JOINT DECISION Total knee patients are given adductor canal blocks or femoral nerve blocks, depending on their pre-op condition.

Sounding alarms about the nation's opioid crisis is fairly easy. Solving it is turning out to be a lot harder. The current epidemic demands that you take a hard look at how effectively your surgical team is using multimodal post-op pain management to limit the use of addictive painkillers. Do your part to stop the overprescribing of opioids and you'll soon realize that the right mix of analgesics, regional anesthesia and continuous nerve blocks helps send joint patients home sooner, healthier and happier.

The main elements
Our multimodal perioperative pain protocol for shoulder arthroscopy — widely considered to be one of the most painful outpatient procedures — decreases the need for opioids and improves recoveries. Regional anesthesia is a key ingredient in the multimodal protocol. Most shoulder arthroscopy patients receive a brachial plexus nerve block with or without general anesthesia. Additional elements include pre-operative acetaminophen (1 gram every 8 hours) and gabapentin (starting with 300 mg 3 times a day); intraoperative ketorolac; and post-operative oral acetaminophen, gabapentin and ketorolac, with oxycodone as needed for breakthrough pain.

The dosage regimens are standard, but we provide enough wiggle room to accommodate significant variability. For example, an opioid-naive patient may do fine with a single-shot regional anesthetic or a regional block plus the multimodal analgesia. But you'd want more prolonged pain control with a patient who's been treated for opioid addiction, so we might opt for an ambulatory catheter and a continuous nerve block that lasts as long as possible.

With our multimodal shoulder arthroscopy protocol, patients have significantly better pain scores after 24 and 48 hours and significantly better quality of recovery scores at 24 and 48 hours and at 1 week, compared with equivalent patients before we instituted the protocol. Additionally, their total oxycodone requirements for breakthrough pain were less than half of what other shoulder patients required. Finally, their average PACU stays were reduced by about 20 minutes, to just under 2 hours.

BUILDING BLOCKS Regional anesthesia is the foundation on which multimodal protocols are built.

By reducing time in the PACU as well as length of stay and readmissions, we're already saving money, and we expect to save much more in the long run.

We have a 23-hour protocol for total joint replacements, but plan to start performing same-day total joints in 2019. We're working toward putting in place all the elements that will set us up for success once we decide to make that move, and we know that pain control is a primary consideration.

Currently for total knees, we use a combination of local infiltration and multimodal analgesia, as well as regional anesthesia and continuous catheters. Most patients receive adductor canal blocks, because they target the saphenous nerve and help preserve quadriceps strength, along with ultrasound-guided injection of local anesthetic behind the knee (the interspace between the popliteal artery and the capsule of the knee, or "IPACK" block). But for patients with chronic pain issues, we typically use femoral nerve blocks, which sacrifice some muscle function but which have been shown to reduce opioid requirements.

We also usually give patients with continuous catheters elastomeric pain pumps, but we'll consider providing "smart" pumps if we feel patients would benefit from having a bolus option. The downside of smart pumps is the alarm functions that may lead to unnecessary phone calls. Patients have also complained that they're noisy and may disturb sleep.

Our protocols for hip arthroscopy and ACL repairs use similar elements to those we use in the multimodal protocols for other procedures.

Making it work
As our multimodal protocols have evolved, we've learned several valuable lessons:

Flexibility is key. Minimizing variability in health care is an important goal, but we found that one-size-fits-all approaches don't work. Multimodal protocols need to be more like large umbrellas under which you can accommodate the experiences, education and preferences of surgeons and other members of the patient care team. For example, one surgeon doing a rotator cuff repair might be very cautious about using NSAIDs, while another might use them very liberally. As anesthesia providers, we may be able to support or refute whether certain analgesic agents have advantages or disadvantages, but we can't simply ignore personal preferences.

Similarly, the umbrella has to be large enough to account for variability among patients. Two patients may be having exactly the same procedure, but if one is opioid na??ve and the other has been treated for addiction to opioids and is currently on buprenorphine, you have to be able to tailor your approaches accordingly.

TEAM EFFORT To develop optimal protocols, anesthesia providers need to work with surgeons, physical therapists, pharmacists and nurses.

Everyone's input matters. Developing optimal protocols requires a coordinated effort on the part of all stakeholders, not just anesthesia providers. To develop effective protocols, your anesthesia providers need to step outside the OR and reach out to administrators, surgeons, physical therapists, pharmacists and nurses, so the entire patient care team can tailor the overall pain management pathway to meet the unique goals of everyone involved.

For example, my goal as an anesthesiologist is to keep patients comfortable and as pain-free as possible. But patients also need to be functional after 6 or 8 weeks. So I work very closely with our physical therapists, and I understand what they consider to be desirable outcomes. As such, if we're doing an arthroscopic release of a frozen shoulder, we have an agreement that these patients are scheduled as the first case of the day and that they begin physical therapy on the day of surgery and continue on postoperative days 1 and 2.

Why? Because the more aggressive the physical therapy is, the more range of motion they're going to have in those initial therapy sessions, which, in theory, can reduce the chance that adhesions will re-form down the road. So we're working together. The therapists can be more aggressive, because patients are relatively comfortable with their regional nerve blocks, but they also have to understand that patients aren't going to be at full strength, because our protocol allows patients to go home with ambulatory catheters.

Starting slow is best. As we've been implementing our protocols, we've also learned that change often involves overcoming some resistance. That's why we always start each protocol with a pilot program involving 20 or 30 patients, and we set parameters and desired outcomes ahead of time. In addition to opioid reduction, we measure length of stay, pain scores, readmissions and any other complications that happen within 30 days. Positive outcomes help get buy-in from everyone involved as we move forward with implementing the protocols.

The big payoff
The beauty of creating multimodal protocols is that once they're up and running, all you have to do is plug patients in. We've created tools in our EMR that allow patients to answer simple yes-or-no questions in the surgeon's office, and thereby establish whether a given patient is a candidate for a given protocol.

Once the protocols are established, every provider knows exactly what's expected, and anybody who opens that patient's chart will have all the needed documents and information in hand to be able to follow the proper steps.

Fine-tuning your protocols takes effort and time, but after that, it's just a matter of having all the parties involved touch base every few months, review the data and talk about how well the clinical pathways are working and whether any tweaks might be appropriate. OSM