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The Role of Inpatient/Acute Pain Services for Perioperative Pain … 137
approach. While the anesthesiologist, resident, or fellow will ultimately perform the
block and administer sedation, the integrated team of nurses and technicians help
with the time-out process prior to needle insertion; help position the patient, set up
the block tray supplies, and ensure proper documentation either on a paper chart or
electronic medical record.
After performing a peripheral nerve catheter, a member of the APS team will
evaluate the patient by performing a sensory and motor exam to ensure a successful
block. Once the scheduled surgery is completed, patients with nerve catheters can
either be sent home with a home catheter device or be admitted overnight for observa-
tion. The APS team is responsible for following up with patients in either discourse.
If the patient is sent home with a catheter, the patient and a family member are
educated on how to use the pain pump device and troubleshoot common catheter or
pump-related issues. They are also provided with a phone number to call anytime
with concerns. A member of the APS team, either a resident, fellow, or nurse, will
follow up with the patient daily until the catheter is removed. For patients staying
overnight in the hospital, the on-call APS team members will assess the patient
overnight and during morning rounds to ensure adequate pain control. They will
help troubleshoot any patient or catheter-related issues. The team will also evaluate
the catheter dressing site to ensure the insertion site is clean and dry with no obvious
signs of infection and that the catheter is not displaced or dislodged. The concentra-
tion of local anesthetic, rate of infusion, total volume, and maximum dose per hour
is determined and titrated by the APS team. Based on physical exam findings and
subjective patient experience, the settings of basal and bolus LA infusions can be
adjusted to ensure more significant pain relief and patient satisfaction. The team will
additionally assess the nurse-reported pain scores, opioid utilization, diet progression,
and primary team services’ communication to determine expected patient disposi-
tion. Depending on the hospital system, nurses, physical therapists, surgeons, internal
medicine physicians, sub-specialty physicians, and social workers may work together
with the patient. In the end, however, all teams must work cohesively to ensure an
expedited and smooth recovery process for the patient. It is important to note that
effective communication of t he expectation of pain with a nerve block is integral to
improving patient satisfaction and reducing patient anxiety. Recently with growing
use of interfascial plane blocks, continuous catheters can be placed for these blocks
also to enable prolonged postoperative analgesia, for example erector spinae plane
(ESP) block catheters or serratus anterior plane (SAP) block catheters for patients
with rib fractures.
Apart from ensuring adequate postoperative pain control, assessing patients for
any side effects or complications of a peripheral nerve catheter is imperative. Specifi-
cally,every patient should be evaluated for local anesthetic systemic toxicity (LAST),
which can initially present with mild symptoms, such as tinnitus, perioral numbness,
and metallic taste. If not immediately recognized and treated, LAST can progress
to agitation, confusion, seizures, arrhythmia, cardiac arrest, and even death [6]. It
is imperative that all members of the inpatient pain team are educated on how to
recognize and treat LAST. In summary, an i npatient APS team should be able to
work as an integrative team to evaluate and troubleshoot peripheral nerve catheters,
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138 H. Kalagara et al.
offer a multimodal pain plan, eloquently and concisely manage patient expectations,
and systematically approach any deviations from the expected course or unexpected
complications. Unfortunately, not all healthcare systems have the resources, finan-
cial ability, or trained personnel to offer nerve catheters or establish an organized
inpatient pain team for catheter follow-up. These groups often resort to single-shot
blocks and either a nurse or physician may or may not follow up with the patients
postoperatively.
3 Home Catheters
There are many benefits associated with peripheral nerve catheters, including postop-
erative analgesia, decreased opioid consumption, improved participation in rehabil-
itation, and increased patient satisfaction. When performed appropriately, there are
minimal side effects [27–29]. However, persistent safety concerns may limit enthu-
siasm for discharging patients with a peripheral nerve catheter. Physicians remain
concerned over the potential for catheter migration in an unmonitored setting, the
potential for local anesthetic systemic toxicity, and injuries associated with an anes-
thetized extremity. One way to address these concerns is through the utilization of
dilute concentrations of local anesthetics, which, if delivered intravascularly, should
only produce minimal s ymptoms [30]. This, in conjunction with a direct phone line
to an available physician or nurse, allows an APS team to monitor their patients
closely, troubleshoot malfunctioning catheters, and answer questions. Thirty percent
of patients utilized this phone resource even though they were discharged with verbal
and written instructions [31]. While not every hospital system has the resources
or infrastructure to support the ability to discharge patients with peripheral nerve
catheters, the patient benefits of peripheral nerve catheters should strongly argue
for integrating them into a multimodal analgesic paradigm. Having an APS team
will help to manage these home catheters more effectively on a regular basis in a
systematic manner.
4 Single Shot Blocks
When a nerve catheter is not indicated, or a specific surgery does not necessitate
long-term pain control, a single shot nerve block, paravertebral block (PVB) or inter-
fascial plane (IFP) blocks can be offered for postoperative pain control. The duration
of a single shot block depends not only on the anatomical location of the block
and the patient’s age but also on the local anesthetic of choice and what adjuvants
are added (i.e., adrenaline, dexamethasone, dexmedetomidine, clonidine, buprenor-
phine) with the local anesthetic. On average, a single shot block with ropivacaine
or bupivacaine can last between 12–24 h. Single shot blocks, for example, are typi-
cally offered for outpatient procedures such as upper and lower extremity surgeries,
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The Role of Inpatient/Acute Pain Services for Perioperative Pain … 139
breast lumpectomy or mastectomy, arterio-venous fistula creation, etc. Most patients
are discharged from the hospital, and follow-up on post-operative day one depends
on the expectations of the current inpatient APS practice. Some centers do offer
single shot intrathecal (spinal) opioid injections for certain surgeries preoperatively
especially for ERAS programs. If the patient is admitted overnight, a member of
the APS team, depending on the institution, may evaluate the patient to assess pain
scores and overall patient satisfaction. Some APS teams may not have an organized
way of following up single shot blocks, and patients will only have follow-up with
the APS team as necessary if concerns arise. However, the ability to routinely assess
patients following regional anesthesia procedures offers an opportunity for enhanced
quality improvement initiatives and rapid intervention in circumstances where block
resolution is delayed or results in significant patient discomfort.
5 Neuraxial Catheters
For major surgeries such as open abdominal or pelvic surgery, extensive lower
extremity surgery, or thoracic surgery, a thoracic or lumbar epidural catheter can
be offered for intraoperative and postoperative analgesia [7]. Contraindications to
neuraxial catheters include patient refusal, history of spine surgery, spine hardware,
coagulopathy, bacteremia, signs of infection at the anticipated needle insertion site,
or hemodynamic instability. A neuraxial catheter can be considered if the bene-
fits outweigh the risks after a collaborative discussion occurs between the patient,
surgical team, and anesthesiologist. The entire APS team is involved in patient care
during the procedure. For example, the APS technician will help position the patient
appropriately while the nursing team performs a pre-procedure safety check (time-
out) to ensure the correct patient is undergoing the correct surgery and the correct
block is being performed. The physician will place the epidural catheter and direct
sedation administration while the nursing staff can help document procedure details,
including the spinal level of insertion, depth of needle and catheter, type of catheter
used, and any complications noted during the placement or during the test dose
administration [7]. After the successful placement of the epidural, the APS team will
dictate the local anesthetic of choice, rate of infusion, as well as the number of bolus
doses allowed every hour.
Similar to the management of peripheral nerve catheters, there is a system-
atic approach to evaluating epidural catheters, such as evaluating the sensory and
motor blockade of a neuraxial catheter, assessing pain scores, opioid usage, oral
intake, and ambulation. A discussion with the surgical service should also occur,
outlining their plans for removing surgical tubes and drains, expected disposition,
and methods for diagnostic or therapeutic studies. This information can help guide the
optimal duration of therapy and limit epidural catheter duration dependent complica-
tions including infection [8]. Some centers prefer paravertebral (PVB) catheters for
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140 H. Kalagara et al.
thoracic and other major abdominal surgeries instead of epidurals to enable postop-
erative analgesia and to overcome the risks and limitations of these central neuraxial
blocks.
Based on the ASRA anticoagulation guidelines, the APS team ensures proper
discontinuation of anticoagulants before neuraxial blockade. They also dictate which
anticoagulants can be administered while a neuraxial catheter is in place and at what
doses and frequencies, how extended anticoagulation should be held before neuraxial
catheter manipulation or removal, and when anticoagulants can be reinitiated once
a neuraxial catheter is removed [9]. Before the placement of any neuraxial block, it
is imperative that the entire APS team is familiar with appropriate anticoagulation
recommendations.
It is well known that epidurals can cause hemodynamic perturbations via sympa-
thectomy and its associated vasodilation. It is also well known that the periopera-
tive period is associated with significant fluid shifts and potential blood loss. The
combination of inadequate resuscitation and iatrogenic sympathectomy can cause
hypotension and associated sequela. Therefore, an inpatient APS team needs to be
cognizant of a patient’s fluid status, needs for vasopressor support, and changes
in labs consistent with hemoconcentration or hemodilution [10]. Another critical
aspect of evaluating a patient with a neuraxial catheter is to assess their gastroin-
testinal function by assessing their ability to tolerate PO medication and have bowel
movements or pass flatus. Along the same lines, it is also important to evaluate for
nausea and vomiting. A patient that can tolerate a PO diet without nausea while also
demonstrating a return of gastrointestinal motility through passing flatus is likely
making strides toward utilizing PO medication for pain control and discontinuing
the neuraxial catheter. This comes into play often with abdominal surgeries and the
potential for ileus and small bowel obstruction. If the patient cannot tolerate PO/NG
medications, then pain control options include neuraxial or IV medication, which
are incompatible with progression to discharge and may worsen nausea and potential
ileus. A neuraxial catheter, in and of itself, should decrease the incidence of postop-
erative ileus by decreasing opioid consumption and via blockade of the sympathetic
fibers that slow gastrointestinal transit [11–12].
Sometimes, even when a neuraxial catheter is placed convincingly and without
problems, maintaining an effective and safe block is challenging. It is important to
know how to troubleshoot common problems and know when there is a concerning
finding. Common issues the inpatient APS team encounters include no sensory or
one-sided sensory blocks, epidural catheter migration, inadequate local anesthetic
dosing, hypotension, infection, or erythema at the insertion site, etc [13]. To effec-
tively care for patients with any neuraxial block, the inpatient APS team must be a
well-educated team of individuals trained to assess the indications and contraindi-
cations of offering the procedure and manage neuraxial-related side effects and
complications.
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The Role of Inpatient/Acute Pain Services for Perioperative Pain … 141
6 Lidocaine Infusion
A peripheral or neuraxial nerve block procedure involves bathing targeted nerves
in local anesthetic to disrupt the pain signaling pathway from the periphery to the
central nervous system. However, if the APS team determines there is a contraindi-
cation to performing such a procedure, administering intravenous lidocaine can
benefit selected patients. Numerous articles have illustrated systemic lidocaine’s
anti-inflammatory and cytokine reduction properties [14]. While the mechanism of
action for lidocaine on peripheral nerves is via sodium channel blockade, the mech-
anism of action for intravenous lidocaine infusion at therapeutic doses is believed to
be via blockade of the muscarinic and NMDA receptors [14–15].
IV lidocaine has been used as part of a multimodal analgesic regimen for many
types of surgery. For a specific subset of surgeries, there seems to be a decrease in
opioid consumption, length of hospital stay, pain scores, occurrences of postoperative
ileus, and postoperative nausea and vomiting. While a reduction is noted in most
studies, it may not be statistically or clinically significant [15–16]. The subset of
surgeries with the most evidence-based support for IV lidocaine is abdominal surgery
and genitourinary surgery, specifically laparoscopic abdominal surgery and radical
retropubic prostatectomy [17]. Some patients may show particular benefit when
opioid medications have been deemed ineffective or if they have been shown to have
acute hyperalgesia [15]. In contrast, the administration of intravenous lidocaine for
obstetric and breast surgery did not show improvement in their i ncidence of pain,
postoperative nausea, and vomiting, opioid consumption, or length of stay [16].
Due to lidocaine’s potential to block cardiac sodium channels, significant cardiac
disease can be considered a relative contraindication. Additionally, IV lidocaine
infusions should be used cautiously in patients with significant renal or hepatic
dysfunction due to altered metabolism. Seizure disorders, neurologic disorders, and
breastfeeding patients may also represent relative contraindications to intravenous
lidocaine infusions [16]. Therefore, if the APS department at a particular institution
oversees patients on IV lidocaine infusions, the team must be well educated on the
signs and symptoms of LAST. Typically, to initiate a lidocaine infusion, a loading
dose of 1.5 mg/kg ideal body weight is given over 10 min, followed by an infusion
of 1.5 mg/kg/hr ideal body weight. Infusions may be considered for 24 h following
surgery but may be discontinued sooner if side effects are noted [16]. An APS team’s
role in IV lidocaine infusion management should include appropriate patient selection
and initiation of the infusion, dosing, and titration, answering questions regarding
side effects or concerns while also ensuring that patients don’t receive additional
nerve blocks or fascial plane blocks with local anesthetics while the IV lidocaine is
running. Because of the potential for neurologic and cardiovascular abnormalities
associated with IV Lidocaine infusions, having a dedicated APS team to oversee
patient care is critical. Variations in clinical practices are seen where these patients
are being managed postoperatively in the intensive care unit (ICU) or on general
floors.
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142 H. Kalagara et al.
7 Patient Controlled Analgesia (PCA)
The benefits of opioid Intravenous Patient Controlled Analgesia (IV PCA) are
well documented and include improved patient satisfaction and pain control when
compared to nurse-administered opioid boluses, decreased anxiety due to enhanced
patient feelings of control over their pain medication, and increased mobility and thus
a reduced risk of deep vein thrombosis [18]. While there are documented benefits
of IV PCA, there are multiple side effects, including nausea, drowsiness, constipa-
tion, and respiratory depression. Programming an IV PCA requires consideration
of the initial loading dose, intermittent demand dose, lockout interval, and hourly
limit. Numerous opioid medications are amenable to IV PCA, and common choices
include morphine, hydromorphone, fentanyl, and sufentanil. The choice of opioid is
patient dependent and outside the scope of this discussion.
While the primary medicine or surgical team manages the initiation, titration,
and discontinuation of IV PCA at some institutions, this role is tasked to the inpa-
tient APS team at other institutions. To evaluate a patient with an IV PCA, the
APS team will do a thorough chart review and examine the patient to review pain
scores, IV PCA settings, IV PCA bolus attempts, IV PCA boluses received, non-
opioid analgesic orders, and reported side effects (respiratory depression, sedation,
constipation, nausea, vomiting). If the patient reports unsatisfactory pain control
without side effects (and appropriate IV PCA utilization, i.e. 2–3 demands per hour),
increasing the intermittent bolus dose amount or frequency of the intermittent bolus
dose is a consideration that could be discussed with the patient and primary team
[19–20]. If, however, the patient reports opioid-related side effects and their pain is
still unsatisfactory, a conversation with the patient that focuses on risks and benefits
associated with IV PCA utilization and consideration of other non-opioid analgesic
techniques may be beneficial. The optimal goal of any team managing the IV PCA
is to transition the patient as quickly and safely as possible from IV PCA to an oral
multimodal pain regimen in preparation for discharge. Respiratory rate monitoring
with a priority on patient safety is critical to preventing opioid-related adverse events
while using IV PCA.
8Ketamine
Ketamine is a phencyclidine analog that is a dissociative anesthetic agent that reverses
central sensitization and enhances descending pain-modulating pathways [21]. As an
infusion, it has been used for many decades to treat acute and chronic pain and severe
depression [22]. Recently, there has been a surge of use in the perioperative period
in patients with refractory pain and post-surgical patients with chronic pain who
are opioid-tolerant [22]. Because there is such wide variability in patient selection,
indications, and monitoring, several associations, such as the American Society of
Anesthesiologists (ASA) and the American Society of Regional Anesthesia and Pain
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The Role of Inpatient/Acute Pain Services for Perioperative Pain … 143
Medicine (ASRA), created consensus guidelines for the use of intravenous (IV)
ketamine infusions.
Ketamine is increasingly being administered under an APS team’s guidance in
inpatient settings. Ketamine infusions are often started in patients undergoing surgery
where the expected post-operative pain is severe such as might be encountered
following open abdominal surgery, thoracic surgery, and spine surgery, or in opioid-
dependent patients expected to have an acute exacerbation of a baseline chronic pain
condition. In select patients with severe sleep apnea, ketamine is often used as an
adjunct to limit opioid administration. While the decision to start a ketamine infu-
sion is primarily made by the intraoperative anesthesiologist or primary surgical or
critical care team, the APS team is often consulted to direct further management.
If the ketamine infusion is started in the operating room, a bolus dose of ketamine,
typically 0.3–0.5 mg/kg, is given before an infusion of 0.1–0.2 mg/kg/hr is initiated
[23]. At this infusion rate, the subanesthetic dose of serum ketamine concentration
of 100–200 ng/ml is known to produce analgesia [24–25]. Perioperative ketamine
infusions are typically continued through two postoperative days. The APS team is
responsible for evaluating patients every day and titrating the ketamine infusion rate
to improve patient comfort and minimize the occurrence and severity of side effects.
It is generally recommended that the ketamine infusion rate not exceed 1mcg/kg/
hr [26]. Ketamine should be avoided in patients with severe cardiovascular disease,
active psychosis, pregnancy, severe hepatic dysfunction, and elevated intraocular or
intracranial pressure. Ketamine infusions should also be titrated down or even stopped
if the patient is experiencing side effects, including confusion, disorientation, changes
in sensory perceptions such as auditory or visual hallucinations, or loss of motor
coordination. In institutions with a dedicated inpatient APS team, the responsibility
falls on this team of trained individuals to perform daily pain evaluations during
morning rounds, assess the need to continue or discontinue the infusion, illicit the
patient for side effects, and coordinate with the primary team to formulate a plan for
a smooth transition off IV ketamine to multimodal oral pain medications. While not
all institutions have a dedicated inpatient pain team, it is a significant advantage and a
safety net to have a team trained to recognize indications, contraindications, dosing
titration, and side effects of ketamine. These patients can be managed on regular
floors with nursing team care coordination with APS support.
9 Consults
At any institution with an established APS team, a variety of perioperative respon-
sibilities are shared among the team. One such responsibility is accepting and
addressing consultations for the APS team to evaluate patients. Consultation requests
for the APS team come in a variety of forms. For example, the primary team may
request the APS team to perform an epidural blood patch (EBP) for a patient suffering
from a post-dural puncture headache. At most institutions, the anesthesiologist will
assist in placing an EBP. However, some requests may go directly to the chronic pain
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144 H. Kalagara et al.
service or the neurosurgery team. If a patient has major aortic surgery and needs a
spinal drain placed for protection from spinal cord ischemia, the APS team might be
consulted to place and follow up on a spinal drain. Post-lung transplant, if a patient
is difficult to wean from the ventilator due to pain, the APS team can be consulted
to place either an epidural catheter or paravertebral blocks to help expedite extuba-
tion, improve respiratory mechanics, and enhance pain control. In any hospitalized
patient with poorly controlled pain, the APS team might be asked to evaluate the
patient for recommendations about opioid regimen changes, multimodal analgesia,
potential regional anesthesia, IV ketamine or IV lidocaine initiation, or consulta-
tion for evaluation by chronic pain specialists. Patients with severe vascular disease
with ischemic extremity pain may benefit from increased perfusion to the affected
limb. The APS team can help perform extremity blocks that lead to a more localized
sympathectomy and temporarily dilate extremity vasculature to improve blood flow.
If patients have a history of opioid use disorder or are already taking medications
like methadone and Suboxone, the APS team is often approached before surgery
to evaluate the patient and make further recommendations for acute surgical pain
management. Similarly, if a patient has a history of high baseline opioid consump-
tion, the APS or chronic pain teams can consult to discuss perioperative medication
plans and help set expectations.
10 Pros and Cons of APS Team
There are many considerations when addressing in-hospital pain. It has been shown
that implementing an Acute Pain Service (APS) with dedicated physicians and
nurses effectively improves post-operative analgesia, decreases adverse effects, and
improves patient perception of care [30, 32]. These dedicated physicians and nurses
are trained to be cognizant of the effects of peripheral and neuraxial catheters,
different analgesic options, associated side effects with different medications and
procedures, and troubleshooting inappropriately functioning analgesic therapies.
While it is essential to recognize the benefits of an acute pain service, there is a
cost associated with an acute pain service. It has been shown that there are inappro-
priate referrals to the acute pain service resulting in increased costs to the patient and
occurrences where the patient received no benefit from the service [33]. Implemen-
tation of an APS can lead to improved patient outcomes. Keys to a successful APS
include leadership by anesthesiologists, interdisciplinary coordination, education of
patients and health care providers, standardization of regional anesthesia procedures,
and systematic billing practices. Given the current focus on perioperative opioid use,
an APS team can provide individualized inpatient pain management plans, institute
multimodal analgesia options, and collaborate with other providers involved with
perioperative pain management. In addition to taking care of patients, the APS team
invests tremendous time and energy to train young nurses and physicians through
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The Role of Inpatient/Acute Pain Services for Perioperative Pain … 145
education, research, and patient care. A dedicated, multidisciplinary team knowl-
edgeable and trained to handle perioperative pain management is vital to successful
patient care.
11 Key Points
•
An inpatient/acute pain service is a multidisciplinary team specializing in
perioperative pain management of mostly surgical and limited non-surgical
patients.
•
The acute pain service examines a patients’ preoperative history and identifies
indications and contraindications to regional anesthesia while establishing post-
operative pain management strategies that seek to minimize opioid administration.
•
The acute pain service team troubleshoots peripheral nerve and neuraxial blocks,
offers multimodal pain plans, eloquently and concisely manages patient expec-
tations, and systematically approaches deviations from the expected course to
unexpected complications.
•
Managing a successful acute pain service requires effective leadership, interdis-
ciplinary coordination, education of patients and health care providers, standard-
ization of regional anesthesia procedures, and systematic billing practices.
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