Clinical Sections

Pain Management

This anesthesiology-based consult service strives to provide optimal pain control for in-patients recovering from major surgery and individuals suffering exacerbations of medically-related and oncological pain. The program emphasizes didactics, as well as hands-on experience. Residents learn the uniqueness of pain perception and patient responses to the newest forms of analgesic therapy. This includes assessment, formulation and initiation of therapy, and continual follow-up and adjustment of therapy. They receive instruction regarding the pharmacological and physiological properties of central, neuraxial and peripheral acting analgesics and gain expertise with a variety of techniques, including placement, testing and maintenance of epidural catheters and peripheral neural catheters.

The Service offers dedicated resident and attending coverage twenty-four hours a day, seven days a week. Approximately fifteen to twenty in-house patients are followed daily by the pain team, which consists of attending and resident anesthesiologists, a clinical nurse coordinator and an assistant clinical coordinator. Patients range from sixteen to over ninety-five years of age. They include individuals recovering from highly invasive and painful procedures, those who are elderly debilitated and sensitive to opioids, patients who are opioid dependent and tolerant to standard doses of analgesics, and those allergic to morphine and demerol.

Residents accompany the attending or nurse pain specialist on morning and evening Pain Service rounds. A thirty to forty-five minute lecture is provided every Wednesday through Friday following morning signout rounds, and key papers in the acute pain syllabus are discussed. Residents are responsible for preparing a case entitled "The Pain Service Case of the Week," in which an interesting or unusual patient is presented and a clinical summary is posted in the anesthesia conference room. Residents and the Pain Fellow attend a Wednesday afternoon fellow conference on pain management. This 48 week lecture series follows the outline of the American Board of Anesthesiology examination in pain management. In addition to traditional pharmacological pain management, the service is committed to alternative methods of pain control including acupuncture and transelectrical neural stimulation.

Analgesic investigation has focused on the following areas:

• The multimodal administration of non-opioid analgesic analgesics in an effort to improve pain control reduce epidural and IV PCA opioid requirements. We are currently evaluating preoperative administration of IV acetaminophen and Oral COX-2 inhibitors as adjuncts to opioid-based analgesia. These agents were noted to reduce morphine requirements by 35-44%, while reducing pain with effort, such as ambulation and deep breathing or cough. We continue to test the hypothesis that reduction in opioid exposure may lead to improvements in cognitive function, particularly in elderly patients, and may reduce the incidence of opioid induced ileus. We are also testing whether multimodal improvements in effort dependent pain may improve post-surgical pulmonary function and reduce the incidence of pneumonia.
• We continue our leadership role documenting the safety and efficacy of hydromorphone for epidural infusions and patient-controlled epidural infusion. To date over 10,000 patients have been treated with solutions containing hydromorphone and hydromorphone plus bupivacaine, and quality of pain relief and the incidence of adverse effects have been entered into a large prospective database.
• We continue as a lead site evaluating the post-surgical application of E-TRANS Fentanyl, an iontophoretic transdermal PCA device that patients can use to self administer small doses of fentanyl, and Dilaudid CR a 24hr sustained release oral opioid for control of moderate to severe acute pain.
• We are the lead site evaluating EDLA-40K for post-orthopedic pain management. EDLA is a solution of extended release bupivacaine that can provide up to 72hrs of pain control following peripheral neural injection.