Exit Strategy
As I talk with ‘happily surprised’ patients post-operatively on rounds or on telephone calls, sometimes they transition to what appears to be fear and dread. It is when they go from how they feel now to what they will feel later when the peripheral nerve block catheter is pulled. Many patients go home with a disposable local anesthetic pump on the day of surgery or thereafter as the case may be, but there are some that stay inpatients for several days that should be past the inflammatory phase of their procedure and generally should not require this modality for their analgesia at this point. But how do you know? In both of these cases, you need to be prepared for how you are going to handle this transition. [nonmember]…
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Transitioning from one modality to another is one of the times when patients can experience the worst pain during their recovery. In addition to having a reasonable plan in place, it is also vitally important to reassure patients that you have a reasonable plan to handle this. I count it as a deficiency in the system (though that is not always the case) when a patient brings this concern to me on rounds or during a telephone call the next day or so. In my opinion, we should have reassured them as part of our system before it occurred to them to worry. “Doc, I’m doing great right now, but I’m really worried about what it’s going to be like when you take this thing out…”
Patients are fearful of the reality of the pain that is hiding behind their nerve block and what they will do for it once they are out of the facility. The last thing I want to do is ruin a fantastic experience for the patient and be perceived as ‘kicking them out’ without adequate analgesia. In the literature and in the experience of countless patients that I have talked with about past surgeries, this reality for many of them (especially leaving as outpatients with a single injection nerve block) is common and not a good one at all.
I’ll discuss a plan to handle this transition for inpatients planning for discharge home on the day that their peripheral nerve catheter is pulled. To ensure that there has been enough time for the infusion to significantly diminish, the RN should turn it off very early in the morning on the day that discharge home is planned. This gives the patient one more good night of sleep. It is helpful to do this at a time the RN is already doing something for the patient. The catheter is not pulled at this time since they may still have significant pain, some other reason that delays discharge home and it allows for an additional bolus prior to discharge. Once the patient wakes up, give them whatever opioid the surgeon is prescribing for them to have at home as a scheduled medication. At a stated time in the morning, if pain is adequately covered and discharge is still planned, the RN pulls the catheter unless (usually for upper extremities, trunk or chest) a bolus is planned prior to discharge to extend analgesia even further. This way, we know (and the patient knows as well) that they have been brought ‘all the way’ through the storm.
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