Place anesthetic in wound during recovery to cut pain
Fewer narcotics needed, patients’ ambulation easier
Post-surgical pain control has come a long way since the days when patients were sent home with oral narcotics and no other way to control pain. One method of pain control that has been in use by orthopedists for several years, and now is being used by other specialists, is in-the-wound pain control.
"It is important to control pain because post-surgical pain is a physical and psychological risk factor that interferes with healing and delays the patient’s recovery," says June L. Dahl, PhD, professor of pharmacology and pain specialist at the University of Wisconsin in Madison.
The advances in pain control such as the use of COX-2 inhibitors, spinal opiates, and long-acting oral narcotics such as oxycodone have made it possible for more surgical procedures to move into the outpatient arena, Dahl says. "Because patients don’t have to remain in the hospital for intravenous narcotics, orthopedic procedures such an anterior cruciate ligament [ACL] repair, abdominal hysterectomies, C-sections, and hernia repairs now can be done on an outpatient basis," she explains.
Although orthopedists have used in-the-wound pain control for several years, other specialists are seeing the value of nontraditional pain control for incisions. By using a pain pump that places an anesthetic directly into the incision site, Stephen E. Zimberg, MD, gynecological surgeon at the Cleveland Clinic in Fort Lauderdale, FL, has been able to handle all of his abdominal hysterectomy patients as 23-hour stay patients rather than inpatients. "By converting all of these patients from inpatients to outpatients, we cut the hospital’s expense of providing care by 30%," he explains.
Although laparoscopic hysterectomy patients usually are handled in same-day surgery, the ability to use in-the-wound pain control to move abdominal hysterectomy patients out of the inpatient surgery unit is important for surgeons who are not as adept at laparoscopic procedures, Zimberg says. "This can be an advantage to the same-day surgery program because abdominal hysterectomies require fewer costly disposable supplies than a laparoscopic procedure," he adds.
A small catheter that is similar to a soaker hose with small holes along it is placed directly under the incision site, explains Zimberg. "For hysterectomies, I close the peritoneum and place the catheter between the peritoneum and fascia before I close," he says. "This allows the anesthetic to pool in the area of the incision without going into the abdominal cavity."
Zimberg typically uses Marcaine, but other surgeons have used lidocaine.
"I use a two-day pump that contains 100 cc of anesthetic and injects 2 cc per hour," Zimberg says. This is sufficient to eliminate the incisional site pain and enables the patient to get up and move around more quickly, he adds. In yet-to-be-published studies that Zimberg and his colleagues have conducted, anesthetic levels never go higher than 50% of the level considered toxic, he says.
Because there are no moving parts and the flow restrictor keeps the level of medication constant, the pump is very safe, Zimberg points out. "The only caution I can offer is to pay attention to the connector between the pump and the catheter," he says. "There is an air filter in the connector that should not be covered with a bandage."
Making sure that this point is taught in staff and patient education ensures that the filter is not covered, he adds.
Pain control is more effective because there is a consistent level of medication, according to Sharon Schwartz, RN, administrator at Wausau (WI) Surg-ery Center. "We’ve been using the pain pumps for two years on a regular basis," she says. "Our orthopedic surgeons use it for procedures such as ACL repairs, but our plastic surgeons also use it for pain control after breast augmentation."
The actual implantation of the catheter does not add time in the operating room, but because the anesthetic starts to work on the incisional pain within the hour, patients usually can leave the post-anesthesia care unit more quickly and more comfortably, Schwartz explains.
No matter how effective in-the-wound pain control can be, it’s essential that surgeons and same-day surgery staff realize that no single therapy can effectively control pain, Dahl says. "Multimodal therapy, such as the use of a pain pump and oral narcotics, will give the patient the most effective pain control," she suggests.
Zimberg does prescribe oral narcotics for his patients, but he points out that in-the-wound pain control has eliminated the need for patient controlled analgesia pumps. "We also find that patients use less narcotic medication when the incisional pain is controlled by the pain pump," he adds.
Staff education related to the pain pump is essential, but not overwhelming, Schwartz says. "The operating room staff must understand the implantation of the catheter and how to fill the pump, but it is not a complicated procedure," she says. Patient education prior to the procedure and in the recovery room also is needed, but pain pump manufacturers provide patient education material, she adds.
Physicians play an important part in patient education because it is up to them to set realistic expectations, Schwartz points out. "Our physicians discuss different pain control and offer the pain pump as an option before the patient is scheduled for surgery," she says. "They explain the pain pump addresses incisional pain and oral medications will be available for other pain," she explains.
Because of the amount of education prior to surgery and in the recovery room, patients have been very comfortable with the pain pumps and have expressed great satisfaction with the results, she adds.
Removal of the catheter is simple, Zimberg says. "My patients just pull it out themselves," he says. Other physicians may have the patient come to their office in for their postoperative visit and to remove the catheter, he says.
With the importance of pain control a focus of accreditation organizations, medical associations, and same-day surgery staff themselves, the variety of pain control methods that are now available are exciting, says Dahl. "It’s critical that we recognize the importance of evaluating the use all modalities such as in-the-wound pain pumps and oral medications in the best way possible to control pain and improve patients’ recoveries," she says.
Sources and Resources
For more information about pain control, contact:
- June L. Dahl, PhD, Professor of Pharmacology, University of Wisconsin Medical School in Madison, 1300 University Ave., Madison, WI 53706. Telephone: (608) 265-4012. E-mail: [email protected].
- Sharon Schwartz, RN, Administrator, Wausau Surgery center, 2809 Westhill Drive, Wausau, WI 54401. Telephone: (715) 842-4490. E-mail: [email protected].
- Stephen E. Zimberg, MD, Department of Gynecology, Cleveland Clinic, 2950 Cleveland Clinic Blvd., Fort Lauderdale, FL 33331. Telephone: (954) 659-5565. Fax: (954) 659-5560. E-mail: [email protected].
The following companies offer in-the-wound pain control pumps:
- Breg, 2611 Commerce Way, Vista, CA 92083. Telephone: (800) 321-0607 or (760) 599-3000. Fax: (800) 329-2734. Web: www.breg.com.
- dj Orthopedics, 2985 Scott St., Vista, CA 92081. Telephone: (800) 321-9549 or (760) 727-1280. Fax: (760) 734-3595. Web: www.djortho.com.
- I-Flow Corp., 20202 Windrow Drive, Lake Forest, CA 92630. Telephone: (800) 448-3569 or (949) 206-2700. Fax: (949) 206-2600. Web: www.i-flowcorp.com.
- Sgarlato Laboratories, 130-C Knowles Drive, Los Gatos, CA 95032. Telephone: (800) 421-5303 or (408) 374-9901. Fax: (408) 374-9924. Web: www.sgarlatolabs.com.
- Stryker Instruments, 4100 E. Milham Ave., Kalamazoo, MI 49001. Telephone: (800) 253-3210 or (269) 323-7700. Web: www.strykercorp.com.
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