Anesthesia and Pain Assessment for Foot, Ankle, Knee, and Hip Surgery

Anesthesia and Pain Assessment for Foot, Ankle, Knee, and Hip Surgery

Melinda Aquino

Kevin A. Elaahi

Benjamin Cole Miller

Sumitra Miriyala

Matthew R. Eng

Elyse M. Cornett

Alan David Kaye


Pain is often viewed as a subjective variable that can be difficult to quantify. However, it is a variable that is being viewed as increasingly more important as it pertains to postoperative care. It has been shown that patients who admit to a higher level of pain postoperative equate their surgery with a lower level of satisfaction. In one study that evaluated total knee replacements, it was found that pain was the highest reason for patient dissatisfaction postoperatively.1 Postoperative pain not only affects the patients’ operative outcome, well-being, and satisfaction from medical care but also directly affects the development of tachycardia, hyperventilation, decrease in alveolar ventilation, transition to chronic pain, poor wound healing, and insomnia. Patients typically undergo lower extremity orthopedic surgery due to pain and lack of function. Preoperatively, it is important for surgeons to discuss the expectations of the surgical outcome with the patient and be prepared to mitigate any unrealistic expectations that the patient has, related to pain relief and gain of function. Especially since pain may worsen shortly after surgery before it gets better. Severe postoperative pain has an adverse impact on early physical recovery especially in the acute setting (the first 2 days postoperative). Patients who report lower pain have a faster recovery process and return to activity. Postoperative pain is also costly as it lengthens hospital stays and requires more intensive care. After drowsiness and digestive discomfort, pain is the most common cause of delay in being discharged. The failure to provide good postoperative analgesia is multifactorial. Insufficient education, fear of complications associated with analgesic drugs, poor pain assessment, and inadequate staffing are among the most common causes.2 To achieve maximum pain management, preoperative evaluation and planning must be just as important as postoperative care.3 This includes directed pain history, physical exam as well as a plan control plan. To achieve an adequate postoperative pain assessment, a 10-point pain assessment scale has been implemented with 1 being no pain and 10 being the worst pain imaginable. The key to sufficient control is to reassess the patient and determine if he or she is satisfied with the outcome. Together, the pain and satisfaction ratings minimize that inadequately treated pain goes unnoticed. A multimodal approach combining localized analgesic treatments with systemic injection of analgesic drugs results in improved pain management. It is showing that in orthopedic surgery, regional analgesia is significantly shortening the period of recovery after knee and foot surgeries. In effectively treating postoperative pain, physicians will be able to prevent their patients from developing things such as chronic pain syndrome.4 In providing patients with the access to a pain assessment by their medical team and in turn having that determine how they are cared for allows the patient to not only feel as though they are a greater part of their care team but also provide the staff with
a better understanding of the patient’s pain level. A true pain assessment requires not only the viewpoint of the medical team but also the patient’s input as well. In doing so, the choice of appropriate pain management can be provided while simultaneously allowing patients the opportunity to be a part of their health care. In giving patients the chance to make decisions on their own behalf, they are able to feel more in control of their pain, which shows to act as a sort of psychological therapy as well.3

Barriers and Solutions for Improving Pain Management Practices in Foot, Ankle, Knee, and Hip Surgery Patients

Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief.5 Inadequate pain management affects 80% of the global population and that up to 50% of the general population could be affected by chronic pain. Barriers to pain management are multifactorial and can have significant implications for functional outcomes.6 Health care practitioners report that one of the key barriers is a feeling of apprehension toward the appropriate use of diverse pain medications. Due to the constantly evolving field of pain management, many health care professionals do not administer state of the art treatments.7 It is for this reason staying up to date becomes all the more vital, and it can have a tremendous outcome in the management of patients. Another barrier can be caused by a lack of communication between the patient and medical team as well as among the medical team itself. Patient participation in decision-making regarding pain management is associated with less time in severe pain, better pain relief, lower pain severity, and improved quality of care. With increasing consumer access to health care information, patients are more knowledgeable and demand greater involvement in clinical decisions. It is then through patient education that the medical team may provide the patient with the understanding of what is going on to be able to assist in their care. Through patient education prior to surgery as well as identifying and planning a pain goal, this barrier can be mitigated.8 However, with the need for greater communication and patient education, medical care team members can find themselves struggling to find the time to undertake these crucial discussions. One critical way to aid with this issue is to adopt a policing attitude toward patients to confirm that routine medications are given at specified times. Furthermore, it is important that every member of the team be educated as well as on just how important it is to control the pain in these patients in order to provide them with the best care. With regard to lack of communication between the medical team, it is important for every member of the team, from physician to pharmacist to patient, to discuss the goals for pain management and be on the same page with how to treat it. Cultural factors are a barrier that can greatly affect treatment. In the elderly, pain can be challenging for multiple reasons, including medical problems contributing to pain and an inability to self-report due to cognitive impairment. Due to cultural beliefs, some patients may prefer nonpharmacological treatments, which may make managing pain more difficult. These instances further emphasize the need for physicians and medical team members to stay up to date on alternative approaches to pain management and to have an open dialogue in handling it. As pain management continues to evolve, so do the medications. Many of these newfound medications can play great roles in helping alleviate pain. However, they often come with their own adverse risks and can make administering them to certain patients at higher risk of side effects challenging. With more and more medications being created to help deal with pain, it makes choosing the right ones for the right patient even more of a delicate process. This can lead to physician hesitancy in prescribing
new medications and can lead to specific vulnerable groups such as the elderly, pregnant or breastfeeding women, children, people with substance abuse, and the mentally ill having a greater risk for inadequate pain management. Education is the cornerstone of any effective strategy to remove the barriers toward optimal pain management. Pain management should be introduced as a core and major topic of the curriculum in any medical school and residency programs, so as to embed the importance of addressing pain early on in the career of a physician.9

Decreasing Severe Pain and Serious Adverse Events While Transporting Lower Extremity Orthopedic Surgical Patients

During the preoperative and postoperative period, severe pain and serious adverse events are common and strongly associated while moving ICU patients for procedures.10 It is the responsibility of the operating room anesthesia and surgical team to move the patient from the operating room to recovery. This is usually done while simultaneously monitoring and performing additional therapeutic tasks such as manual ventilation.11 During this time, it is important to prevent the patient from harming himself postanesthesia and to reduce movement to the surgically fixed area. Anesthesia is usually one of the first members of the medical team to talk to the patients after a surgery and can quickly and effectively administer pain medication or nerve blocks in accordance with the patients’ pain. Having an anesthesia team member travel with the patient allows the patients’ pain be managed immediately and therefore decrease the pain before it becomes too severe.12 This is a vital part of the process as early pain mitigation has been shown to be correlated to better outcomes postoperatively. Studies have shown that improved pain management is associated with improved patient outcomes; however, pain remains underevaluated and undertreated. One essential factor in mitigating the pain caused in moving has been found to be when preliminary reports are provided to the receiving team members, allowing them to better prepare for the patient arrival. Not only does this allow for safer care upon arrival but also maximizes patient safety during travel. One of the most common causes of pain in the hospital setting with knee, ankle, and foot injury patients is moving patients and turning of patients for various nursing care procedures.13 Other serious adverse effects associated with the moving of patients include cardiac arrest, arrhythmias, tachycardia, bradycardia, hypertension, hypotension, desaturation, bradypnea, or ventilatory distress. It has been shown that serious adverse events occur in up to one out of three experiences of moving patients. The moving of patients can often cause pain to the patient, which can lead to these adverse events noted to be associated with patient moving. In improving pain management prior to moving patients, there has been noted to be a decrease in the amount of serious adverse effects. This can likely be attributed to the fact that pain induces reflex responses that may alter respiratory mechanics and increase cardiac demand through tachycardia and increased myocardial oxygen consumption. To ensure safe and effective care transfers, strategies are needed to improve shared situational awareness, teamwork, patient flow, and resource efficiency. Safe transfers involve coordination, optimal timing, early mobilization, participation, and multidiscipline approach. It has been shown that differences in pain appreciation exist between different members of the medical team. Physicians have been shown to underevaluate patients’ pain compared to nurses, while nurses under-evaluate patients’ pain compared to assistant nurses.14 It is with this knowledge that incorporating medical education early on in the educational process of the various disciplines so as to make medical team members more aware of pain management and the impact that it can cause in the recovery of a patient.15

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May 8, 2022 | Posted by in PAIN MEDICINE | Comments Off on Anesthesia and Pain Assessment for Foot, Ankle, Knee, and Hip Surgery
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