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BUILDING BLOCKS Regional anesthesia has played an important role in the migration of more complex ortho cases to the outpatient setting.Effective drug therapies and pinpoint nerve block placement keep patients' knees from throbbing and shoulders from aching after some of ortho's most pain-inducing procedures. Managing post-op pain and limiting PONV risks are essential to maintaining clinical efficiencies, patient satisfaction and overall surgical success. Here's how we keep your patients comfortable, from the moment they arrive to the time they're ready for discharge.
Pre-op prescriptions
Patients are prepped and ready for surgery about an hour before undergoing involved procedures such as ACL or shoulder repairs. They receive 200mg of celecoxib and 650mg of acetaminophen. An important note: Aspiration risks increase if the drugs are given less than an hour before the procedure's start time. These patients also have nerve blocks placed. (Most aren't sedated before block placement, but those that are receive 1mg of midazolam.) One of the biggest contributors to the evolution of outpatient orthopedics is the growing popularity and use of nerve blocks to control patients' discomfort.
POSITIVE IMPACTS
Less Pain, More Gain
Uncontrolled pain sparks a cascade of negative consequences:
- Patients in pain receive more narcotics, which increases PONV risk.
- Nauseated, sick patients stay in PACU longer, which slows down your case schedule and limits the amount of procedures you can host in a day.
- And it doesn't end there. Patients in discomfort after surgery are dissatisfied with the care they receive and less likely to ambulate post-operatively, which increases deep vein thrombosis risk in the long term.
- More immediately, patients with uncontrolled post-op pain might have to go back on oxygen, or can suffer drops in blood pressure or atelectasis of the lungs.
- Patients who never get ahead — and stay ahead — of their post-op pain can't rest fully at home during their convalescences, which delays the healing process, stiffens joints and ultimately results in poor overall outcomes.
On the other hand, an effective pain-control regimen increases patient satisfaction. Patients are amazed at having surgery and moving throughout the facility essentially free of pain. That's a huge psychological boost. They'll tell their friends that your facility manages pain well, and word will spread about the quality care you provide.
Comfortable patients also don't linger in recovery, leading to increased efficiency and case throughput. If the last patient of the day can be discharged ahead of or on schedule, you'll be able to send some staff members home and avoid overtime hours.
— Greg DeConciliis, PA-C, CASC
When performed effectively, nerve blocks essentially eliminate pain throughout the surgical procedure and immediately post-operatively, usually for 24 hours, and sometimes for up to 48 hours. The most important benefit of regional blocks, however, occurs during procedures, when getting ahead of patients' pain lets anesthesia providers potentially eliminate narcotic use altogether. Patients who receive nerve blocks do remarkably well after surgery, and limiting or eliminating narcotic use leads to less PONV.
It's also amazing how efficiently patients with effective nerve blocks move through the facility. They receive fewer pain medications, have virtually no PONV and enter PACU close to pain-free. They're therefore up and eating and drinking soon after leaving the OR, move quickly to step-down recovery, meet with loved ones (a definite patient satisfier) and are discharged to home in a timely manner. Patients are also coherent and comfortable when listening to post-op instructions, which leads to better at-home care.
IN THE FLOW Fluid balance in patients allows for more effective drug metabolism.Patients with histories of PONV or high-risk warning signs receive scopolamine patches in pre-op. We closely monitor their fluid levels and keep them in constant balance. We notify our anesthesia providers of the increased PONV risks so they can limit narcotic use, give anti-emetics ondansetron or dexamethasone prophylactically and deliver fluids liberally.
Fluid imbalance in patients is a big issue that can heighten PONV risk — adequate fluid balance allows for more effective drug metabolism, which contributes to lower required doses of pain medication, and therefore less PONV. In high-volume ortho facilities like ours, where things run on time and efficiency is key, patients are prepped and brought to the OR in short order. Pre-op nurses must be aware of this, and flow IV fluids generously. Anesthesia providers and PACU nurses must also understand the role fluid balance plays in staving off PONV, and allow for fluids to flow liberally for the entirety of patients' stays.
MIND GAMES
Does Mental Makeup Predict Pain Perception?
Patients' mental health influences how much pain they experience following knee and hip replacement surgery, according to a pair of studies presented at the 2012 annual meeting of the American Academy of Orthopaedic Surgeons.
In one study (tinyurl.com/ajsjfo8), researchers surveyed 97 patients who were about to undergo total knee arthroplasty to assess their anxiety levels when faced with stressful events such as surgery, their typical levels of anxiety and their potential for "catastrophizing" — an extreme response to stress that manifests in rumination, magnification and perceived helplessness.
After measuring pain scores in patients for 7 days after their surgeries, the researchers discovered that catastrophizing did not influence how much pain patients experienced. However, men with anxiety traits experienced high levels of post-op pain that extended their hospital stays during recovery. Anxiety wasn't an accurate predictor of post-op pain in women, according to the study, which notes women experienced higher post-op pain than men and were generally less satisfied with the level of pain control they received.
In a second report (tinyurl.com/aws2vaa), researchers examined approximately 1,650 patients who took antidepressants up to 3 years before undergoing hip replacement surgery. Patients who took antidepressants reported greater pain and dissatisfaction with their surgeries' results, according to surveys given to patients before the surgeries and at 1 year post-op.
— Daniel Cook
OR offerings
We pre-anesthetize patients, if appropriate, with propofol and gas (preferably desflurane or, alternatively, isoflurane). We administer fentanyl or ketorolac to help control pain. For patients who need narcotics but haven't received a prophylactic anti-emetic dose, we'll often give 1mg of hydromorphone along with ondansetron or dexamethasone.
Techniques surgeons use play important roles in helping to control patients' post-op pain. Their pre-incision injections of bupivacaine or a lidocaine-bupivacaine mix pre-anesthetizes the surgical site, helping tremendously to complement a nerve block's efficacy. Additional bupivacaine can be delivered safely in the OR because less amounts of the drug are delivered during initial image-guided nerve blocks. Pre- and post-op injections into joint areas are also extremely effective for patients who don't receive nerve blocks before, for example, straightforward knee scopes or carpal tunnel procedures.
REGIONAL ANESTHESIA
Nerve Blocks' Essential Elements
Here are a few key factors that contribute to effective nerve block placement.
1. Trained professionals. Some anesthesia providers are better than others at placing blocks, so ensure you're working with professionals properly trained to employ the latest techniques and technologies. Suggest that providers interested in launching a regional program — or improving their current skills — take continuing education courses or seek out training by an expert peer.
Why do the regional skills of your providers matter? Patients suffer psychologically and physiologically when ineffective blocks are placed. First, they were stuck once and the block didn't take — an unnecessary stressor during an already stressful time. Second, and most importantly, they'll experience pain. The more medication needed to eliminate patients' pain once they've perceived it, the greater the PONV risk and the longer the recovery stays.
2. Ultrasound guidance. Anesthesia providers expert in placing blocks with nerve stimulators may argue this point, but in my opinion, image-guided regional anesthesia is now the standard of care. Ultrasound imaging technology lets providers more easily locate targeted nerves and inject the anesthetic around them more accurately, potentially leading to better blocks with less anesthetic administered.
Using smaller doses of medication during block placement is key to overall pain-control efforts. If providers inject less bupivacaine to place a block, surgeons can supplement more of the drug at the surgical site during surgery. (Many of our surgeons pre-inject bupivacaine or a lidocaine-bupivacaine mix around the intended surgical site, which improves pain control, leads to lower narcotic use and, therefore, less or less severe PONV.
3. Staff assistance. The perioperative team should help out anesthesia providers with nerve block placement, if possible. They should prepare the medications and block area so providers can perform blocks efficiently without delaying the case schedule — a common complaint and misconception of volume-driven surgeons.
— Greg DeConciliis, PA-C, CASC
SOFT TOUCH Minimally invasive techniques and pre-incision injections around the surgical site limit post-op pain.PACU pearls
Recovery nurses give patients warmed blankets, elevate the joints that were operated on (if possible) and place ice packs on the operative area. Patients are urged to sit up and interact with friends and family as soon as possible so they're inspired to head home.
The medications patients receive during surgery certainly contribute to PONV, but what they're given in PACU also factors into the risk equation. Nurses try to avoid giving IV pain meds to patients who received effective nerve blocks and are PONV-free in recovery, which gets them up and eating and drinking quickly, and ready for less powerful oral meds to control break through pain.
Patients in discomfort are given fentanyl only — we almost never administer morphine or meperidine, which are associated with increased PONV and worse overall outcomes. Patients may receive first- and second-line-of-defense anti-emetics: ondansetron or dexamethasone. Ephedrine is a third-line treatment option if patients' blood pressure levels are acceptable.
Our anesthesiologists do a terrific job of controlling pain. Most patients come to the PACU with pain scores of less than 5 on a 10-point scale, and leave with scores of less than 3.
Ahead of the curve
Effectively controlling post-op pain and PONV will keep you on the cutting edge of surgical care. ACL repairs and complex shoulder cases were inpatient procedures no more than a decade ago. Both are now mainstays of outpatient orthopedic centers. More minimally invasive surgical techniques contributed to this evolution, but don't discount the role improved pain control plays in letting you perform more involved outpatient procedures.
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