The Pillars of Post-Op Pain Control

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.