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Get the Upper Hand on Orthopedic Pain
5 strategies to manage post-surgical pain in your ortho patients.
Dan O'Connor
Publish Date: July 25, 2014   |  Tags:   Orthopedics
shoulder arthroscopy PAINFUL PROCEDURE Shoulder arthroscopies produce significant post-operative pain. Getting through those first 24 hours is key.

When it comes to painful procedures, few cause more ouch! than arthroscopic rotator cuff repairs. “They hurt,” says orthopedic surgeon Charles Getz, MD, of the Riddle Surgery Center in Media, Pa., pausing for emphasis before adding: “A lot.”

Dr. Getz says it’s “always a shocker” to patients when the super-numbing regional block wears off 12 to 15 hours after the surgery and then pain rears its ugly head. “They go from being really happy to having a good amount of pain.”

Dr. Getz says patients will do 1 of 3 things when the breakthrough pain hits — start taking their pain medication (good, but it’d be better if they got a loading dose of pain meds on board as prescribed before the pain starts), go to the emergency room (bad) or call the surgeon at 2 a.m. (really bad). Here’s how they manage pain at the Riddle Surgery Center, where the orthopedic team boasts of pain control so “impeccable” that most shoulder patients report next-day pain scores of 3 or 4 out of 10.

1. Debunk patients’ myths about regional anesthesia. For all the good they’ve done to revolutionize pain control, nerve blocks have one potential drawback: They can give patients the false sense of security that they’ll feel as great hours later in their living room as they do right now in your recovery room. “I feel great, doc,” they’ll say. “I don’t know what you were talking about when you said I’d have pain.” You know how the story plays out: The regional block wears off, the prescription pain pills hardly touch the pain and you get the 2 a.m. phone call. “You need to stress to patients that the block will wear off,” says anesthesiologist Derick Mundey, DO. “You don’t know when it will wear off, but it will. I’ve gotten enough of those calls in the middle of the night.”

Patients might be led to believe that a regional block and a pain catheter will leave them comfortably numb for 5 days. Your job is to temper expectations. Dr. Mundey suggests calling patients scheduled to receive nerve block catheters in the shoulder or knee a day or 2 before surgery to give them the straight scoop about regional anesthesia. He’ll e-mail them a handout that details what they can expect with a block on the first, second and third day after surgery. “The morning of surgery there’s too much anxiety and they’re not listening,” he says.

Dr. Mundey removes the mystique surrounding a surgical block, stressing that it is temporary and fleeting. In 10 to 12 hours, it’ll stop working, he tells them. “I explain that the surgical block is what we put in the OR to lessen the amount of anesthetic burden,” he says. “I tell them it will get you through the ride home and onto the couch.”

He also stresses to patients who’ll go home with a pain catheter (0.2% ropivacaine) that it’s only one-third the strength of the surgical block (0.5% ropivacaine). “When we send them home with pain catheters, we typically run them at a diluted-down version,” says Dr. Mundey. “We want them to get the sensation back and move that [limb] again.”

WORKING THE PAIN SCALE
Set Realistic Pain Scores of 2 or 3 or 4

pain scale

It’s not realistic for orthopedic patients to expect a pain score of 0 to 1 in the days after surgery. But here’s what anesthesiologist Derick Mundey, DO, of the Riddle Surgery Center in Media, Pa., stresses to them. If you comply with our multimodal pain management protocol, your pain will be manageable. A take-home pain catheter will get you down to a 4 or 5. Add by-mouth pain medication, and you’ll be down to a 2 or 3.

2. Don’t forget the pain meds. At discharge, tell the patient’s driver to head straight to the pharmacy to fill the pain pill prescription, typically Vicodin or Percocet, and perhaps muscle relaxants as well. Even though patients don’t yet feel pain, the trick is to get patients to take a loading dose of opioids while the block is still working. “It’s important to get pain meds in the system before the block wears off,” says Dr. Mundey. “It will hurt when the block wears off. If you take the pain medication preemptively, you won’t fall off of the ledge. You want to put that warning in their minds.”

Dr. Mundey tells caregivers to set an alert or an alarm on their smartphone and administer a pain pill to the patient every 4 hours for the first 24 post-op hours, disrupting their sleep if you must. “Don’t let the block wear off completely and wake up with 10-out-of-10 pain. You’ll wind up in the ER because you let the pain get out of control,” he says. “After the block wears off, then you can manipulate your pain meds the next morning.”

Sometimes, blocks will begin to wear off before discharge. In that case, you’ll want to get pain meds on board while the patient is in post-op. Nick Stuardi, CRNA, MSN, of the Riddle Surgical Center, says to start pain meds by mouth when the patient can move his blocked limb. As he explains, when you administer a nerve block, sensory loss happens first, then motor blockade. But as the block wears off, the opposite happens — motor skills return before sensory feeling. In the case of a blocked hand, patients will be able to move their fingers before they can feel their fingers. It’s time to get pain meds on board at the first sign of finger wiggling, says Mr. Stuardi. “Start the meds before they leave and have them set the clock from there.”

Some patients might assume the stoic stance that pain is a normal byproduct of surgery and that taking pain medication is a sign of weakness. Tell them “not to be shy about taking the pain meds as they’re prescribed the first 24 to 48 hours after surgery,” says Dr. Getz. “A lot of people are reluctant to take their pills until their pain is real bad. Start early and take them regularly for the first few days.”

nerve blocks

3. Make it multimodal. At the Riddle Surgery Center, they attack pain along its many pathways. Dr. Getz will sometimes augment opioids with anti-inflammatories and muscle relaxers like Valium. “It’s spasm and not pain a lot of times,” he says. He’ll add Lyrica in certain cases. More recently, they’ve been using IV acetaminophen and IV ibuprofen, says Mr. Stuardi.

Dr. Getz says a multimodal approach to pain has a significant side benefit. It gives patients a sense of control, a feeling that they can manage their pain on their own. This is part of the reason why he sends patients home with at least 2 pain medications, 1 of which is not an opioid. “It makes them feel like they have some flexibility,” he says. “Start with this. If it’s not enough, you can use another.”

Dr. Getz says the top 2 pain-control challenges are ensuring that the pain medication is both adequate and appropriate. Pain control is also procedure-dependent, he adds. “Some procedures are going to hurt more than others,” he says. “Medications only give you so much pain control. You have to educate patients that some amount of pain is going to be normal.” The goal, he says, is “to make the experience, which is going to be unpleasant, as pleasant as possible.”

4. Tailor your blocks. Especially in hand surgeries, Riddle is tailoring its blocks so that patients are more numb for less time. “They don’t like the detached feeling of their limb,” says Mr. Stuardi. They’ll use a lower concentration of local anesthetic so that the patient has a less dense motor block while still maintaining a good sensory block. “It’s the best of both worlds: Patients can move their extremity, but they’re still not having pain,” he says.

5. For patients already on pain meds. Another concern, especially nowadays, is managing post-op pain in patients who regularly take pain meds for back pain or some other chronic ailment. “Be sure to ask patients what their exposure to opioids is,” says Dr. Getz. If a patient is on a standing dose of Vicodin, let’s say, Dr. Getz will instruct him to continue with his normal dosing and prescribe a different add-on narcotic like Percocet for breakthrough pain. In such cases, he might ask the patient’s pain management doctor to coordinate the post-op pain relief. “Patients are happy dealing with one person,” he says.

Intraoperatively, they’ll sometimes administer a stronger IV narcotic analgesic such as Dilaudid to patients who are taking a standing dose of opioids. “But we’ll given that solely in the beginning of the case,” says Mr. Stuardi. “We’ll frontload the medication so it won’t impact discharge.”

For opioid-users, regional blocks have been a true blessing. “An effective block is the great equalizer no matter what kind of pre-operative narcotic dose the patient has been taking,” says Mr. Stuardi.

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