Anesthesia for Latissimus Dorsi Flap for Breast Reconstruction

What is a latissimus dorsi flap?


Latissimus Dorsi Flap in Breast Reconstruction. Cancer Control. 2018 Jan-Dec; 25(1): 1073274817744638.

A Retrospective Study of Latissimus Dorsi Flap in Immediate Breast Reconstruction. Front. Oncol., 04 November 2021.

Anesthetic Techniques

Regional Anesthesia For Breast Reconstruction. [Updated 2022 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

Anaesthesia for breast surgery. BJA Education, 18(11): 342e348 (2018).

Anaesthesia for free flap breast reconstruction. BJA Education, Volume 16, Issue 5, May 2016, Pages 162–166.

Paravertebral Analgesia with Levobupivacaine Increases Postoperative Flap Tissue Oxygen Tension after Immediate Latissimus Dorsi Breast Reconstruction Compared with Intravenous Opioid Analgesia. Anesthesiology February 2004, Vol. 100, 375–380.

Treatment of Post-Latissimus Dorsi Flap Breast Reconstruction Pain With Continuous Paravertebral Nerve Blocks: A Retrospective Review. Anesth Pain Med. 2016 Oct; 6(5): e39476.

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives. J Pain Res. 2018;11:1567-1581.

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis. J Clin Anesth. 2021 Sep;72:110274.

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials. Can J Anaesth. 2022 Apr;69(4):527-549.

Efficacy of erector spinae plane block for analgesia in breast surgery: a systematic review and meta-analysis. Anaesthesia. 2021 Mar;76(3):404-413.

Erector Spinae Plane Block Similar to Paravertebral Block for Perioperative Pain Control in Breast Surgery: A Meta-Analysis Study. Pain Physician. 2021 May;24(3):203-213.

Erector Spinae Plane Block for Mastectomy and Breast Flap Reconstructive Surgery: A Three Case Series. Open Journal of Anesthesiology
Vol.10 No.01(2020), Article ID:97889,8 pages.


Liposomal bupivacaine (Exparel) is a longer acting form of traditional bupivacaine that delivers the drug by means of a multivesicular liposomal system.

Exparel FDA drug sheet

  • Max Dose: 266 mg or 4mg/kg (6yo-17yo). Interscalene NB max dose (adults) =133mg
Exparel website: Field blocks
Exparel website: Interscalene NB

Exparel dosing company info: Pocket Dosing Guide , Billing Guide

Liposomal bupivacaine: a review of a new bupivacaine formulation. J Pain Res. 2012; 5: 257–264.

Emerging roles of liposomal bupivacaine in anesthesia practice. J Anaesthesiol Clin Pharmacol. 2017 Apr-Jun; 33(2): 151–156.

Liposomal bupivacaine peripheral nerve block for the management of postoperative pain. Cochrane Database Syst Rev. 2016 Aug 25;2016(8):CD011476.

Liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain. Cochrane Database Syst Rev. 2017 Feb; 2017(2): CD011419.

Novel Local Anesthetics in Clinical Practice: Pharmacologic Considerations and Potential Roles for the Future. Anesth Pain Med. 2022 Feb; 12(1): e123112.


The role of liposomal bupivacaine in thoracic surgery. J Thorac Dis. 2019 May; 11(Suppl 9): S1163–S1168.

Intercostal nerve blockade for thoracic surgery with liposomal bupivacaine: the devil is in the details. J Thorac Dis. 2019 May; 11(Suppl 9): S1202–S1205.

  • VATs: Dilute liposomal bupivacaine (266 mg, 20 cc) mixed with 20 cc injectable saline. We use two syringes to save time (refill syringe between injections).
  • For planned thoracotomy, we add 60 cc injectable saline for wider injection.
  • The efficacy of this strategy requires attention to specific details, such as timing and technique of injection, dilution with saline, and injection of multiple interspaces (typically interspaces 3–10 when technically possible).
  • Inject EXPAREL slowly and deeply (generally 1-2 mL per injection) into soft tissues using a moving needle technique (ie, inject while withdrawing the needle)
  • Infiltrate above and below the fascia and into the subcutaneous tissue
  • Aspirate frequently to minimize the risk of intravascular injection
  • Use a 25-gauge or larger-bore needle to maintain the structural integrity of the liposomal particles
  • Inject frequently in small areas (1-1.5 cm apart) to ensure overlapping analgesic coverage

Liposomal Bupivacaine Versus Bupivacaine for Intercostal Nerve Blocks in Thoracic Surgery: A Retrospective Analysis. Pain Physician. 2020 Jun;23(3):E251-E258.

Intercostal Blocks with Liposomal Bupivacaine in Thoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth. 2021 May;35(5):1404-1409.

Is liposomal bupivacaine superior to standard bupivacaine for pain control following minimally invasive thoracic surgery? Interactive CardioVascular and Thoracic Surgery, Volume 31, Issue 2, August 2020, Pages 199–203,

Paravertebral Nerve Block With Liposomal Bupivacaine for Pain Control Following Video-Assisted Thoracoscopic Surgery and Thoracotomy. J Surg Res. 2020 Feb;246:19-25.

Rib fractures case report: ESP block

Evaluation of an Enhanced Recovery After Surgery Protocol Including Parasternal Intercostal Nerve Block in Cardiac Surgery Requiring Sternotomy. Am Surg. 2021 Dec;87(10):1561-1564.

Ultrasound-guided Modified Parasternal Intercostal Nerve Block: Role of Preemptive Analgesic Adjunct for Mitigating Poststernotomy Pain. Anesth Essays Res. 2020 Apr-Jun; 14(2): 300–304.

Comparison of preincisional and postincisional parasternal intercostal block on postoperative pain in cardiac surgery. J Card Surg. 2020 Jul;35(7):1525-1530.

Ultrasound-guided parasternal intercostal nerve block for postoperative analgesia in mediastinal mass resection by median sternotomy: a randomized, double-blind, placebo-controlled trial. BMC Anesthesiol. 2021; 21: 98.

Pain Relief Following Sternotomy in Conventional Cardiac Surgery: A Review of Non Neuraxial Regional Nerve Blocks. Ann Card Anaesth. 2020 Apr-Jun; 23(2): 200–208.

A Novel Use of Liposomal Bupivacaine in Erector Spinae Plane Block for Pediatric Congenital Cardiac Surgery. Case Rep Anesthesiol. 2021; 2021: 5521136.

Breast/Gen Surg

Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction. Plast Reconstr Surg Glob Open. 2022 Jan 19;10(1):e4010.

Perioperative Blocks for Decreasing Postoperative Narcotics in Breast Reconstruction. Anesth Pain Med. 2020 Oct; 10(5): e105686.

Opioid-sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review. Plast Reconstr Surg Glob Open. 2021 Nov 16;9(11):e3932.

Comparison of the efficacy of erector spinae plane block performed with different concentrations of bupivacaine on postoperative analgesia after mastectomy surgery: ramdomized, prospective, double blinded trial. BMC Anesthesiol. 2019; 19: 31.

Efficacy of liposomal bupivacaine versus bupivacaine in port site injections on postoperative pain within enhanced recovery after bariatric surgery program: a randomized clinical trial. Surg Obes Relat Dis. 2019 Sep;15(9):1554-1562.

The use of extended release bupivacaine with transversus abdominis plane and subcostal anterior quadratus lumborum catheters: A retrospective analysis of a novel technique. J Anaesthesiol Clin Pharmacol. 2020 Jan-Mar; 36(1): 110–114.


Pain Control and Functional Milestones in Total Knee Arthroplasty: Liposomal Bupivacaine versus Femoral Nerve Block. Clin Orthop Relat Res. 2017 Jan;475(1):110-117.


Transversus Abdominis Plane Block With Liposomal Bupivacaine for Pain After Cesarean Delivery in a Multicenter, Randomized, Double-Blind, Controlled Trial. Anesth Analg. 2020 Dec; 131(6): 1830–1839.

Ketamine and Methadone: Is more of a good thing better?

I’ve done a good deal of research on the benefits of an ERAS and Cardiac ERAS protocol to help with decreased length of hospital stay as well as early extubations and perioperative adjuvant pain control with ketamine, methadone, regional anesthesia, adjuvants to regional, etc.

What about ketamine and methadone in combination to aid decreased postoperative narcotic use?

  • Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology Newly Published on March 2021. doi:
    • 0.2 mg/kg of methadone (based on ideal body weight, up to a maximal dose of 20 mg)250 mg of ketamine was added to the dextrose 5% in water bag (total volume 500 ml). 500 ml bags were connected to a pump that was programed to deliver an infusion of ketamine dosed at ideal body weight (or an equal volume of dextrose 5% in water) at a rate of 0.3 mg · kg−1 · h−1 from induction of anesthesia until surgical closure, at which time the infusion was decreased to 0.1 mg · kg−1 · h−1. The infusion was maintained at a rate of 0.1 mg · kg−1 · h−1 in the postanesthesia care unit (PACU) and for the next 48 postoperative hours. Dosing of ketamine was based on recommendations in the literature17,18  and from clinical experience at our institution.
  • From Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology Newly Published on March 2021. doi:

    Management of Neuropathic Chronic Pain with Methadone Combined with Ketamine: A Randomized, Double Blind, Active-Controlled Clinical Trial. Pain Physician. 2017 Mar;20(3):207-215.

    Role of Ketamine and Methadone as Adjunctive Therapy in Complex Pain Management: A Case Report and Literature Review. Indian J Palliat Care. 2017 Jan-Mar; 23(1): 100–103.

    Ketamine: an introduction for the pain and palliative medicine physician. Pain Physician. 2007 May;10(3):493-500.

    Prescription of Controlled Substances: Benefits and Risks. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.2020 Jun 27.

    The perioperative combination of methadone and ketamine reduces post-operative opioid usage compared with methadone alone. Acta Anaesthesiol Scand. 2012 Nov;56(10):1250-6.

    The similarities and differences in impulsivity and cognitive ability among ketamine, methadone, and non-drug users. Psychiatry Res. 2016 Sep 30;243:109-14.

    Comparison of ketamine-dexmedetomidine-methadone and tiletamine-zolazepam-methadone combinations for short-term anaesthesia in domestic pigs. Vet J. 2015 Sep;205(3):364-8.

    A Systematic Review of NMDA Receptor Antagonists for Treatment of Neuropathic Pain in Clinical Practice. Clin J Pain. 2018 May;34(5):450-467.

    [Drugs for postoperative analgesia: routine and new aspects: Part 2: opioids, ketamine and gabapentinoids]. Anaesthesist. 2008 May;57(5):491-8.

    Aprepitant (Emend)

    Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies. Ther Clin Risk Manag. 2020; 16: 1305–1317.

    Patient risk factors (including female gender, non-smoker, history of PONV, or motion sickness) could be quantified using risk scores such as the Apfel score and the Koivuranta score, while surgical procedures such as laparotomy and cholecystectomy confer additional PONV risk. Other perioperative risk factors of PONV includes the length of surgery, the use of volatile anesthesia, including nitrous oxide, as well as perioperative opioid administration. Perioperative risk reduction interventions include multimodal, opioid sparing anesthesia, avoidance of volatile anesthetic, as well as nitrous oxide exposure. Gan et al2 have extensively reviewed various options for PONV prophylaxis and rescue treatment, which includes pharmacological and non-pharmacological interventions. The authors acknowledged that currently the biggest challenge in PONV management is often low compliance to the guidelines.

    Fig 1. Summary of the expert consensus guidelines on postoperative nausea and vomiting (PONV) management.

    Palonosetron monotherapy for PONV prophylaxis is more effective than other 5-HT3 antagonists, including ondansetron, granisetron, ramosetron; it is also more effective than dexamethasone. Palonosetron has comparable efficacy to aprepitant.

    Aprepitant is a competitive Neurokinin (NK)-1 receptor antagonist which was also initially approved for the treatment of chemotherapy-induced nausea and vomiting. It is administered orally, although an intravenous equivalent is also available, in the form of a pro-drug Fosaprepitant. It has a half-life of 9–13 hours, and it has been suggested that its duration of action may be as long as 40 hours.  Fosaprepitant is approved only for chemotherapy-induced nausea and vomiting. As a single agent prophylaxis, 40 mg aprepitant has similar efficacy as 0.075 mg palonosetron. Clinical trials and meta-analyses have reported that aprepitant is more effective in preventing PONV when compared to ondansetron. Similar to palonosetron, the aprepitant is also shown to be beneficial in ambulatory surgery due to its long duration of action and lower risk of postdischarge nausea and vomiting. Vallejo et al59 conducted a clinical trial of 150 patients with moderate-to-high risk undergoing ambulatory plastic surgery, and found that aprepitant plus ondansetron was associated with significantly lower incidence of postdischarge nausea and vomiting than ondansetron alone.

    Amisulpride is a dopamine receptors antagonist. While initially licensed as an antipsychotic, in February 2020 the FDA approved its IV formulation for prophylactic and rescue therapy of PONV. The anti-emetic dose for prophylaxis is 5 mg IV, 10 mg IV for rescue treatment, whereas its antipsychotic dose is 50–1,200 mg/day orally.

    Comparing the efficacy of aprepitant and ondansetron for the prevention of postoperative nausea and vomiting (PONV): A double blinded, randomised control trial in patients undergoing breast and thyroid surgeries. Indian J Anaesth. 2019 Apr; 63(4): 289–294.

    This study found that the antiemetic efficacy of ondansetron and aprepitant was comparable in preventing PONV in patients undergoing thyroidectomy and mastectomy. We found both ondansetron and aprepitant were equally efficacious in preventing emetic episodes, reducing the incidence of nausea and delaying the time to request of a rescue antiemetic. Although not statistically significant, the aprepitant group had a higher incidence of vomiting in the 12-24 h period. However, this group took longer to develop the first episode of vomiting and also to receive the first dose of rescue antiemetic, when compared with ondansetron group. Although the ondansetron group had less vomiting after 12 h, there was a higher incidence of nausea (both being statistically insignificant). So, overall there was no statistically significant difference in the incidence of PONV in both the groups.

    Single-dose aprepitant vs ondansetron for the prevention of postoperative nausea and vomiting: a randomized, double-blind Phase III trial in patients undergoing open abdominal surgery. BJA: AUGUST 01, 2007; VOLUME 99, ISSUE 2, P202-211.

    BJA:Aug2007, Vol99;Issue2,P202-211. Fig4. Kaplan–Meier curves for the time to first vomiting during the 48 h after surgery.
    BJA. Fig 3 Proportions of patients with no vomiting 0–24 and 0–48 h after surgery, by treatment group (modified intent-to-treat population). For each group, the error bar represents the value of the upper bound of the 95% CI for the percentage of patients achieving the endpoint. For 0–24 h, n = 293 for aprepitant 40 mg, n = 293 for aprepitant 125 mg, and n = 280 for ondansetron 4 mg. For 0–48 h, n = 292 for aprepitant 40 mg, n = 290 for aprepitant 125 mg, and n = 279 for ondansetron 4 mg.


    Aprepitant at both doses was non-inferior to ondansetron for complete response 0–24 h after surgery (64% for aprepitant 40 mg, 63% for aprepitant 125 mg, and 55% for ondansetron, lower bound of 1-sided 95% CI > 0.65), superior to ondansetron for no vomiting 0–24 h after surgery (84% for aprepitant 40 mg, 86% for aprepitant 125 mg, and 71% for ondansetron; P < 0.001), and superior for no vomiting 0–48 h after surgery (82% for aprepitant, 40 mg, 85% for aprepitant, 125 mg, and 66% for ondansetron; P < 0.001). The distribution of peak nausea scores was lower in both aprepitant groups vs ondansetron (P < 0.05).


    Aprepitant was non-inferior to ondansetron in achieving complete response for 24 h after surgery. Aprepitant was significantly more effective than ondansetron for preventing vomiting at 24 and 48 h after surgery, and in reducing nausea severity in the first 48 h after surgery. Aprepitant was generally well tolerated.

    Neurokinin-1 Receptor Antagonists in Preventing Postoperative Nausea and Vomiting: A Systematic Review and Meta-Analysis. Medicine (Baltimore). 2015 May; 94(19): e762.

    Fourteen RCTs were included. Meta-analysis found that 80 mg of aprepitant could reduce the incidences of nausea (3 RCTs with 224 patients, pooled risk ratio (RR) = 0.60, 95% confidence interval (CI) = 0.47 to 0.75), and vomiting (3 RCTs with 224 patients, pooled RR = 0.13, 95% CI = 0.04 to 0.37) compared with placebo. Neither 40 mg (3 RCTs with 1171 patients, RR = 0.47, 95% CI = 0.37 to 0.60) nor 125 mg (2 RCTs with 1058 patients, RR = 0.32, 95% CI = 0.13 to 0.78) of aprepitant showed superiority over 4 mg of ondansetron in preventing postoperative vomiting. NMA did not find a dose-dependent effect of aprepitant on preventing postoperative vomiting.

    Limited data suggested that NK-1R antagonists, especially aprepitant were effective in preventing PONV compared with placebo. More large-sampled high-quality RCTs are needed.

    In conclusion, our study found that NK-1R antagonists, especially aprepitant, helped preventing PONV in patients undergoing surgery with general anesthesia by decreasing the incidence of nausea and vomiting, and delaying the time to first vomiting. However, more data from high-quality RCTs and a comprehensive evaluation of related adverse events were needed before a recommendation of using NK-1R antagonists to prevent PONV could be made.

    Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia: January 2014 – Volume 118 – Issue 1 – p 85-113.

    Postoperative nausea and vomiting (PONV) are common and distressing to patients. The general incidence of vomiting is about 30%, the incidence of nausea is about 50%, and in a subset of high-risk patients, the PONV rate can be as high as 80%. Unresolved PONV may result in prolonged postanesthesia care unit (PACU) stay and unanticipated hospital admission that result in a significant increase in overall health care costs. The goal of PONV prophylaxis is therefore to decrease the incidence of PONV and thus patient-related distress and reduce health care costs.

    Figure 1: Risk score for PONV in adults. Simplified risk score from Apfel et al.9 to predict the patient’s risk for PONV. When 0, 1, 2, 3, and 4 of the risk factors are present, the corresponding risk for PONV is about 10%, 20%, 40%, 60%, and 80%, respectively. PONV = postoperative nausea and vomiting.
    Figure 2
    Simplified risk score for PDNV in adults. Simplified risk score from Apfel et al.19 to predict the risk for PDNV in adults. When 0, 1, 2, 3, 4, and 5 risk factors are present, the corresponding risk for PDNV is approximately 10%, 20%, 30%, 50%, 60%, and 80%, respectively. PDNV = postdischarge nausea and vomiting; PONV = postoperative nausea and vomiting; PACU = postanesthesia care unit.
    Table 2: Strategies to Reduce Baseline Risk. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.
    Table 3. Antiemetic Doses and Timing for Prevention of PONV in Adults. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.
    Figure 4. Algorithm for management of postoperative nausea and vomiting. PONV = postoperative nausea and vomiting. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting
    Anesthesia & Analgesia118(1):85-113, January 2014.
    Table 4. Pharmacologic Combination Therapy for Adults and Children. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.

    Ondansetron is also as effective as dexamethasone and haloperidol 1 mg IV, with no difference in effect on the QTc interval. However, it is less effective than aprepitant for reducing emesis and palonosetron for the incidence of PONV.

    Compared with palonosetron 0.075 mg, granisetron 2.5 mg is as effective at 3 hours and 3 to 24 hours but less effective at 24 to 48 hours. Palonosetron 0.075 mg is more effective than granisetron 1 mg and ondansetron 4 mg in preventing PONV.

    Aprepitant was significantly more effective than ondansetron for preventing vomiting at 24 and 48 hours after surgery and in reducing nausea severity in the first 48 hours after surgery. It also has a greater antiemetic effect compared with ondansetron. When used in combination, aprepitant 40 mg per os, plus dexamethasone, is more effective than ondansetron plus dexamethasone in preventing POV in patients undergoing craniotomy. A dose-ranging study for gynecologic laparotomy patients found a 80 mg per os dose of aprepitant is the most appropriate dose and is more effective than a 40 mg dose.

    Preoperative dexamethasone 8 mg enhances the postdischarge quality of recovery in addition to reducing nausea, pain, and fatigue. Dexamethasone also has dose-dependent effects on quality of recovery. At 24 hours, patients receiving dexamethasone 0.1 vs 0.05 mg/kg required less opioid and reported less nausea, sore throat, muscle pain, and difficulty falling asleep. A meta-analysis evaluating the dose-dependent analgesic effects of perioperative dexamethasone found that doses >0.1 mg/kg are an effective adjunct in multimodal strategies to reduce postoperative pain and opioid consumption.

    A recent meta-analysis suggests that with prophylactic low-dose droperidol (<1 mg or 15 µg/kg IV) in adults, there is still significant antiemetic efficacy with a low risk of adverse effects.

    When haloperidol 1 mg was compared with ondansetron 4 mg and placebo, there was no difference in QTc effect among the 3 groups. There was no difference in PONV incidence between haloperidol and ondansetron given before the end of surgery, but both were not significantly better than placebo at 24 hours. There was no difference in early antiemetic efficacy between haloperidol 1 mg and ondansetron 4 mg and no difference in the risk of QT prolongation. Comparing haloperidol 2 mg IV vs ondansetron 4 mg IV given before the end of surgery, there was no difference in effect on early versus late PONV or QTc prolongation. However, Meyer-Massetti et al. recently reviewed the literature and all FDA Med Watch reports of haloperidol-associated adverse events and recommended doses of haloperidol <2 mg to reduce the risk of side effects and QT prolongation. 

    Meclizine 50 mg per os plus ondansetron 4 mg IV is more effective than either ondansetron or meclizine alone.

    Scopolamine patch can be applied the evening before surgery or 2 to 4 hours before the start of anesthesia due to its 2- to 4-hour onset of effect. Adverse events associated with TDS are generally mild, the most common being visual disturbances, dry mouth, and dizziness.

    Perphenazine is a phenothiazine derivative that has been used for the prevention of PONV at doses between 2.5 mg to 5 mg IV or IM.

    Metoclopramide is a weak antiemetic and at a dose of 10 mg is not effective in reducing the incidence of nausea and vomiting. Metoclopramide in 25 and 50 mg doses had an effect similar to ondansetron 4 mg for early PONV but a smaller effect than ondansetron for late PONV. Dyskinesia or extrapyramidal symptoms were 0.6%, and 0.6%, respectively, and can increase with increasing metoclopramide doses.

    Mirtazapine 30 mg per os plus dexamethasone 8 mg reduces the incidence of late PONV by >50% compared with dexamethasone 8 mg alone. Less rescue medication is needed with the combination of antiemetics.

    Gabapentin doses of 600 mg per os given 2 hours before surgery effectively decreases PONV. Given 1 hours before surgery, gabapentin 800 mg per os is as effective as dexamethasone 8 mg IV, and the combination is better than either drug alone.

    Midazolam 2 mg when administered 30 minutes before the end of surgery was as effective against PONV as ondansetron 4 mg.

    The following strategies are not effective for PONV prophylaxis: music therapy, isopropyl alcohol inhalation, intraoperative gastric decompression, the proton pump inhibitor esomeprazole, and administration of nicotine patch 7 mg to nonsmokers. The latter modality may actually increase the incidence and severity of PONV. Although isopropyl alcohol inhalation is not effective for the prophylaxis of PONV, aromatherapy with isopropyl alcohol was effective in achieving a quicker reduction in nausea severity compared with promethazine or ondansetron when used for the treatment of PONV (Evidence A2).

    A meta-analysis of 40 articles including 4858 subjects concluded that P6 stimulation with 10 different acupuncture modalities reduces nausea, vomiting, and the need for rescue antiemetics compared with sham stimulation (Evidence A1). The efficacy of P6 stimulation is similar to that of prophylactic antiemetics such as ondansetron, droperidol, metoclopramide, cyclizine, and prochlorperazine. In subgroup analysis, there was no difference in effectiveness in adults compared with children or invasive versus noninvasive modalities for P6 stimulation. The timing of transcutaneous acupoint electrical stimulation does not impact PONV, with similar reductions being achieved with stimulation initiated before or after induction of anesthesia. Neuromuscular stimulation over the median nerve also reduces the incidence of PONV in the early postoperative period, particularly when tetanic stimulation is used.

    The additional costs associated with PONV in placebo patients are up to 100 times higher compared with prophylaxis with a generic antiemetic, and the cost of treating vomiting is 3 times higher than the cost of treating nausea. When using a willingness to pay rate of $100 per case avoided, PONV prophylaxis proved cost-effective in groups with a 40% risk of PONV. Lower drug acquisition costs would generally support PONV prophylaxis in patient groups at a lower risk for PONV. The decision about whether or not to use PONV prophylaxis, or to treat patients with established symptoms, not only depends on the efficacy of the drug but also on the baseline risk for PONV, adverse effects of the antiemetics, and drug acquisition costs, which will vary from 1 setting to another.

    When nausea and vomiting occur postoperatively, treatment should be administered with an antiemetic from a pharmacologic class that is different from the prophylactic drug initially given, or if no prophylaxis was given, the recommended treatment is a low-dose 5-HT3 antagonist. During the first 4 postoperative hours, patients who failed PONV prophylaxis with ondansetron 4 mg did not respond either to a second administration of ondansetron 4 mg or to crossover with granisetron 0.1 or 1 mg.

    The results show that mixing IV and per os antiemetics at various perioperative times decreases PDNV. For instance, 1 study found that dexamethasone 8 mg IV at induction plus ondansetron 4 mg IV at the end of surgery plus ondansetron 8 mg per os postoperatively had a greater effect on decreasing PDNV than ondansetron 4 mg IV alone at the end of surgery.

    Table 7. PONV-Prevention Algorithm in All Patients Including Low-Risk Patients Plus Additional Interventions for High-Risk Patients. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia118(1):85-113, January 2014.

    When developing a management strategy for each individual patient, the choice should be based on patient preference, C/E, and level of PONV risk. Among the interventions considered, a reduction in baseline risk factors and use of nonpharmacologic therapy are least likely to cause adverse events. PONV prophylaxis should be considered for patients at moderate to high risk for PONV. Depending on the level of risk, prophylaxis should be initiated with monotherapy or combination therapy using interventions that reduce baseline risk, nonpharmacologic approaches, and antiemetics. Antiemetic combinations are recommended for patients at moderate and high risk for PONV. When rescue therapy is required, the antiemetic should be chosen from a different therapeutic class than the drugs used for prophylaxis, and potentially one with a different mode of administration. If PONV occurs within 6 hours postoperatively, patients should not receive a repeat dose of the prophylactic antiemetic. An emetic episode more than 6 hours postoperatively can be treated with any of the drugs used for prophylaxis except dexamethasone, TDS, aprepitant, and palonosetron.

    Category A: Supportive Literature

    Randomized controlled trials report statistically significant (P < 0.01) differences between clinical interventions for a specified clinical outcome.

    Level 1: The literature contains multiple randomized controlled trials, and aggregated findings are supported by meta-analysis.

    Level 2: The literature contains multiple randomized controlled trials, but the number of studies is insufficient to conduct a viable meta-analysis for the purpose of these guidelines.

    Level 3: The literature contains a single randomized controlled trial.

    Multimodal Analgesia Pain Management

    Methadone: perioperative use; acute and chronic pain


    Orthopedic Surgery

    Updates on Multimodal Analgesia for Orthopedic Surgery. Anesthesiol Clin. 2018 Sep;36(3):361-373.

    Enhanced Recovery After Surgery (ERAS)

    ERAS for general surgery

    Cardiac ERAS

    Non-Opioid Analgesics

    Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg. 2017 Jul 1;152(7):691-697.

    Preemptive Analgesia Decreases Pain Following Anorectal Surgery: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial. Dis Colon Rectum. 2018 Jul;61(7):824-829.




    Regional Anesthesia

    TAP block

    Regional for Cardiothoracic Anesthesia

    PECS and serratus blocks

    Thoracic blocks: ESP, PVB, TEA block

    Paravertebral catheters

    Regional Anesthesia catheters

    Adjuncts to prolong regional anesthesia

    Regional Anesthesia for Cardiac Surgery

    Gathering data for Cardiac ERAS program for our hospital as well as the SCA. This page will be continuously updated as I find more information.


    What I’m using these days:

    • August 2020: None as we do not have programmable intermittent bolus pumps for regional.

    Methadone: perioperative pain use

    Methadone for perioperative pain #methadone #pain #ERAS

    There’s a lot of great data that methadone use decreases postoperative narcotics use in cardiac surgery patients, and I believe it would really be a beneficial drug in an ERAS pathway for early extubation, decreased LOS in ICU and hospital, and better patient satisfaction.  Please see the articles below/attached for references.

    Methadone for cardiac surgery: 0.2-0.3 mg/kg prior to incision – perhaps different metabolism on CPB so consider split dosing pre-pump and post-pump. Dose adjustment with age and other co-morbidities. At induction, one half of the study opioid (either 0.15 mg/kg of methadone or 6 μg/kg of fentanyl) was administered via an infusion pump over 5 min. The remainder of the study opioid (0.15 mg/kg of methadone or 6 μg/kg of fentanyl) was infused over the next 2 h. Either 0.3 mg/kg of methadone (maximum dose of 30 mg) or 12 μg/kg of fentanyl (maximum dose of 1200 μg) was added to 100-ml bags of normal saline (total volume 100 ml).

    Methadone for non-cardiac surgery: 0.2mg/kg prior to incision. REVIEW: Intraoperative Methadone in Surgical Patients: A Review of Clinical Investigations. Anesthesiology 9 2019, Vol.131, 678-692.

    Methadone for obesity: 0.15 mg/kg IBW+20% at induction. J Pain Res. 2018; 11: 2123–2129. Intraoperative use of methadone improves control of postoperative pain in morbidly obese patients: a randomized controlled study.

    Methadone for outpatient surgery: 0.15 mg/kg ideal body weight. Anesth Analg. 2019 Apr; 128(4): 802–810. Intraoperative Methadone in Same-Day Ambulatory Surgery: A Randomized, Double-Blinded, Dose-Finding Pilot Study.

    OVERALL: A variety of doses have been used in clinical trials, ranging from 0.1 to 0.3 mg/kg, with the majority of studies using a dose of either 0.2 mg/kg or a fixed dose of 20 mg.

    Methadone has a long elimination half-life (1–2 days). It is cleared predominantly by hepatic metabolism, primarily via N-demethylation to 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), which is pharmacologically inactive, and thence secondarily to 2-ethyl-5-methyl-3,3-diphenylpyrroline (EMDP).

    Together these investigations established that a) CYP3A has no influence on single-dose intravenous or oral methadone plasma concentrations, b) CYP3A plays a minimal (if any) role clinically in single-dose methadone N-demethylation and clearance, c) methadone is not a clinical CYP3A substrate, and d) clinical guidelines stating that methadone is a CYP3A4 substrate and warning about CYP3A4 drug interactions needed revision. In addition, CYPs 2C9, 2C19, and 2D6 do not appear to contribute materially to clinical methadone N-demethylation and clearance.

    In summary, it is now obvious that CYP2B6 a) is a predominant catalyst of methadone metabolism in vitro; b) mediates clinical methadone metabolism, clearance, stereoselective disposition, and drug-drug interactions; and c) genetic polymorphisms influence methadone disposition. Thus, both constitutive variability due to CYP2B6 genetics, and CYP2B6-mediated drug interactions, can alter methadone disposition, clinical effect, and drug safety. Rewritten clinical guidelines stating that methadone is a CYP2B6 substrate and warning about CYP2B6 drug interactions may improve methadone use, treatment of pain and substance abuse, and patient safety.

    FDA Drug Datasheet

    From Anesthesiology 5 2015, Vol.122, 1112-1122.
    From Anesth Analg. 2019 Apr; 128(4): 802–810.

    What I’m doing these days:

    • March 2021
      • Cardiac: Ketamine current pt weight (non-adjusted) 0.2mg/kg/hr start after induction (after lines placed) + 0.35 mg/kg 5-10 minutes prior to incison. Change from 0.2mg/kg/hr to 0.1mg/kg/hr when rewarming. Infusion off when driving sternal wires. Methadone currently not available.
      • Non-cardiac (cases 2+ hours duration) Ketamine: 0.3mg/kg (non-adjusted, current weight) at induction. Methadone currently not available.
      • Outpatient: ketamine not currently available for use.
    • July 2020
      • Cardiac: Ketamine IBW 0.3mg/kg total: 0.2mg/kg prior to incision + 0.1mg/kg when separate from CPB
      • Excel spreadsheet dosing

    Adult Cardiothoracic

    Adult Non-Cardiac

    From Perioperative Methadone and Ketamine for Postoperative Pain Control in Spinal Surgical Patients: A Randomized, Double-blind, Placebo-controlled Trial. Anesthesiology Newly Published on March 2021. doi:

    Adult Outpatient

    Pediatric Surgery

    Methadone Pharmacology & Effects

    Prescription of Controlled Substances: Benefits and Risks. [Updated 2020 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:

    The role of methadone in opioid rotation-a Polish experience. Support Care Cancer. 2009 May;17(5):607-12.

    ERAS for Cardiac Surgery

    ERAS for cardiac surgery. #eras #pain #multimodal #opioids #surgery #cardiac #perfusion #perfusionist

    I have been utilizing ERAS in general surgery, OB, and ortho cases. Diving into one of my more tricky populations, I opted to see what ERAS practices are out there for cardiac surgery. Careful what you look for my friends. There’s actually a good amount of information out there!

    Updated: Dec 2021

    Up-To-Date: Anesthetic management for enhanced recovery after cardiac surgery (ERACS). Nov 2021.

    Guidelines for Perioperative Care in Cardiac SurgeryEnhanced Recovery After Surgery Society Recommendations.  JAMA Surg. 2019;154(8):755-766. doi:10.1001/jamasurg.2019.1153

    ERAS CS: Opioid Reduction Strategies in Cardiac Surgery – STS 8 in 8 Series. Sept 2020.

    ERAS CS: Standardizing Evidence Based Best Practice in Periopertive Cardiac Surgical Care. Nov 2020.

    CTSNet: “Cardiac Surgery Re-start and Beyond – Optimizing ICU Resource Utilization and Patient Safety”. Sept 2020.

    CTSNet: “Enhanced Recovery After Cardiac Surgery Part II: Intraoperative and Postoperative.” June 2019.

    CTSNet: ERAS Guidelines for Perioperative Care in Cardiac Surgery. July 2019.

    ACCRAC podcast: ERAS for Cardiac Surgery

    ERAS Cardiac Consensus Abstract – April 2018

    Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: a randomized clinical trial. European Journal of Cardio-Thoracic Surgery, Volume 54, Issue 3, 1 September 2018, Pages 491–497,

    ** Audio PPT ** American Association for Thoracic Surgery: Enhanced Recovery After Cardiac Surgery. April 2018

    The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. The Journal of Thoracic and Cardiovascular Surgery. April 2018Volume 155, Issue 4, Pages 1843–1852.

    Enhanced Recovery for Cardiac Surgery. J Cardiothorac Vasc Anesth. 2018 Jan 31. pii: S1053-0770(18)30049-1. DOI:

    From Journal of Anesthesiology

    A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg. 2017 Jan;153(1):118-125.e1. doi: 10.1016/j.jtcvs.2016.09.016. Epub 2016 Sep 19.

    Enhanced Recovery After Cardiac Surgery Society

    **Enhanced Recovery After Cardiac Surgery Society Expert Recommendations**

    My blog posts:

    Key Points

    • Level 1 (Class of recommendation=Strong Benefit):
      • Tranexamic acid or epsilon aminocaproic acid should be administered for on-pump cardiac surgical procedures to reduce blood loss.
      • Perioperative glycemic control is recommended (BS 70-180; [110-150]).
      • A care bundle of best practices should be performed to reduce surgical site infection.
      • Goal-directed therapy should be performed to reduce postoperative complications.
      • A multimodal, opioid-sparing, pain management plan is recommended postoperatively
      • Persistent hypothermia (T<35o C) after CPB should be avoided in the early postoperative period. Additionally, hyperthermia (T>38oC) should be avoided in the early postoperative period.
      • Active maintenance of chest tube patency is effective at preventing retained blood syndrome.
      • Post-operative systematic delirium screening is recommended at least once per nursing shift.
      • An ICU liberation bundle should be implemented including delirium screening, appropriate sedation and early mobilization.
      • Screening and treatment for excessive alcohol and cigarette smoking should be performed preoperatively when feasible.
    • Level IIa (Class of recommendation=Moderate Benefit)
      • Biomarkers can be beneficial in identifying patients at risk for acute kidney injury.
      • Rigid sternal fixation can be useful to reduce mediastinal wound complications.
      • Prehabilitation is beneficial for patients undergoing elective cardiac surgery with multiple comorbidities or significant deconditioning.
      • Insulin infusion is reasonable to be performed to treat hyperglycemia in all patients in the perioperative period.
      • Early extubation strategies after surgery are reasonable to be employed.
      • Patient engagement through online or application-based systems to promote education, compliance, and patient reported outcomes can be useful.
      • Chemical thromboprophylaxis can be beneficial following cardiac surgery.
      • Preoperative assessment of hemoglobin A1c and albumin is reasonable to be performed.
      • Correction of nutritional deficiency, when feasible, can be beneficial.
    • Level IIb (Class of recommendation=Weak Benefit)
      • A clear liquid diet may be considered to be continued up until 4 hours before general anesthesia.
      • Carbohydrate loading may be considered before surgery.

    ERAS for cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia



    Cardiac ERAS. JCVA 2020. PDF.

    **Guidelines for Perioperative Care in Cardiac SurgeryEnhanced Recovery After Surgery Society Recommendations. JAMA, May 2019.**

    Alvimopan and ERAS

    From Anesthesia & Analgesia 2018

    Alvimopan / Entereg

    The Food and Drug Administration approved alvimopan in 2008 as an oral, peripherally acting opioid μ-receptor antagonist to accelerate GI recovery in patients undergoing bowel resection.87,88 A pooled analysis of 3 prospective randomized trials demonstrated that a 12 mg dosing regimen provided optimal reduction in GI morbidity and return of GI function after abdominal surgery.89

    Vaughan-Shaw et al90 performed a meta-analysis involving 3 studies of 1388 patients undergoing open abdominal surgery (bowel resection and hysterectomy) within a defined accelerated recovery program. This study demonstrated a 16- to 20-hour reduction in the time to GI recovery and discharge order associated with alvimopan use. It is important to note that the defined accelerated recovery program in each of these studies was limited to early removal of prophylactic NG tubes, clear liquids on POD 1, and encouragement of ambulation. Each study utilized patient-controlled analgesia with heavy doses of opioids.91 Therefore, these trials were conducted in open surgery within the setting of an opioid-centric treatment pathway, which is not consistent with most modern day ERPs. There are no high-quality prospective randomized trials examining the efficacy of alvimopan within the setting of an opioid-restricted modern day ERP or after minimally invasive surgery.

    However, there are large database studies evaluating the use of alvimopan in current practice. The Michigan Surgical Quality Collaborative group reported that the usage of alvimopan in the community resulted in a decrease in mean LOS (4.8 vs 6.4 days) due principally to a reduction in ileus (7.9% vs 2.3%).92 Similarly, the Surgical Care and Outcomes Assessment Program evaluated 14,781 patients undergoing elective CRS comparing those that did (11%) and did not receive (89%) alvimopan and found a LOS reduction of 1.8 days and a cost reduction of $2017 related to ileus reduction in patients receiving alvimopan.93 Adam et al94 reported on a single institution experience of 660 patients after implementation of alvimopan as part of an established ERP (197 alvimopan; 463 no alvimopan) and demonstrated a faster return of bowel function, a lower incidence of ileus, a shorter LOS, and a hospital cost savings of $1492 per patient. These results are consistent with similar retrospective cohort study by Itawi et al.95 It should be noted that the potential benefits of alvimopan are likely related to the amount/duration of opioid analgesics as demonstrated by 2 separate retrospective studies demonstrating minimal benefit in a laparoscopic colectomy population managed with minimal opioids.96,97

    The data suggest a reproducible benefit associated with the use of alvimopan in open CRS; however, the cost/benefit ratio must be considered within the context of the opioid administration of each institution’s ERP. Barletta et al50 confirmed that the intravenous opioid dosage that results in ileus might be quite modest (2-mg hydromorphone). Additional data would be helpful to clearly define the minimum dose exposure and route of administration of opioids that would best guide the use of alvimopan within a comprehensive ERP. However, if modest opioid exposure is anticipated, the agent appears to be cost-effective.

    Enhanced Recovery After Surgery (ERAS)


    Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011 Oct; 5(5): 342–348.

    Dario Bugada, Valentina Bellini, Andrea Fanelli, et al., “Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach,” Surgery Research and Practice, vol. 2016, Article ID 3561249, 6 pages, 2016. doi:10.1155/2016/3561249

    Enhanced Recovery After Surgery: If You Are Not Implementing it, Why Not? PRACTICAL GASTROENTEROLOGY • APRIL 2016.

    A Systematic Review of Enhanced Recovery After Surgery Pathways: How Are We Measuring ‘Recovery?’ Session: Poster Presentation. Program Number: P613


    Sturm L and Cameron AL. Fast-track surgery and enhanced recovery after surgery (ERAS) programs. ASERNIP-S Report No. 74. Adelaide, South Australia: ASERNIP-S, March 2009.

    Summary of Enhanced Recovery after Surgery Guideline Recommendations. Canada.

    Patients Benefit From Enhanced Recovery Programs: Are Better Prepared for Surgery, Have Less Pain, Studies Show. Oct 2016. American Society of Anesthesiologists.

    Enhanced Recovery after Surgery Guideline: Perioperative Pain Management in Patients Having Elective Colorectal Surgery: A Quality Initiative of the Best Practice in General Surgery Part of CAHO’s ARTIC program. April 2013.

    Preserved Analgesia With Reduction in Opioids Through the Use of an Acute Pain Protocol in Enhanced Recovery After Surgery for Open Hepatectomy. Regional Anesthesia & Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 451–457.

    Regional Anesthesia for surgery and other comparative studies. Sweden.

    ERAS: Role of Anesthesiologist. UTSW.

    Stanford Anesthesia ERAS pathway website


    Enhanced Recovery after Surgery Versus Perioperative Surgical Home: Is It All in the Name? Anesthesia & Analgesia: May 2014 – Volume 118 – Issue 5 – p 901–902

    The Role of Regional Anesthesia in ERAS pathways. Sept 2015. UCSF.

    ERAS Pathway Improves Analgesia, Opioid Use and PONV Following Total Mastectomy. Anesthesiology News. May 2016.

    Anesthesia Practice and ERAS. Cooper University Hospital. 2017.

    ERAS: Anesthesia Tutorial of the Week. Number 204. Nov 2010.

    ERAS and Anesthesia. Anesthesia Business Consultants. May 2015.

    All about ERAS: Why anesthesiologists need to understand this concept. Becker’s ASC Review. June 2015.


    I’d love to incorporate my findings and use of lidocaine infusions and ketamine infusions on intraoperative and postoperative pain as a multimodal pain management pathway.

    What we’re using:

    • July 2020
      • Acetaminophen 1g PO (cardiac, gen surg)
      • Celebrex 400mg PO (gen surg)
      • Gabapentin 600mg PO (gen surg)
      • Lyrica 75mg PO (cardiac)
      • Entereg mg PO (gen surg)