Pain Management

PATHWAYS Ultrasound-guided nerve block placement is but one of the many keys to successful pain management for anesthesiologist Derick Mundey, DO.

Anesthesiologist Derick Mundey, DO, of the Riddle Surgery Center in suburban Philadelphia, likens surgical pain to a moving target, one that you can shoot down with a tailored, multimodal approach that takes into account both the subjective nature of pain and the many ways to attack it.

“Modern medicine tries very hard to make pain a measurable quantity, like heart rate and blood pressure,” says Dr. Mundey, “but it’s important to realize that pain does not easily fit onto a 0-to-10 scale. It’s also unrealistic for a post-surgical patient to have pain as a 0 to 1 on the pain scale.”

The goal is not to eradicate pain, he says, but to manage it as best as possible, which often means using different modalities, one on top of the other, to eliminate gaps in pain relief and extend by minutes or hours the time patients are recovering at home in relative comfort. For example, rather than waiting for a regional block to wear off before patients get pain medication into their systems, Dr. Mundey instructs them to take a loading dose of opioids while the block is still working. Overlapping a block with an opioid means a patient will feel as well in your recovery room as he will hours later in his living room.

For his mastery over the mystery that is surgical pain, Dr. Mundey is the winner of the OR Excellence Award for Pain Management. Here are the pillars to Dr. Mundey’s pain management.

Multimodal approach
Morphine and other narcotics remain the gold standard for the treatment of acute pain, while regional nerve blocks, both single-shot blocks and nerve block catheters, are gaining popularity, says Dr. Mundey. Other adjuncts he commonly uses include muscle relaxants like metaxalone or cyclobenzaprine, NSAIDs, anticonvulsants like gabapentin or pregablin, and tricyclic antidepressants, including amitriptyline or nortriptyline.

As an example, he says a narcotic-na??ve patient coming for a routine shoulder or knee procedure will get oral medicines in pre-op that include a long acting narcotic, an NSAID and possibly gabapentin. The patient will then get a nerve block 30 to 45 minutes before the procedure for adequate pre-emptive analgesia. In the PACU, he’ll give short-acting narcotics for breakthrough pain and often another dose of oral narcotics before discharge.

Timing is key, says Dr. Mundey. Most nerve blocks will last 10 to 12 hours, much longer in many patients. He instructs the patient to start his oral pain meds as soon as his next dose is scheduled upon arriving home and to continue to take them around the clock as scheduled — no matter if the nerve block hasn’t worn off — until post-op day 1. “An adequate amount of pain medicine will be in their system before the nerve block wears off,” says Dr. Mundey. He also sends patients home with a muscle relaxant “since breakthrough pain can sometimes be caused by muscle spasms.”

Educate patients and family
When the patient wakes up in the recovery room and has minimal pain, he might have a false sense of security that he won’t experience pain, says Dr. Mundey. This may lead him to skip his oral pain medication until he feels pain, when the block has worn off, at which point it’s too late to successfully control.

Educate the patient and whoever will be caring for him at home on the importance of the multimodal approach to treating pain. “This might include calling the patient a day or 2 before surgery to explain regional anesthesia and nerve blocks, stressing that a nerve block is only a temporary relief from the pain and might only last 10 to 12 hours,” says Dr. Mundey. Explain that the goal of the block is to get the patient through the intra-op period, to keep him comfortable for the recovery room and ride home, and to get him to start eating and drinking so that he can take his oral pain medicines and continue taking them without interruption, he says.

If the patient goes home with a peripheral nerve block catheter with an infusion, Dr. Mundey gives him a phone number he can call with any questions or concerns about pain management 24 hours a day.

Set realistic pain goals
This starts with the surgeon during pre-op visits and continues throughout the perioperative encounter, says Dr. Mundey. “The nurses and the anesthesiologist continue to drive home the point that surgery hurts, but if patients comply with their multimodal pain management protocol, which may include nerve blocks and multiple different types of pain meds, their pain can be manageable,” says Dr. Mundey, who stresses to patients that manageable does not mean the absence of pain and varies from patient to patient.

OPIOID-SPARING
Pain Pumps for Up to 5 Days of ‘Ahh’

NON-OPIOID PAIN MANAGEMENT Orthopedic surgeon Joseph Guettler, MD, says it’s imperative that physicians and patients explore alternatives to narcotics for pain management.

To help reduce the side effects of narcotics, Unasource Surgery Center in Troy, Mich., regularly performs femoral nerve blocks for surgeries like ACL reconstructions and adductor nerve blocks for routine knee arthroscopies, says orthopedic surgeon and sports medicine specialist Joseph Guettler, MD.

Dr. Guettler is a proponent of non-narcotic pain relief pumps that reduce post-surgical pain for up to 2 to 5 days by delivering an automatic and continuous regulated flow of local anesthetic through a specially designed catheter inserted near the surgical site or in close proximity to nerves. “My patients experience fewer narcotic-related side effects and a faster early recovery when compared to narcotics alone,” says Dr. Guettler. “I truly believe — as I tell my patients — that these nerve blocks have revolutionized early post-operative pain control.”

— Dan O’Connor