Advances in Post-op Pain Management

Ultrasound technology and multimodal approaches are helping patients ambulate more rapidly while reducing their need for opioids.

Thomas Durick, MD, had a puzzle on his hands. Fortunately, the answer could be found in his pocket.

When a surgeon recently came to him expressing concern over a patient scheduled for scar revision following breast surgery, Dr. Durick, an assistant professor of anesthesiology at The Ohio State University College of Medicine in Columbus, pondered suitable nerve block options.

Comfort and convenience

The surgeon hoped to perform the procedure in-office, as the patient displayed extreme tenderness. Intercostal blocks seemed fitting for the touch-sensitive area around the rib cage, albeit a technique Dr. Durick hadn’t employed with ultrasound guidance before. Thanks to a handheld ultrasound device, he felt confident after a quick review of the case to administer three-level intercostal blocks on both sides of the patient.

The outcome? The patient awoke pain-free and was quickly discharged.

“The advances in ultrasound technology and image quality are making blocks safer, they’re making them easier, they’re going to improve your success rate, and you may be able to do blocks that you didn’t do before,” says Dr. Durick.

From ultrasound-guided continuous and single-shot nerve blocks to smart pain pumps, providers have significantly improved post-op pain control in a manner that is light on opioids and heavy on rapid ambulation. Let’s look at the available options.

Exploring multimodal approaches

Changes and advancements in pain management are currently driven by two primary factors: the imperative to minimize opioid overprescription and the benefits of utilizing cutting-edge technology. Compact ultrasound devices, easily carried in one’s pocket and pairable with smartphones and tablets, are making a dramatic difference, and have become popular with a growing number of anesthesiologists. At the same time, many states have implemented regulations that limit the quantity of opioids surgeons can prescribe after surgery. Surgeons themselves are increasingly committed to avoiding opioid dependency in their patients.

What can I give them before, during and after the procedure that’s going to help them have the best recovery? 
Thomas Durick, MD 

“Our focus is on doing what we can to minimize the amount of opioids that we need to use in every case that we can,” says Daniel P. McGrane, MD, medical director at Lakeside Ambulatory Surgery Center in Omaha, Neb.

Dr. McGrane refers to multimodal analgesia as the cornerstone of Lakeside’s post-op pain management program. Whether through nerve blocks or the surgeon’s application of local anesthetic during the procedure, this dual approach ensures comprehensive pain management, he explains. Lakeside practitioners variously incorporate oral medications such as acetaminophen, celecoxib, meloxicam or gabapentin. Strategies vary based on a blend of surgeon preferences, the nature of the surgery and patient acceptance.

A prime example of Lakeside’s multimodal approach is the application of single-shot nerve blocks with the addition of liposomal bupivacaine in a capsule that releases the local anesthetic gradually over time and offers pain relief that typically lasts from 72 to 96 hours.

Initially, its applications were limited, requiring FDA approval for each specific use. As such, Lakeside reserved use of liposomal bupivacaine for shoulder surgeries. However, recent expansions in its indications have broadened its utility, while availability of Medicare reimbursement has brought down its cost. It’s now proven both a feasible option and immensely beneficial at Lakeside, providing exceptional pain control for patients undergoing total joint procedures, says Dr. McGrane.

Adopting ultrasound-assisted nerve blocks

Thanks to ultrasound technology, practitioners achieve greater precision, reducing the need for multiple needle insertions and minimizing patient discomfort, says Dr. McGrane. Procedures move more quickly, enhancing the center’s efficiency while decreasing patient anxiety.

At Lakeside, ultrasound is increasingly used to guide peripheral nerve blocks, as the precision required means any deviation can lead to failed blocks or unintended effects. Orthopedic surgeries like shoulder, hip, knee and foot procedures can benefit greatly from various nerve block techniques. Other examples include hernia repairs, C-sections, chest surgeries, breast reductions and abdominoplasty.

Another patient perk: Nerve blocks facilitate a smoother transition from the surgery center to home, says Angela Johnson, RN, BSN, director of nursing at Lakeside. Seamless, convenient and, most importantly, safe care is of paramount importance to the center. “We try to get people in and out as efficiently and as safely as appropriate for their type of surgery,” notes Ms. Johnson.

While opioids can cause nausea and vomiting, blocks often avoid such side effects while providing relief for 12 to 24 hours — and much longer with the broader multimodal pain management plan in place at Lakeside, she adds.

Even if a surgeon prefers not to use nerve blocks and opts for local anesthesia instead, Dr. Durick says he always discusses the possibility of a nerve block with the patient before the surgery. This preemptive discussion ensures that — should the patient experience significant pain after waking up — providers have the option to proceed with a nerve block without delay. Obtaining consent beforehand avoids the need to administer excessive narcotics postoperatively.

BLOCK BASICS

How Regional Anesthesia Is Administered

FORWARD PROGRESS Advances in ultrasound technology and image quality are improving clinicians’ success rates and expanding the types of nerve blocks facilities can perform.  |  Pamela Bevelhymer

Essential for preventing or managing various types of pain, nerve blocks may be administered for post-op pain management in several ways, says Thomas Durick, MD, an assistant professor of anesthesiology at The Ohio State University College of Medicine in Columbus.

• Single-shot nerve blocks are typically administered shortly before the procedure or after the patient has been anesthetized. They primarily help to manage pain during and after surgery and last approximately 12 to 24 hours.

• Long-acting local anesthetics such as liposomal bupivacaine may be paired with single-shot nerve blocks. This formulation slowly releases the anesthetic over time to provide benefits similar to catheter-based continuous blocks, eliminating the need for catheter insertion.

• Nerve block catheters offer sustained pain relief by continuously delivering a diluted local anesthetic around the nerve for extended periods ranging from 24 to 72 hours. This minimizes discomfort for the patient while maintaining effective pain management.
—Dara McBride

Addressing challenges with training

Beyond nerve blocks, ultrasound technology also can assist in facilitating a spinal block, an approach that has proven beneficial in Dr. Durick’s practice on many occasions. Additionally, Dr. Durick believes ultrasound is invaluable for starting IVs, assessing lung function and examining the heart mid-procedure.

However, while ultrasound technology enhances precision by providing real-time visualization, it doesn’t entirely eliminate the risks or challenges associated with nerve blocks. Facilities should invest in comprehensively training anesthesia providers to use new ultrasound devices after they’re purchased.

For surgery centers, especially those in private practice, concerns about additional costs associated with ultrasound devices — such as needles and medications — may arise. But with portable ultrasound becoming more widely available, the return on investment for facilities may be realized more quickly, and facilities can bill for the technical component. Meanwhile, patients benefit from reduced postoperative nausea and vomiting, lower pain scores, decreased opioid use and faster recovery times. All of this ultimately translates into long-term cost savings.

At Lakeside Surgery Center, in-service training helped to ensure staff understood the nuances and requirements associated with the use of liposomal bupivacaine and its unique properties, how to use ultrasound guidance during nerve blocks and other multimodal pain management techniques.

Emphasizing optimal postoperative care

Integrating the latest ultrasound tech and a multimodal approach into standard practice can elevate quality of care, enhance patient outcomes and optimize pain management strategies.

In his three decades of care, Dr. Durick has witnessed the evolution of nerve block techniques from a reliance on methods such as nerve stimulators to the routine use of ultrasound-guided nerve blocks. The latest techniques, used together, help providers get patients alert, comfortable and free from nausea and significant levels of pain shortly after surgery.

“It’s that pain relief: What can I give them before, during and after the procedure that’s going to help them have the best recovery? And it’s the other side of that: What don’t I need to give them?” says Dr. Durick. Administering a narcotic to patients after a successful nerve block gives them all the side effects without any advantages, he adds.

An approach that’s tailored to each patient and procedure, fittingly speaks to the experiences of practitioners embracing advances in postoperative pain management. It also underscores the importance of judicious opioid use and a patient-centered mindset that guides both teaching and practice. OSM