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Choosing Regional Anesthesia and
Acute Pain Management to Improve Your Recovery: |
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 You and your surgeon may have already discussed some of the options you have available for types of anesthesia: general, local, or regional. This decision depends on what you want, what your anesthesiologist recommends, and what your surgeon wants. If your surgery involves your arm (shoulder and down), your leg (hip and down), or an incision in your chest or abdomen, regional anesthesia is usually a good option to consider. Regional anesthesia is part of our routine at Wake Forest University Baptist Medical Center (WFUBMC). Hundreds of our patients benefit from regional anesthesia every month. Simply put, regional anesthesia is putting a part of your body to sleep by using numbing medicine injected through a needle. In many cases, numbing medicines can also be given by a catheter for several days. In this case, physicians of the Regional Anesthesia and Acute Pain Management (RAAPM) Team will visit you after surgery to help your surgeon prevent pain. Most patients prefer that regional anesthesia be combined in the operating room (OR) with medicines given through an i.v. to provide relaxation and sleep. This is why it is our routine to begin giving i.v. medicines before the OR and even before we place any needles.
For some surgeries, regional anesthesia must be combined with deep unconsciousness followed by a breathing tube placement while you are unconscious in the OR. There are other surgeries, medical conditions, or surgeon requests where it is better to avoid some types of regional anesthesia or to use only general anesthesia. As with any type of surgical or medical treatment, side effects are possible. For regional anesthesia, these are incomplete pain relief, soreness or bruising at the needle site, or tingling that lasts for days. Spinals and epidurals can cause headaches about 1% of the time. Serious complications are fortunately very rare and are similar to those from the surgery: injury from infection, injury from bleeding, or injury to a nerve.
Some proven advantages of regional anesthesia are better pain relief, less narcotic use, earlier mobility, less nausea, better bowel function, and (for some surgeries) less blood loss and less risk of blood clots.
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The Three Types of Regional Anesthesia |
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Peripheral Nerve Blocks: A needle or catheter is placed along the path of nerves to your arm or leg. Numbing medicine is injected to provide 4-20 hours of pain relief. If a peripheral nerve block catheter is used, numbing medicine is given continuously to prevent pain for days— plus you will have a button to safely give yourself more numbing as you need it. Always, you will have back-up pain medicines available by mouth or your i.v.
Epidurals: A needle is placed between the bones of the back for injection of pain relieving medicines. Sometimes, epidural pain medicine specially formulated to last two days is injected through this needle. Other times, a better choice is a small catheter left in place. Then, continuous numbing and pain relieving medicines given through this epidural catheter (along with a button for extra doses) will help prevent pain. In either case, you can lie, sit, and usually walk with an epidural. Commonly, we use this catheter for several days during your recovery--usually until you are able to take pills to easily control pain.
Spinals: A thin needle is placed between the bones of your back, and a single injection of numbing medicines is made to numb both legs. We choose spinal medicines that last from 1 to 8 hours, depending on the predicted length of your surgery and your recovery plans.
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Getting Ready to Go to the Operating Room |
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 When you arrive at the hospital, plan to park in the closest lot, parking lot “B” and proceed to the Surgical Sciences Waiting Area (see map below). One or two family members may come with you to the hospital. Check in with the receptionist. A staff member will call your name and escort you to the Regional Anesthesia and Acute Pain Management (RAAPM) Area (left) where you will change into a gown, have your anesthesia started, and wait to go into the OR where your surgery will be performed. The one or two family members accompanying you may wait with you in the RAAPM Area, keeping you company until it is time for you to have your blocks placed and again until it is time to have your surgery. Ask the staff to adjust the lights and music to your comfort.
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LARGER VIEW OF MAP
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• Several personnel will double check all your paper work and confirm and reconfirm the site and side of your surgery, your allergies, and parts of your medical history. An attending or resident surgeon will mark the site and side of your body on which you are having surgery, using a non-permanent pen mark and his or her initials. You will be asked “which side?” and other information many times before surgery as part of important initiatives for your safety. In general, you will have been asked to come to the hospital around 2 hours prior to surgery in part to allow time to get all these safety procedures accomplished at a time when our attention can be devoted to your care— even before surgery.
• Another important part of your care in the RAAPM area is to explain your options and our normal procedures for regional anesthesia and to complete a final preoperative assessment including a brief exam. Sometimes we’ll be giving you information you may have heard before when you were discussing surgery with your surgeon or with personnel in the Preoperative Assessment Clinic. It is also common to be asked to repeat or go into more detail about aspects of your medical history. Importantly, you will often be asked to sign an anesthesia consent form which states that options have been explained and you understand them. This is the time for making a decision about what the best options might be for you, your anesthesiologist, and your surgeon might be. You will usually be asked if you will consent to blood transfusion if it is absolutely needed for medical reasons during your surgery. This does not mean that we know such a transfusion is planned or even likely, but rather that we have documented your wishes as a matter of our routine.
• An IV is started in a vein (most likely in your arm) to give fluids and medicines. Numbing medicines will be used prior to placing this IV. At the same time of IV placement, blood tests may be drawn to save you another needle poke later.
• We will give you medicine to help you relax. You may feel dizzy or drowsy. This is normal. Before you get drowsy, we will ask you to remove your eyeglasses and may ask you to remove your dentures and give them to your family. We will make you drowsy before we administer any nerve blocks unless you request otherwise.
• It is normal for us to sedate you and place nerve blocks well in advance of your surgery. This is to ensure that the start of your surgery is not delayed and we have plenty of time to take care of you. Your family members will leave for these medical procedures. Unless you request otherwise, your family members may rejoin you after sedation and nerve blocks while you await surgery.
• Before you leave the RAAPM area for surgery, the orders and plans for your post-operative pain management will be placed in the computer if members of the RAAPM team will be helping your surgeons manage your pain relief after surgery.
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In the Operating Room |
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 You will be transported to the OR by members of the anesthesia team caring for you in the operating room. We will use the same transport bed, oxygen mask, and warm blankets from the RAAPM area.
The full OR team will greet you and verify your name, side of surgery, and your type of surgery in the OR. Your OR anesthesia team will watch your breathing, heart rate, and blood pressure throughout your surgery. There will always be someone with you keeping you safe. We will give you fluids and medicines through the IV line. After you are sedated (drowsy) and numb, the nurses will place a catheter in your bladder if your surgery is planned to be involved, long, or your surgeons feel you will need one after surgery. If you need one, it will remain until you are able to easily walk to the bathroom on your own. Operating rooms are cool, but we will keep you as warm as possible with forced-air warming blankets or warmed fabric blankets.
The duration of surgery varies with each person, surgery, and surgeon. While you are in surgery, your family may wait and (hopefully) relax in the surgical waiting room. They will be given a pager if they leave to attend to other matters or go to the cafeteria in the hospital. The nurses working with your surgeon will call your family periodically to tell your family how you are doing during surgery. When your surgery is over, you will go to one of our Post-Anesthesia Care Units (PACU) located within the OR suite.
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Post-Anesthesia Care Unit |
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After your surgery, your surgeon will talk to your family or friends by phone to let them know how you are doing. In the PACU, the nurses are specifically trained to care for people recovering from surgery and anesthesia and will watch you closely. When you wake up in PACU, the nurse will tell you where you are and that your surgery is over. You may have some blurred vision, dry mouth, chills, or a mild sore throat if general anesthesia and a tube in your windpipe was used during surgery. If you have pain in the PACU after surgery, your nurse will have orders to give you medicine to make you more comfortable. As you wake up, you will be aware of the nurse checking the dressing on your incision, taking frequent blood pressure measurements on your arm, and monitoring your oxygen saturation with a clip on your finger. You will stay in the PACU for at least one half an hour, often longer, depending on the type of surgery you had and the anesthesia you were given. For the privacy of all our patients, no visitors are allowed in the adult PACU.
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Pain Management After Surgery |
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Most patients having surgery at WFUBMC have their pain management plans ordered by their surgical team. In fact, most hospitals do not even have a RAAPM team. Luckily at WFUBMC, RAAPM doctors who specialize in pain management will visit you daily to help keep your pain under control if your surgeon requests it and if certain of the methods below are planned. Effective pain management is known to be very important for your recovery. That is why it is our opinion that it is best if these plans start prior to scheduling your surgery with a discussion of pain management with your surgeon. We in RAAPM will plan to do everything possible to meet you and your surgeon’s planned request for us to help with the best pain management possible after your surgery.
Your nurse and RAAPM team will ask you to rate your pain before and after you get your pain medicine. They do this because you have an important role as the leader of the team ensuring you get good pain control. We use a scale— either visual or verbal--- such as the one below.
This scale is an important tool to measure how well we are doing with your pain control. Zero is no pain. Remember that “10” is not the worst pain you have had: it is the worst pain you could imagine having. You will have some pain after surgery: we will work with you to make you as pain-free as possible. For more advice on how to control pain, ask your nurse for a free copy of “Pain Control.”
If we are asked by your surgeon to help with your postoperative pain management, we will likely first plan to use some form of regional anesthesia (as described above), placed in the RAAPM area (also as described above) prior to your surgery. After surgery and starting in the PACU, our daily visits may extend until the next day or over several days depending on your surgery and recovery. After surgery, you will likely experience extended pain relief from the anesthesia that you received in the RAAPM area. On the day of surgery and day(s) following, your pain management by RAAPM likely will involve one of these methods:
Peripheral Nerve Block: numbing medicines given before surgery that last for 4-20 hours after surgery to provide pain relief to part of your arm or leg. Pain pills are also available for pain before and after these numbing medicines gradually start to wear off.
Continuous Peripheral Nerve Block: numbing medicines are given to numb up your shoulder, arm, or part of your leg using a small tube near nerves for one to several days. Your nurse will explain that you can push a button to give yourself more numbing medicine, if you need more. You may also ask for pain pills for pain not relieved by the numbing medicines. Certain patients at WFUBMC can be discharged from the hospital with a disposal pump administering continuous peripheral nerve blocks at home.
Continuous Epidural Analgesia: Numbing medicines and very small amounts of pain medicines are given using a small tube usually in the middle of your back. A button helps you control the amount of medicine you receive. These medicines are directed toward the area of your incision, so they generally leave your legs unblocked allowing you to walk. These types of epidurals are known to decrease complications after surgery in patients with medical problems and maximize recovery of bowel function after abdominal surgery.
Epidural Extended Release Morphine: Pain medicine, especially formulated to last two days, is given though a needle in your lower back before surgery.
PCA pump: IV pain medications are given when you push a button when you need medicine. The pump is attached to an IV. This is generally used in situations where surgeons have requested no regional anesthesia, regional analgesia was not planned out in advance by your surgical team, regional anesthesia cannot be done safely, or regional anesthesia is unlikely to be effective. Generally, when the RAAPM team uses a PCA pump, it is added to other more effective methods of pain relief or very large amounts of narcotic-type pain medicines are required to control pain using a non-standard PCA.
Pain pills and IV pain medicines: Your nurse will put the pain medicine into your IV when you ask for it. However, here is an important fact to keep in mind: If your pain management is by the RAAPM team, the pain pills already ordered for you are actually stronger and much longer-lasting than these IV medicines. Many patients think just the opposite! It works out better for most patients if they use pills first whenever possible. Some of the pills you receive for pain management are non-narcotic in nature and are given on a schedule rather than when you ask for them. Although these pills will not usually get the job done on their own, they have been shown to reduce the amount of narcotic pain medicines patients need and to do so dramatically after surgery.
Pain pills take time for your nurse to get to you and then to work. That’s where the IV medicines come in because they have one advantage—they are faster-acting and may help as an addition to the pills. So, do not wait until your pain gets bad to ask for your pain pills. Use pain medicines so that you do not hurt too badly, you can get out of bed, move around better, and do your breathing exercises. This will help you recover faster, prevent lung problems, decrease the chance of a blood clot, and shorten the length of time you might have pain. Because nausea and itching are common side effects of all narcotic-type pain medicines, your RAAPM team will have already ordered these medicines when we wrote your pain medicine orders before surgery. Please make sure to ask for them as well, if you need them.
Good luck for a speedy recovery from the RAAPM team. |
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