ESTABLISHING AN ORGANIZED REGIONAL ANESTHESIA-DRIVEN acute pain medicine service (APMS) is critical to provide essential postoperative pain medicine in both the hospital and ambulatory environments (1). Postoperative pain is the patient’s greatest preoperative concern and remains undertreated. A balanced multimodal approach incorporating pharmacologic, nonpharmacologic, and regional anesthetic and analgesic interventions is essential. Enhanced recovery after surgery (ERAS) protocols are beneficial when incorporated into perioperative pain management treatment plans.

I. APMS structure

A. Depending on the volume and demand of the service and the nature of the practice (academic vs. private practice), the APMS can be divided into an acute pain service (APS)/epidural service, a pain consult service, and a peripheral nerve catheter (PNC)/regional analgesia service. Alternatively, all the aspects can be combined into a comprehensive service.

B. Roles for the APMS team should be defined and include:

1. Director oversees direction of service, develops policies and protocols, directs educational and research initiatives, and collaborates with other services such as pharmacy and information technology.

2. APMS attending daily rounds, supervises regional anesthesia/analgesia procedures, and pain consultations.

3. APMS resident/fellow daily rounds, performs regional anesthesia/analgesia procedures and pain consultations, promptly responds to calls and questions regarding pain management and/or complications, and coordinates APMS recommendations with primary services.

4. APMS nurse specialist provides continuity on service, daily rounds, educates ward nurses on policies/protocols, performs quality improvement, calls discharged patients with indwelling PNCs for follow-up, and coordinates APMS recommendations with primary services.

5. Alternatively, and predominantly in nonacademic settings, a physician assistant or nurse practitioner can fill the role of APMS resident/fellow or nurse specialist, or this can also be done independently under the APS director’s oversight.

C. Challenges

1. Education and frequent communication with nursing and physician staff regarding breadth and limitations of the services provided are essential.

2. Availability of APMS on a 24-h/d and 7 d/wk basis is required to address unusual complications, technical malfunctions, and dose adjustments of neuraxial and PNCs. This requires commitment and support from the anesthesiology staff. Ideally, patients on the APMS should be evaluated twice daily, particularly those individuals with indwelling pain management catheters in place.

3. The APMS should provide and communicate management recommendations to the primary service. There are times when the pain service will be the primary prescriber of analgesic medications. Typically, this will be the case when managing an epidural catheter or if the patient requires complex management beyond what the primary service is able to provide. There must be clear communication to avoid duplicate orders and to enable a smooth transition of care when the condition has stabilized.

D. APMS rounding

1. Key questions should include:

a. Location of pain

b. Pain score (0 to 10) at rest and with activity

c. Any significant side effects, for example, nausea, sedation, itching, and weakness

d. Baseline (preadmission) pain scores, locations, medications, and intolerances

2. Physical examination should include:

a. General sensorium

b. Lower extremity strength/sensation for epidural and lower extremity blocks and upper extremity strength/sensation for upper extremity blocks. For thoracic epidural catheters, assess the patient’s strength with hip flexion because this movement requires use of the hip flexors (L1-L3) and quadriceps (L2-L4) which are more likely to be affected if there is local anesthetic in the upper lumbar spine. This is also a way to assess how pain is interfering with function.

c. Assessment of catheter insertion site. Verify that the sterile occlusive dressing is intact without significant amounts of blood or leakage of infusate, that the catheter remains at an appropriate depth (compare with documentation on procedure note), and that the skin is without erythema, induration, or tenderness.

3. For a sample APMS note template, Figure 16.1.

II. Neuraxial analgesia

A. Epidural analgesia include continuous epidural infusion (CEI) and patient-controlled epidural analgesia (PCEA)

a. Superior postoperative analgesia (overall, at rest, and with activity) compared to intravenous patient-controlled analgesia (IV PCA) with opioids (2,3).

b. Improved respiratory function (can prevent splinting), preventing postoperative atelectasis and pneumonia (3).

c. Decreased duration of ileus versus systemic analgesia (3).

2. Epidural placement level for select procedures (for specific considerations, see Chapter 7)

a. The surgical incision site dictates the appropriate level for epidural placement. Mid-thoracic epidurals are ideal for thoracic surgery, low-thoracic epidurals are ideal for abdominal surgery, and lumbar epidurals are used for obstetric analgesia. Thoracic epidurals have a positive effect on respiratory function and splanchnic sympathetic block, which can help return of bowel function. Unlike thoracic epidurals, lumbar epidurals can impair ambulation, cause urinary retention, and lack the benefits of improved respiratory and bowel function (4).

b. Epidural spread of infusate is preferentially cephalad rather than caudal in both the lower thoracic (2:1) and lumbar (3:1) spine following bolus injection (5); however, spread is typically equal in the mid-thoracic spine and preferentially caudad in the high-thoracic spine. Additionally, other factors such as spinal pathology, age, and bevel direction when threading the catheter may also influence the spread (4).

c. Choice of epidural infusion rate and infusate (for standard infusates, Table 16.1)

d. The options for medication delivery include CEI-only, bolus-only options, or PCEA including both a continuous and demand option. The continuous infusion rate can range from 0 to 14 mL/h (typical starting dose is 8 mL/h); standard demand dose is 2 mL every (q) 10 minutes.

(1) Changing the epidural infusate to local anesthetic alone (continuous only, no bolus) with the possible addition of an IV opioid PCA.

(a) Consider in opioid-tolerant patients with chronic pain, especially patients taking greater than 30 oral morphine equivalents per day.

(b) Consider if epidural does not provide adequate analgesia for the surgical incision(s) or if patient has baseline pain in an area not covered by the epidural.

(c) Although this configuration may address inadequate analgesia in the situations mentioned, disadvantages related to higher doses of systemic opioids may occur (i.e., ileus, nausea, and confusion).

(2) See below for adjustments based on prevalent side effects.

a. For full anticoagulation guidelines for neuraxial and peripheral nerve blocks procedures, refer to ASRA guidelines (6).