Next-Level Pain Management From Pre-op to Rehab and Recovery

Share:

Anesthesia providers share extended pain block strategies and keys to opioid-free recovery for same-day surgery patients.

George Dugan, CRNA, RN, an anesthesia provider for Temple University Health System in Philadelphia, is no stranger to pain. His patients frequently suffer for months and sometimes even years before agreeing to a surgical intervention. “You meet so many people who tolerate daily pain for long periods and forego surgery until they can’t take it anymore,” says Mr. Dugan.

A contributing factor to these patients’ reticence is their fear of postoperative pain. Mr. Dugan himself put off a much-needed total knee replacement (TKR) for years despite declining mobility.

“The daily pain was tolerable with acetaminophen and aspirin,” he says. “Plus, I knew all about the recovery time and potential pain that goes along with a TKR. After all, the surgeon is screwing a titanium prosthetic into your femur.” Some patients opt out of getting surgery on the other knee because of the pain and discomfort they experience the first time around.

Fateful meeting

In 2023, Mr. Dugan went out one evening with friend and former colleague Armen Voskeridjian, MD, director of anesthesiology for the Jefferson Surgical Center at the Navy Yard in Philadelphia. “Armen told me all about a series of blocks for the genicular nerves surrounding the knee that he’d been using for ACL surgeries,” recalls Mr. Dugan. “He guaranteed me five to 10 days pain-free.” Mr. Dugan had assisted Dr. Voskeridjian on OB and trauma surgeries at Albert Einstein Medical Center’s Level 1 trauma center more than a decade earlier. “Armen trained himself on how to do ultrasound-guided regional anesthesia, which tells you how hungry he is to learn. I decided right then that I was ready to get my knee fixed so long as he could be my anesthesiologist,” says Mr. Dugan.

As luck would have it, Dr. Voskeridjian was still credentialed at the surgery center where Dugan wanted his knee replacement done. The anesthesiologist knew the surgeon and contacted him. With some shuffling of his schedule, Dr. Voskeridjian was able to provide anesthesia service for his friend’s surgery.

Test theories, share results

“I’m a firm believer in questioning orthodoxy and putting your theories to the test,” says Dr. Voskeridjian, who has co-authored several peer-reviewed, double-blinded studies on pain management techniques. “For the past couple of years, we’ve been getting great results using adductor canal blocks (ACBs) and the interspace between the popliteal artery and capsule of the posterior knee (iPACK) blocks for ACL surgeries. For an ACL, using an ACB is preferable to a femoral nerve blockade because it doesn’t knock out the quadriceps, which can delay recovery and the patient’s ability to start physical therapy.” Dr. Voskeridjian has added a third infiltration — one that he discovered — to the ACB and iPACK, above the sartorius muscle, that further improves pain control.

Targeting multiple pain pathways around the knee for a more effective block isn’t the whole story. Soon after starting at the Navy Yard in January 2020, Dr. Voskeridjian began mixing dexamethasone, a steroid adjutant, with 30mL of ropivacaine to stretch out the duration of his blocks. He points to various studies in recent years, including his own, showing that steroids such as dexamethasone are effective beneficial adjuvants for pain management.

These days, he uses liposomal bupivacaine instead of ropivacaine because of its longer duration and higher safety profile for the heart. “It’s much easier to use and it’s just a single injection with no need for bulky and technically challenging catheter placements,” says Dr. Voskeridjian. “You get at least 72 hours of coverage after surgery.” That’s the critical and notoriously difficult window when surgical patients often turn to prescription opioids for breakthrough pain.

Dr. Voskeridjian’s willingness to experiment with multimodal formulations and administer multi-nerve blocks has produced longer pain blockage for the surgeries he and his team at the Navy Yard handle compared to a few short years ago. “Our patients are going five to seven days pain-free following knee surgeries,” he says. “For Achilles tendon tears and other kinds of lower-tier injuries, it’s as long as seven to 10 days. My theory is lower extremity nerves are more sensitive to local anesthetics.”

Dr. Voskeridjian promised Mr. Dugan somewhere between five to 10 days of no pain following his surgery. As it turns out, he underpromised and overdelivered. “I went 16 days pain-free and was walking four hours after surgery,” says Mr. Dugan. “I took two oxycodones after the block wore off but probably could’ve done without them entirely.”

A friend of Mr. Dugan’s who had his knee replaced around the same time didn’t fare nearly as well. “His pain was so severe that he took his entire three-week supply of oxycodone in one week,” he says.

Lessons learned

OAM-nurse
SIGNAL STOPPER Customized nerve blocks and multimodal anesthesia are a combination that stops pain on multiple fronts.

Dr. Voskeridjian is willing to test his hunches for the sake of patient efficacy. Most if not all his best practices reinforce the Navy Yard anesthesia team’s Minimal to No Opioid mission. Here are some steps he and his team follow for patients from pre-op to post-op to rehab and recovery.

Dr. Voskeridjian starts every patient on a schedule of oral acetaminophen the day before surgery. His patients also get it the morning of surgery and intravenously during surgery. In a randomized clinical trial he conducted with orthopedic surgeon Joseph Abboud, MD, senior vice president of clinical affairs at the Rothman Orthopaedic Institute in Philadelphia, patients who received 1000 mg of acetaminophen orally every six hours for one day prior to and after surgery took significantly fewer narcotics overall and reported significantly better overall pain control.

Asking patients to rate their standard level of pain, as any medical professional knows, can be very subjective. Follow-up questions help Dr. Voskeridjian get a more accurate picture of the patient’s day-to-day pain. “If a person says they’re at an eight out of 10, I might challenge them,” he says. “‘Your vital signs look pretty good. Are you sure your pain is that bad?’ The patient might reevaluate and say, ‘Yeah, you’re right, it’s more like a five.’”

Dr. Voskeridjian advocates the use of customized nerve blocks and multimodal anesthetics and analgesics to reduce surgical patients’ pain. “Utilizing nerve blocks is always preferred preoperatively,” he says. “Regional anesthesia is proven to improve pain results and reduce opioid use. Infiltrations of a local anesthetic by the surgeons also help, especially when they’re not requesting a block.”

After a surgical procedure, patients almost always want to know if it’s safe to resume an activity and how long they need to wait.

“I tell them just about anything they can do to get up and move around,” says Dr. Voskeridjian. “If they ask for pain adjuvant control therapies, I might suggest yoga, acupuncture, meditation or walking. The mind-body connection is just huge for recovery.”

He follows up with a text or phone call within days of surgery from his personal phone, not an office line. Some of his peers think that’s a bad idea, but he wants patients to be able to contact him.

If it were easy...

Despite the advances in anesthesia care since 2000, pain management for ASC patients still has room for improvement. Close to a third of same-day surgery recipients report moderate to severe pain following their procedures, with pain levels spiking on the second day post-op, according to a 2022 analysis which examined 40 studies on the topic.

What can ASCs do better to alleviate pain? Mr. Dugan recommends surgeons learn more about blocks from experts, then practice the blocks over an extended time period.

Dr. Voskeridjian agrees. “Surgeons must want to learn about the most effective blocks in use, but anesthesia must be the driving force doing the educating on pain control and relief,” he says. Administrators need to understand that high-quality pain care isn’t cheap. Catheters leak and are expensive to maintain, and multimodal drugs are expensive. But while the upfront costs are high, the payoff in providing patients with a low-pain, opioid-free path to recovery is tough to argue with. OSM

Related Articles

Lessons Learned From a Renowned Team Physician

As a well-known team physician for not one but two professional Chicago franchises — the Bulls and the White Sox — Adam Yanke, MD, PhD, sees his fair share of non-athlete...

No Muss, No Fuss for Hand and Wrist

In the world of hand and wrist surgery, the Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique has revolutionized both pain management and the patient...