Anesthesiology

Background

Optimal care of the patient undergoing a surgical procedure includes effective pain management. Clinical studies continue to indicate that routine orders for intramuscular injections (IM) of narcotics fail to relieve pain in about half of postoperative patients. Unrelieved pain may result in shallow breathing, retained pulmonary secretions, and pneumonia. It may also trigger deleterious stress responses including increased pulse and blood pressure, impair the immune response and healing, promote breakdown of the tissues, and elicit negative emotional responses. Intramuscular injections of narcotics may result in uneven and unpredictable absorption from the muscle. Pain medication requirements vary for many reasons including age, fitness, personality type, normal pattern of pain medication use, liver function, and surgery performed. Pain is an individual, subjective experience, therefore, the pain medication to produce analgesia (pain relief) should be individualized.

Recognizing this deficit, the Department of Anesthesiology at GBMC established the Acute Pain Management Service (APMS) in 1990. The problem with effective pain control is not the medications, but the manner in which they are delivered. There have been two important advances in the field of pain management: 1. Intravenous Patient Controlled Analgesia (IV PCA) and 2. Epidural Analgesia.

What is the Acute Pain Management Service (APMS)?

The APMS is a team of board-certified anesthesiologists and a specially trained nurse who have been consulted by the surgeon to manage the patients postoperative pain needs. Anesthesiologists are best suited to manage postoperative pain because they are familiar with the pharmacology of analgesics, possibility of drug interactions, and the short and long-term effects of the drugs administered intraoperatively. The team conducts patient care rounds twice daily. Patients are assessed for degree of pain relief, level of sedation, side effects, amount of drug used, and overall satisfaction. On rounds, the anesthesiologist and nurse will treat any side effects, adjust dosages, and educate the patient and family regarding pain management. An anesthesiologist is available in the hospital 24 hours a day to answer pain related questions or respond to patient needs.

What type of patients are referred to the pain service?

Surgical procedures where management by the Acute Pain Management Service is indicated include; thoracic surgery, major abdominal or pelvic surgery, major vascular surgery, and major orthopedic surgery.

Medical conditions that warrant pain management by the APMS include the following: significant pulmonary or cardiac disease, obesity, chronic debilitating illness, patients at increased risk for pneumonia or thrombophlebitis, drug dependency, severe burns or trauma, acute ischemic peripheral vascular disease, sympathetically mediated pain or patients whose pain is poorly controlled.

What is Patient Controlled Analgesia? (PCA)

It is a delivery method that allows the patient to individualize the amount of medication delivered, based on need, up to a predetermined maximum. A continuous infusion of narcotic medication is attached to the IV with a button to push, which allows supplemental doses to be administered by the patient. A computer limits the number of allowable doses to prevent overdose. PCA delivers small frequent doses of pain medication minimizing the peaks and valleys in analgesia levels. Patients prefer PCA because it reduces the anxiety many feel about getting their pain medication on time and they appreciate the ability to control their own pain medication. Other benefits of PCA include improved pain control, no lag time between perception of pain and initiation of analgesia, significant decrease in side effects, including: nausea and vomiting, sedation, respiratory complications and depression. Patients on PCA are more alert and responsive, the cough reflex is less suppressed which allows patient to clear their lungs more effectively, patients become ambulatory sooner and progress to physical therapy and rehabilitation. Also patients on IV PCA tend to use less narcotic to achieve comfort than those receiving IM injections.

What is Epidural Analgesia?

Epidural analgesia is the most effective method of postoperative pain management. A small plastic tube (catheter) is placed into the epidural space and taped along side the back. (please refer to  Frequently Asked Questions About Anesthesia) to find out more about epidural anesthesia. Narcotics and/or local anesthetics are placed into the epidural space to provide patients with longer lasting and more effective pain relief. Patients receiving epidural analgesia are more alert, have fewer side effects, better pulmonary function, are extubated earlier, spend less time on a ventilator, ambulate earlier, use significantly less narcotic, and have shorter ICU and hospital stays. Studies suggest that postoperative epidural analgesia is associated with reduced postoperative cardiac complications in high-risk patients. Epidural infusions of local anesthetics improve blood flow to the lower portion of the body and significantly reduce the risk of developing abnormal clotting and phlebitis in the legs after surgery. Administration of epidural local anesthetics also shorten the time for recovery of bowel function after abdominal surgery.

Are these services covered by my insurance carrier?

Most health care insurance plans, including Medicare, provide reimbursement for the Acute Pain Management Service. The patient is responsible for any deductible or co-payment. The Acute pain Management Service is billed under the name Physicians Anesthesia Associates, PA. Direct any questions regarding APMS billing to 410-828-2731.

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