Block Evaluation 4
“Doctor, you’re block isn’t working…..”
I get calls to the PACU and get told while rounding on my patients that a patient is hurting. If you are proficient at doing blocks and focused on optimizing pain control, you probably have to briefly fight the urge to say, “They can’t be hurting…I put that block in!” Right after this, there is a brief moment of worry and disbelief. “What if…what if my block…failed?” This disconcerting feeling may diminish, but it won’t completely abate until you lay eyes on the patient yourself. At this point, I begin to review in my head what objective ultrasound cues that I had during block placement and what I recall from the intraoperative management.
I’m not saying this happens to you, of course, but you may cover the PACU when your partners place blocks. Of course. The question of what to do and how to evaluate the patient still remains. There are numerous clues that you have at your disposal to evaluate the patient’s report of pain. I will discuss some of this in this edition of ‘Tips and Tricks’.
The complaint of pain by a patient may, in fact, be pain. And it is possible that the complaint of pain is due to acute pain from the surgical site that should be covered by the nerve block. In reality, it is a rare circumstance (especially in the PACU) that this is actually the problem. I am fortunate to work with a thoughtful and well-trained group of CRNA’s, PACU RN’s and floor/ICU RN’s (that have heard me go on and on about pain evaluation more times than they probably care to have heard) who know: 1) what questions to ask the patient beyond an initial complaint 2) how to objectively evaluate the patient and 3) what to do in the meantime. It does continue to frustrate me on occasion when I arrive to see a patient that has received a dose of IV opioids (after requiring zero opioids intra-operatively and had ‘railroad track’ vitals throughout the case) who is now quite sedated, and I determine with further investigation that their complaint of pain actually consists of a ‘pressure’ sensation that is creating a sense of anxiety…and when I can get them awake enough to respond, they tell me that this sensation is still fully present.
The most common circumstance that I encounter when evaluating complaints of pain in the PACU is [nonmember]…
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actually anxiety. The most common situation on the floor (or in the ICU) that I encounter is that the patient ‘expected’ to have pain, and they report their sensation of pressure (or even numbness!) as pain. The reality is that most complaints of pain (or affirmative responses when asked) in patients with continuous nerve blocks in place are not actually the result of pain. When I say ‘pain’ here, I should say that I mean in the more strict sense that it is not from nociception. Pain may encompass a variety of sensations, I am well aware, but I have found that it is often unnecessary and usually an error to ‘treat’ most of the complaints of pain, as pain per se, with opioids or even with bolusing a nerve block catheter (generally less of an error than the former in my opinion). This error also occurs when using a numeric pain scale system with no further objective clinical evaluation of pain. I would make the argument that if psychological factors influence the perception of pain, then a simple cognitive behavioral intervention may alter the psychological influence (i.e., anxiety due to a ‘misinterpreted’ pressure sensation) and lead to the new perception that pain is not present. After a brief conversation, I have had patients say things like, “I guess you’re right, I guess I’m not hurting.” I can sometimes see the gears turning, and watch them have an ‘A-ha!’ moment. They will wipe their tears and go on like nothing ever happened. I have treated this kind of ‘pain’ with words, not opioids, numerous times.
I hope you know that I am not the type that broadly dismisses pain or patient complaints. I consider myself an advocate for optimizing post-operative analgesia and have spent the better part of this month alone lecturing across the west coast about the general inadequacy of acute post-operative analgesia in contemporary practice and all of the negative financial and outcome-related problems associated with it (a topic for another edition or two). I have mentioned elsewhere that I prefer to observe the patient (and their vital signs) from a distance at before I talk with them (then I scan the anesthesia record if we’re in the PACU, especially if the block was placed before surgery). I have come to realize that many times the patient doesn’t really know what they are experiencing, and it is not helpful to directly ask the patient to give me their diagnosis. Sometimes, I approach patients with small talk to distract them and gauge their ‘relative’ preoccupation with pain and say something like,” Hey, how are you doing?” or ”Is there anything bothering you?” Regularly, I get responses like, “I’m fine; just a little cold” or “Yes, this Foley is driving me crazy!” If you’ve had an exploratory laparotomy and no opioids, and your Foley catheter is the first thing you mention and your biggest thing bothering them, then the subcostal blocks are working just fine!
The correct thing to do when a patient indicates they are experiencing pain is to ask the location of the pain. If we don’t ask, we will treat their back pain with a 10ml bolus of local anesthetic into their interscalene catheter. We fall into this trap because we are all ‘expecting’ that complaints of pain are going to be from the operative site and that the intensity is going to be severe. I can recall a patient in the PACU that had a nephrectomy who complained of ‘side pain’. He said his whole side hurt, yet he had no cold temperature sensation from T7 to T12, well above and below his incision. When I finally listened, he made it clear that it was his non-operative side. He was hurting from lying on it for so long. Being specific about the location of the pain may be what allows you to recognize that the shoulder pain after an open shoulder repair is not a completely failed block but just one where the cervical plexus wasn’t covered adequately. This problem is easily addressed by a bolus of local anesthetic or a quick superficial cervical plexus block. It would be a shame to pull the catheter at this point!
The next thing to do is to ask what it feels like. Do not accept, “It just hurts.” Make them be specific. I will lead them with throbbing, constant, aching or lots of pressure. I never give them a starting prompt of sharp or burning. This is followed by an objective physical exam to determine the presence and pattern of any local anesthetic effect. I prefer to use cold alcohol pads instead of having them discriminate a sharp sensation.
I know these seem like minor points and very basic concepts, but attention to details like these will lead to the appropriate use of I.V. or P.O. opioids or catheter boluses, and it may prevent the removal of a correctly placed catheter or serious respiratory depression and/or a nausea-riddled extended PACU stay.
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