The effectiveness of peri-operative pain management for orthopaedics
- zeropainphilosophy
- Jan 25
- 2 min read
Updated: Feb 1
Zero Pain Practice - Animal Orthopaedics Christchurch, NZ
Authors - Dr Rebecca Weight & Alice Finch
What would you like to improve?
Effectiveness of perioperative pain management in orthopaedic surgery patients, specifically focusing on cases where preoperative ultrasound-guided nerve blocks are incomplete or fail intraoperatively.
Selection of Criteria – How will you measure improvement?
Incidence of intraoperative breakthrough pain (defined by the need to increase ketamine CRI rate or administer additional opioid boluses).
Postoperative Short Form Glasgow Composite Pain Scores (SF-GCPS) recorded in recovery.
Requirement for postoperative methadone or other rescue analgesia.
What will your target for improvement be?
Achieve median SF-GCPS ≤ 1 in recovery.
Who will inform the practice team responsible for driving change?
Dr Weight to brief the surgical team at the surgeon meeting and then nurses at the full team meeting. Summary of changes added to the perioperative analgesia protocol.
Data Collection
● Method: Retrospective review of orthopaedic cases using ultrasound-guided preoperative nerve blocks.
● Data collected:
○ Nerve block completeness (effective vs incomplete/failure).
○ Any intraoperative analgesic interventions (increased ketamine CRI, opioid administration).
○ SF-GCPS on arrival and in recovery
○ Use of methadone or other additional postoperative analgesics.
Data Analysis
Findings demonstrated that:
● Incomplete or failed nerve blocks were associated with increased intraoperative analgesic interventions.
● These patients had higher SF-GCPS values in recovery and were more likely to require methadone or other additional medications.
● The existing analgesic protocol delayed NSAID use until the night after surgery, and postoperative nerve blocks were not routinely repeated.
Implement Change
Following analysis, the following protocol adjustments were introduced:
NSAIDs administered preoperatively when appropriate (ASA 1, normotensive, no hx of GI upset patients).
NSAIDs administered postoperatively, pre-discharge when appropriate (ASA 2, no hx of GI upset). These patients should be normothermic, responsive and able to support themselves in sternal recovery prior to administration.
Postoperative nerve block repetition when the initial block was deemed to have failed.
Data Collection
● Method: Prospective review of orthopaedic surgical cases under the revised protocol.
● Date range: August–October 2025.
● Data collected: Same as in Cycle 1 (block effectiveness, intraoperative interventions, GCPS, postoperative analgesic requirements).
Data Analysis
● Marked reduction in intraoperative interventions (ketamine/opiates).
● Median GCPS reduced to 1 across recovery assessments.
● Only occasional cases required methadone or additional analgesia.
Was the target met? Yes
Did the change made in Cycle 1 affect this?
Yes – pre (or post) operative NSAID administration and postoperative nerve block repetition were both associated with improved pain control.
Explain how
Earlier NSAID administration provided preemptive anti-inflammatory effect, while postoperative nerve block reinforcement maintained local analgesia during the early recovery phase, reducing overall pain burden and GCPS scores.
Is there a need for further interventions?
● Consider a future audit comparing individual nerve block techniques to assess predictors of incomplete blockade.
● Consider replacement of the ultrasound unit as incidences of incomplete nerve blocks seem to be increasing (subjectively).
Could you conduct this same audit?
Do you have the tools and support you need?
We recommend the resources on the RCVS Knowledge website for clinical audit support.
Comments