80 something year old male came for reverse total shoulder replacement. He had severe COPD as well as an EF 20% with CHF. He had been appropriately optimized. Preoperatively, we performed an anterior approach suprascapular block (10ml, 0.25% bupi) combined with an infraclavicular block (20ml, 0.25% bupi). In retrospect, we could have used 5ml for suprascapular block and 15ml for infraclavicular block.
Liposomal bupivacaine (Exparel) is a longer acting form of traditional bupivacaine that delivers the drug by means of a multivesicular liposomal system.
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
20-something year old primip came today with preeclampsia and was deemed a c/s candidate for her 26 week baby. She was 5’8″, 165lb and had no prior issue with previous surgeries. She was started on magnesium preop. The mag was held intraoperatively and would resume postoperatively. Pt was in sitting position for her spinal, which was placed at L4-5. Good clear CSF return. 0.75% bupi dosed at 13.5 mg with intrathecal fentanyl 15mcg and intrathecal morphine 0.2mg. BP decreased from 150s to 130s, which was appropriate. Patient stated she had increased tingling and decreased mobility in her legs. All symptoms and signs appropriate with her spinal. Patient passed the Allis clamp test prior to incision. She was quite anxious: propofol was given IV for anxiolysis. Patient was adamant about breastfeeding/pumping for her baby. No complications with delivery. Uterus was externalized and patient was sensitive to pressure and tugging/manipulation. IV fenatnyl and IV morphine were given along with IV propofol. When uterus was internalized, patient felt more pressure that seemed unbearable. More IV pain meds were given. Suggestion was made for intraperitoneal chloroprocaine. Patient able to tolerate fascial closure as well as staple skin closure.
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.
Consider continuing current or decreased buprenorphine dose
Consider non-opioid therapies: ketamine, gabapentin, acetaminophen, regional, lidocaine infusions, etc.
Team management with pain physician, surgeon, anesthesiologist, nurses, and patient
When mild to moderate acute pain is anticipated for a short period of time (e.g. dental extraction), consider treating the pain with buprenorphine and nonopioid analgesics such as NSAIDs. The total daily dose of buprenorphine can be increased (to a maximum of 32 mg sublingual/day); it should be given in divided doses every 6-8 hours.
When opioid analgesic therapy is expected to be required for a short period of time for moderate to severe pain, federal guidelines recommend holding the buprenorphine and starting short acting opioid agonists. While the buprenorphine’s effects diminish (20-60 hours), the patient should be monitored carefully for the first several days as higher opioid doses may be needed to compete with the presence of buprenorphine on mu-opioid receptors. Before restarting buprenorphine, the patient should be opioid-free for 12-24 hours, otherwise the reinitiation of buprenorphine could precipitate withdrawal. This process should be overseen by an approved buprenorphine provider.
Another option is to continue buprenorphine and use short-acting opioid agonists at high enough doses to overcome buprenorphine’s partial agonism. One retrospective chart review found decreased opioid requirements in patients who were continued on buprenorphine during and after surgery. Opioids that have a higher intrinsic activity at the mu-opioid receptor, including morphine, fentanyl, or hydromorphone, are all options, while opioids with less efficacy such as hydrocodone or codeine should be avoided.
If a patient is expected to have an ongoing, long-term need for opioid analgesia (e.g. cancer progression), consider replacing buprenorphine with methadone. Then, other as needed ‘full’ mu-opioid receptor agonists can be added for breakthrough pain without problems related to use of a partial opioid agonist.
Nov 2021: (includes Oct ASA annual mtg recommendations)
Buprenorphine is a good analgesic. Some patients prefer it to other opioids, even post-op. It is not recommended to stop buprenorphine, which can lead to relapse in 50% of patients. There is a significant increase in mortality in patients in the first month after buprenorphine is stopped.
Regional Anesthesia & Pain Medicine journal recommends no weaning.
Mass General considers high dose to be more than 16 mg daily.
Different approach suggested in Anesthesiology 2016 paper.
If patient is on 32 mg, only 5% of mu receptors are left for anesthesiologist to work with. If patient is on 16 mg, 20% of mu receptors are available. If patient is on 8-10-12 mg, 50% of mu receptors are available, which is why this is considered optimal by some. Need to overcome receptors with opioids that are high potency, high affinity and titratable, fentanyl and hydromorphone.
With an opioid crisis at its peak, physicians need to be more cognizant of the various pain modalities available to patients. Gabapentinoids are one of the many non-opioid options to help with acute and chronic pain.
Sleepy Time 