Pain is known as the 5th vital sign, but unlike heart rate, blood pressure, respiratory rate and temperature, you can't measure pain unless you count the Wong-Baker Faces Pain Rating Scale, its happy-to-sad faces going from smiling (0, no hurt) to frowning and teary (10, hurts worst). You can, however, prevent and manage the highly subjective symptom of surgery before, during and after the procedure. How you do so is highly variable, depending not only on the type of procedure, the patient and the surgeon, but also on the anesthesia provider's training, his philosophy and his success rates with different interventions.
All of this makes pain management an unpredictable science. Ask 10 anesthesia providers for their No. 1 strategy for preventing post-operative pain, and you're likely to get 10 different answers. Whereas some believe that it all starts with good local infiltration of the surgical site, others swear by the newer non-opioids or continuous peripheral nerve catheters for post-op pain. How do you control surgical discomfort? Let us count the ways.
Multimodal plan of attack
Each anesthetist follows a well-worn game plan. They can deviate from the plan as the case calls for, of course, but the plan captures the essence of their pain management philosophy. Learn the anesthetist's go-to pain-control move, and you learn much about the practitioner, Daniel K. O'Neill, MD, associate director of adult off-site anesthesiology services at NYU Langone Medical Center in New York, N.Y., uses sodium channel blockade for antinociception whenever possible. "Dose opioids generously prior to incision," he says, "and titrate based on respiratory rate during emergence."
Then there's Patricia Cherniawski, CRNA, APN, of Whitney and Ramsey Oral and Facial Surgery Center in Harrisonburg, Va. "Decadron early in induction and surgeons instilling local with epinephrine injection before incision," she says. "I'll often use Benadryl for more anti-inflammatory, antiemesis and sedation properties. Occasionally ketamine up front on longer cases in a low dose, usually 20mg."
For Dave Berkheimer, CRNA, of RemCare Anesthesia Solutions in Altoona, Pa., who specializes in same-day joint replacement, it's all about nerve blocks. "Regional with ultrasound guidance has revolutionized pain management," says Mr. Berkheimer.
Every anesthetist has a game plan. What's yours? Today more than ever, with so many therapies and so many mechanisms of action acting on different pain receptors available to you, your pain plan of attack is likely to be multimodal. Multimodal analgesia is when you combine agents that have different underlying mechanisms of action that work along different parts of the pain pathway. You're usually able to reduce the dosage of each agent, and have fewer adverse effects.
Bruce Rioux, CRNA, director of anesthesia services at Millinocket (Maine) Regional Hospital, describes his far-reaching multimodal approach as preemptive analgesia, use of regional blocks, PCA [patient-controlled analgesia], epidurals, non-narcotics, cold therapy and opiates.
It's likely to be non-narcotic, as well. "I use 9 or 10 non-opioid modalities to treat pain during the entire perioperative period," says Carrie Frederick, MD, director of anesthesia services at a plastic surgery center in Portland, Maine. "That's what multimodal means. It doesn't mean 1 or 2 other modalities; it means multiple modalities at varying times in the perioperative period and continuing post-op. If you understand the current concepts of pain physiology, it's both insufficient and foolish to just be using narcotics to treat pain."
Dr. Frederick says she doesn't use narcotics before or during the case. Nor does she use IV meds in the recovery room on ambulatory patients. She gives patients 3 Percocet to take home. "You must know if they have adequate pain control on oral agents before you discharge them," she says.
Pain control is a bit of a mind game for Charles A. DeFrancesco, MD, staff anesthesiologist at Delmont Surgery Center in Greensburg, Pa. Dr. DeFrancesco says his strategy for managing post-op pain begins long before the patient is wheeled into the OR. Pre-operatively, he ensures that his patients have realistic expectations of the degree of discomfort they may experience after their procedure. "Patients may expect to experience little or no pain," says Dr. DeFrancesco. "Post-operatively, when they realize that isn't the case, they may become anxious and think something is wrong, thus increasing their pain perceptions and analgesic requirements."
Ms. Cherniawski agrees with the power of pre-op teaching. "Assure them they will be numb when they wake. Then tell them to elevate the surgical site, get plenty of rest and apply cold packs post-op," she says. "It's rare that anyone complains while they are still in the PACU. Most problems occur with hyperanxious patients and with patients with a long history of chronic pain and significant narcotic use."
It's best to begin patient education in the surgeon's office with discussions of multimodal therapies and regional anesthetics, says a Texas CRNA.
SAY IT AIN'T SO
Common Misconceptions About Post-Op Pain
We asked a panel of anesthesia providers for the misconceptions surgeons and OR nurses have about post-op pain.
- That nausea is a reason to avoid opioids or use codeine, says Daniel K. O'Neill, MD, associate director of adult off-site anesthesiology services at NYU Langone Medical Center in New York, N.Y.
- That it's possible to have a pain score of zero after an invasive operation, says Louis G. Stanfield, CRNA, PhD, DAAPM, Massena (N.Y.) Memorial Hospital.
- That it takes too long to perform a regional anesthetic vs. a general anesthetic, says a CRNA from Texas.
- That standard doses apply to everyone, says Bruce Rioux, CRNA, director of anesthesia services at Millinocket (Maine) Regional Hospital.
- That the only way to treat pain is with narcotics, says Carrie Frederick, MD, director of anesthesia services at a plastic surgery center in Portland, Maine.
- That field injection with local prevents all post-operative pain, says a CRNA.
- That all patients need the same amount of drug, says an anesthesiologist.
- That the same treatment regimen works for all patients, says Janice J. Izlar, CRNA, DNAP, of the Georgia Institute for Plastic Surgery in Savannah, Ga.
- That narcotics work just fine, so there's no need to change, says anesthesiologist Denise Weiss, DO, of Salina, Kan.
Top challenge in managing post-op pain
Managing surgical pain is not without its challenges, from covering the cost of disposable pain pumps and dealing with "opiophobic" colleagues who underdose analgesics intraoperatively to avoid respiratory depression, says Dr. O'Neill, to narcotic-dependent patients and impatient surgeons who don't want anesthetists to take the time to do blocks, says anesthesiologist Denise Weiss, DO, of Salina, Kan. A note on this last point: Since some blocks take up to 20 minutes to set, regional anesthesia requires a change in protocol. Many recommend using a separate block room when possible or bringing patients into the OR as soon as the room is clean and administering anesthesia while nurses set up the case.
Early in the post-op recovery period, when patients are not fully awake and alert, it's often difficult to administer adequate analgesic medications especially opioids without risking respiratory depression, says Dr. DeFrancesco. "Patients may be writhing in pain, but at the same time, not breathing adequately," he says. "This is especially challenging in patients with obstructive sleep apnea."
You're probably familiar with the patient who is snoring one minute and requesting medication for horrible pain the next. "Without any intervention, the patient is back to sleep within a minute," says Janice J. Izlar, CRNA, DNAP, of the Georgia Institute for Plastic Surgery in Savannah, Ga.
Patrick McCarty, DDS, of McCarty Anesthesiology in Boston, Mass., says it's a struggle to get surgeons on board with the appropriate choice of local.
Non-opioid paradigm shift
For a growing number of surgical facilities, the newer non-opioids, like Exparel (bupivacaine liposome injectable suspension) and Ofirmev (IV acetaminophen), have become the foundations of their multimodal analgesia regimens. "I find that the newer non-opioids are best utilized in a pre-emptive analgesic strategy," says Dr. DeFrancesco. "They are extremely useful if given early, before incision, and can significantly decrease post-op opioid requirements."
Exparel and Ofirmev have also reversed the order of drugs anesthesia providers administer to control post-op pain. Rather than starting with opioids, those who use Exparel or Ofirmev use these non-opioids first, and then layer on NSAIDs and opioids. The results? Less pain, less opioids, less side effects.
The Texas CRNA says that PACU nurses have, in many cases, seen a reduction in post-op analgesics due to their use. The newer non-opioids' opioid-sparing effect is desirable, says Dr. O'Neill. They provide an alternative to opioids in many cases, and in those cases where opioids are necessary, smaller doses are usually all that is necessary, adds Mr. Rioux.
Exparel, injected into the soft tissues of the surgical site, is a single-dose local analgesic. A single intraoperative injection treats pain at the source with reduced opioid requirements for up to 72 hours. "Sometimes we use bupivacaine for longer action on patients with more invasive-type procedures or those with long rides home," says Ms. Cherniawski. Ofirmev, administered as a 15-minute intravenous infusion, "is great for kiddos and people with narcotic intolerance," says Dr. Weiss. "From a business standpoint, it helps us bring in more patients often the ones who have had unpleasant, painful experiences with another physician."
Regional anesthesia, a big part of why more invasive cases are being done on an outpatient basis, is increasingly demonstrating outstanding clinical results, minimizing recovery room stays, saving money and enhancing patient satisfaction. Regional blocks play a valuable part in the multimodal approach and help reduce both peripheral and central sensitization, says Dr. Frederick. Regional anesthetic techniques "trick" the body, preventing painful impulses from reaching the spinal cord.
"We are able to discharge patients to home sooner than a required 23-hour observation or outright admission for post-op pain management," says the Texas CRNA. "Regional anesthesia is frequently the only modality needed for the immediate post-operative period," adds Mr. Rioux.