Pre and post surgical pain control protocol: A novel approach for patient comfort
By P.K. Clark D.M.D. Founder and clinical director of WhiteCap Institute.
As needed for pain (P.R.N) was all I was exposed to in my training years. Someone once said “if you do what you’ve always done you’ll get what you’ve always got. I have not always been satisfied with the P.R.N. approach. My son is a fifth-year OMS resident at UCSF. He has helped me see beyond P.R.N. I was introduced to a better way, ‘by the clock’.
Rather than wait for the pain to spike, the ‘by the clock’ approach instructs the patient to take their medications at a pre-appointed time. This protocol makes perfect sense to me and has made a significant difference for my patients. Prior to making changes from P.R.N., I would have patients experience a pain spike. Once this pain was present it was very difficult to get them comfortable again. Sometimes it would take half a weekend for the pain to finally subsided. From time to time my patients experiencing on unrelenting pain would consume more and more medication. This behavior would further complicate the situation. With this scenario the patient would get sick and vomit. This requires additional prescription drugs to get them comfortable and to reverse the symptoms of over medication. To fully optimize the novel effective of ‘by the clock’ post-surgical pain control protocol it is important to realize that pain is a result of pain inflammatory mediators. These pain mediators are created by separate and different inflammatory pathways. As surgical clinicians we must use medications that cover both pathways. By doing so we are more likely to have comfortable patients. The remarkable thing of this protocol is the use of over the counter (OTC), Tylenol and Advil. At first I have to admit I was a little skeptical.
Here’s how this ‘by the clock’ pre and post surgical protocol works. To begin the patient needs to take 600 mg of Advil the night before surgery. Next the patient needs to take another dose of 600 mg of Advil the morning of the surgery. If the patient has been instructed to take nothing by mouth (NPO) six hours prior to the surgery it’s acceptable to make an exception for medication with a little water. This pre-surgical component is vital to the efficacy of the post-surgical protocol. Without the loading dose of Advil in your patient’s bloodstream the results of comfortable recoveries are compromised.
The first step in post-surgical pain control is getting their medication onboard before they even leave the office. I am an advocate of an OTC cocktail of 500 mg tylenol and and 400 mg Advil ‘by the clock’ i.e. every four hours. We give our patients a cup with the cocktail to swallow with an applesauce squeeze pack. The applesauce thickness helps with swallowing, especially with bilaterally numb patients. We feel the sugar in the applesauce also helps regain some blood-sugars levels that may be low because of the fasting N.P.O. requirement of IV sedation. I learned that this first dose chair side prior to patient dismissal is critical to the protocol. Envelopes are then prepared with two Advil and one 500 mg Tylenol. On each of the envelopes we boldly mark the time that they need to swallow the contents, even if that means waking up in the middle of the night. The perfect time to maximize the pain control is every four hours. Years ago, I would ask my patient to follow my OTC ‘by the clock’ regiment with varying results. Not until I gave them the medication chair side and the pre-made pill packets did I realize it’s real potential. It’s very important to get off on the right foot with this protocol. Patient compliance can be sketchy. However, we have seen dramatic improvement with the envelopes we give each of our surgery patients. I’ve become a real fan of this protocol.
If the procedure is a big one, i.e. bilateral sinus augmentations with a bunch of implants I would build envelopes for two or three days. For less invasive procedures I would recommend one day. worth of envelopes. After the one day or two days is completed we would advise the P.R.N approach. Different protocols would need to be utilized in your kidney or liver compromised patients.
The Icing on the Cake
In addition to this pain control protocol we have one adjunctive therapy with the acronym of R.I.C.E.; rest, ice, compression, and elevation. We as dentists do not use cryotherapy to its full advantage. We advocate four hours of nonstop compressive ice packs over the surgical site for the first day. We ask for four additional hours of compressive ice on the second day. Elevation refers to the surgical site position relative to the patient’s heart. We request our patients sleep with two pillows or even in a lazy boy lounge chair to help with this elevation.
I hope this info is helpful for your surgical outcomes. Give it a try it has been a solid addition to post operative pain control for our patients. Thanks for reading.
P.K. Clark Bio
Dr. Clark is a practicing dentist, lecturer, and surgical mentor. He received his DMD from Oregon Health Science University and maintained a successful private practice in the Portland, Oregon area for nearly 20 years.