page 19 Authors/Study Design, Purpose and Sample Results and Conclusions Critique of Strengths and Weakness Yauger, Y, Bryngelson J, Weiss C, et al. Patient outcomes comparing CRNA-administered peripheral nerve blocks and general anesthetics: A retrospective chart review. AANAJ. 2010.78(3) 215-220. Design: Retrospective chart review Purpose: To compare quality indicators and operative time demands between patients undergoing shoulder or knee arthroscopy under GA vs. RB. Sample: 342 patients undergoing shoulder or knee arthroscopy, with either GA or RA. RA in this study refers to either interscalene block for shoulder arthroscopy or femoral nerve block for knee arthroscopy. Result: * The GA group used 25.9min less anesthesia provider time overall but spent 20.3 min longer in PACU than the RA group. * 15.5% of GA patients had PONV vs. 10.0% of RB patients, a statistically insignificant difference. * RA patients had a significant decrease in pain scores post- operatively and used less opioid than the GA group. * 12 patients in the RA group bypassed the PACU, while no patients in the GA did. Conclusions: Significantly less opioid use and pain scores when RA is used over GA. Strengths: • Large sample size • CRNA- only study Weaknesses: • Only ASA 1 and 2 patients. • Only GA or RB, no combined tech- nique patients • Retrospective study Anesthesia eJournal www.anesthesiaejournal.com Volume 5 - No. 3 2017 Page 20 Table 2 Demographics N =76 Gender Age Years Weight kg BMI Kg/m2 ASA status M = 37 (51%) - - - 1=1 Mean F = 39 (49%) 52.9 83 30.4 2= 3 Min 19 51 18.2 3= 52 Max 83 159 51.8 4=1 Table 3 Techniques Anesthetic Airway Adjunct Surgical Approach RA+GA= 68 (90%) ETT= 65 Open= 58 GA only= 6 (8%) LMA= 3 Arthroscopy= 15 RA+ sedation= 2 (2%) - Not indicated= 3 Table 4 VAS Scores N =76 VAS Arrival VAS 1 hr. VAS DC Mean 1.27 1.69 0.37 Reported score of 0 59 (77.6%) 48 (63.2%) 59 (77.6%) Table 5 PONV Data Postop Nausea Postop Vomiting PONV Prophylaxis PONV Rescue 5 (6.6%) 2 (2.6%) 69 (90.8%) 3 (3.9%) REFERENCES 1. American Hospital Association Website. AHA research policy page. The Opportunities and Challenges for Rural Hospitals in an Era of Health Reform http://www.aha.org/research/policy/2011.shtml accessed June 4th, 2015. 2. Ozzeybek D, Oztekin S, Mavioglu O, et al. Comparison of the haemodynamic effects of interscalene block combined with general anaesthesia and interscalene block alone for shoulder surgery. The Journal of International Research. 2003; 31: 428- 433. 3. Fredrickson MJ, Krishnan S, Chen CY. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current techniques. Anaesthesia. 2010; 65: 608-624. 4. Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the realbenefits of single-shot interscalene block please stand up? A systematic review and meta-analysis. Anesthesia & Analgesia. 2015; 120(5) 1114-1129. 5. Hadzic A, Williams BA, Karaca PE. et al. For Outpatient Rotator Cuff Surgery, Nerve Block Anesthesia Provides Superior Same-day Recovery over General Anesthesia. Anesthesiology. 2005; 102:1001–1007. 6. Lehmann L, Loosen G, Weiss C, Schmittner M. Interscalene plexus block versus general anaesthesia for shoulder surgery: A randomized controlled study. Eur J Orthop Surg Traumatol. 2015; 25(2) 255-61. doi: 10.1007/s00590-014-1483-3. Epub 2014 May 15. Accessed June 4th, 2015 7. Yauger, Y, Bryngelson J, Weiss C, et al. Patient outcomes comparing CRNA-administered peripheral nerve blocks and general anesthetics: A retrospective chart review. AANAJ. 2010.78(3) 215-220. 8. Gonano C, Kettner SC, Ernstbrunner M, Schebasta K, Chiari A, Marhofer P. Comparison of economical aspects of interscalene brachial plexus blockade and general anesthesia for arthroscopic shoulder surgery. British Journal of Anaesthesia. 2009; 103 (3): 428–33 (2009) doi:10.1093/bja/aep173. Accessed June 4th, 2015. 9. Gohl MR, Moeller RK, Olson RL, Vacchiano CA. The addition of interscalene block to general anesthesia for patients undergoing open procedures. AANAJ. 2001. 69(2) 105-109 Anesthesia eJournal www.anesthesiaejournal.com Volume 5 - No. 3 2017 Page 21 http://www.aha.org/research/policy/2011.shtml Appendix 1 Data Collection Tool Case Number (1, 2, 3 etc.):________ Demographics Age: _______Gender: Male ______ Female _____ Height (cm): Weight (kg): BMI (kg/m2): ASA Status _________ Co-morbidities: _________________ Inpatient ______ Outpatient________ Diagnosis: ________________________________________ Upper Extremity Surgical Procedure: _________________________________________________ Surgical Approach: Open incision____________ Scope________________ Type of Anesthesia _________Regional and General Anesthesia Type of Block: _________________ General using LMA: _____ OET: ________ _________Regional with Sedation Type of Block______________________ _______ General without Block _______ Local/MAC Comments: _______________________________________ OR and PACU Times (minutes) Total OR time _____Total Anesthesia time: ______ Total PACU time: ___________ Perioperative Data Preoperative Pain Medications Opioid: _____________ Amount: _____________ Route: IV______ PO______IM_____ NSAID: _____________ Amount: ____________ Route: IV______ PO______IM_____ Acetaminophen Amount: ____________ Route: IV______ PO______ Other Type: ______________ Amount: _____________ Route: IV______ PO______IM_____ Intraoperative Pain Medications Opioid: _____________ Amount: _____________ Route: IV______ PO______IM_____ NSAID: ______________ Amount: ____________ Route: IV______ PO______IM_____ Acetaminophen Amount: _____________ Route: IV______ PO______ Other: ______________ Amount: _____________ Route: IV______ PO______IM_____ Postoperative Pain Management Local Anesthesia Infiltrated at Incision Site (by surgeon): YES____ NO_____ Catheter placed for post op pain: YES______ NO_______ Pain scores in PACU: Arrival VAS _______ 1 hour VAS_______ Pain score at discharge: VAS______ Comments: ________________________ Pain Medication Use in PACU Opioid: ______________ Amount: _____________ Route: IV______ PO______IM_____ NSAID: ______________ Amount: _____________ Route: IV______ PO______IM_____ Acetaminophen: Amount: _____________ Route: IV______ PO______ Other: ______________ mount: _____________ Route: IV______ PO______IM_____ PONV and Treatment Nausea: (Y/N) Vomiting: (Y/N) PONV Prophylaxis given: Drug: Dose: Route: ____________ Rescue meds for PONV: Drug: Dose: Route: ____________ Complications Delay in discharge: (Y/N) Reason: _______________ Length of Delay: _______________ Unplanned postop hospital admission: (Y/N) Reason___________________________ _ Other: ______________________________________________________ Anesthesia eJournal www.anesthesiaejournal.com Volume 5 - No. 3 2017 Page 22