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126 M. Donnelly and P. W. Coleman
90% of the intervention group recommended that others having surgery watch the
videos and read the pamphlets they received [13].
Recent work in this area has demonstrated that the addition of a short 12-min video
at the preoperative visit, in addition to usual care of a preoperative clinic visit and short
briefing with the anesthesiologist on day of surgery, reduced preoperative anxiety
and resulted in vital sign maintenance closer to baseline in the preoperative period
[14]. This study targeted patients who would be offered a spinal anesthetic, and the
video specifically discussed spinal anesthesia, the surgical procedure, and addressed
“common myths” about surgery and anesthesia. Another group had similar findings
with a preoperative video on spinal anesthesia demonstrating an ability to reduce
anxiety and hemodynamic parameter deviation from preoperative baseline [15]. A
different group also examined the impact of an instructional video on anxiety in
patients being offered regional anesthesia [16]. The authors examined the impact of
a short [7, 9] for patients who were scheduled to receive either a brachial plexus block
or a spinal anesthetic. This video was viewed 2 weeks prior to surgery during the
patient’s preoperative assessment. Anxiety levels immediately prior to and following
surgery were found to be lower in the group who viewed the video.
Another benefit of preoperative education is related to patient expectations about
pain control and the postoperative process. Halawi et al. found that the most impor-
tant predictor of admission to an extended care facility, following admission for total
joint arthroplasty, was related to patient expectations [19]. Patient expectations are a
modifiable factor which can be influenced by preoperative processes and educational
efforts [19]. Postoperative opioid consumption has also been shown to be influenced
by preoperativepatient education and a reframing of analgesic benchmarks that might
be expected to require opioid analgesics. Yajnik et al. examined the impact of using
a simple educational tool created by the regional anesthesia group for patient educa-
tion [20]. This patient education card introduced the patient to the analgesic options
available to them following surgery. This card was reviewed prior to block place-
ment in preoperative holding, at the time of admission to the floor, and on daily pain
management team rounds visits. Utilization of this education framework was associ-
ated with a significant reduction in postoperative analgesic administration [20]. Other
studies have demonstrated that the impact of preoperative education may extend well
beyond what is typically considered a part of the postoperative phase of care. In
one study, preoperative education regarding opioid use was shown to reduce opioid
dependence following rotator cuff repair two years following surgery. The inter-
vention used included preoperative opioid education delivered verbally, via video,
and paper materials [5]. Khorfan examined a comprehensive intervention that aimed
to reduce postoperative opioid use in general surgery patients [21]. In this study,
changes to education were comprehensively expanded to include provider educa-
tion, standardized patient materials, setting pain management goals and expectation,
and installing an opioid waste disposal site. In this study 71% of patients reported
receiving preoperative education, 87% reported receiving postoperative education,
and 65% reported receiving both [21]. Those who received preoperative education
reported feeling more prepared to manage their pain following surgery. Postopera-
tive education alone was not associated with feeling prepared to manage pain, and
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Preoperative Preparation for Regional Anesthesia 127
receiving both pre and postoperative education provided the most patient prepared-
ness for pain management. Preoperative education and a feeling a preparedness to
manage pain were associated with a diminished postoperative opioid requirement.
These findings support the effectiveness of preoperative education programs that
seek to improve patient preparedness to manage pain following surgery and reduced
opioid use in the postoperative period [21] Patient education on opioid use and abuse
was studied as part of a much broader intervention implemented to improve the use
multimodal postoperative pain management strategies and lessen opioid prescribing
in a general surgery population. In those patients presented with enhanced education
offerings, dramatically fewer opioids were prescribed, increased levels of non-opioid
medications were utilized to address pain complaints, and patients overwhelmingly
(81%) reported good or excellent pain control [22].
Patient satisfaction can also be impacted by the provision of preoperative educa-
tion efforts that focus on the process and plan for delivery of anesthesia. A patient
education handout used in a multilingual patient population demonstrated significant
improvements in patient satisfaction. The patients enrolled in this study indicated that
they better understood the role of anesthesiologists, options related to anesthesia and
options for pain control after being exposed to the educational pamphlet prior to their
surgical procedure [12]. When examining patient satisfaction in surgical populations,
it has been consistently demonstrated that the addition of a video or multimedia
interface to a patient’s preoperative education platform improves satisfaction over
brochures or in person verbal interactions [17, 23, 24].
4 Regional Anesthesia
In studies examining patient concerns about anesthesia, it has been noted that approxi-
mately 27% of patients considering regional anesthesia were concerned about perma-
nent paralysis, back injury, and seeing the procedure [25]. It has been demonstrated
that a preoperative appointment with an anesthesiologist can improve the acceptance
rate of regional anesthesia and reduce anxiety about the process. Patients undergoing
total joint arthroplasty had a preoperative appointment with an anesthesiologist prior
to surgery where an assessment was performed and a discussion about the rela-
tive merits and risks of general vs spinal anesthesia was conducted. Patients were
surveyed before and after these visits and the impact of this visit resulted in patient
preference for spinal anesthesia increasing from 39 to 76%. Forty-seven percent of
those patients who changed their mind from initially desiring general anesthesia to
ultimately requesting spinal anesthesia indicated that it was because they felt more
knowledgeable about the anesthesia choices available to them. The implementation
of preoperative anesthesia discussions was also associated with a significant decrease
in anxiety related to the upcoming surgery [26].
Decision aids represent effective tools that can be implemented at various points
in a patient’s health care journey to assist in determining “preference sensitive” deci-
sions. Preference sensitive decisions are frequently those where there is little clinical
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128 M. Donnelly and P. W. Coleman
benefit associated with one path versus the other but where there may be value- or
experience-based reasons why one therapeutic path is selected above another. In the
context of preference sensitive decisions, the use of decision aids has been shown to
result in decreased indecision, improved patient engagement, and improved satisfac-
tion with the decision making process [27]. In addition, the use of decision aids has
been shown to help establish clearer expectations around care, lessen anxiety in deci-
sion making and foster a better overall understanding of the healthcare options [27]. In
this context, decision aids are tools used to facilitate discussions between healthcare
professionals and patients. They are not meant to be a substitute for physician consul-
tation. Ideally, decision aids can be incorporated into the process of shared decision
making during anesthesia care discussions. The shared decision-making process is
similarly employed when there is no medically best choice and patient preferences
play a role in determining next steps in the patient’s healthcare journey. Figure 1
depicts the shared decision making process and the critical steps in the process [28].
Decision aids are ideally utilized during these types of patient encounters and can
facilitate collaborative decision making around patient care [27].
Regional anesthesia and pain management strategies frequently fall into this cate-
gory of preference sensitive decision making. As such, decision aids can provide
substantial assistance in the process of shared analgesic decision making between
the patient and the anesthesia professional [27, 29]. The ASA has developed deci-
sion aids for both peripheral nerve blocks and neuraxial nerve blocks. The use of
Fig. 1 The SHARE approach [28]
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Preoperative Preparation for Regional Anesthesia 129
these aids has been associated with an increased degree of patient engagement in
the preoperative regional anesthesia discussion and an improved understanding of
regional anesthesia [30]. Further research seeks to evaluate the impact of similar
decision aids in the setting of planned Monitored Anesthesia Care [27].
5 Modality of Education
Multiple preoperative education modalities have been examined without one yet
emerging as the clearly superior method. Studies evaluating patient preference for
delivery of education have demonstrated that they would prefer to obtain education
via a pamphlet or in a preoperative visit. Video education dissemination and group
information session were less preferred modalities for preoperative education [25].
There has been an extensive use of web-based tools for surgical education that have
demonstrated improvements in patient satisfaction and engagement across multiple
surgical specialties [31]. Video based information concerning anesthesia has been
demonstrated as beneficial in a number of studies [13, 16]. Ensuring that language
included in education offerings is targeted at an appropriate reading level will ensure
that delivery is accessible to patients. Timing of educational endeavors should aim to
begin in the preoperative phase and ideally in the surgeon’s office after the decision
has been made to proceed with surgery [4]. Preoperative education should then
continue through any presurgical encounter up to and including the day of surgery.
The perioperative surgical home (PSH) has been defined as “a micro-healthcare
system centered on the patient from the time of the decision for surgery to the physical
and social recovery as an outpatient up to 30 days after discharge from the hospital
with a triple aim of improving (i) clinical outcomes and the (ii) patient experience, as
well as (iii) reducing healthcare costs” [32]. This model of care is patient-centric and
requires that caregivers and family members are engaged as partners in care. This
model of care will often include patient education, patient centered optimization
and evaluation prior to surgery [32]. Patient counseling and education fit easily into
the PSH model of care to improve outcomes for patients and organizations. Shared
decision making and values-based decision making are critical strategies in this
construct [33]. A recent literature review demonstrated that the implementation of
the PSH often resulted in decreased length of stay, decreased use of postoperative
opioids and increased likelihood of discharge to home [34]. Of the elevenmanuscripts
included in this review, all but one identified preoperative education and counseling
as a critical part of the PSH.
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130 M. Donnelly and P. W. Coleman
6 Conclusion
Preoperative education is a critical part of patient care and can aid in the process of
setting patient expectations surrounding the s urgical experience, reducing anxiety,
improving patient satisfaction, reducing long and short term opioid use, and encour-
aging patient engagement in decision making about their surgical and anesthetic
care. Multiple education modalities have been developed and evaluated but more
research is needed to determine the optimal content, timing and delivery method in
regards to regional anesthesia preoperative education. There are potential benefits of
this work which may extend beyond the preoperative and immediate postoperative
period and this is another area that should be targeted for further exploration. Deci-
sion aids are known as useful adjuncts in the shared decision making process and
have demonstrated efficacy in reducing decisional conflict and anxiety and facili-
tating values-based decision making for individual patients. More research is needed
in this area to further define how these tools impact patient experiences and utilization
of health care resources.
The preponderance of work in this area supports efforts to provide preopera-
tive anesthesia education for patients prior to the day of surgery. A wide variety of
approaches have achieved success in improving perioperative outcomes by providing
preoperative education on anesthesia and regional anesthesia. The decision aids
created by the ASA are evidence-based and readily available tools which should
be more widely utilized. These aids represent a valuable adjunct in achieving a more
patient centered approach to conversations about regional anesthesia with patients.
7 Key Takeaways
1. Preoperative education about anesthesia, whether in-person, video or static,
decreases patient anxiety and may improve outcomes.
2. Preoperative education about regional anesthesia improves acceptance of
regional anesthesia and decreases patient anxiety.
3. Decision aids can help facilitate improved patient participation and decision
making.
4. The perioperative surgical home may provide a framework for the incorporation
of preoperative education for regional anesthesia.
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Preoperative Preparation for Regional Anesthesia 131
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The Role of Inpatient/Acute Pain Services
for Perioperative Pain Management
Hari Kalagara, Asaf Gans, Lauren Gatewood, and Sindhuja Nimma
Abstract Pain management is a significant concern for patients undergoing
surgery. This chapter delves into the many roles an Inpatient Pain Service (IPS)
or Acute Pain Service (APS) team can play in perioperative pain management. The
APS team is a dedicated group of anesthesiologists, anesthesia fellows and resi-
dents, nurses, and technicians who work together to aid in safe and effective periop-
erative pain management. Its goals are to help reduce opioid consumption, reduce
delays in hospital discharge, improve patient satisfaction, maximize patient safety,
and answer patient questions. The IPS team helps place and manage peripheral and
neuraxial nerve blocks/catheters, manage intravenous (IV) lidocaine and ketamine
infusions, manage patient-controlled analgesia (PCA) pumps, or implement a combi-
nation of these techniques. There are tremendous benefits to implementing these
strategies, including reducing the side effects of opioids, facilitating participation
in rehabilitation, and improving pain control. Members of the APS team should be
experts in choosing the best pain relief intervention, managing, and troubleshooting
perioperative pain, identifying contraindications to different interventions, recog-
nizing regional anesthesia and medication-induced emergencies and side effects.
This chapter may serve as a guide for a successful acute pain service and the scope
of practice within its different roles.
Keywords Acute pain service
· Regional anesthesiology · Inpatient pain service ·
Perioperative care · Pain management · Peripheral nerve block · Peripheral nerve
catheters
· Epidural catheters · Ketamine infusion · Lidocaine infusion · Acute
pain consultation
· Chronic pain · Multidisciplinary team
H. Kalagara (
B
) · A. Gans · L. Gatewood · S. Nimma
Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL 32224,
USA
e-mail: Kalagara.Hari@mayo.edu
L. Gatewood
e-mail: Gatewood.Lauren@mayo.edu
S. Nimma
e-mail: Nimma.Sindhuja@mayo.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_10
135
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136 H. Kalagara et al.
1 Introduction
The acute pain service (APS) or inpatient pain service (IPS) is a dedicated, multidis-
ciplinary team specializing in perioperative pain management of inpatient surgical
patients. Pain management is a significant concern for patients undergoing surgery,
and inadequate pain management is often the cause of hospital discharge delays
[1–3]. The APS team as an organized unit was first described in the late 1980s.
Soon after, hospitals worldwide adopted this concept and developed it into an orga-
nized establishment addressing many patient concerns by incorporating education,
research, and clinical care [4].
In most established academic and private practice hospitals, the APS team is led
by physician anesthesiologists with fellowship-level training or expertise in regional
anesthesiology and acute pain medicine [5]. However, the inpatient APS functions
best as an integrated team that includes physicians, nurses, technicians, residents,
fellows, nurse practitioners, and other medical professionals. Since pain is universal
to all post-surgical patients, it is essential to understand the APS team’s role in
addressing individual patient pain management strategies through assessment and
implementation of data-driven management protocols. This team assumes a variety
of roles in their efforts to address pain control, improve continuity of care, enhance
patient education, drive research endeavors, and, most importantly, promote patient
safety. In the following sections, we address the numerous roles of the inpatient APS
team in managing perioperative pain.
2 Peripheral Nerve Catheters
Before the utilization of peripheral nerve blocks for upper and lower extremity surg-
eries, surgeons and anesthesiologists depended heavily on opioids to manage acute
postoperative pain. While multimodal analgesia is strongly encouraged, opioids
remain a potent problem. Given the recent opioid crisis, non-pharmacological inter-
ventions have gained increasing attention in addressing intraoperative and postoper-
ative pain [5]. Peripheral nerve catheters (PNC) are typically placed before surgery
in a dedicated preoperative area, immediately post-operatively in the postanesthesia
care unit (PACU), and at times in the operating room (OR). The APS team examines
the patient’s preoperative history and scheduled surgery and identifies indications
and contraindications to offering a nerve block to ultimately establish post-operative
pain expectations.
From performing a peripheral nerve block to following up with the patient post-
operatively, the inpatient APS team plays an incredibly important role. The APS
team decides the local anesthetic of choice and technique (i.e., single shot block
versus peripheral nerve catheter) after a discussion with the surgical team and the
patient. Peripheral nerve catheters are more challenging to place than single-shot
injections; however, they offer longer-lasting pain control compared to a single-shot
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