3 Key Advances in Post-op Pain Management

Pain Management

By: Jared Bilski

Published: 4/24/2020

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New tools focus on providing targeted analgesia with fewer opioids.


The opioid epidemic has forced frontline providers, clinical researchers and even patients to think about better ways to manage post-op pain. It’s no easy task. Ask 10 different patients who underwent the same procedure about their level of discomfort, and you might get 10 different answers. That’s why new approaches to keeping patients comfortable after surgery must be based on knowing how much they’re hurting.

1. Quantifiable scores

Innovations in pain monitors offering the promise of a reliable, objective system for measuring and monitoring pain could soon be a reality. Anis Dizdarevic, MD, the director of regional anesthesia and acute pain medicine at Montefiore Medical Center in the Bronx, N.Y., says pain monitors employ the analgesia nociception index (ANI) and nociception level (NoL) index. These measurements are based on capturing changes in different parameters such as heart rate, respiratory rate, sympathetic tone and parasympathetic tone, and providing a number or “index” that represents the patient’s level of nociception — the sensory nervous system’s response to harmful or potentially harmful stimuli.

Essentially, pain monitors take into account the physiological factors that are affecting patients under anesthesia, put them into an algorithm and provide an accurate reading of the level of pain they’re likely to be in — and the corresponding level of analgesia they’re likely to need. Compare that to the current level of pain “monitoring,” which involves providers looking for variations in a single parameter.

“They may see an elevated blood pressure, while all other readings are stable, and treat that blood pressure thinking the patient is in pain,” says Jacob Hutchins, MD, MHA, executive medical director of M Health Fairview ASC in Minneapolis. “But if the patient’s baseline blood pressure was [the only parameter that was] elevated, it’s unlikely they’re in discomfort.”

He believes pain monitors can help to eliminate those misconceptions by incorporating patient data into a single number, which providers can use to guide their pain management interventions

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Dr. Hutchins, who points out biotech and pharma companies are focusing on developing effective ways to manage pain, sees the opioid crisis as a catalyst for bringing pain-monitoring devices to market as quickly as possible. Dr. Dizdarevic agrees. “Entire sections of tech companies like Google and Apple are devoted to healthcare innovation and patient monitoring, so I believe different versions of these monitors will be available in the next five years,” he says.

2. Extended relief

Objectively identifying the source and intensity of a patient’s pain will help providers choose the most effective modalities to treat it. Advances in pain pump technology are allowing more providers to employ continuous peripheral nerve blocks to accurately target the specific source of pain and provide days of extended relief — all while decreasing the need for post-op opioid prescriptions.

The relief cryoanalgesia can provide allows patients to better prepare for their upcoming joint replacement surgery.
— Jacob Hutchins, MD, MHA

While the benefit of having a guaranteed means of extending the relief from a nerve block can’t be understated, there are other considerations that factor into the decision to send patients home with a continuous catheter and pain pump as opposed to relying on a single-shot block.

“There’s the increased cost of using the catheter, the procedure itself takes a little bit longer to perform, and there’s the setup and equipment that the patient has to carry around,” points out Dr. Dizdarevic.

Catheter migration can also be an issue. “The catheter displacement rate is between 20% and 30%,” says Dr. Hutchins. “You may achieve a great catheter placement initially, placing it in the perfect spot, but it can move over time to where the patient stops receiving the numbing effects of the analgesic.”

Unlike error-prone designs of previous generations of pumps — which surgeons were reluctant to send patients home with due to concerns about leaks, kinks and failure — today’s pumps are durable, user-friendly and, of course, effective. Patients appreciate receiving pumps that let them self-administer a bolus of medication, a simple benefit that helps them feel like they’re regaining control of their own care after relinquishing it on the day of surgery.

Advanced pain pumps give providers confidence to administer denser blocks. They also let patients “top themselves off” if post-op pain becomes unbearable or reduce the infusion rate if they don’t like the feeling of numbness at the surgical site.

3. Nerve freezing

IN CONTROL Patients appreciate the ability to give themselves a bolus of medication to treat breakthrough pain.

Cryoanalgesia involves positioning a probe to target a nerve in the patient, and then venting carbon dioxide or nitrous oxide through the probe to freeze the targeted nerve and block the pain signal it would send to the brain — for several weeks to months at a time.

While much has been said about the potential analgesic benefits of using cryo to treat acute pain, very few surgical facilities currently employ this pain-relieving technology. M Health Fairview, however, is an exception. The facility has already performed 30 to 50 cryo treatments, many of which were done on patients preparing to undergo total knee replacements. What’s more, the facility expects to increase that number significantly moving forward.

M Health Fairview providers administer cryo treatments in an HOPD setting two to four weeks before patients undergo total joint replacement surgery. The two groups that benefit most are chronic opioid users and overweight patients. For the latter group, the relief cryo can provide ultimately allows them to better prepare for their upcoming procedures.

“Surgeons will often urge overweight patients to lose weight prior to their total joints procedures,” says Dr. Hutchins. “But if you’re in severe knee pain, it’s tough to perform exercises that can help you lose weight.”

For these patients, Dr. Hutchins sees great value in what cryo can do. “We’ve been using it to provide analgesia before total knees, so patients can exercise, lose some weight and come in as a better overall candidate for the procedure,” he says.

Data suggest the fewer opioids chronic opioid users are on at the time of surgery, the better they’re likely to recover from it. The idea is to use cryo as a means of helping chronic opioid users reduce their consumption in the months or weeks leading up to their procedures.

While research to support the benefits this promising pain relief technique is lacking, Dr. Hutchins likes what he’s seeing so far from patients receiving cryo treatments. “They’re coming to their one-month follow-up appointments and seem to be in less pain and they’re using fewer opioids,” he says.

Comfort measures

You owe it to your patients to use the latest proven technologies to treat pain. Not doing so can have major consequences. “Some research suggests poorly controlled acute pain increases the likelihood that patients could develop chronic post-operative pain, which could become a lifelong issue,” says Dr. Hutchins.

That’s the last thing any patient expects when they undergo an elective procedure meant to improve their overall health. In the end, as technologies like pain monitors, infusion pumps and cryoanalgesia find their way into standard pain management protocols, patients will benefit the most. OSM

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