A Personalized Plan for Post-op Pain

Patient Experience Pain Management Anesthesia

By: Jared Bilski | Managing Editor

Published: 10/14/2021

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Avoiding cookie-cutter analgesia regimens will ultimately improve outcomes.


When asked about the importance of a personalized approach to post-op pain control, Mike MacKinnon, DNP, FNP-C, CRNA, immediately launches into a story about a patient he treated years ago who had a long history of opioid dependence. “The sheer personal anxiety and terror this patient had about taking an opioid and falling back into addiction made even considering narcotics as an option for decreasing post-op pain out of the question,” says Dr. MacKinnon, an anesthesia provider for Northeastern Anesthesia in Show Low, Ariz.

That left him in a tough spot because it was a major GYN surgery, not the type of procedure where you could simply block potentially painful areas with regional anesthesia. Plus, an epidural wasn’t an option.

Without the standard methods available for pain control at his disposal, Dr. MacKinnon was forced to come up with an analgesic option that was tailored to his patient’s unique situation. “I ran ketamine and magnesium drips over a 23-hour period during the patient’s recovery to control the worst of the pain,” he says. “The patient was then able to manage her discomfort with acetaminophen and ibuprofen until she was discharged.” Most importantly, the patient never had to take any opioids.

Yes, this is a rather extreme and specific example, however, it does get right to the heart of a core truth about combatting post-op pain: There’s no one-size-fits-all option. Providers owe it to their patients to treat pain on an individual basis through a combination of pre- and intraoperative multimodal cocktails, appropriate nerve blocks and local anesthetic infusions.

• Personalized cocktails. Setting patients up for successful post-operative outcomes requires a thoughtful approach to the pre-op administration of pain meds, an approach that eschews a standardized dosing regimen.

“Don’t give every patient the same dose of your pre-op cocktail,” says Tom Durick, MD, an assistant professor at The Ohio State University Wexner Medical Center in Columbus. “The same dose of gabapentin you administer to a 42-year-old in for a knee replacement might cause delayed emergence in an 82-year-old hip replacement patient.”

Reducing the use of opioids is an important goal, but Dr. Durick reminds providers that these powerful pain control drugs do have their place leading up to and just before surgery for certain patient populations.

“Don’t disallow your chronic pain patients and opioid dependent patients the ability to treat their pre-op pain with the meds they’ve been using,” he says. “Withdrawal is a real thing, as is dependence. It isn’t always a bad idea to give these patients a small dose of narcotic to minimize the pain of surgery.”

Dr. Durick also urges surgical leaders to remember that cookie-cutter order sets can have ranges or recommendations for medications, and that it generally benefits the patient to give your staff the ability to use a lower dose of certain meds if the situation calls for it. “You can always give more of a medication later if the anesthesia provider or surgeon requests it,” he says. “Getting medications in and taking effect before surgery can make all the difference for short, painful procedures.”

REALITY CHECK Providers have a responsibility to let patients know that they’ll experience some discomfort after surgery, but the right mix of medications will keep breakthrough pain in check.  |  Pamela Bevelhymer

Dr. MacKinnon agrees about the importance of a personalized approach to multimodal preoperative cocktails and says this phase of care ultimately comes down to three things: A provider’s experience with different drugs, the time they’ve spent reading the current research and talking to other providers about what they’ve done in the multimodal space, and their ability to tailor the approach to the patient’s health history.

Past and current opioid usage is obviously an important factor in creating an opioid-sparing analgesia regimen. “These individuals are enzymatically induced to burn through opioids much faster, but you can utilize other drugs to hit different nerve receptors,” says Dr. MacKinnon. Opioid usage isn’t the only thing that can diminish the effectiveness of preoperative painkillers on patients — regular or weekend binge drinking and marijuana usage can do so as well.

The four most common drugs that Dr. MacKinnon uses for opioid-sparing analgesia are dexmedetomidine, a drug that prevents central sensitization or the development of chronic pain; ketamine, an NMDA antagonist; and magnesium and lidocaine, both of which also prevent central sensitization.

Whether he uses all these medications, one of them or some in combination with small doses of opioids depends on the type of procedure being performed. For instance, he can start an IV of all four drugs, run it for the bulk of a two- or three-hour surgery and turn off the drip a half-hour before the end of the case. In these cases, the patient wakes up with little discomfort. For faster procedures, this regimen usually isn’t necessary. “I might give just a small bolus of one or two of the medications,” says Dr. MacKinnon. That’s the beauty of multimodal pain management — you tailor it the patient, the surgery and the situation.

• Regional anesthesia. The ability to target and block the specific location of a patient’s pain is a critical component of analgesia. Indeed, many anesthesia providers see regional anesthesia as the most important component of pain control. “The biggest part of multimodal analgesia is regional anesthesia,” says Dr. MacKinnon. “If you can block a specific nerve, the concern of pain becomes a non-issue.”

Dr. Durick was an early adopter of nerve blocks and urges other providers to always consider this option for all patients — especially those with increased pain management needs. Whether it’s a fascial plane block like a PECS I and II or TAP block, or an ultrasound-guided nerve block like an adductor canal or brachial plexus nerve block, Dr. Durick suggests addressing the possibility of administering a block — even there’s potential for it to be placed postoperatively — with the patient before the surgery and get them to sign a consent. This way, he says, the consent is already in place should you need to perform a rescue block.

Regardless of whether your anesthesia providers employ single-shot or continuous nerve blocks with programmable pain pumps, Dr. Durick says the key to improved outcomes is ensuring patients are comfortable enough to start rehab and physical therapy before they leave your facility and during the critical first few days at home. “Extended analgesia allows patients to move without pain soon after surgery, decreases scarring and clot formation, and improves post-op functionality,” he explains.

THE RIGHT MIX Individual preoperative cocktails are often based on a provider’s experience with different drugs as well as their ability and comfort level in tailoring the combination to the specific needs of the patient.  |  Pamela Bevelhymer

There’s a human element of any pain control protocol that can’t be understated. Even the perfect multimodal cocktail coupled with an expertly placed nerve block can be less effective if the provider doesn’t do what’s needed to keep the patient’s pre-procedure anxiety at bay. “You have to do the little things — sitting on a chair next to the patient at eye level, talking to them directly and not just running through everything that’s going to happen to them in a monotone voice,” says Dr. MacKinnon. “That sets the tone and gains people’s trust.”

Once that trust is gained, patients tend to relax, and their anxiety is reduced. But providers also owe it to patients to offer an honest assessment of the surgical process, which could include pain, discomfort and even the possibility, however remote, of a failed block. “Setting expectations is really important,” says Dr. MacKinnon. “Tell patients, ‘There is going to be pain, but we’re going to manage it in the best way we can before and during surgery, and if that doesn’t work, we’re going to fix it afterward.’”

The biggest part of multimodal analgesia is regional anesthesia.
— Mike MacKinnon, DNP, FNP-C, CRNA

Patients need to hear that message because otherwise they may go into surgery thinking they’ll wake up in complete comfort. As Dr. MacKinnon puts it, “Some pain is a lot of pain when you’re expecting none.”

Effective pain control ultimately comes down to addressing the specific needs of individual patients, regardless of whether you’re a small facility with a light caseload or a busy anesthesia provider who does thousands of blocks each year.  

An individualized approach to pain control requires providers who truly listen to the patient’s concerns from the start and are willing to veer from their typical analgesic regimen as needed.

Tailoring your treatment plan to the patient’s individual pain is a team effort that requires everyone involved — surgeons, anesthesia providers and nurses — to sit down together and discuss the best strategy directly with the patient, says Dr. MacKinnon. “As a team, we have to assure patients that the surgeon, anesthesia providers and nursing team will do everything in their power to take care of the pain,” he says. “We communicate constantly to address pain-related issues. We all approach post-op pain management with the right mindset, which is ‘I’m going to do the best I can for this patient for this surgery and their particular situation.” OSM

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