Dr. Edward R. Mariano is the Chief of Anesthesiology and Perioperative Care Service and Associate Chief of Staff for Inpatient Surgical Services for the VA Palo Alto Health Care System. He is also Associate Professor of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine. We interviewed him recently.
- You have been involved in a program /w the VA that minimizes the use of opioids before and immediately after surgery. What are you doing that’s different?
At the VA Palo Alto Health Care System, we apply the concept of “multimodal analgesia” for every patient who has surgery which is supported by the American Society of Anesthesiologists. What that means is we see the source, transmission, and processing of pain as separate targets for pain relief strategies, and we implement these strategies together. Acute pain is usually sudden in onset resulting from a known stimulus like surgery or trauma. While I believe that the response to acute pain must be swift, there is no one way to prevent or treat it. Opioids are one class of pain medications that can help affect the way the spinal cord and brain process pain, but other classes of medications like anti-inflammatory agents or “NSAIDs” and interventions that decrease the transmission of pain signals like nerve blocks can make a big difference. With a nerve block, a physician anesthesiologist injects a local anesthetic or numbing medication near a nerve that supplies the site of surgery. At the VA Palo Alto, our physician anesthesiologists use ultrasound to see where the nerves are and inject the numbing medication accurately and safely. We often insert a small catheter tube about the size of a piece of angel hair pasta near the nerve to continuously infuse a low dose of numbing medication near the nerve for 2-3 days after surgery to provide targeted pain relief. Without a catheter for continuous infusion, the numbing medication only lasts a few hours. The use of nerve block techniques is a key part of our multimodal pain management approach for patients having surgery at VA Palo Alto. Since the local anesthetic medication is injected in one specific site, it does not interact with other medications that patients receive by mouth or intravenously. It also provides a targeted form of pain relief that has been shown in research studies to decrease overall opioid use and improve patients’ quality of recovery from surgery.
- You said in a recent interview that it’s important to manage people before they come for surgery. I think you called it “Pre-habilitation “How are you doing that and what does it involve?”
I will be honest and say that we don’t have this figured out yet. However, what we do know is that it is clearly time to rethink the way we prepare patients for elective surgery. The concept of identifying chronic medical problems and optimizing patients’ care before they have surgery goes back to Dr. Albert Lee in 1949. Today, patients who are scheduled for elective surgery may be referred to an anesthesiology preoperative evaluation clinic, if one exists, for further testing prior to surgery. However, since the surgery is already scheduled, there may be limited time to truly optimize a patient’s chronic medical conditions such as hypertension, diabetes, or heart disease that took years to develop. Add to this time pressure the tremendous physiologic stress that surgery and the subsequent rehabilitation put on the body, and it is not difficult to see why the current state is not ideal. We would not expect ourselves to run a marathon on short notice without adequate training and preparation–why would we expect this from our patients having major elective surgery?
At the VA Palo Alto our physician anesthesiologists are embarking on a journey to improve the way we coordinate the care of our surgical patients using a model called the Perioperative Surgical Home. For our pilot group, we have selected our patients scheduled for total knee replacement. When our surgeons identify a patient who is eligible for this surgery but has multiple medical problems including chronic pain, we are offering to provide early consultation which may involve assessment of a patient’s risks and benefits from the procedure, consideration of alternative treatments, and development of a plan to optimize the patient’s medical condition, medication management, and nutrition before the patient is scheduled for the procedure. We are also now providing recommended exercises for patients to do prior to surgery and even offering referrals for physical therapy for selected patients in order to develop their strength and endurance before undergoing knee replacement (“pre-habilitation”). We can even work directly with primary care physicians within the VA system to better prepare patients for future surgery similar to what the Strong for Surgery program is doing in the state of Washington.
- What are you finding?
It is still too early to tell if our pre-habilitation program is working. However, getting our physicians from anesthesiology, pain medicine, surgery, and primary care together in a room to talk about new ways to coordinate the care of our surgical patients by itself has been a major step in the right direction. We also recently engaged members of our Veteran and Family Advisory Program made up of our patients and their relatives to help us work on improving our approach to pain management and perioperative care.
- I remember when I had back surgery. If the doctor told me I wasn’t going to have some heavy pain killers I might have had second thoughts. How do patients react when you tell them?
Our patients have been very receptive to our multimodal pain management approach, and many have even told me that they choose VA Palo Alto because we stay on the “cutting edge.” For example, we have conducted several research studies in recent years to show how effective nerve block techniques can be for postoperative pain management. In fact, one of our studies was one of the first to demonstrate that the use of a newer nerve block technique can actually increase how far patients can walk the day after total knee replacement. By using different strategies to fight pain on multiple fronts (inflammation, transmission of painful signals, and processing of pain), we can provide better pain control and avoid relying only on opioids. I always try to emphasize to patients that we are not taking pain medication away; we are actually providing more comprehensive pain relief by attacking multiple targets with medications that work differently than opioids. Opioids are also not without side effects. They can cause patients to stop breathing, especially those with sleep apnea, as well as produce nausea, vomiting, itching, constipation, oversedation, and confusion.
- What’s the reaction of other doctors as you share your findings?
In the medical community, I think the response has been positive. There has been a great deal of interest in improving in-hospital pain management because it has a direct effect on the overall patient experience. The challenge is to implement change in clinical practice. That is a whole separate conversation, and there are no easy solutions. Suffice it to say that changing clinical practice takes training and leadership to overcome existing barriers.
- What are some other areas that you plan study in and around the use of opioid (or anywhere else for that matter)
Right now I’m excited about a couple of projects that we are working on to demonstrate how our group manages clinical practice change in anesthesia care and pain management. By instituting a multimodal pain management program for spine surgery patients similar to our total joint replacement model, we have been able to decrease our use of intravenous opioid patient-controlled analgesia (IV PCA) six-fold while still providing effective pain relief and rehabilitation. We have implemented this strategy for our patients having intra-abdominal surgery as well, and we are just starting to analyze our data but expect similar results.