Changing to a non-opioid paradigm involves getting buy-in from multiple stakeholders, most importantly the patient. We have found that preoperative counseling is a critical part of the pathway.
Preoperative counseling begins in the outpatient setting and should include:
- Reason for why stent may need to be placed after ureteroscopy such as ureteral edema, postoperative hydronephrosis, stone fragments, etc.
- The treatment timeline to include stent removal in office
- What to expect when the stent is in place / common stent symptoms
- The use of NSAIDs for stent pain: “People do really well after this surgery with Tylenol and our super strength special prescription anti-inflammatory (Diclofenac or Ketorolac or Celecoxib etc.)”
- Worrisome signs / When to call clinic or visit the emergency department
Collaboration with the perioperative team is imperative. The use of intraoperative NSAIDs should be discussed with the Anesthesia team:
- Ketorolac should be considered for anyone without renal dysfunction / ASA, NSAID allergy
- Dosage may be reduced for advanced age
- Just because patient has been determined to get opioids postoperatively doesn’t mean they can’t get ketorolac (unless contraindicated as above)
- It is important to let anesthesia team know that you plan on discharging the patient without any opioids as they are likely to reduce PACU narcotic orders if aware
Postoperatively, communication with the PACU nursing staff is critical regarding care plan:
- Reiteration of non-opioid plan for discharge
- Standardized discharge medications through Enhanced Recovery Stent Pathway orderset
- Review of ureteroscopy specific discharge instructions, medication regimens, and warning signs