As our nation is plagued by an unprecedented epidemic of opioid abuse, our role as regional anesthesiologists is crucial in perioperative pain management. Americans consume 80 percent of the world’s opioids, yet we represent only 4.4 percent of the world’s population. According to the U.S Department of Health and Human Services, 259 million opioid prescriptions were filled in 2012, enough to provide one for every adult in America. In 2014 the death rate from opioid overdose was higher than any year ever recorded.
Regional anesthesia can provide pain relief without opioids, improve outcomes, and increase patient satisfaction. Our acute pain and regional anesthesia teams in Santa Monica and in Westwood have undertaken initiatives to implement regional techniques as part of our patients’ perioperative care.
Patients who need major thoracic and abdominal surgery routinely receive epidural analgesia that is continued for two or more days postoperatively. UCLA surgeons appreciate how regional anesthesia decreases patients’ opioid consumption and pain scores postoperatively. Many of our orthopedic surgery patients can be discharged home on the day of surgery or the morning after with a portable infusion pump (On-Q), leading to minimal oral analgesic requirements at home.
Here are highlights of our recent work in progress:
Some 330,000 hip fractures occur annually in the United States, and the prevalence is expected to increase to 550,000 by year 2040. The pain associated with hip fractures is a major impediment to recovery, and can delay ambulation and physical therapy. Even though opioids can be effective in post-operative pain management, they carry significant risks in the elderly population including oversedation, constipation, and an increased risk of falls.
Our regional team is implementing a hip fracture protocol in collaboration with orthopedic surgeons at Santa Monica-UCLA Orthopaedic Hospital. Patients begin a multimodal analgesia protocol on admission, which includes placement of a fascia iliaca nerve block catheter. The fascia iliaca block provides comfort and ease during lateral positioning for spinal anesthesia. With this block, our patients are able to rely on non-opioid analgesics for pain control.
The quadratus lumborum (QL) block is a variation of the transversus abdominis plane (TAP) block. Local anesthesia spreads into the paravertebral spaces, resulting in abdominal wall analgesia over the T6 to L1 dermatomes. This block is safe for adults and children alike, and may be used during pregnancy. We use QL blocks as an effective analgesic tool for abdominal surgeries, and in management of acute postoperative pain following iliac crest bone graft harvesting.
Acute post-mastectomy pain is a major challenge for our patients, as it can result in prolonged hospitalization, emotional distress, and increased risk of developing chronic pain.
Thoracic paravertebral block can provide superior postoperative analgesia. We have implemented a multimodal analgesia protocol for our patients to receive a paravertebral catheter prior to surgery. With activation of the catheter during surgery, and administration of non-narcotic analgesics, we have been able to decrease opioid consumption significantly. Many patients go home sooner than expected with our continuous portable infusion pump that delivers local anesthesia directly to the surgical site.
The Acute Pain Service, a division of the Department of Anesthesiology, now based at Ronald Reagan UCLA Medical Center, has undergone major changes in recent years. We are committed to providing our patients with multiple options for postoperative pain management to help them to recover from their surgeries.
Our service consists of faculty members who rotate on a weekly basis, a nurse practitioner, and two residents who rotate with us on a monthly basis. As the number and variety of procedures that we perform on the service have increased dramatically over the past few years, our residents develop a more comprehensive experience by the end of their rotation.
The Acute Pain Service offers pain management on a 24-hour basis for postoperative patients. Our residents' diligent efforts in the postoperative care and management of our patients are why we consistently attain high satisfaction ratings among our patients and our surgical colleagues. Our nurse practitioner plays a vital role in orienting the new residents on the service, maintaining continuity of care, sharing the workload, and building working relationships with other nurses on different services.
Residents complete their rotation with an understanding of how to assess and manage acute postoperative pain, trauma pain, cancer-related pain and acute pain exacerbation in patients with chronic pain who need to be admitted to the hospital. They become competent in the pharmacologic management of pain as well as interventional pain management.
The goal of the Santa Monica/UCLA Medical Center and Orthopaedic Hospital Regional Anesthesia and Perioperative Pain Medicine Service (SMR&PPMS) is to improve patient care and acute pain management by utilizing regional anesthesia techniques for surgery and postoperative pain control. Perioperative regional anesthesia has been shown to improve patient outcome and assist with the early phases of rehabilitation, especially with orthopedic surgeries. Epidural analgesia, nerve blocks, continuous nerve blocks, and local anesthetics are among the many modes employed.
Prior to surgery, the regional anesthesiologists discuss the risks, benefits, and alternatives of anesthesia with the patients. If there are no contraindications, the patients are advised about the possibilities of getting peripheral nerve blocks with catheters, epidural analgesia, or other types of regional anesthesia. The peripheral blockade and/ or epidural will be placed prior to the start of surgery. If a peripheral nerve catheter or epidural catheter is placed, a member of the team will follow the patients postoperatively.
A member of the pain service is on call 24 hours a day to achieve optimal safety, comfort, and pain control for patients. Our multimodal approach to pain management includes a combination of oral medications, IV narcotics with patient-controlled analgesia, and deep breathing exercises, and allows for superior pain control following surgery.