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Narcotic-sparing strategy affords safe, successful pain management

Article-Narcotic-sparing strategy affords safe, successful pain management

Chicago — A pain control regimen tailored to the type of procedure and aiming to minimize reliance on narcotics has been highly effective in maintaining comfort and enhancing overall satisfaction among patients undergoing aesthetic surgery, Laurie A. Casas, M.D., tells Cosmetic Surgery Times.

Dr. Casas
"While control of postoperative pain has been a somewhat overlooked aspect of the management of surgical patients, its importance is highlighted by new pain management standards issued a few years ago by the Joint Commission on Accreditation of Healthcare Organizations that required accredited facilities to assess pain as a 'fifth vital sign' after surgery. In my own practice over the last 20 years, I have always focused attention on methods to optimize pain control because apprehension about postoperative pain is a major feature of patients undergoing elective cosmetic procedures," says Dr. Casas, associate professor of surgery, Northwestern University Feinberg School of Medicine, Chicago.

Tailoring approach to pain

In deciding on what agents to use and for what duration, Dr. Casas divides the procedures into categories according to type and area of tissue involved and uses that as a guide to tailor the regimen.

Procedures that are "skin only," such as a blepharoplasty, generally result in minimal pain that can be addressed with an analgesic/anti-inflammatory medication. Procedures involving more extensive muscle manipulation or dissection, such as breast augmentation, most facelifts or abdominoplasty, or that cause extensive soft tissue trauma, i.e., liposuction in multiple areas, lead to more significant acute postoperative discomfort and require more aggressive treatment targeting the inflammation, bruising and swelling that are contributing to pain.

Acetaminophen plus an oral anti-inflammatory agent are mainstays used in all patients. For anti-inflammatory treatment, Dr. Casas generally prescribes the COX-2 inhibitor celecoxib (Celebrex, Pfizer).

"I avoid the nonsteroidal anti-inflammatory drugs, such as ibuprofen, ketorolac and naproxen, because they inhibit platelets and can prolong bleeding. If a patient is sulfa-allergic and celecoxib is contraindicated, I prescribe nabumetone (Relafen, Glaxo SmithKline), which is a partially selective COX-2 inhibitor with a minimal effect on platelet aggregation," she explains.

The anti-inflammatory agent is administered one hour prior to surgery and then taken once or twice a day postoperatively while pain persists.

East meets West

In the past several years, Dr. Casas has begun to use two herbal agents with anti-inflammatory activity, arnica montana and bromelain, to reduce bruising and swelling in procedures involving muscle and soft tissue manipulation.

"One drawback of arnica montana is that it is not exceptionally user-friendly because it has to be dissolved under the tongue either using five smaller pellets or one larger pellet three to five times a day," Dr. Casas notes.

Controlled, continuous infusion of the local anesthetic bupivicaine delivered directly into the surgical site is used to relieve deeper, localized pain, such as patients might experience after abdominoplasty or breast augmentation. That modality may be continued for up to 72 hours to provide reliable pain control with good safety.

"This is a great option when I anticipate the level of postoperative pain on a scale of one to 10 will reach seven or higher during the first few days hours after the procedure," she explains.

For procedures involving the muscle, such as submuscular breast augmentation, Dr. Casas adds low doses of the muscle relaxant cyclobenzaprine (Flexeril, ALZA) that helps to minimize pain by reducing muscle spasms.

The duration of use of the various modalities is tailored according to the individual. While the anesthetic pump is almost never used for more than three days, the oral medications are continued as long as bruising and/or soreness persist.

Dr. Casas says that by using this combination approach over the last five to seven years, she has greatly minimized patient need for narcotics. That, by itself, has had an important effect on enhancing postoperative comfort.

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