Pain management in the ambulatory setting — Key thoughts on a multimodal approach for TJR procedures

Surgery centers will need strong pain management protocols in place to successfully perform total joint procedures on an outpatient basis. Keith Long, MD, associate chairman in the anesthesia department of anesthesia at Winchester (Mass.) Hospital and medical director of Winchester Hospital's ASC, discusses the benefits of a multimodal approach and the importance of this approach for outpatient total joints procedures.  

Question: How have advancements in pain management paved the way for surgeries to transition to the ASC setting?

Dr. Keith Long: The biggest change we have made in our practice to manage perioperative pain is the switch to multimodal pain therapy in conjunction with ultrasound-guided nerve blocks when indicated. The majority of our regional nerve block patients receive a continuous catheter with an ON-Q pump, which is typically discontinued on postop day three. With this technique, most patients receive little to no narcotics both during surgery and in the post-anesthesia care unit.

As an example, a typical shoulder repair patient receives less than 100 mcgs of fentanyl total during their stay at our facility and is discharged from our facility in about 60 minutes to 90 minutes after arriving in the PACU. We have several days during the week where the majority of patients receive nothing — neither narcotics nor antiemetics — in the PACU post-op. Having patients awake, pain-free and nausea-free in the PACU allows us to expedite discharges from our facility and also increases patient satisfaction.

Q: What goes into having a strong total joints program in ASCs? Are there certain elements that differentiate a successful program from an unsuccessful program?

KL: For outpatient total joints, you need to be able to control the side effects, which are primarily pain and nausea. We aggressively treat both. Our total knee patients receive multimodal pain management, as well as a tibial nerve block. They also get an adductor canal block with a catheter that stays in place for 48 hours.

Q: How can ASCs ensure patients are recovering well at home?

KL: I recommend having some type of tracking method post-operatively for when the patients leave the facility. We use the ON-Q* TRAC application, which is web-based and automatically surveys the patients for up to 90 days. The application tracks several indicators and has been very helpful. We even get an email notification if one of our patients checks into an ER for any reason. A few things we have learned from the app include:

•    Forty percent of patients feel their post-op pain was less than expected, while 40 percent think it was about as expected.
•    The average number of narcotics taken per 24 hours was about 2.5 pills for the first two to three days and then drops significantly.
•    The overwhelming majority of patients were big fans of the regional catheters.
•    We don't seem to be getting spikes in narcotic use on day one and two as a single shot block wears off.
•    Our side effects seem to be at a manageable level.

Q: Where do you see the ASC industry trending?

KL: The trend is pushing more complicated patients and surgery into the ASC setting. Pain management will be one of the key determinates in a successful ASC.

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