The Pillars of Post-Op Pain Control

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Combining regional anesthesia with the right multimodal drug cocktail keeps patients' discomfort to a bare minimum.


With opioid-sparing protocols firmly positioned as the standard for managing post-op pain, surgeons and anesthesiologists have become masters of multimodal analgesia, perfectly combining a little bit of this and a little bit of that to send satisfied patients home in as little pain as possible. With that in mind, here are the key strategies that should be a part of your facility's pain management efforts.

  • Regional anesthesia. For notoriously painful procedures, nerve blocks — delivered via a single-shot block or continuously through the aid of a pain pump — have become a staple of opioid-sparing techniques in recent years. And for good reason. These blocks provide sufficient analgesia for 24 to 48 hours after surgery and, in some cases, even longer.

That's a critical window for managing post-op pain caused by tissue inflammation following the trauma of surgery. The inflammation maxes out in 48 hours and then rapidly decreases, says Ashish Sinha, MD, PhD, DABA, MBA, FASA, a professor at the University of California Riverside, and designated institutional official and program director of anesthesiology at UC Riverside/Riverside Community Hospital. "If I can block the pain for two days, that's ideal," says Dr. Sinha. "Once the pain is under control, you're able to rehab better."

Opioid usage in the pre- and intra-op phase has a compounding effect. "The more narcotics used in the OR, the more narcotics PACU nurses need to administer during recovery," says Dr. Sinha. Regional anesthesia mitigates this dangerous domino effect and ultimately gets your patients up and ready for discharge more quickly.

When nurses give patients more narcotics, those patients are going to take longer to ambulate and go home, points out Dr. Sinha. "That defeats the entire purpose of managing post-op pain," he says. "Outpatient surgery is based on quick-in, quick-out care."

Not only is regional anesthesia the ideal opioid-sparing analgesic technique for minimizing post-op pain in ambulatory surgery patients, the process itself has evolved significantly in recent years — with virtually everything being done with the precision of ultrasound guidance and newer blocks resulting in speedier recoveries.

LIQUID GOLD There's been a surge in use of IV formulations of drugs such as lidocaine, magnesium and ketamine.   |  Pamela Bevelhymer

Take the adductor canal block, which is becoming ubiquitous with knee surgery analgesia. "Historically, we used to do femoral nerve blocks because it provides excellent pain relief, but it does cause some muscle weakness," says Naum Shaparin, MD, director of pain services at Montefiore Medical Center in the Bronx, N.Y. "The adductor canal block can give patients the pain relief without the same type of motor effect."

Superior, opioid-sparing pain relief isn't the only reason to utilize regional anesthesia whenever possible. If your facility isn't reliant on regional, you could have a difficult time recruiting the top anesthesiologists and CRNAs. "Regional anesthesia is one of the most popular and sought-after fellowships within the anesthesia community right now, so you can expect many more providers with significant subspecialty and fellowship-level expertise to enter the field," says Dr. Shaparin.

  • IV formulations. Combining regional anesthesia with the right multimodal cocktail of non-opioid drugs is a proven way to keep patients' post-op pain at bay. In fact, outpatient facilities are increasingly using IV formulations of many non-opioid medications, says Dr. Shaparin. He points out that IV acetaminophen and three approved IV NSAIDs, as well as ketamine, magnesium and steroids such as dexamethasone (Decadron), are often given to patients undergoing outpatient procedures.

The challenge with these medications, according to Dr. Shaparin, is assessing the individual efficacy of any one medication in multimodal pain therapies because they're typically measured by their combined effect.

"Acetaminophen, lidocaine and steroids are administered at the same time as peripheral nerve blocks, so it's difficult to say which one made more of a difference than the others," he says. Still, the overall effectiveness of the combination is undeniable.

"Collectively, multimodal techniques that include various IV medications and peripheral nerve blocks make a huge difference in controlling pain," adds Dr. Shaparin.

Dr. Sinha has also noticed a recent surge in the use of IV formulations of medications such as lidocaine, magnesium and ketamine. The increased use of ketamine makes sense given its benefits. "It's the only complete anesthetic we have in the sense that it causes analgesia, anesthesia and it does not depress respiration," says Dr. Sinha.

Patients must understand that there will be some pain — and we’ll do our best to manage it as effectively and as safely as possible.
— Naum Shaparin, MD

The unique properties of ketamine make it an ideal medication for certain patients, particularly those with chronic pain or opioid issues. "It's the only anesthetic that works through the NMDA receptors," says Dr. Sinha. "All the other anesthetics work through the GABA receptors."

Because ketamine suppresses NMDA receptors before surgical pain is felt, it has shown great effectiveness at preventing the "wind-up phenomenon" in at-risk patients, adds Dr. Sinha.

  • Patient education. While the exact amount of pain patients will feel following surgery varies greatly from person to person, this much is almost always true: They will experience at least some pain post-operatively. That's why it's critical for surgeons to manage patients' expectations about how they'll feel after surgery. "The first thing I recommend is beginning the conversation as early as possible," says Dr. Shaparin. "Patients need to understand that if they're having knee surgery, they'll be in pain — and we'll do our best to manage it as effectively and as safely as possible."

The mindset in which patients enter the OR on the day of their surgery could ultimately play a role in their recovery, as well. Do everything you can to ease patients' anxiety about the procedure they're about to undergo. This means communicating early and often about everything they're likely to encounter during the surgical process; the earlier you communicate, the better.

"If you're going to place a peripheral nerve block and the patient finds out only on the day of surgery that they'll have a needle stuck into their neck or groin or leg in the pre-op phase, this new information is going to make some patients uncomfortable," says Dr. Shaparin.

At Montefiore, surgeons eliminate uncomfortable surprises by having all patients who will receive a nerve block watch a video about the process before they arrive for surgery.

Fewer opioids, less pain

Ultimately, an effective pain management regimen has a pre-op component, an intraoperative component and a post-op component — and it should include non-opioid analgesics, says Dr. Shaparin. However, while Dr. Shaparin obviously believes narcotic-reducing pain management is important, he makes a key distinction in opioids' role in surgery: "It's important to note that opioid-sparing does not mean opioid-free," he says. "Those phrases aren't the same. We're not trying to eliminate opioids altogether, we're just trying to use less of them."

Thanks to evolving regional blocks and tried-and-true multimodal cocktails, in most cases you can use fewer opioids to effectively manage patients' post-op pain. OSM

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