Multimodal Acute Pain Management at Deaconess Hospital

Pain management is a primary humanitarian role for the physician today. Not surprisingly, pain control is often the most remembered feature of a patient's hospital stay. Effective pain management, patient safety, and excellent clinical outcomes are highest priorities for the surgeons and staff of the Deaconess Hospital Total Joint Replacement Center (DHJRC).

Attention to patients' pain has been designated the "Fifth Vital Sign," along with monitoring their pulse, blood pressure, respirations, and temperature. However, understanding patients' pain is a complex process which must factor in their physical suffering, psychological state, cultural factors, and even their age and sex. While complex in its various causes, acute surgical pain is now well understood and must be effectively addressed according to Dr. Mark Snyder, Director of the DHJRC.

Acute surgical pain is experienced in four major levels of the body's nervous system: the brain, the spinal cord, the nerves, and the site of surgery. No single medication can control all four levels at once. This is why a new approach to acute pain management was developed by Dr. Snyder at the Deaconess Hospital. "Multimodal Pain Management" involves the intentional targeting of all four levels of the nervous system before, during and after the joint replacement procedure.

Historically, acute surgical pain has been controlled with varying degrees of success using strong narcotic medications and post-operative anesthetic techniques like epidurals (a small catheter tube is left just outside the spinal cord overnight to deliver anesthetic and narcotic medications). Unfortunately, dependence on these methods alone can increase problems in the recovery phase like mental confusion, inconsistent pain control, nausea and vomiting, and even delayed walking and exercise skills. Fortunately, there is now a more effective way to both better control acute surgical pain and lessen the side effects of treatment!

Dr. Snyder, and other Deaconess Hospital joint replacement surgeons, team up with anesthesiologists to use a combination of spinal and nerve blocks (anesthetic agents like Novocain), surgical wound injections, and various medications to better control patients' acute surgical pain. Whenever possible, patients' pain is better preempted when it is blocked before they experience it. Preempting pain can occur with nerve blocks and medications as gentle as acetaminophen (TylenolTM) and anti-inflammatory drugs. Using smaller doses of a variety of medications that target the four levels of pain perception and processing in the nervous system is considerably "more effective and better tolerated than only using narcotic drugs" explained Dr. Snyder.

Joint replacement wound injection is accomplished using the "Deaconess Hospital Joint Cocktail." This method involves injecting at the time of surgery, a mixture of low dose narcotic, anesthetic, and anti-inflammatory medications diluted in sterile saline fluid. The DHJRC is today more internationally respected because of the scientific presentations the center's surgeons have given. Not surprisingly, the "Multimodal Pain Management" strategies are among the most enthusiastically received offerings.

Whenever possible, hip and knee replacement patients at the Deaconess Hospital receive these new and more effective pain management methods. Sometimes patients' drug allergies and sensitivities preclude the use of certain medications. Even then, other surgical innovations like "minimally invasive total joint replacement" can be utilized if the patients' surgeons determine they are safe and appropriate for any given patient. Dr. Snyder showed the benefits of these new pain management tools, and minimally invasive surgery, through prospective outcome studies presented at national and international scientific meetings.

Patients, nursing staff, and physical therapy staff have all noticed a dramatic improvement in pain and ease of recovery while joint replacement patients are in the hospital. Pain control benefits even extend into the weeks of outpatient therapy required for optimal patient recovery. This prolonged benefit might be due to "reducing the 'memory' of pain that these new pain control methods can accomplish" says Dr. Snyder. Less pain and faster recovery are certainly worthy goals of any genuine center of excellence, like the DHJRC. And patients reap the benefits of these types of medical and surgical advances.