Rapid Recovery: The Right Multimodal Regimen Is Essential to Patient Satisfaction

The best post-op path forward demands maximum efficiency in pain control.

The most sophisticated anesthesia providers agree that the services they provide can be as much art as science. When one considers the vast number of anesthesia options and the vast variations among patients, surgeons and procedures, there can never be one “right” answer to the question of which multimodal anesthesia and pain management approach is best for any given patient.

But one thing is clear: Understanding and providing multimodal options is the best path forward for facilities that seek to maximize efficiency and minimize the negative impact of dissatisfied patients.

Thomas Durick, MD, associate clinical professor of anesthesiology at The Ohio State University Wexner Medical Center in Columbus, calls ambulatory anesthesia a “non-accredited subspecialty” with its own specific set of goals. “I tell our residents that ambulatory anesthesia boils down to this: You need to have a reason for everything you give your patient in, on or through the skin,” says Dr. Durick. “Every drug you give can affect how quickly that patient is able to get out of that surgery center. My goal in every single case is to have the patient awake, alert, not sick and in no pain 10 minutes after we’re done.”

He may not be batting a thousand, as Dr. Durick freely admits, but “if you don’t have that as your plan before you go in, you’ll never achieve it,” he says.

Where it began, where it begins

The quest among outpatient centers to provide pain relief without depending on opioids has driven the development of multimodal anesthesia and analgesia approaches. The field has advanced so far and so quickly that it can be easy to forget how the multimodal evolution started. At this point, smaller doses of opioids may still be a component of a broader multimodal regimen, but increasingly they are only playing a bit part, not a leading role.

Today, the most effective regimens typically start with nerve blocks. ”Everything related to doing ultrasound-guided regional anesthesia is evolving constantly,” says Mike MacKinnon, DNP, CRNA, FNP-C, FAANA, assistant program director of the National Nurse Anesthesiology Program, which prepares RNs to become certified registered nurse anesthetists (CRNAs). “There are new blocks and better techniques — additional injection sites that decrease pain better. Also, ultrasound technology evolves every year. You continually get clearer, more precise and sharper images, which helps you put the local in a better spot and get a better result overall.”

This technology is well within reach for many outpatient centers. “Ultrasounds are no longer expensive,” says Dr. Durick. “There are so many handheld ultrasounds with tremendous resolution that you can get for a few thousand dollars. Your facility doesn’t need to spend $50,000 or $60,000 on an ultrasound machine to get the benefits.”

Once a block is in place, a multimodal cocktail administered during surgery can involve numerous ingredients, depending on several factors. Dr. MacKinnon recommends a mixture devised by Jason McLott, MSN, CRNA, that is composed of specified amounts of lidocaine, ketamine, magnesium and dexmedetomidine. “You can modify the doses in some cases,” says Dr. MacKinnon. “For example, for a super-short case, you’re not going to give the higher doses that you may see in that mix. But it gives you an idea of some of the different options you can use.”

Not every outpatient surgery center stocks all the ingredients of the McLott Mix, but ketamine and dexmedetomidine should generally be available. Ketorolac and IV acetaminophen, both of which are likely to be available at most ASCs, can also be effective, says Dr. MacKinnon.

Liposomal bupivacaine is another option. “It’s just phenomenal for some incredibly painful surgeries such as orthopedic surgery, podiatry and hemorrhoidectomy,” says Dr. Durick. “You can literally give the patient three days of pain relief instead of three hours.”

No ‘one size fits all’

REGIONAL RELIEF The most effective pain control regimens typically start with carefully placed nerve blocks.

With so many options, where do anesthesia providers start when deciding which approach to take? Dr. MacKinnon recommends listening carefully to patients. “If you take the time to listen, you’ll get information like, I’m afraid of opioids because of a news story I saw about fentanyl,” he says. “I don’t force anything on anybody. If they don’t want it, even if their concern may not be as valid as they think it is, I’m not going to give it to them. I’ll do other things to help mitigate their pain instead.”

Talking with patients can also reveal whether they’re concerned about previous substance- or alcohol-abuse issues, or about a tendency for opioid-induced PONV. “If you can manage those patients without opioids, you make them incredibly happy,” says Dr. MacKinnon.

Most surgery centers have a hard-line cutoff regarding obese patients, but the line has budged a little recently thanks to the development of multimodal techniques. “Over the years, we’ve started to see larger patients be acceptable at outpatient surgery centers,” says Dr. McKinnon. “You can do a lot of these cases without opioids and not have to worry about the additional respiratory depression risk. You can add blocks, you can do spinals for hips and total knees, so you just need to give them a little bit of sedation to get them through the case. You still need to be vigilant about things like obstructive sleep apnea and hypoventilation syndrome, but we can manage it better than ever before.”

The final answer

Ultimately, says Dr. Durick, the best way for anesthesia providers to approach multimodal anesthesia is to do what they’re best at doing. “For somebody who is not good at nerve blocks, it’s not going to work well for them,” he says. “It’s going to lengthen the procedure. It’s going to frustrate the surgeon, and if a block doesn’t work, they’re going to be less willing to try it the next time. So whatever you’re best at, that’s the best anesthetic.”

That advice comes with a very big caveat, however. “I ask those people why they’re working in ambulatory if they can’t do nerve blocks,” says Dr. Durick. “There really isn’t a good excuse anymore. Saying ‘I’m too late in my career’ is just nonsense, because it benefits patients and benefits care. For me, it’s about having a good rapport with your surgeons and becoming skilled and competent in nerve blocks so you’re not delaying cases for 20 or 30 minutes that should take two or three minutes.”

Skill acquisition

There are, says Dr. Durick, numerous opportunities for anesthesia providers to get up to speed on multimodal techniques. For example, many handheld ultrasound machines include built-in educational vignettes. “You can literally look it up right while you’re doing it,” he says.

To succeed in the rapidly evolving world of multimodal anesthesia, the doctors agree, the most important thing for providers is to stay current. “For me, the Society for Ambulatory Anesthesia meeting is so important because you interact with peers who are doing what you’re doing,” says Dr. Durick. “We may not all be doing total joints or eyes or plastics, but we’re all doing ambulatory anesthesia and we all respect and appreciate the nuances of trying to do what your patients need to be able to go home the same day.

“Being in that group setting, listening to the experts, hearing about new ideas, new medications and new techniques, information about coding, reimbursement, legislation — it’s invaluable,” he adds. “It’s one thing to be in a Zoom meeting with 200 people; it’s another to be at a meeting where somebody’s giving a really robust presentation with information that you can take back to your practice the next day and make a difference. Everybody wins.”

Just as you, your patients and your surgeons win when you’re able to implement a flexible, effective and efficient multimodal anesthesia and analgesia regimen that suits all your patients’ needs. OSM