Regional Anesthesia and Appropriate Multimodal Perioperative Pain Management

Many patients fear postoperative orthopedic surgery pain. Conventional methods to limit such pain involve long hospital stays and narcotics. When the opioid epidemic began in earnest, surgeons faced a two-fold task: limit postoperative pain and prevent opioid addiction.

To address these issues, orthopedic surgeons at The George Washington University Hospital exchanged general anesthesia and narcotics for regional anesthesia with light sedation and no narcotics.

“Regional anesthesia and appropriate multimodal perioperative pain management can not only optimize patient recovery but also provide them the most comfort possible,” says David M. Lutton, MD, shoulder and elbow specialist with Washington Circle Orthopaedics Associates and assistant clinical professor in The George Washington University Department of Orthopedic Surgery.

Long-Term Relief Without Narcotic Use

Of his surgical patients, Dr. Lutton estimates that 99 percent receive a regional indwelling intrathecal catheter along with general or conscious sedation. Through the use of the catheter, patients experience approximately 72 hours of post-op pain relief. For certain patients, this is sufficient. However, those predisposed to opioid addiction may require additional relief to prevent the need for opioids.

To determine who needs additional pain management, Dr. Lutton and his team hold extensive preoperative conversations with patients. Postoperative expectations are discussed, as are pain management and patient history of opioid use and abuse. Those patients who are predisposed to addiction are ordered to return to the hospital 72 hours post-op to have their catheter reservoirs refilled. This provides a total of six or seven days of postoperative pain management. Even among patients with personal histories of addiction, this is sufficient for long-term pain management.

“These patients are very motivated,” Dr. Lutton says. “They don’t want to go back down that slippery slope [of addiction]. If we can avoid narcotics entirely, we mitigate that risk.”

A Pandemic Shift

Such an approach has led to great progress, particularly among shoulder replacement patients. The COVID-19 pandemic served to speed up that progress.

Previous to the COVID-19 pandemic, the majority of patients remained at the hospital for two to three days following their procedure. According to Dr. Lutton, no more than 10 percent of his patients returned home the day of their operation.

COVID-19 resulted in patient reprioritization. The fear of post-op pain was replaced by the fear of hospital-based infection. This caused more patients—between 50 and 75 percent of those undergoing shoulder replacement—to avail themselves of the opportunity to return home the day of their procedure. Among those who remain overnight, the primary driver is not pain; it is a lack of the social support necessary for a safe transition home.

Fuller, Safer Recovery

With traditional anesthetic approaches, postoperative cognitive recovery can take a week. Avoiding general anesthesia and narcotics reduces the recovery timetable. In addition to helping those with a history of opioid addiction, the shift toward regional anesthetic enhances safety for elderly patients who Dr. Lutton is seeing in increasing numbers.

Forging Ahead

Initially, this addiction prevention process lengthened surgery by 30 minutes, as the pain block was administered. Today, GW Hospital’s pain service initiates the block before surgery, allowing surgeries to stay on schedule. The process is overseen by GW Hospital’s acute pain management service.

As the use of regional anesthetic and non-narcotic pain management becomes more common, Dr. Lutton expects more orthopedic surgeries will be taken out of the hospital setting and performed in outpatient facilities and surgery centers.

Podcast – Addiction Prevention: Nerve Blocks and Progressive Pain Management

Listen to Dr. Lutton's podcast to learn more.

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