Preoperative Surgeon Clinic Visit
1) Consider weaning opioids before surgery
If a patient has not chronically used opioids for 90 days or more prior to surgery, and has not taken doses equal or over 90 MME per day, then give the patient generic opioid weaning instructions.
The ideal decrease is approximately 10% per week.
- For example, if a patient takes 5-10 mg oxycodone four times per day (max of 40 mg daily), that patient should aim to take a max of 35 mg daily by the end of week one.
- If they only take 5 mg four times per day (20 mg daily), they should aim to halve one of the tablets and take 17.5 mg total by the end of week one.
More detailed instructions can be found through the US Department of Health and Human Services.
2) Educate patient and set expectations around pain
Work with nurses to set expectations with the patient around what pain they will experience after surgery and educate them on pain management strategies.
Expectations to set include:
- Postoperative pain is normal and an important part of your body’s response to surgery
- Pain after surgery is temporary and will gradually improve
- The goal of pain management is to make it manageable enough that patients can meet important recovery goals
- Encourage patients to set personal functional goals and keep a journal of their daily experience with these goals
- Some examples include: doing household chores, walking the dog, getting mail, effective coughing, standing without pain, walking around the house or community for 5 minutes, attending an important social event, sleeping at night without pain waking them up, returning to usual employment, etc.
- Multiple different types of medications and strategies will need to be used to make the pain manageable
3) Place pre-op orders for non-opioid pain medications
For all patients, unless contraindicated, place orders for:
- NSAIDs1 (celecoxib 400 mg PO x1 or IBU 600-800 mg PO/IV x 1) in pre-op holding
- Acetaminophen2 1000 mg (if >50kg) PO/IV x 1 in pre-op holding
Regional anesthesia is encouraged for any procedure unless contraindicated.3 Good options to discuss with the anesthesiologist include:
- TAP blocks
- Rectus sheath plane blocks
- Paravertebral blocks
- Epidural blocks
Day of Surgery (Preoperative Environment)
1) Ensure that medication protocols are followed
Ensure that orders are placed for NSAIDs and acetaminophen before surgery, unless contraindicated.
If the patient has moderate to severe pain, defined as more than 3/10 on a self-reported pain scale, contact the anesthesia team for escalated preoperative pain management.
2) Counsel patient on pain expectations
Work with nurses to set expectations with the patient around what pain they will experience after surgery. The following expectations should be covered:
- “You will have pain after surgery, and we will help you manage it.”
- “You will receive several medications for pain that work together to reduce your pain. We will try to minimize the use of opioids in order to minimize their side effects.”
- “We will ask you frequently about your pain. You should tell an RN as soon as you cannot reasonably tolerate your pain.”
- “We encourage you to set functional goals for pain management and keep a daily journal of your experience with these goals.”
- Explain what this means to the patient. For example, a goal can be to take a deep breath, walk around the unit, stand up unassisted, etc.
3) Coordinate around regional anesthesia for maximum efficiency
The anesthesiologist will place a regional anesthesia nerve block unless contraindicated. Clear and frequent communication is crucial during this phase to ensure the surgery can be carried out.
Ensure that an order has been placed for regional anesthesia. Regional anesthesia should NOT be forgone for the sake of time, unless the patient’s well being or another patient’s well being is at risk and time sensitive.
Coordinate workflows with the nursing, anesthesia, and surgery teams regarding the nerve block needs and timing to maximize efficiency.
Day of Surgery (Intraoperative Environment)
1) Have clear and frequent communication with anesthesia team
The surgery and anesthesia team should communicate about any painful stimuli that takes place during surgery.
2) Use subcutaneous local anesthetic at all incisions
4) Use active CO2 removal after passive desufflation
For CO2 removal use:
- Pulmonary recruitment maneuver and 30° Trendelenburg with anesthesia consultation
OR - Active suction5
Postoperative Environment
1) Reinforce pain expectations with the patient
Reinforce expectations with the patient around what pain they will experience after surgery. The following expectations should be covered:
- “You will have pain after surgery, and we will help you manage it.”
- “You will receive several medications for pain that work together to reduce your pain. We will try to minimize the use of opioids in order to minimize their side effects.”
- “We will ask you frequently about your pain. You should tell an RN as soon as you cannot reasonably tolerate your pain.”
2) Encourage physical activity
Persistently encourage the patient to:
- Walk
- Follow Up Out of Bed orders
- Eat
- Perform ADLs
3) Follow pain management order set if necessary
If pain is not controlled by first line orders, follow PAIN MGMT Surgical Multimodal Pain Management ADULT (Record ID: 3040001722).
4) Encourage minimal opioid use
Time of Discharge
When a patient is discharged, encourage them to treat their pain with NSAIDs and other non-opioid measures before using opioids.
Your patient will receive this pain education document. They will also receive this pain and activity journal. Please encourage use of this tool.
Adhere to the Minnesota Opioid Prescribing Guidelines, Part III Post-Acute Pain Phase Prescribing Recommendations.
Do not prescribe more than 7 days of opioids and do not prescribe short acting opioids in greater total amounts than 100 MMEs unless major tissue disruption or severe pain is expected.
Preoperative Surgeon Clinic Visit
1) Educate patient and set expectations around pain
Set expectations with the patient around what pain they will experience after surgery and educate them on pain management strategies.
Expectations to set include:
- Postoperative pain is normal and an important part of your body’s response to surgery
- Pain after surgery is temporary and will gradually improve
- The goal of pain management is to make it manageable enough that patients can meet important recovery goals
- Encourage patients to set personal functional goals and keep a journal of their daily experience with these goals
- Some examples include: doing household chores, walking the dog, getting mail, effective coughing, standing without pain, walking around the house or community for 5 minutes, attending an important social event, sleeping at night without pain waking them up, returning to usual employment, etc.
- Multiple different types of medications and strategies will need to be used to make the pain manageable
Day of Surgery (Preoperative Environment)
1) Ensure that medication protocols are followed
Ensure that orders are placed for NSAIDs and acetaminophen before surgery, unless contraindicated.
If the patient has moderate to severe pain, defined as more than 3/10 on a self-reported pain scale, contact the anesthesia team for escalated preoperative pain management.
2) Counsel patient and family/caregivers on pain expectations
Set expectations with the patient around what pain they will experience after surgery. The following expectations should be covered:
- “You will have pain after surgery, and we will help you manage it.”
- “You will receive several medications for pain that work together to reduce your pain. We will try to minimize the use of opioids in order to minimize their side effects.”
- “We will ask you frequently about your pain. You should tell an RN as soon as you cannot reasonably tolerate your pain.”
- “We encourage you to set functional goals for pain management and keep a daily journal of your experience with these goals.”
- Explain what this means to the patient. For example, a goal can be to take a deep breath, walk around the unit, stand up unassisted, etc.
3) Coordinate around regional anesthesia for maximum efficiency
The anesthesiologist will place a regional anesthesia nerve block unless contraindicated. Clear and frequent communication is crucial during this phase to ensure the surgery can be carried out.
Coordinate workflows with the nursing, anesthesia, and surgery teams regarding the nerve block needs and timing to maximize efficiency.
Patients should be asked the following early in the pre-op preparation and before receiving any sedation medication for the nerve block:
- Do they need to use the bathroom?
- Do they have family they need to see before surgery?
- Do they need to sign any consent forms before surgery?
Failure to ask these questions before the patient receives sedation medication can delay the regional anesthesia process, potentially leading to the patient not receiving the regional block and ideal pain management.
Postoperative Environment
1) Reinforce pain expectations with the patient
Reinforce expectations with the patient around what pain they will experience after surgery. The following expectations should be covered:
- “You will have pain after surgery, and we will help you manage it.”
- “You will receive several medications for pain that work together to reduce your pain. We will try to minimize the use of opioids in order to minimize their side effects.”
- “We will ask you frequently about your pain. You should tell an RN as soon as you cannot reasonably tolerate your pain.”
- “We encourage you to set functional goals for pain management and keep a daily journal of your experience with these goals.”
- Explain what this means to the patient. For example, a goal can be to take a deep breath, walk around the unit, stand up unassisted, etc.
2) Encourage physical activity
Persistently encourage the patient to:
- Walk
- Follow Up Out of Bed orders
- Eat
- Perform ADLs
Day of Surgery (Preoperative Environment)
1) Place necessary orders for pain management
Ensure that orders are placed for NSAIDs and acetaminophen before surgery, unless contraindicated.
If the patient has moderate to severe pain, defined as more than 3/10 on a self-reported pain scale, the anesthesia team will be contacted for escalated pre-operative pain management.
Treat moderate to severe preoperative pain with opioids. Consider starting a ketamine infusion and/or a lidocaine infusion when the patient arrives to the OR.
2) Deliver regional anesthesia in coordination with the other care teams
Regional anesthesia is encouraged if at all possible.
Regional anesthesia should NOT be forgone for the sake of time, unless the patient’s well being or another patient’s well being is at risk and time sensitive.
Clear and frequent communication is crucial during this phase to ensure the surgery can be carried out. Coordinate workflows with the nursing, anesthesia, and surgery teams regarding the nerve block needs and timing to maximize efficiency.
Day of Surgery (Intraoperative Environment)
1) Have clear and frequent communication with surgery team
The surgery and anesthesia team should communicate about any painful stimuli that takes place during surgery.
3) Use regional anesthesia catheter when possible
If a regional anesthesia catheter is present in the OR, use the infusion during surgery.
Postoperative Environment
1) Schedule non-opioid treatments for pain
Place orders for the following treatments, unless contraindicated:
- Acetaminophen 1000 mg
- NSAIDs (IBU 600 mg)
- Frequent ice packs
- Heat for shoulder or muscle pain
2) Follow pain management order set for different levels of pain
Reference PAIN MGMT Surgical Multimodal Pain Management ADULT (Record ID: 3040001722) to manage different pain levels.
3) Use pain management consultation if the patient meets certain criteria
The patient should be referred to pain management consultation if they:
- Require ketamine or lidocaine infusion after leaving the PACU
- Had chronic high dose opioid use (>90 MME daily) prior to surgery AND regular opioid dosing is not achieving expected results
- Are on a partial opioid agonist AND regular opioid dosing is not achieving expected results
4) Physiological normalization
Physiological normalization is when patients are able to return to normal activities, such as walking around, sleeping with a normal circadian rhythm, toileting alone, etc.
Before discharging the patient from PACU, please:
- Reinforce the importance of Up Out of Bed orders to the RN and patient
- Encourage the patient to adhere to progressing diet orders