On reflection, most people recognize how key experiences altered their paths and gave direction to their lives over years. In an article for Anesthesia News, Lex Hubbard, MD explains how he found his passion for anesthesiology and potential for the specialty.
During an interview in 1984 at Presbyterian Hospital in Charlotte, N.C., Hubbard said, “After dressing in scrubs, I met an anesthesiologist who was finishing a short case. We went to the PACU to see a patient he admitted there only an hour beforehand. The patient was recovering from abdominal aortic aneurysm surgery – the way it was done back then, with a laparotomy incision from the xiphoid to the symphysis pubis. The patient was alert, communicative, hemodynamically stable and able to position himself for comfort. He was not on a ventilator. I was in awe. The same patient in our hospital would still be ventilated, and not at the observed stage of recovery until sometime on the first postoperative day, hopefully. What made the difference? The anesthesiologist had given intrathecal morphine preoperatively to relieve early postoperative pain.”
While traveling back home to Shreveport, La., he thought, “Anesthesiologists have knowledge and skills to improve surgical outcomes.” Over the next few decades, he would realize the truth of Ludwig Wittgenstein’s observation: “how small a thought it takes to fill someone’s life.”
In 1984, there was limited literature on intraspinal morphine, but Hubbard intended to achieve for his patients what he observed in Charlotte. He started using epidural morphine infusions for postoperative analgesia for patients admitted to the ICU following thoracotomy or laparotomy. In the ICU, patients would be safe as he learned more. Surgical outcomes were noticeably improved, and surgeons started requesting epidural analgesia. He soon started using morphine-bupivacaine infusions and admitting patients to surgical wards, bypassing the ICU.
By 1989, hospital administrators were persuaded by Hubbard’s team’s commitment and success to invest in resources for an acute pain management service. He then partnered with Chris Pasero, MSN, RN, FAAN, a nurse at Schumpert Medical Center, to write the Acute Pain Management Service Operation Manual. The manual was comprehensive in defining an anesthesia specialists relationship to patients, nurses, surgeons and departments requisite for their goals. The keys to success were:
- Institutional commitment
- Multidisciplinary participation (admin, physicians, nurses and pharmacists)
- Documents describing the service
Lex and Chris were so successful that they became educators. Chris was one of the founders of the American Society for Pain Management Nursing, and Lex was on the American Society of Anesthesiologists task force to write the first Practice Guidelines for Acute Pain Management in the Perioperative Setting.
In 1997, an article published in the British Journal of Anaesthesia titled “Multimodal Approach to Control Postoperative Pathophysiology and Rehabilitation,” by Henrik Kehlet, MD, a gastrointestinal surgeon from Copenhagen, Denmark, was the inspiration for the Collaborative Outcome Management Service Operation Manual. The collaborative manual can be thought of as an early attempt to “enhance recovery after surgery.” In fact, they were contemporary to a group of Northern European surgeons who started enhanced recovery after surgery (ERAS) as a model of care. Kehlet is known as the “Father of ERAS.”
Lex’s group went on to improve surgical outcomes by merely managing pain. Surgeons gradually caught their drift by changing routine postoperative care. Colorectal surgeons changed their care plans, and after Hubbard and Kehlet engaged them in 1998 to involve anesthesiologists, length of stay was reduced to roughly half.
“Maybe it was the internist in me who recognized opportunity for anesthesiologists to proactively manage determinants of surgical outcome. Maybe not. I encourage young anesthesiologists to improve surgical/anesthesia outcomes. There is plenty left to do,” says Hubbard.
Optimizing Patients with Chronic Pain for Elective Surgery
Many clinicians and academicians believe that chronic pain is a disease in its own right, whereas others believe it comprises only a symptom.
Regardless, there is an emerging national dialogue about optimizing chronic pain before elective surgery – just as one would seek to optimize cardiovascular, pulmonary or endocrine disease, for example. Anesthesiology News interviewed Heath McAnally, MD, MSPH, and Beth Darnall, PhD, about their perspectives on the need for preoperative optimization of chronic pain. Both clinician authors believe that focusing on the problems well in advance of proposed elective operations will lead to a greater likelihood of enhanced recovery “before” surgery. Below are some highlights of their evidence and reasoning.
Why elective surgery in poorly optimized patients with chronic pain is not smart.
Dr. McAnally: Let’s start with economics. We have evidence that preoperative optimization, in general, saves money across the perioperative encounter in terms of reduced postoperative complications, length of stay, readmissions, etc. When you drill down to specific factors of importance, across the board, regardless of surgical discipline, you see the same key issues driving these outcomes: postoperative infections; inadequately controlled pain; gastrointestinal issues such as nausea, constipation and ileus; and, worst of all, respiratory compromise as well as ICU admissions and mechanical ventilation.
It turns out that preoperative chronic pain – and its twin, chronic opioid use – are obviously associated with and confounded by many other factors, such as tobacco use, a deconditioned state, anxiety states, etc. that contribute.
Dr. Darnall: Decades of research illustrate that the current mental and physical health status of an individual predicts their ability to withstand forces of new stressors. Surgery is a controlled injury and generally incredibly disruptive and stressful. Optimizing individuals with a complete tool kit of services and resources can help connect them with needed treatments, and equip them with skills and information to help steer their recovery in a favorable direction.
We bear an ethical imperative to prepare patients to manage new postsurgical pain and other issues surrounding their surgery, management of existing health conditions, and better support their surgical recovery. People with chronic pain require a higher level of care in the surgical setting. If we fail to meet their needs, they are at risk for suffering longer and needlessly so.
Determining if Someone is Ready for the OR from a Pain Management Standpoint
Dr. Darnall: We would identify the major opportunities to enhance surgical preparedness and enhance surgical recovery across a range of domains, including social, functional, psychological and medical. From a behavioral perspective, it is vital for people to understand how to help themselves recover quicker after surgery.
We want to empower individuals to have an active role in having a degree of control over their experience of pain. The data suggest that actively engaging people in their daily pain care plans helps manage pain and distress, and puts more control in their hands.
Sometimes elective surgeries can be delayed until a person receives treatment designed to improve post-surgical outcomes. We always have an opportunity to support people mentally, emotionally and medically. By doing so, we help ensure best outcomes.
Dr. McAnally: I’d like to suggest that we need to try to determine operative readiness from a “systems theory” perspective, given that we know that chronic pain is a complex biopsychosocial-spiritual phenomenon. Literature shows clear interactions between what may on the surface look like unrelated/disparate issues, but in reality are highly intertwined. For example, we know that adequate sleep – and particularly slow-wave sleep – is critical for wound healing and resolution of inflammation.
I believe we need to be focusing on the impact that convergence of multiple factors confers to operative readiness.
Factors Considered the Most Important to Optimize
Dr. McAnally: It’s behavioral health. While “fitness for surgery” (indicating physiologic reserves), as our forebears used to say, is important, I believe that the psychological construct of resilience is the single most important determinant of outcome.
Dr. Darnall: All health factors are important. That said, data from multiple studies and meta-analyses suggest that the most important individual-level factors are psychological, mainly because our psychology affects everything: how much we engage in movement, follow rehab exercises, access social support or isolate, and whether we are able to help ourselves when we are suffering.
But any one focus in isolation is a disservice to patients. We should not apply behavioral medicine and self-management and then withhold pain medication after surgery. The idea is to optimize patients so they need less medication and intervention because what we are doing for them is working. Data from my research group show that ultra-brief behavioral treatment (two-hour skills-based pain class) leads to substantial reductions in pain-related distress and pain interference.
This is not to diminish the importance of smoking cessation or fitness, simply to illustrate that with accessible solutions many patients can be rapidly optimized to manage pain and surgery-related distress.
Practical Steps to Achieve Optimization
Dr. Darnall: My work focuses on providing patients with information and skills that they can use to self-regulate distress and pain before and after surgery. I developed a digital treatment that is web-based and includes three 15-minute video modules on managing pain-related distress by calming the central nervous system, and patients download a personalized plan and binaural audio file for daily use. Not everyone will engage with such a resource, but everyone should be offered a free resource like this as part of their medical care plan.
The first step in optimization is communicating that patients play an important role in their desired surgical outcome: better health, less pain, better function. Engagement starts with compassion, a caring bond with a clinician, removing the blame from the patient, and helping them know that we are all on the same team, rooting for them and providing tools to support them.
Dr. McAnally: From the individual patient and clinical perspective, it’s an ever-improving (I hope) process, but what we’re doing in our VALERAS Preoperative Optimization Program has three necessary components. The first is establishing buy-in, both from the patient and from the surgeon.
The second is tapping into both motivation and forming habits. Surgery has been defined more than once in the literature as “a teachable moment.” By and large, if you give consistent and good pep talks – a committed team for this is critical – it’s not hard to spark motivation for healthy lifestyle modifications in the short term.
Our program currently comprises 10 preoperative visits: five focusing on somatic issues and run strictly by the chronic pain clinic team, and five focusing on both somatic and psychological issues and run primarily by our psychology associates.
This leads me to the third component. We believe that the interplay between the risk factors we’ve been talking about (e.g., poor self-efficacy and catastrophizing, toxic habits, etc.) are best addressed together – within reason, of course. Nonetheless, healthy eating and toxin avoidance improve sleep, which allows for better exercise, which improves sleep, and so forth. We focus on six main issues generally: psychological pathology, poor sleep, tobacco, chronic opioid use, poor nutrition and “motion starvation.” We’re finding that a boot camp approach, with encouraging and edifying coaching, works really well.
To recap, we have to help people become fit for elective surgery – psychologically and physically – or suboptimal recovery will continue among patients with chronic pain. The data are convincing. We all need to play a part in enhanced recovery before surgery.
Finding Passion and the Meaning of Being an Anesthesiologist. anesthesiologynews.com
Enhanced Recovery Before Surgery: Putting the Horse Before the Cart. anesthesiologynews.com