AROUND THE BLOCK Nicolette Wise, DO, performs a supraclavicular nerve block before surgery, assisted by Dr. Tiona Langton, DO.

When surgical patients at Capital Region Medical Center in Jefferson City, Mo., marvel at how little pain they've had to endure, despite having been given few, if any, opioids, they may want to express their gratitude. But whom should they thank? Depends whom you ask.

"Our excellent pain management is largely attributable to our excellent pre-operative and post-operative nursing staff," says Tiona Langton, DO, the hospital's chief of anesthesiology. "They're very attentive to each patient and always in communication with us for their needs."

Ah, but Dr. Langton is being typically modest, says Beth Rackers, RN, CNOR, the clinical educator for surgical services at the hospital. The dozen anesthesiologists and CRNAs who take a personal interest in every patient are the ones who deserve most of the credit, she says. "They do a phenomenal job. When I think about how I'd want to feel in respect to pain after having surgery, I think about the anesthesia staff we have at Capital Region."

The nurses? The anesthesia providers? The staff as a whole? Credit — and gratitude — should be given to everyone. What's propelled Capital Region to such impressive heights and earned the hospital this year's OR Excellence Award for Pain Management is teamwork. Teamwork makes winners, and the ultimate winners in this story are the patients who, even in the aftermath of major procedures, are likely to feel remarkably comfortable without having to worry about the undesirable — and potentially dangerous — side effects associated with opioids.

Proponents of regional
"All of our efforts are done to minimize the patient's narcotic requirements throughout the perioperative period," says Dr. Langton. "We have a multimodal analgesic approach to all of our cases."

Whenever possible, the planning starts several days in advance. The facility's anesthesia providers try to interview every patient and discuss their experiences, their preferences and their co-morbidities. Then they tailor their approach accordingly. "One of the biggest factors in their success is their willingness to step up and take initiative," says Ms. Rackers. "They're genuinely friendly folks and they work great together with the rest of the staff."

As well-versed proponents of regional anesthesia, the anesthesia group routinely administers ultrasound-guided femoral, adductor canal, supraclavicular, popliteal, interscalene and axillary nerve blocks. "We also do a large number of transversus abdominis plane blocks for laparoscopic procedures, colon surgeries and hernia repairs," says Dr. Langton, adding that those are typically accompanied by injections of liposomal bupivacaine that provide up to 72 hours of analgesia.

Of course a few skeptical patients, having had the concept behind regional blocks explained to them for the first time, cock their eyebrows and decide they'll pass, says Ms. Rackers. "They're a little leery because it's a new thing," she says. They decide on more traditional approaches instead. And then the pain begins to kick in, and they sometimes change their minds.

"They often end up wishing they'd had the blocks," says Ms. Rackers. "So they ask our anesthesia providers to place the block after surgery." It's an unusual request, but "without hesitation the anesthesia group gets right on it," she says, noting how easy the group is to work with. "They go above and beyond for our patients. And they strive so hard to be team players. They never act as if they're more important than anybody else."

READY FOR DISCHARGE Patients rarely require more than 10mcg of fentanyl in the recovery room.

QUICK RECOVERIES
Multimodal Regimen Fuels Speedy Discharge

Plastic surgeon Matthew Schulman, MD, has reduced opioid use in his New York, N.Y., facility with a multimodal approach that incorporates pre-operative, intra-operative and post-operative analgesia. Patients receive 1,000 mg of acetaminophen immediately before they're brought into the OR. After induction, lidocaine is injected into the surgical area, which reduces the need for opioids. Then, during surgery, liposomal bupivacaine is injected around the site, which functions as a field and nerve block, sometimes providing up to 3 days of pain control. Once awake, patients get another 500 mg of acetaminophen and 220 mg of naproxen orally. As a result of the regimen, patients rarely require more than 10 mcg of fentanyl in the recovery room, says Dr. Schulman, and they have less nausea, so they mobilize and recover faster.

Comforting cocktail
Regional blocks are just the beginning of the multimodal tack favored by the providers at Capital Region. During the perioperative phase, the staff proactively targets pain in all of its varying manifestations with non-opioid analgesic adjuncts consisting of NSAIDs, acetaminophen, ketamine, and steroids, says Dr. Langton. "These non-opioid agents are particularly helpful with our obese patient population and patients with obstructive sleep apnea," she adds.

With discomfort diminished and the sluggishness brought on by opioids largely averted, patients can become active participants in the healing process.

"When their pain is kept to a minimum, patients want to get up to do their exercises and get on with the activities of daily living," says Ms. Rackers. "That accelerates their healing process. The feedback from the patients on this is excellent. They get to go home sooner because they're able to follow doctors' orders sooner."

And when they get home they're likely to talk to neighbors, friends and family about how much less traumatic the whole experience was than they'd anticipated.

Quality pain management "leaves a very satisfied patient who tells others about their experience," says Ms. Rackers. "And in a small community like this, word gets around quickly." OSM