Pain Management and the Acute Pain Service

Anesthesia residents rotate for 3 months in the University of Chicago Pain Medicine Center. The 3 months are not consecutive but are spread over the 3 years of anesthesia training, 1 month each year. Residents spend approximately half of the time in the Pain Clinic and half of the time on the Anesthesia Inpatient Pain Service.

During the time in the Pain Clinic, residents develop procedural skills and learn to evaluate complex chronic pain syndromes.

In an environment conducive to learning and with attending supervision, anesthesia residents practice technical skills as early as the third month of anesthesia residency during the chronic pain rotation.

Residents participate in daily lectures on various pain topics and in multidisciplinary conferences within the institution and the Chicagoland area. Each month of the rotation in the Pain Clinic, residents improve their knowledge of common and uncommon pain syndromes.

At the end of the rotation they are able to diagnose (through a differential diagnosis algorithm) many pain syndromes and formulate a complex treatment plan with attending supervision. Among the pain syndromes are the following:

Low back, radicular, facet arthropathy, neck, myofascial, inflammatory, sympathetically mediated, cancer, neuropathic, and facial pain, including trigeminal and occipital neuralgia.

Residents perform the following procedures:
Lumbar epidural steroid injections; lumbar facet intra-articular injections; lumbar medial branch nerve block; joint injections of shoulder, knees, hips; sacroiliac joint injections; trigger point injections.

All procedures in the pain clinic are performed using image-guided techniques such as fluoroscopy and ultrasound.

Residents also may choose a pain elective in the third year. At this level, residents function on par with pain fellows and participate in more complex cases. They help diagnose complex pain syndromes such as complex regional pain syndrome, central sensitization, failed back surgery syndrome, chronic post-surgical pain, and phantom limb pain.

During the elective rotation or during the last required chronic pain rotation, residents may participate in complex pain and surgical procedures; kyphoplasties; spinal cord stimulators (trials and implants), intrathecal drug delivery systems (trials and implants), radiofrequency ablations (medial branch, trigeminal, splanchnic), sympathetic chain blocks (stellates, celiac, lumbar sympathetic, superior hypogastric, ganglion impar).

Under the direct supervision of the pain faculty, residents acquire the tools to understand chronic pain and suffering and to tackle it in an effective and compassionate way.

The Acute Pain Service Rotation

The acute pain service (APS) experience is a two-week rotation within the month-long pain medicine rotation. Residents can elect more than one month of pain medicine. 

While on the APS, trainees have the opportunity to prevent and treat acute and chronic pain. As a consulting service, the APS provides postsurgical care for some of the most challenging and in-need patients in the hospital. Of note, it is one of the most utilized consult services in the medical center.

The APS uses a modern, progressive approach to pain management. Faculty members are board certified in pain medicine and experts in regional anesthesia. The APS can be a transition to outpatient pain management. All APS faculty also care for outpatients. 

The APS serves complicated patients in the pediatric and adult hospitals including the intensive care units, the burn units, wound rounds, and the preoperative and intraoperative care for complicated pain patients having surgery.

At the heart of the APS experience is an education in pain science. The pathophysiology of acute and chronic pain is the starting point for assessment and therapeutic planning. Residents learn the neurobiology of pain and the molecular mechanisms of pain, and the treatment of refractory pain. Clinically, therapies are selected in a pathway-targeted fashion and based on primary literature and clinical data. Optimizing the doctor-patient relationship is another key didactic component of the rotation. Appropriate treatment can only be identified after an individualized assessment followed by patient education and continued reassessment. 

At the University of Chicago, the APS provides a myriad of therapies that have the potential to improve a patient’s comfort and postoperative function. Residents learn the selection criteria, risks, and alternatives as well as the technique and its analgesic mechanism of action. 

The APS team performs a multitude of bedside and procedure suite-based rescue therapies for acute pain. The team utilizes a procedure cart linked to the electronic health record (pictured). Patient monitoring and data captured at the mobile station give staff immediate access to critical resuscitation medications and equipment.

Some common procedures include:

  • Bedside ultrasound-guided transversus abdominis plane (TAP) and/or rectus sheath block via single shot or catheter.
  • Ultrasound-guided paravertebral blockade via single shot or catheter
  • Bedside adductor canal block via single shot or catheter after total knee arthroplasty
  • Bedside upper and lower extremity blockade for acute surgical pain via continuous catheter and or single shot
  • Bedside sympathetic blockade via ultrasound-guided block for cardiovascular symptomatology or sympathetic pain syndromes
  • Various peripheral nerve blocks for facial pain and headache
  • Continuous infusion therapies
  • Low dose ketamine outside of the ICU
  • Lidocaine infusion (ICU and OR only)
  • Bedside epidural placement
  • Sympathetic blockade for acute on chronic abdominal pain and pelvic pain
  • Neurolytic blocks for cancer pain
  • Intrathecal catheter placement for continuous therapy
  • Continuous peripheral nerve blockade for aggressive physical therapy

The APS faculty members serve on national committees for the specialty and subspecialty and contribute to several high impact textbooks and journals. Faculty active conduct prospective research on acute pain, rescue blocks, patient-centered care, continuous peripheral neural blockade, and epidural training simulation. 
The APS faculty lead several medical center initiatives and committees for patient safety and access to novel and developing pain therapies. When not lecturing outside of the institution, the APS faculty members lecture on pain management in other departments. Several surgical care pathways have been shaped by collaboration with the APS.

The many academic and clinical activities conducted by the faculty are available for residents and fellows. Motivated residents have written book chapters or review articles, presented scientific posters, and conducted clinical research with the faculty. The department’s rotation is a unique educational experience within anesthesia training.