BUILDING BLOCKS Regional anesthesia should be the foundation in your multimodal pain management plan.

Orthopedic procedures hurt. A lot. Zeroing in on a pain management plan that lets patients recover quickly is essential to positive case outcomes. When it comes to sending patients home comfortable and happy after joint repairs and replacements, keep these 5 key points in mind.

1. Opioids aren't the answer
While opioids are the old favorite, multimodal plans that combine analgesic medications with different mechanisms to provide additive or synergistic effects are especially effective for orthopedic procedures. Plus, by reducing opioid use, you reduce opioid-related adverse events that slow down patients' recoveries.

The goal of a good multimodal plan is to reduce the use of opiates to the role of a rescue drug. Opioids have many well-known, unwanted side effects. They may seem like a "cheap" and easy option to treat pain, but they can come with additional unseen costs — such as longer PACU stays. This is especially true in the aging patient population.

Instead of relying on opioids, the best pain control cocktail will likely include a mix of antipyretics (acetaminophen and nonsteroidal anti-inflammatories), glucocorticoids (steroids), alpha-2 adrenergic agonists (dexmedetomidine and clonidine), gabapentin-type drugs (pregabalin and gabapentin), N-methyl-D-aspartate (NMDA) antagonists (ketamine, magnesium, methadone and dextromethorphan) and local anesthetics.

2. Consider newer, non-opioid options
While acetaminophen, NSAIDs and steroids are common in multimodal plans, recent studies have looked at the benefits of newer non-opioid analgesics — like pregabalin, gabapentin and ketamine — for orthopedic surgery, particularly for spine and total joint procedures (see "What's In Your Pain Control Arsenal?").

These studies have suggested that the use of gabapentin-type drugs pre-operatively can help orthopedic patients decrease post-op pain and opioid consumption. Researchers in one study found that patients who received 300 mg of pregabalin before undergoing total hip arthroplasty had reduced pain and morphine consumption in the first 24 hours after surgery. This was coupled with a multimodal plan that included 1 g of acetaminophen pre-operatively and post-operatively, spinal anesthesia intraoperatively and morphine PCA post-operatively.

A LAYERED APPROACH Consider using nerve blocks in addition to oral medications for painful procedures like ACL repairs, suggests Sylvia Wilson, MD.

In addition to pain relief, these drugs have also shown signs of improving movement following orthopedic surgery. In one randomized study, patients were given 600 mg of gabapentin pre-operatively and 0 mg, 100 mg, 200 mg or 300 mg of gabapentin post-operatively. They also were given celecoxib, femoral and sciatic nerve blocks, and spinal anesthesia. Researchers found that those given gabapentin had improved knee flexion and decreased opioid consumption, compared with those who didn't. Similar results were found in another study that looked at patients undergoing ACL repairs.

For total joint repairs, ketamine has also been shown to be effective. When patients received ketamine intraoperatively while undergoing total knee replacement, researchers found they had decreased morphine consumption, decreased pain scores at both rest and movement, and improved knee range of motion.

It should be noted that decreasing pain doesn't always mean increasing dosage. In one study, patients undergoing lumbar discectomy were given 0 mg, 300 mg, 600 mg, 900 mg or 1,200 mg of gabapentin 2 hours before surgery. Researchers found those who received less than 300 mg consumed more fentanyl post-operatively than the other groups. However, those who received the 900 mg and 1,200 mg doses didn't consume fewer opioids than the 600 mg group, but they did experience more side effects. This has led many facilities to use 600 mg of gabapentin as an optimal pre-op dose for post-op pain relief.

3. Regional anesthesia is a great foundation
Regional anesthesia is an important element — if not the foundation — for multimodal analgesia in orthopedic procedures. Since general anesthesia can prolong recovery times, your providers should use regional anesthesia as the primary anesthetic or post-op analgesia whenever plausible.

Nerve blocks should especially be considered for painful lower extremity procedures such as ACL repairs and foot and ankle cases — though make sure you also look at individual patient factors and fall risks for these cases. While single injection nerve blocks may provide adequate analgesia as patients transition from your facility to their homes, ambulatory catheters can extend analgesia for several days.

Anesthesia providers are using these continuous peripheral nerve blocks more frequently as complex orthopedic procedures, like total joints, move to the outpatient setting. Placing peripheral catheters and starting local anesthetic infusions can add additional costs to your cases, but they can also potentially create savings by shortening PACU stays and keeping patients from being readmitted for uncontrolled pain.

Further, reported complications for continuous peripheral nerve blocks are rare — reported infection rates are less than 1% and doses are controlled so local anesthetic toxicity doesn't seem to be an issue. However, as mentioned above, falls do pose a risk. Make sure you carefully select patients who will receive lower extremity blocks and educate them on preventing falls.

It's important to couple regional anesthesia with oral medications to prevent rebound pain. A patient who receives a 12-hour block may feel great when he first heads home, but as the block wears off, the pain can send him on a late-night trip to the ER. Instead, instruct patients to start their medication regimen while the surgical site is still numb, making the transition from blocked to sensate extremities more comfortable.

MULTIMODAL MEDS
What's In Your Pain Control Arsenal?

FROM ALL ANGLES Attack pain along multiple pathways to optimize patient comfort.

Studies have shown that using a combination of medications can help keep patients comfortable after notoriously painful orthopedic procedures. Here are the big players to keep in mind:

• Acetaminophen and NSAIDs are commonly used following orthopedic surgery, both individually and combined. Acetaminophen/paracetamol alone can provide acute post-op pain relief for up to 4 hours in some patients, with few side effects. As a sole analgesic, NSAIDs are more effective, but they come with concerns for bleeding, ulcers or renal dysfunction. Additionally, there have been some questions over whether NSAIDs affect bone healing — though systematic reviews of spine fusion have shown no negative effects.
  One common solution is to use a combination of the 2 medications so NSAIDs are used for a shorter amount of time or at a reduced dose. This also can improve pain relief: A 2010 study suggested the combination of paracetamol and NSAIDs may provide superior analgesia to either medication alone.
• Glucocorticoids are commonly used to improve analgesia and prevent post-operative nausea and vomiting. Because of this, they can help patients recover quickly after surgery. For example, a single intraoperative dose of dexamethasone has been associated with reductions in pain, opioid consumption and PACU stay. Studies have also suggested that steroids don't impact infection rates or delay wound healing.
• Gabapentin-type drugs include gabapentin and pregabalin, which can reduce pain caused by damage to the nerves during surgery. Studies have shown that patients who receive these drugs preoperatively often have less opioid consumption and decreased pain following surgery. Plus, they seem to work particularly well for orthopedic procedures.
• NMDA receptor antagonists are becoming more popular in outpatient procedures. Ketamine in particular has been shown to work well for patients with chronic pain and opiate dependence. In one study, patients with chronic pain who received ketamine intraoperatively reported decreased post-op pain intensity and morphine consumption compared with those who didn't. Even more surprisingly, these patients reported that these numbers remained low at 6 weeks post-op, despite also reducing their opiate consumption over that time.

— Sylvia H. Wilson, MD

4. Don't forget the ice
One cheap, easy, safe — and underrated — way to reduce pain and inflammation is by using cryotherapy, or cold therapy. Cryotherapy has been studied and used extensively in sports medicine to minimize the swelling and inflammation that usually result in pain. It can also help get patients moving faster. Studies have shown that the use of cryotherapy can improve passive motion and knee flexion 1 week after ligament repair.

Including cryotherapy in your pain management plan can be as simple as using ice packs, though there are specialized devices designed to stay colder longer for patients recovering at home. Some of these devices also compress the area while cooling it, which, evidence suggests, may further improve analgesia.

5. Understand the risks
All medications must have a risk-to-benefit ratio. While most providers are aware of common concerns for acetaminophen (liver dysfunction) and NSAIDs (renal disease, ulcers, bleeding), fewer are familiar with gabapentin-type drugs and ketamine.

Gabapentin-type drugs can be associated with increased somnolence and should be avoided in patients with high BMIs or known obstructive sleep apnea. Additionally, they may cause confusion in the elderly, although this can be difficult to distinguish from opiate-related confusion. Also, both NSAIDs and gabapentin-type drugs should be avoided if renal disease is present in the patient.

Although ketamine is a still a fairly new medication to outpatient surgery, it has received a great deal of press for its efficacy in small analgesic doses for procedures in the emergency department. While it has very few contraindications, it must be emphasized that it is small, analgesic doses — not large, anesthetic doses — that are needed for an adequate result.