Acute Pain Service (APS)

Most Recently Updated by Alex Linse MD, June 2025

WARNING

Currently a Draft; still needs reformatting

Important People

Director, Acute Pain Service: Dr. Olivia Romano

APS Attendings: Drs. Roland Flores, Adrian Hendrickse, Kyle Marshall, Marina Shindell, Inge Tamm-Daniels, Matt Lyman, Jake Lloyd, Keleigh McLaughlin, Mike Canepa, Simrat Kaur, Aidan Hoie, Nathan Reitberg, Mitchell Gist, Renuka George

APS Advanced Practice Providers (APPs): Rob Montgomery (Lead), Robin Konrad, Allison Wines, Holly Bender, Leah Vick, Morgan Klas

Acute pain is a different rotation since you are not in the OR. You will be placing pre-operative regional nerve blocks and epidurals for post-operative pain management. You will be managing patients with epidurals and nerve block catheters on the floor, and you will be performing pain consults throughout the hospital for patients with complex pain management. It can be hectic at times and being very organized is key! You will be managing orders and checking out drugs for many different patients over the course of the day and there is a lot of paperwork!

There is typically a CA-1 on APS-Pain (rounding service), a CA-1 on APS-Regional (blocks), and a CA-3 on APS-Regional. Occasionally, there will be an intern on APS-Pain as well. Each resident, from both the Pain and Regional services, will cover one weekend of rounding, including interns.

Prior to starting

Get an orientation from the residents currently on service. Be sure they show you where to find equipment in the storeroom, how to make the daily block lists, the order-sets for blocks/ultrasound and epidurals, and which services to sign into on Haiku

Meet with Rob Montgomery. Rob is our Clinical Nurse Specialist on service and is very helpful in familiarizing you with the ins and outs of the EPIC and APS rounding lists as well as how to navigate the ZZ PAIN MEDICINE context.

MOST IMPORTANT: READ!! You will be expected to know WHY you are performing the blocks, not just HOW to do them. This is a good time to familiarize yourself with topics such as:

Local anesthetics -- mechanisms of action, toxicity, allergies, use in peripheral v. neuraxial anesthesia.

Upper extremity blocks -- interscalene, supraclavicular, infraclavicular, axillary

Lower extremity blocks -- femoral, saphenous, popliteal, ankle

Neuraxial -- Epidurals (difference between thoracic and lumbar), spinal, combined spinal epidural.

Videos and ultrasound images of the various blocks

Block Buddy Pro ($99/year - can use education funds)

Great resource for quick reference, great US technique instructions and pictures.

ASRA coags App

Each afternoon…

“The List”

The OR Schedule for the following day will be delivered to you by the pre-op charge nurse in the late morning or early afternoon. Your job is to mark the cases that will need blocks with a “B” on that list and then fill out the indicated information on the APS block list worksheet for the following day. This block list is located on Microsoft Teams, under Department of Anesthesiology/APS/Files/APS Daily Block list.xls.

The columns include Patient name, Procedure/Block, Sedation/Meds, Block Note, PostOp Orders, APS Rounding List, Anesthesia Consult, EPIC List

Once you have finished writing down the info you need from the case list, return it to the charge nurse so those patients can be placed in bays near the APS desk in the morning. This is usually one of their final tasks before going home, so they appreciate your expedience in returning it to them 😉.

If you are unsure if a particular case or patient requires a block, ask your attending or fellow. It has become customary to email the attending surgeon the day prior to confirm if they want regional anesthesia for their patient(s). This is typically the job of the APS fellow.

Most Orthopedic surgeons (Dayton, Hogan) expect blocks for their total joints and typically do not need to be emailed unless there are extenuating circumstances. However, you MUST email the Ortho Trauma surgeons (Gorman, Stoneback, Alfonso) and Dr. Lindeque for confirmation. They often prefer post-op blocks or no block at all.

Be sure to CC the following day’s APS team including the attending, fellow, and resident (if not yourself), as well as the in-room attending and resident to be sure everyone is on the same page.

Note the number of first case starts as you may need to call in reinforcements (e.g., APS Rounding Resident, Senior Days, Wildcard) to get them all done.

If there are transplant or thoracic patients requiring epidurals, you may need to recruit the in room resident. It is your responsibility to contact and confirm this with that resident. You will need to get the pertinent information from this resident for The Rounding list (LOR, catheter depth, etc.) and to complete orders.

The above communication with the other residents and the surgeons should be noted on the Block List.

Peri-Op Order Sets

There is an APS Peri and Post op order set (see end of section). This order set has been organized as a combined effort between these surgical teams and the APS to include certain pain medications these patients should receive perioperatively and post op (Total Joints). If patients are on a particular pain regimen at home, this needs to be reviewed with the patient prior to going into surgery and addressed at the time of placing postop orders. It may be appropriate to reorder home pain meds immediately or have alternative analgesia ordered. It is best to coordinate these decisions with the primary team.

Placing orders the night before eliminates confusion and keeps things moving in the morning. It is helpful to put these orders in while you are making the Block list for the following day as you will already be in the patient’s chart at that time.

Equipment

Syringes for controlled meds

The APS team administers ketamine, versed, and fentanyl for procedures that are separate from the in-room provider’s standard narcotic bag. Be sure to have 3cc syringes with 18g needles on them ready.

Neuraxial Blocks

Epidurals

There are lists of what items should be gathered for an epidural hanging in the storeroom. Make sure the current resident on service shows you how to put these together.

ProTip: If you ever have to place an epidural on the floor or in the ICU, be sure to take 2 of everything with you because these supplies are lacking in off-site locations. Also, be sure to grab a pair of gloves for your attending.

Spinals

Intrathecal morphine (ITM) and other spinal injections are typically performed in the OR by the in-room providers. They should be prepared to get their own supplies for these procedures in the morning.

HOWEVER, you are still responsible for the other ‘administrative’ tasks surrounding that patient so the rounding team can follow-up on POD1...more on that later...

Peripheral Nerve Blocks (PNBs)

Note in the “Cookbook” (in the storeroom, have the current resident on service show you) the likely volume you will need and set up your syringe/3-way stopcocks accordingly (Ex: 1-20cc and 1-10cc syringe on a 3-way stopcock will get you through most PNBs). Remember these medications should be drawn up as close to procedure time as possible as they all have expiration times after being drawn up. Store them in the LOCKED cart I the APS storage room

Overnight call

Please refer to the Rounding resident responsibilities for information on call/weekend tasks including the role our APPs play in the care of our patients.

In the morning…

You should arrive early to make sure there have been no major changes to the OR schedule affecting your planned first case starts.

Beginning at 0630 (0730 on Mondays), you may begin consenting the patients. However, you should arrive much earlier than this to allow time for any unanticipated roadblocks that may result in a late first-case start.

Prior to 0630, you should double-check the schedule (as previously mentioned) making sure you have heard back from the surgical team regarding blocks you may have been unsure about the evening prior. If you have not heard back and still have questions, now is a good time to look in Amion and page the surgical team to find out. (Amion password: uco)

This is also a good time to start drawing up local anesthetic for the first-case starts

Consents

As each patient is ready to be consented, be sure to do the following:

Introduce yourself as part of the APS and what your role is (will not be in the OR, Rounding team plans to follow-up with you on POD1, despite looking so young you are, in fact, a doctor, etc.)

Perform a brief H&P

H/o regional/neuraxial anesthesia?

Allergies to local anesthetics?

On blood thinners?

If so, what? When was last dose?

You will need to familiarize yourself with the ASRA guidelines (get the ASRA Coags App) regarding anticoagulants/antiplatelet medications for this rotation -- AND THE BOARDS!

Any neuropathies? Weakness? Numbness? Movement disorders?

Perform a basic neuro exam on all patients recieving a block.

Make sure you document these in your block note, it’s called CYA!

Airway exam

Chronic pain issues, and home pain regimen

LOOK AT THE SITE TO BE BLOCKED!

Note any rashes, bruising, swelling, scars, hardware, bandages/casts.

Consents should include, but not be limited to risk of infection, bleeding, nerve damage, failed block, pain, LAST.

Be sure to always consent for general anesthesia along with your neuraxial/peripheral block and any other lines, procedures, depths of anesthesia the in-room providers may need.

Once you consent the patient, indicate that on the Block list. Before you move on to the next patient, politely ask that patient’s nurse to begin putting on monitors so once you grab your local, ultrasound, ketamine/versed, and glove up-- you’re all set!

Performing the block

Make sure all consents are signed prior to administering sedation. If there is not a surgical consent yet avoid sedating medicines.

For procedures with laterality, the site must be marked. We are also rolling out a new process that the site must be marked by an APS fellow or attending prior to block.

Make sure to place an order for the “Ultrasound Guided Nerve Block-APS” so you can pull the patient up on the ultrasound and save the block images to their chart. This order is located in the Nerve Block Order Set and the Preop Anesthesia Order Set.

Politely ask family members to step out. Be sure to have on your mask, cap, and sterile gloves. Perform a time out with the patient’s preop nurse; make sure you touch on allergies, pre-existing neuropathy/weakness, and anticoagulation.

Block with the attending present.

Once you have finished your block, be sure to clean up your sharps, return the ultrasound to the storeroom and clean it, use the block list to document your narcotics, loss of resistance and catheter depth, test dose, time of placement, and any other pertinent information needed for your epidural orders or block note -- which you can write a little later when things settle down.

Block Documentation

It is your responsibility to place each new block patient on the rounding list (this also includes the patients on Total Joint Protocol who do not get a block)

APS Rounding list can be found via Epic, ask Rob Montgomery or any on service to share access to the patient list with you.

Include the specifics of each block, PCEA settings, and prn meds on your sign out. Also include pertinent home meds, such as their pain regimen, and pertinent medical history. Rob is great in terms of instructing you on how to fill out the Rounding list.

Ex: T8-9, PCEA B0.1 H7 8/4/15 (i.e., bupivacaine 0.1%, hydromorphone 7 mcg/ml, basal 8ml/h, demand 4ml, q15 min lockout). Save time and effort by abbreviating as much as possible, but don’t sacrifice the meaning.

EPIC list: find "patient lists" tab on the top of the EPIC screen. Find "shared patient list" on the left side and click the "+" sign. APS should pop up. To add your patient, click [Add Patient], and then click on them under the recent patients tab.

All blocks also need to be charted in EPIC. To do this, get into the intraop record and click the button titled "blocks". Follow the tabs and fill out accordingly.

Rounding Resident Duties:

NOTE: Some days you may be asked to arrive in time to help with first start blocks. Work this out with your co-resident and fellow.

Pre-rounding

Rounding is best done from the ZZ Pain Medicine context (also used in your pain clinic rotation). You can do some rounding activities from the ZZ Anesthesia context, but it is much less robust: with a patient highlighted in patient lists, choose the “Rounding” button in the patient list menu directly above the list.

You are expected to look up the floor patients (pre-round) in EPIC after placing first start blocks in order to speed up team rounds. Pay close attention to pain scores, vitals, PCA/PCEA usage, labs, anticoagulation, primary team notes. In the Summary activity tab within ZZ Pain, add (wrench in) the following reports: Pain, Adult Comprehensive, Med History, Active Meds, Labs.

AM Rounds

Weekday: Team rounds (attending, resident, pharmacist, +/-APP) typically start at 9am but this may vary depending on census or attending. Discuss the rounding plan the evening before with the rounding attending. The day APP will divide the rounding list between you and the other APP(s) on that day. Make sure you print a list for the attending as well. You will see all the ICU patients and typically also patients you rounded on or blocked the day before. The list is usually divided evenly to distribute the workload.

Discuss with your attending/fellow that week to determine if you need to pre-round on patients. Usually, you just chart review and then everyone rounds together.

Pharmacists will place orders under your direction during rounds, be sure to clearly communicate with them so as not to forget or duplicate orders.

After rounds, write notes for all the patients that you rounded on, refer to helpful Smart (dot) phrases below.

Weekends: Sign out from the overnight APP will occur at 7 am. Touch base with your attending beforehand to decide a start time for rounds. Usually there is an APP, and you should split the patients. If not, you must round on and write notes on all of them.

Contact pharmacist prior to starting so they can meet you before rounds.

After rounds, write notes on all patients and take care of floor duties. You are expected to stay at the hospital covering the service / pager until sign out to the overnight APP at 7pm

ProTip: Make a little bag with 1% lidocaine, phenylephrine, dressing supplies to bring on rounds to troubleshoot epidurals. Note: Do not change/bolus a PCEA or IVPCA pump on rounds or in PACU. If something needs to be done immediately, notify the RN and they will do it. If you syringe bolus an epidural with local anesthetic, you are responsible for staying at the patient’s bedside for at least 30 minutes monitoring the patient. (See APS Protocol for Epidural Placement/Bolus on the Floor).

Post-Rounds

After your notes are done, you take care of any floor duties and try to follow up on patients that were blocked that day, either in the PACU or on the floor. When it’s busy, prioritize checking on the epidurals so you can give the overnight APP a good sign out about them. Update both the APS Rounding and EPIC lists, ensure all new patient’s info is entered, including their room numbers so the overnight APP can do PM rounds on them. In the afternoon between ~3-4pm, the day APPs will sign their patients and any new consults out to you, after which you will be responsible for all the patients on service and any new consults until sign out to the overnight APP at 7pm. Of note, some attendings may want to do afternoon rounds whereas others just run the list.

PM Sign Out

There will be an APP or fellow in house overnight every day of the month. Sign out occurs in the APS area of preop, have an updated Rounding list (with room numbers) printed to review with the APP.

If there is no APP (2/2 acation, leave etc.), then you will likely sign out to the Senior Nights resident.

Their shift begins at 9pm. If you are the late resident, you will stay in-house until 7pm and take home call from 7p-9p when you can call the Senior Nights resident to provide handoff.

When to Sign-Off Patients

Epidurals: will follow until the day you pull the epidural out. Be sure to check if the patient is on any anticoagulants and follow the ASRA guidelines in regard to timing for pulling epidural catheters. It is recommended to d/c or modify the current anticoag order to skip a dose, then reorder as appropriate. Using a nursing communication to hold an anticoag dose can be missed by the RN. It is standard to transition the patient to oral pain medicines after the infusion has been stopped but before pulling the actual catheter (make sure their pain is controlled with PO meds!). Place a note after pulling the catheter noting the patient's anticoagulation status and include that the "tip was intact". Moreover, always discuss your plans with the surgical team before pulling your epidural (especially CT!) Patients with chest tubes typically maintain their epidural until their chest tube is removed.

IT Duramorph/hydromorphone/spinal anesthetic: sign off 24 hrs post-block.

Peripheral nerve blocks: sign off POD#1 if single-shot block performed (ensure complete block resolution). For nerve catheters, follow patients for as long as they have catheter in place.

Resources

• The course syllabus
• TrueLearn
• Barash, Miller, Morgan and Mikhail
• ASRA.com

Latest guidelines and advisories

NYSORA.com, SafeUltrasound.org

Smart/Dot Phrases

Rob will share with you dot phrases for use in writing notes. Be sure to consistently use these note templates to initiate new notes and to copy forward existing notes where appropriate.

Order sets

UCH APS Peri & Post op Pain Management

Protocol for total joints, open abdominal and thoracic cases. Place preop orders the night before. Must follow all total joints for at least 24h regardless of whether a block or spinal morphine is placed (see Total Joint Pain Management Protocol) *

UCH Continuous Nerve Block Infusion and Single Shot Nerve Block

UCH Intrathecal Morphine Injection

normal dose 100-250mcg Duramorph (if shortage, 50-100mcg IT hydromorphone)

UCH IV PCA

UCH PCEA

UCH Ketamine Continuous Infusion for Analgesia

UCH Intrathecal Infusion Analgesia

UCH Ambulatory Continuous Nerve Block Infusion