ORX Awards 2021 - Pain Control - ERAS Is Everything

Multimodal pain management — a dedicated focus area practiced by a collaborative team of surgeons, anesthesiologists and nursing staff — is a critical part of the bustling total joints program at Constitution Surgery Center East in Waterford, Conn. As part of the multimodal program, each joint replacement patient is required to attend a two-hour education program designed to prepare them for every phase of their surgery.

“Part of their preparation involves introducing our pain management program and explaining how it works,” says Robert Taylor, RN, BS, the clinical director at Constitution. “We’ve replaced the joints of 300 patients so far this year, all of whom have ambulated to their cars upon discharge because of proper pain management and effective neuromuscular blockades,” he says.

The facility is always looking for ways to improve its pain control efforts and just recently added another weapon to its analgesic arsenal: cryoneurolysis. The treatment involves percutaneously guiding a closed probe next to a nerve. Carbon dioxide or nitrous oxide is sent to the probe’s tip, where it creates an ice ball that encompasses and disables the targeted nerve. Select total knee replacement patients receive the treatment before surgeries — most 30-days prior, but some 10 to 15 days pre-procedure — to reduce their pain and optimize their physical status for surgery. “We just added this technology, and we’re doing around 20 treatments per month,” says Mr. Taylor. “It’s been working really well.”

The latest addition to the surgery center’s multimodal, team-based approach to pain management has had a profound effect on lowering the heavy reliance and dependence on opioid use as the first line of post-op pain control. As surgical leaders everywhere can attest, reducing opioid usage and dependence is a must in today’s outpatient surgery climate. “Mastering multimodal pain management is the key to success for any facility with an orthopedic specialty and a total joints program,” says Mr. Taylor.                    

— Jared Bilski

Time and again, PACU nurses at North Scottsdale (Ariz.) Outpatient Surgery Center expect patients to emerge from surgery with breakthrough pain or PONV, and time and again, those complications simply don’t occur. Andrea Sinon, BSN, RN, CNOR, the nurse administrator at the facility, attributes much of this success to Heather St. Peter, MD, an anesthesiologist staff refer to as the “Multimodal Master.”

“It’s extremely rare for Dr. St. Peter’s patients to experience pain or PONV in the PACU,” says Ms. Sinon. “When she hears about a patient who is at high risk for PONV, she takes it as a personal challenge to prevent the complication and often says, ‘I’ll see you in the PACU.’ It’s her way of saying, ‘Let’s see about that PONV.’”

Her patients not only wake up pain- and nausea-free after surgery, they also generally feel “wonderful,” which leads to sky-high patient satisfaction scores.

Before surgery, Dr. St. Peter’s patients are given a small sip of water and oral acetaminophen (1,000 mg), celebrex (200 mg) and, if they are transferring to an overnight facility, gabapentin (600 mg). Transversus abdominis plane (TAP) blocks provide targeted relief, but Ms. Sinon credits an injection given intraoperatively as the key to pain-free outcomes. “Dr. St. Peter gives patients an intramuscular injection of 50 mg Demerol and 12.5 mg Phenergan,” she says. “It’s the secret sauce that keeps patients coming to recovery feeling great.”

While Ms. Sinon says the Multimodal Master rightfully deserves the lion’s share of the credit for her facility’s analgesic achievements, she’s also quick to point out that North Scottsdale’s pain control success is a total team effort — something that’s apparent by the many personalized messages of thanks written to members of the care team on patient satisfaction surveys.

— Jared Bilski