Invention Versus Innovation in Postoperative Pain Management

by John Ver Halen, MD

Instead of waiting for the next technological “quantum leap” to improve patient care, what can we do better with the tools at hand? Fayezizadeh, et al, describe their impressive (but unsurprising) results using a multimodality pain control program in patients undergoing transversalis abdominis release, and find that time to resumption of oral diet was significantly shorter (versus historical controls)(1). In contrast, when pain management is viewed as a simple direct feedback system (i.e., patients are administered narcotics according to a linear pain scale), the incidence of postoperative nausea and vomiting, ileus, and length of stay goes up considerably.

As we are all aware, patients (and thus, medicine) are far from simple, and require a complex approach. Modern management strategies (e.g., Lean, six-sigma, PDSA cycles) advise us to make small, incremental changes, measure our results, and change accordingly.  To quote Winston Churchill (and Frank Underwood): “To improve is to change; to perfect is to change often.”  Numerous small changes have resulted in the end product of decreased length of stay, decreased narcotic use, and accelerated recovery in patients in enhanced recovery after surgery (ERAS) protocols. The authors’ results are representative of the global experience with these protocols.

Since my hospital system has initiated an ERAS protocol for abdominal surgery, we have noted a similar decrease in the utilization of narcotics, incidence of postoperative ileus, and hospital length of stay. This has been in the absence of an increase in readmissions, or added morbidity. We have subsequently started using it for our complex abdominal wall reconstruction (hernias, fistulas, component separation) with similar results.  We have also changed our mesh repair technique from an inlay, to an onlay technique fixated with fibrin glue to remove trans-fascial suture pain.  Like so many hospital systems, mine is undergoing a transition from “quantity” to “quality”. Some of our measures are objective, while others are patient-centered (e.g., Press-Ganey scores). Undoubtedly, instituting an ERAS system is initially more resource-intensive, and requires significant provider training … but how much does it save? And what are the gains, from a patient perspective? Will these changes be requisite, in the future, for providers and hospitals to survive in the changing environment? Finally, in an era of widespread narcotic abuse, is there a positive impact on society at large?

The immediate challenge to improving the quality of surgical care is not discovering new knowledge, but rather how to integrate what we already know into practice. Once again, this will be a situation where we will be either “flying ahead of the plane”, or “behind the plane” (to borrow project management jargon). Many plastic surgeons are already using Exparel with abdominoplasty and breast augmenation patients, with convincing results in most cases. But I feel as though we are still behind other specialties in utilizing these techniques. My orthopedic colleagues are using complex pre-surgical, intraoperative, and postoperative cocktails that have permitted outpatient knee arthroplasties for years. What will it take, and what will be the result, when we apply these protocols to our patients?

1.  Enhanced Recover After Surgery Pathway for Abdominal Wall Reconstruction: Pilot Study and Preliminary Outcomes.
Plast Reconstr Surg. 134:151S, 2014.


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