Managing Patients’ Post-op Pain: A 360-Degree Overview

Preemptive, preoperative education, expectation-setting and a multimodal regimen are the recipe for success.

Between regional anesthesia, multimodal medication regimens and ERAS pathways executed with military-like precision, postoperative pain management is as efficient ever.

In fact, one can make the argument that perhaps it’s a little too good. After all, there’s still a not-insignificant number of patients out there who believe modern advancements in medication translate to a pain-free surgical experience. It’s up to facility leaders to make sure such patients are set straight before their surgeries take place and not after these individuals take out their misguided frustrations in their patient experience surveys.

Straight talk from the start

Setting realistic expectations about what patients will experience is of paramount importance for providers. Find a way to make that point in a manner any individual is likely to understand. In other words, avoid overly complex, jargon-filled descriptions that are likely to confuse or concern the average patient.

Eugene R. Viscusi, MD, FASRA, professor of anesthesiology and vice chair of pain medicine for the department of anesthesiology and perioperative medicine at Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, always aims to establish a mutual understanding with a patient about to undergo surgery that the goal isn’t “zero” pain but rather no more than moderate pain that doesn’t interfere with activities needed to facilitate their recovery, such as physical therapy and Activities of Daily Living or ADLs. “I like to remind patients that their procedure was recently only done inpatient and that the surgery itself hasn’t changed a lot,” he says. “We have made great strides in pain management, and techniques such as continuous peripheral nerve blocks are what make same-day surgery possible.”

Although some pain is to be expected, anesthesia providers should work to put patients at ease and remind them of their intentions. “It’s our job to do everything we can to make sure that the pain doesn’t interfere with recovery,” says Dr. Viscusi, adding that a discussion around medication side effects must also take place prior to surgery.

“Many patients will tell you they hate nausea and vomiting and are willing to tolerate some pain for fewer side effects,” he says. “Providers can uncover a lot of important information by specifically asking patients, ‘What are your goals in terms of pain control?’”

Christine E. Whitten, MD, a private practice anesthesiologist and author of the popular anesthesia blog airwayjedi.com, advises facility leaders to remember that pain isn’t just a physical experience for patients, it’s an emotional one, too. In fact, as Dr. Whitten points out, the World Health Organization’s definition for pain is, “an unpleasant emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

Pain in the surgical setting also stems from many sources, another factor that is often overlooked. “When it comes to surgery, most patients are thinking about the incisional pain, but there are many other causes of pain,” says Dr. Whitten, citing deep/visceral, IV insertion and site, tube-related (NG, OG, endotracheal and chest), operational site (dressing, cast) and musculoskeletal (Dr. Whitten says Succinylcholine makes you “feel like you were run over by a truck”) pain as examples of the many sources of strong discomfort related to the surgical experience. She believes that all providers play a key role in preparing for patients for exactly what types of pain-related experiences they are likely to encounter along their perioperative journey, and singles out nurses, the providers who get the most face time with patients, as vital agents in the expectation-setting and education process.

Multimodal is magnificent

The best way to minimize or manage post-op pain effectively? Preoperatively, and the earlier the better, according to Dr. Whitten, who says the more providers do before surgery — such as preemptive analgesia to stave off the development of central nervous system hyperexcitability — to reduce pain will ultimately reduce the time the patient spends recovering in post-op. Multimodal analgesia is another key component of pain management. “It’s more effective than any one medication or therapy on its own because it blocks pain at different sites in the body and nervous system,” says Dr. Whitten. “These sites of action include the brain, spinal cord, peripheral nerves and peripheral nociceptors in tissue.”

Dr. Viscusi agrees with this assessment and goes so far as to say, “The best approach to pain management is multimodal analgesia.” Generally, he says the approach starts with a non-opioid base (NSAIDs and acetaminophen) builds other medications as indicated by the type of pain (quality) and patient characteristics, and incorporates local anesthetics, regional anesthesia, gabapentinoids, ketamine, lidocaine, etc. What about opioids? “Opioids are supplemental or rescue on top of non-opioids,” says Dr. Viscusi. “The great myth is that opioids are the most potent analgesics — they are not. Opioids are just one more option in a multimodal platform.”

Every staff member that touches the patient throughout their surgical journey plays a vital role, and like a good multimodal regimen, a cohesive team-based approach to pain control is paramount. “Teamwork and communication are essential to coordinate effective pre-op, intraop and post-op therapy,” says Dr. Whitten. “Without this, effective pain management simply doesn’t work.” OSM