|
Undergoing surgery is never an easy experience, but it can become exponentially
worse when patients experience significant pain or nausea post-operatively.
Fortunately, by preparing your patients and taking aggressive pre-emptive
measures, you can ensure that their recoveries are brief and comfortable
and keep your PACU costs to a minimum.
We asked several experts how they manage and minimize post-op pain and
nausea through all phases of the surgical process. Here's what they had
to say.
Pre-operative: Patient Education
Studies show that patients who know beforehand that they may experience
pain after surgery are able to deal with these complications and return
home much more quickly. Unfortunately, very few surgeons and anesthesiologists
actually warn patients that they will experience post-op pain, says Alan
Kwon, MD, Medical Director for the Kennedy Surgical Center in Sewell,
NJ. He emphasizes the importance of discussing the following points with
your patients:
- how much pain they are likely to experience;
- where it will occur; and
- how long the pain is likely to last.
Make sure patients understand their options
It's also important to discuss anesthesia options with patients, offering
alternatives or a combination of techniques, says Adam Dorin, MD, Medical
Director and the Chief of Anesthesia for the Surgery Center of Chevy Chase
in Maryland. This is not to say that patients should have total control
over their anesthesia care, but the anesthesia provider should consider
their preferences. If, for example, the patient wants to forego a regional
block in favor of being put to sleep, says Dr. Dorin, the anesthesia provider
should take that into account, as long as the patient's request is within
the boundaries of safety.
Give clear post-op instructions.
Dr. Dorin stresses the importance of talking to your patients about
the potential side effects of prescribed pain medications, including nausea,
vomiting, constipation, and drowsiness. To obtain pain relief with as
few side effects as possible, he recommends telling your patients to try
to control their pain first with NSAIDs or extra-strength Tylenol. Taking
a couple of Tylenol as soon as they get home from surgery may help pre-empt
pain and the need for stronger medications.
"Prescribed pain medications are ‘as needed' meds," says Dr. Dorin.
"They should be taken only when they are absolutely needed for pain relief.
If the pain persists and is still too intense after taking extra-strength
Tylenol, the patient should start off with just half of a pill, and no
more than one full pill, of the prescribed medications."
Patients must decide for themselves how much pain they can endure versus
how much medicine-induced nausea they can withstand, says Dr. Dorin. He
believes that most patients will prefer one night of minimal discomfort
to a night of nausea.
Nancy Burden, RN, director of Trinity and Bardmoor Outpatient Surgery
Centers in Florida, agrees that pain management varies widely among individuals.
"Some patients will get sick just looking at pain medicine," she jokes,
"while others can take pill after pill without any adverse side effects."
Put as much of the control back into the hands of your patients as possible,
she recommends, and let them determine their own personal balance between
pain relief and potential side-effects of pain medicine.
All of our experts agree that you should advise patients to take some
form of pain medicine, prescribed or over-the-counter, at the first sign
of pain, before it becomes extreme. Severe pain is very difficult to control.
Identify patients at risk for PONV.
Ms. Burden also suggests that you identify patients who are at particular
risk of post-operative nausea and vomiting (PONV) so you can be prepared
to supplement their pain medication with an anti-emetic.
You can pinpoint at-risk individuals by both the type of procedure they
will be undergoing as well as by specific patient criteria. For instance,
patients with a history of motion sickness and younger women tend to be
more likely to experience PONV, says Ms. Burden. Patients who undergo
laparoscopic surgery, who have tonsil, nose or sinus surgery in which
there may be bleeding in the nose, and children who have eye surgery are
also at greater risk. In contrast, patients who undergo hand, foot, or
cataract surgery almost never suffer from PONV and may be able to be "fast-tracked"
to a phase II PACU.
Intra-Operative: Anesthetic Agent Selection
The anesthesia agents and methods your providers use are the most important
factors in preventing adverse post-op symptoms. All of our experts suggest
supplementing general or replacing general anesthesia with a local anesthetic
or a regional block when possible. This markedly decreases the amount
of general anesthesia needed, which minimizes post-op pain and nausea,
says Dr. Kwon. A good block can also provide post-op pain relief for hours
after the procedure.
To provide continuous pain relief after particularly painful procedures
such as rotator cuff surgery, your anesthesia provider may want to consider
implanting a pain pump filled with a low-dose local anesthetic. Pain pumps
are usually removed within 48 hours, but can be left in place for up to
five days, says Dr. Kwon. Disposable pumps can cost anywhere from $50
to $100, but he believes they may be well worth the expense, especially
if they reduce PACU staffing costs.
Post-operative: Assess and Treat Patients, and Re-state Recommendations
Immediately after surgery, when patients are just regaining consciousness,
ask if they are experiencing any pain, advises Dr. Dorin; they may be
groggy, but they'll still be capable of answering. If the answer is yes,
administer IV pain medication. This pre-emptive measure ensures that they'll
be as comfortable as possible when they are fully awake, responsive, and
stable.
Before resorting to anti-emetics, there may be several steps you can
take to avoid nausea altogether, experts suggest. For example, one of
the biggest mistakes nurses make, says Ms. Burden, is letting patients
sit up too quickly. That little bit of movement may be all it takes to
induce vomiting in a patient who is bordering on being ill. Instruct patients
to lie still until they are fully awake. Also, administer proper pain
control and IV fluids, says Dr. Dorin. Often, nausea symptoms will resolve
on their own. If they don't, then consider an anti-emetic, he says.
Instruct PACU nurses to start off with weaker anti-emetics first, before
moving on to stronger treatments, opines Dr. Dorin. Less potent anti-emetics
lead to fewer sedated patients, and they're also less expensive than the
stronger variety. Dr. Dorin recommends first administering 10 mg of Reglan
for an adult of average weight; the cost is a few cents per dose. A dose
of 0.675 mg to 1.25 mg of Droperidol is comparable, and some studies even
indicate that it may be slightly more successful, but it sedates patients
more than Reglan, says Dr. Dorin. If, after these measures, the patient
is still in need of rescuing, try 4 mg of Zofran. This will typically
cost between $14 and $16 per dose. As a last resort, Dr. Dorin suggests
using a combination technique of 25 mg of Ephredrine and 12.5 mg of Phenergan
for adults of average weight. Although this technique only costs a few
dollars, it is almost always effective and causes only minimal sedation.
However, this combination needs to be intra-muscularly injected, which
makes it less desirable for patients.
Before discharging patients, our experts recommend summarizing your earlier
pre-operative discussion regarding at-home post-op pain control options.
It's also a good idea to make sure accompanying family members and/or
friends are present and that they understand your recommendations as well.
Standard instructions may include:
- Advising patients to refrain from drinking, driving, or making important
decisions for at least 24 hours.
- Recommending that patients start taking Tylenol in the correct weight-adjusted
dose every six hours prior to other agents wearing off.
- Instructing patients to apply ice to help with pain and swelling. "We
give all our orthopedic patients bags of ice to take home if they live
less than 20 minutes away," says Mary Louise Dietrich, Director of the
Coordinated Health Systems Ambulatory Surgery Center in Bethlehem, Pa.
"If they live further away from the facility, we instruct them to make
ice packs by putting ice in a plastic bag, and then placing the bag in
a pillowcase or cloth to avoid frostbite injury to the skin. If patients
don't have an icemaker, a bag of frozen peas is an excellent substitute."
The ice pack must mold easily to the body part, which is why frozen peas
work well, says Ms. Dietrich.
Completely eliminating post-operative pain is not always a realistic
goal. However, there is no reason why patients should experience any significant
discomfort while in your facility, nor should they experience anything
other than minimal discomfort at home. By managing your patients with
a thoughtful approach to anesthesia and an aggressive pre-emptive approach
to pain and nausea, you'll keep your PACU costs down and ensure that patients
come out of surgery as comfortable as possible.
|
