It's not the standard of care by any means, but a multimodal approach to post-op pain management, as opposed to opioid-based therapy, is finding acceptance among a wider audience.
"We have preached the multimodal song now for well over a decade, but finally we are seeing some traction with good results," says Eugene Viscusi, MD, director of acute pain management at Thomas Jefferson University Hospital in Philadelphia. "This has been driven in part by the recognition of opioids as potential drivers for side effects and poorer outcomes, as well as their contribution to the expanding prescription-abuse problem."
Multimodal which combines IV and oral analgesics, regional blocks and other interventions to target the sources and pathways of pain with a decreased reliance on narcotics can sidestep side-effects and speed recoveries, but it's not without a learning curve. So we asked a panel of anesthesia providers for their advice on putting the technique to use.
Lay the groundwork
"I have always believed that a multimodal approach to post-op pain is best," says Charles A. DeFrancesco, MD, staff anesthesiologist at Delmont Surgery Center, a high-volume plastics practice in Greensburg, Pa. But, since patients' expectations can influence their outcomes, he says, "pre-op education is an important part of this. The patient needs to have a realistic expectation of what discomfort they may experience post-op. Often, since cosmetic surgery cases are strictly elective, patients may have the false impression that there will be little to no post-op pain."
Pain is easier to prevent than treat, so make sure your providers get an effective headstart with pre-emptive analgesia, says Dr. DeFrancesco. "For maximum benefit, the drugs must be administered pre-op, before incision or any noxious stimuli.
"Sometimes administering these in the proper timeframe can be challenging at a busy ASC, as other activities may take precedence and the need for other pre-op medications such as antibiotics must also be administered in the same timeframe," he says, noting that the IV drugs such as Caldolor (ibuprofen) and Ofirmev (acetaminophen) that have come to market in the past few years have helped greatly in this regard.
These new analgesics add efficiency on the other side of surgery, too, says Jeff Cryder, BS, BSN, a CRNA at Scott & White Hospital in Temple, Texas. "I've seen a really good response to IV acetaminophen," he says. "The nurses in PACU tell me they have to give less pain medication to the patients I bring in who have received Ofirmev. When they do give pain medication, [they're] having to give smaller doses."
Are you doing it right?
Multimodal or preventive therapy has been around for more than 15 years, but "we're still not doing it adequately," says Carrie L. Frederick, MD, director of anesthesia services for the Plastic Surgery Center in Portland, Maine. "Multimodal doesn't mean 2 or 3 modalities, it means 4, 5, 6-plus modalities, including non-pharmacologic modalities like cryotherapy."
The technique should encompass the entire perioperative process. "Pain management must start in the pre-op period to attenuate peripheral and central sensitization," says Dr. Frederick, "and continue well into the post-op period to attenuate the inflammatory component, which lasts a minimum of 3 days' post-op."
The availability of a range of options will let providers fine-tune the effect. "I personally use 7 non-narcotic modalities pre-incision, and 9 or 10 non-narcotic modalities in all," she says. "While this is not possible for all surgeries, using this many modalities should result in significantly diminished doses of narcotic needed."
It's important to keep in mind that the multimodal approach isn't a single, universal, analgesic blueprint that works for every patient. "One-size-fits-all anesthesia was once the norm," says Louis G. Stanfield, CRNA, PhD, DAAPM, who practices at Mercy Medical Center in Sioux City, Iowa. "It's still evident in some practices. The key feature of a multimodal plan, however, is that it is tailored to the needs of individual patients. Patients are not widgets, and we don't work in a widget factory."
Building an individualized plan comes down to an anesthesia provider's awareness of a patient's history and preferences in addition to the procedure's requirements. "It is incumbent upon anyone practicing anesthesia to have more than one way to do everything," says Dr. Stanfield not everyone will agree to regional anesthesia, for example, due to a fear of needles or fears of paralysis "and to understand the tools and use them appropriately," even if that involves administering opioids.
It's likewise important to understand what can and cannot be expected of multimodal modalities. For instance, he says, "people wrongly conclude that regional anesthesia eliminates post-operative nausea and vomiting. Maybe they're not aware that there are at least 8 discrete causes of PONV, and that you're not going to eliminate PONV merely by relying on regional anesthesia. As with most things in health care, there are very few single-cause issues.
"It's up to us to try to identify the triggers in every patient and provide therapy that matches their individual profiles. Which is, admittedly, harder than saying 'We used blocks, we avoided opioids, we gave Zofran, so there shouldn't be a problem.'"
See your way clear
Ultrasound imaging effectively complements multimodal techniques, and it's better than you may remember, says Gary Lawson, MD, an anesthesiologist at the Adult & Children's Surgery Center of Southwest Florida in Fort Myers. "The technology has improved compared to what was available in the early 2000s or the 1990s, when many who are in practice now were training," and when early limitations may have left them reluctant to use the technology.
Ultrasound's advances, he says, are like "color TVs of the '80s versus HD flat screens of today. Much better resolution." The devices are much smaller, laptop-portable since there's no need for a bulky printer, and optimized for musculoskeletal imaging. Plus, they're much more affordable. "Now they're about $10,000. I have one in every OR," says Dr. Lawson.
The end result? Anatomical accuracy, precisely targeted injections, and more effective regional anesthesia, whether it's a single-shot block or an indwelling catheter for continuous local anesthesia infusion. "It's proof that you're where you should be. It affords you safety you don't have with nerve stimulation," he says. "If the patient is not being served well, it's because practitioners don't know what they're doing."
A key element of the multimodal approach used at Same Day Joints in Altoona, Pa., is periarticular injections into the innervated area around the joint. The anesthesia cocktail blocks sensory but not motor response, allowing near-immediate post-op ambulation but also delivering 48 to 72 hours of post-op pain relief.
"Motor-sensory differentiation," says Dave Berkheimer, BSN, CRNA, the center's co-founder and director of anesthesia as well as the president and CEO of RemCare Anesthesia Solutions. "We call it the 'holy grail of anesthesia.'" Providers have sought a solution for decades as they attacked the 2 functions together. A study of anesthesia literature and the combination of inexpensive, off-patent medications led the Same Day Joints team to develop it in house.
Joint surgery patients are discharged on their feet, without PONV, with a reduced fall risk, with low pain scores, without even a knee brace, says Mr. Berkheimer, and they walk out satisfied. "It's really made a big difference," he says. "And it opens a can of change."