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Archive Orthopedic Surgery 2016

Near-Perfect Pain Control

Inside a surgical hospital's multimodal regimen.

manage both local and systemic pain PLAN OF ATTACK Administer a variety of agents with different mechanisms of action to manage both local and systemic pain.

At the Hospital for Special Surgery in New York City, we've been searching for the optimal multimodal pain management regimen for the last 18 years. Although we haven't yet hit on the perfect plan, we've made tremendous strides in developing a protocol that controls pain, improves patient satisfaction, lowers opioid consumption and reduces post-op stays, all while minimizing complications.

Finding the right mix
To keep patients comfortable enough to head home hours after notoriously painful orthopedic procedures, it's essential to attack the various ways pain is perceived in the spinal cord, the peripheral nerves, the dorsal ganglia, and ultimately the central nervous system and brain. Our current protocol has evolved over time, undergoing many modifications as we've seen what works well, and what's not as effective.

We've come to recognize the advantages of regional anesthesia, which we now use on the vast majority of our patients. In addition to reducing blood loss and preventing deep vein thrombosis, it avoids central nervous depression, places less stress on the cardiopulmonary system, may modify the stress response to surgery, provides excellent pain relief, and allows early painless range of motion and weight bearing. We use general anesthesia only in those rare instances in which the anesthesiologist is unable to perform the spinal or epidural anesthesia for medical or technical reasons.

Parenteral opioids are the source of many of the negative effects of analgesic therapy, so limiting their use is also a major principle of our multimodal approach, which I've outlined here:

  • In pre-op. About an hour before surgery, we administer preemptive analgesia — usually IV acetaminophen, a relatively recent addition to the field that we've found helpful. As a preemptive measure, IV acetaminophen helps prevent the establishment of central sensitization and the amplification of pain.
  • During surgery. Our surgical "cocktail" includes several medications designed to work in different ways on different levels. We inject a steroid-containing local anesthetic into the soft tissues that surround joints. The steroid helps prevent local inflammation, and is combined with just enough morphine to stimulate all 3 opiate receptors in the joint with fewer adverse systemic effects.
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