Hip Replacement

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Multi-Modal Pain Management

Posted in About Anesthesia

In the past most surgeons used only narcotics (Vicodin, Demerol, Morphine) for post-operative pain. This had certain disadvantages. There was a concern that giving too much narcotic could overly sedate a patient, perhaps even causing respiratory depression which could be life threatening. On the other hand giving too little would not sufficiently relieve pain and allow the patient to function with nursing and physical therapy. Patients would vary in their sensitivity to narcotics (a common side effect of narcotics is nausea and vomiting). Getting the dose just right for each patient, while avoiding side effects, was rarely accomplished with narcotics alone.

Our goal for our patients is to allow them to advance rapidly while remaining very comfortable. The advancements we have made in pain management allow patients to begin therapy quickly and meet their milestones within just a few sessions. Although, every patient progresses at their own pace, we have seen that patients can be discharge home 2 or 3 days after surgery.

The concept behind the use of “multi-modal pain management” is that by combining medications that act at different points in the “pain pathway”, you can effectively relieve pain with fewer side effects. Equally important is the concept of preventing pain before it occurs. In the past when using narcotics alone on an “as needed” (or “prn”) basis the patient had to experience pain before it was treated. This not only resulted in more pain for the patient, but required more pain medication to relieve the pain, thereby increasing the chance of side effects. With multi-modal pain management one “stays ahead of the pain” and the patient experiences less pain and is able to function better and participate in a quicker recovery

.Our current regimen is to use a combination of “scheduled” (i.e. not “prn”) medications like oxycontin, Toradol, Celebrex, tramadol and others which work at different points on the pain pathway. This is combined with the use of regional and local anesthetics as well as spinal narcotics (given in conjunction with the spinal anesthetic) that help to prevent pain after surgery. We still use narcotics on an “as needed” (prn) basis, but they are now used only for “breakthrough” pain, not prevented by the multi-modal technique. Usually this is an oral medication, hydrocodone (Norco or Vicodin), Darvocet, codeine or similar that you may have every 4 hours as needed. As needed, the nurse can give an intravenous narcotic although we have found that often the oral medication lasts longer and creates less nausea. Anti-nausea medication is also given on a scheduled basis to try to avoid that side effect.

Pain is now considered the “fifth” vital sign (the others are temperature, pulse, respirations and blood pressure). After surgery you will be asked frequently by your nurse to rate your pain on a 1 to 10 scale (with 1 being very slight pain and 10 being the worst pain you have ever had). It is usually not possible to eliminate all post-operative pain and discomfort. Our goal for you is to avoid pain levels above the 3-5 range (mild to at most moderate), and if you experience a level above this range, to promptly treat it. The nurses will work with you to “stay ahead of the pain” and to try to time your medications before physical therapy sessions.

With multi-modal pain management, patient-controlled analgesia (PCA), a technique that was popular in the past, is less common in our practice yet is still used in certain situations. In this technique the patient controls when they receive intravenous narcotic pain medicine. The machine that provides this control is attached to an IV. There is a push-button that the patient controls. If you are feeling pain that is excessive to you, you merely push the button and a dose of narcotic pain medication is delivered to your IV. This works very fast and within a minute or two you feel the effect. A computer controls the dose and frequency. Typically the interval allowed is every 10 minutes or greater. If you push the button sooner than that, nothing happens. The computer can also be programmed to provide a baseline infusion (a constant amount of medication) to try to prevent pain from occurring, although there is concern about giving too much medication and depressing respirations, so the baseline infusion is rarely used.

With multi-modal pain management we have found PCA to be counter-productive in most situations. It requires the patient to push the button frequently, since intravenous narcotics are very short acting. That means if you fall asleep for a while you usually wake up in pain, since you haven’t been pushing the button. Also, since this is an intravenous narcotic, there is a high side effect of nausea and vomiting. Patients are frequently either in significant pain or narcotized (sleepy) from getting too much medication. Again, getting the dose right for each patient is difficult. We have found that for most patients, the multi-modal approach is sufficient, and they don’t require frequent intravenous narcotics. If, however, patients come into the hospital already taking significant doses of narcotics, or if we are unable to use spinal anesthesia with spinal narcotics, we will use PCA as an adjunct to our usual multi-modal regimen.

While we cannot guarantee that you will have no pain after surgery, and we do not believe that this is a realistic goal, with multi-modal pain management we have seen less pain, faster recovery, an easier ability to work with physical therapy, and a faster discharge to home.

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