Managing Post-Operative Pain with Outpatient Procedures
APRIL 23, 2018
R. Presley Swann, MD
R. Presley Swann, MDSame-day orthopedic surgery allows patients to recover in the comfort of their own homes rather than in a hospital bed, and provides multiple benefits to patients for improved recovery. By enabling patients to recover at home, the potential risk of hospital-acquired infections is decreased.1 In addition, the home environment enables patients to recover away from the disruption and restrictive beds of the hospital environment, which can cause long-term sleep deprivation and, in turn, slow down the recovery process.1 As such, the drive to perform total joint replacement procedures on an outpatient basis continues to increase.
Despite the benefits, a potential challenge clinicians must take into account when considering outpatient total joint procedures with their patients is effective management of post-operative pain.2 More than 73 million surgical procedures are performed in the US each year, and up to 75% of patients may experience pain after surgery.3 While post-operative pain can have a significant impact on patient recovery, inadequate pain management remains common and can result in a number of negative clinical outcomes, including deep vein thrombosis, pulmonary embolism, coronary ischemia, myocardial infarction, pneumonia, poor wound healing, insomnia, and demoralization.3
Until recently, post-operative pain was primarily treated with opioids—and according to the CDC, the increase in opioid prescribing is a contributing factor to the increase of prescription overdoses.4 Opioid-based pain medications may produce significant adverse effects, with both clinical and financial consequences. Even a 1-day opioid prescription may pose a 6% risk of long-term opioid use, and as many as 1 in 5 patients become a routine opioid user after 10 days of narcotic analgesia. 5 Additionally, opioids can cause a number of negative side effects for patients, including nausea, vomiting, and drowsiness.6 Every opioid-related, in-hospital adverse event increases costs by an average of $4,700.7,8
New techniques and approaches like continuous peripheral nerve blocks (CPNBs) are playing a significant role in making post-operative pain more manageable and providing patients with superior acute postoperative pain relief while decreasing the amount of opioid-related adverse effects. CPNBs have been successfully introduced in the ambulatory setting to provide on-going analgesia at home9, as well as in the hospital setting. Unlike short-duration, single-shot nerve blocks, which can cause rebound pain at 24 hours after surgery, CPNBs allow patients to experience continuously extended pain relief for days in the outpatient setting, which can then be titrated to their needs via a portable post-operative pain pump.10,11
CPNBs can also help patients ambulate faster and improve their range of motion more quickly.9 Further, CPNBs have been shown to reduce the need for opioids.12 Results of a recent study demonstrate that a continuous adductor canal block decreases opioid consumption in the first 48 hours after total knee arthroplasty, and improves postsurgical outcomes, including distance ambulated and pain experienced. 13
In an effort to both improve my patients’ experience and provide a needed alternative to opioids for post-surgical pain management, I have been using CPNBs for the past 3 years in an outpatient setting, mainly with my patients that are undergoing knee replacements and pelvic osteotomies, as this multimodal approach provides pain relief while reducing opioid use. In my experience, this approach allows patients to be comfortable after surgery and capable of activity as they move through recovery, helping to keep pain management from compromising their postsurgical success. Additionally, with total knee replacements, CPNBs allow me to send my patients home on the day of surgery. With pelvic osteotomies, patients are able to go home the next day, rather than the several days of recovery in a hospital setting required previously.
In advance of scheduling an outpatient total joint or other procedure, I meet with my patients and their families to determine if same-day surgery is appropriate for them and discuss post-surgical expectations, including available options for pain management. Ideal patients should be free of major cardiac or pulmonary comorbidities.14 Additionally, I ensure that patients have assistance at home, as both patients and their caretakers need to execute a coordinated discharge plan in order to achieve an optimal at-home recovery.
Through careful planning and leveraging effective pain management techniques such as CPNBs, same-day joint procedures are a realistic option for many patients. However, as with everything in healthcare, open communication with both patients and their caregivers is critical. This is not only the case for decisions around the procedure itself but the recovery process as well. Many patients may still be unaware that there are alternatives to opioids for post-surgical pain relief and may be hesitant to undergo a procedure as a result. By ensuring patients and their caregivers are educated regarding their options for both care delivery and pain management, we are providing a needed opportunity to improve the overall patient experience while increasing satisfaction and speeding post-surgical recovery.
1. Healing at Home: The Impact & Reduced Risks of Recovering at Home. Sound Options website. soundoptions.com/blog/healing-at-home-the-impact-reduced-risks-of-recovering-at-home. Published August 7, 2013. Cited December 12, 2016.
2. Chan EY, Blyth FM, Nairn L, Fransen M. Acute postoperative pain following hospital discharge after total knee arthroplasty. Osteoarthritis Cartilage. 2013;21(9):1257-263. doi: 10.1016/j.joca.2013.06.011.
3. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national
survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-40.
4. Opioid Painkiller Prescribing: Where You Live Makes a Difference. CDC website. cdc.gov/vitalsigns/pdf/2014-07-vitalsigns.pdf. Updated July 2014. Cited December 6, 2016.
5. Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006-2015. CDC website. cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm. Published March 17, 2017. Accessed February 7, 2018.
6. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. JAMA. 2016;315(15):1624-1645. doi: http://dx.doi.org/10.15585/mmwr.rr6501e1.
7. Oderda GM, Gan TJ, Johnson BH, Robinson SB. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliat Care Pharmacother. 2013;27(1):62-70. doi: 10.3109/15360288.2012.751956.
8. Kessler ER, Shah M, Gruschkus SK, Raju A. Cost and quality implications of opioid-based postsurgical pain control using administrative claims data from a large health system: opioid-related adverse events and their impact on clinical and economic outcomes. Pharmacotherapy. 2013; 33(4):383-391. doi: 10.1002/phar.1223.
9. Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract. 2012; 2012:560879. doi: 10.1155/2012/560879.
10. Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the real benefits of single-shotinterscalene block please stand up? A systematic review and meta-analysis. Pain Medicine. May 2015;120(5):1114-1129. doi: 10.1213/ANE.0000000000000688.
11. Visoiu M, Joy LN, Grudziak JS, Chelly JE. The effectiveness of ambulatory continuous peripheral nerve blocks for postoperative pain management in children and adolescents. Pediatric Anesthesia. 2014; 24(11):1141-1148. doi: 10.1111/pan.12518.
12. Klein SM, Grant SA, Greengrass RA, Nielsen KC, Speer KP, White W, Warner DS, Steele SM. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg. Dec 2000; 91(6):1473-8. doi: 10.1097/00000539-200012000-00033
13. Hanson NA, Allen CJ, Hostetter LS, et. al. Continuous ultrasound-guided adductor canal block for total knee arthroplasty: a randomized, double-blind trial. Anesth Analg. 2014;118(6):1370-1377. doi: 10.1213/ANE.0000000000000197.
14. Romero A, Joshi GP. Adult patient for ambulatory surgery: are there any limits? American Society of Anesthesiologists. 2014; 78(9):18-20.
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