Reconsidering Pain

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Practitioners should think about surgical pain more comprehensively, focusing on reducing pain before it occurs

According to the CDC, each year more than 51.4 million surgeries are performed in the U.S. These procedures, ranging from major surgeries requiring hospital stays to minor outpatient surgeries, are virtually pain free because of modern anesthesia techniques. However, post-surgical pain is still an issue.
CRNAs learn to quickly establish close rapport with their patients, assessing their needs and educating them about what to expect during the operative and postoperative period. This often includes setting reasonable expectations and giving them the opportunity to express any concerns. In my experience, the most common concerns patients have are how much pain they will experience when they wake up, and if they will experience postoperative nausea and vomiting (PONV).

Nurses play an important role in properly managing patients’ expectations when talking to them about post-surgical pain, recovery and the possible side effects of pain medications. Every member of the care team needs to work together to help patients make more informed choices throughout their entire operative period. For example, patients should be informed that post-surgery narcotics are often the source of unwanted side effects such as nausea and vomiting (including PONV), constipation, ileus and dependency. Therefore, limiting their use and duration of use may help minimize unwanted side effects. This kind of education, coupled with new technologies, can change the way caregivers and patients think about pain.

When thinking about pain, practitioners need to think comprehensively. All of us should ask ourselves: How can we best manage pain before, during and after surgery to minimize patients’ discomfort and, ultimately, prevent chronic pain and reduce the overuse of narcotic drugs?

Ultrasound-Guided Regional Anesthesia

Ultrasound-guided regional anesthesia (USGRA) is one of the newest techniques CRNAs are using to administer regional anesthetics. According to a recent study published in Regional Anesthesia & Pain Medicine, the use of UGRA was positive when compared to alternative techniques. Another study published in the October 2012 issue of Pain Medicine concluded that ultrasound technology helped healthcare providers improve patient safety with the delivery of regional anesthesia.

USGRA allows practitioners to visualize the patients’ nerves and surrounding structures, therefore giving them the ability to inject anesthetic medications with precision not previously afforded.

Regional anesthesia can be used as the sole surgical anesthetic and/or to provide pain relief during the postoperative period. By inserting an indwelling catheter connected to a controlled medication delivery device, patients’ pain is reduced for several days postop. Many patients are also being discharged home with the local anesthetic medicine still infusing. By reducing the patient’s most severe pain, he or she is often able to take fewer narcotics and manage post-surgical pain with medications like ibuprofen.

Groundbreaking Research

Middle Tennessee School of Anesthesia’s (MTSA)Center of Excellence focuses on pain management trends and surgical pain-related research. MTSA students and faculty are currently exploring a number oftheories-including the significance of chronic pain and the possible link between narcotics and the reoccurrence of cancer.

The Gate Control Theory of Chronic Pain says if we can use anesthetic techniques that prevent a person’s body from reacting to pain, we can ultimately prevent chronic pain. In other words, during surgery, we can’t prove that a person does not feel pain, we can only prove that he or she does not remember it. We also know specific people, including amputees and cardiac patients, are more likely to develop chronic pain after surgery. Understanding this, we believe if we could prevent the brain from establishing a pain pathway to the surgical spot – we could prevent chronic pain, and most post-surgical pain could be managed with over-the-counter medications.

Better pain management can be critical not only for a patient’s well-being, but for their overall health. Preliminary research from the British Journal of Anesthesia indicates there may be a direct correlation between surgical pain management and the reoccurrence of certain forms of breast cancer. The theory suggests narcotics and inhaled anesthetic drugs may reduce a person’s ability to fight cancer cells. In other words, when cancer is surgically removed from a patient, any remaining cancer cells could be more likely to metastasize if that patient is taking narcotics for pain relief.

Although there is no conclusive evidence, this type of research challenges us to look at patient care a different way, and we will continue exploring the effects common therapies may have on recovery and survival.

Acute Pain Management

To make surgical pain more manageable and decrease the patients transitioning from acute to chronic pain, we need to think about pain comprehensively. Everyone on the care team needs to think about managing
the pain before it occurs.

Although registered nurses often take the front line with patient care, the entire healthcare team including surgeons, anesthetists, pharmacists and therapists play vital roles ensuring the best patient experiences and outcomes.

New technologies make comprehensive acute pain management possible, yet a limited number of CRNAs are capable of incorporating USGRA into their practices. Few hospitals are equipped with the technology (ultrasound console), and only a handful of hospitals have CRNAs who are trained to use the technology.

In future years, hospitals across the U.S. will have better access to technology, and those providing care will have the skills and training needed to comprehensively treat acute pain, reduce chronic pain, and decrease dependency on prescription drugs, which increases the likelihood of undesired long-term outcomes.

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About Author

Christopher P. Hulin, CRNA, MBA, DNP

Christopher P. Hulin is the president of the Middle Tennessee School of Anesthesia.

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