Blocks for Shoulders

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.

Supraclavicular block versus interscalene brachial plexus block for shoulder surgery: A meta-analysis of clinical control trials. International Journal of Surgery, Volume 45, September 2017, Pages 85-91.

  • Supraclavicular block could provide similar analgesic efficacy compared with interscalene block.
  • Ultrasound-guided supraclavicular block was associated with a low incidence of hoarseness and Horner syndrome.

Interscalene versus supraclavicular plexus block for the prevention of postoperative pain after shoulder surgery: A systematic review and meta-analysis. European Journal of Anaesthesiology 36(6):p 427-435, June 2019

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial. Anesthesiology July 2018, Vol. 129, 47–57.

From Anesthesiology July 2018, Vol. 129, 47–57.

A Randomized Comparison Between Interscalene and Small-Volume Supraclavicular Blocks for Arthroscopic Shoulder Surgery. Regional Anesthesia & Pain Medicine 2018;43:590-595.

A combination of infraclavicular and suprascapular nerve blocks for total shoulder arthroplasty: A case series. Acta Anaesthesiol Scand. 2021; 65: 674– 680.

Suprascapular nerve block is a clinically attractive alternative to interscalene nerve block during arthroscopic shoulder surgery: a meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research volume 16, Article number: 376 (2021).

Evolution of Anesthetic Techniques for Shoulder Surgery: A Narrative Review. Osteology 20222(1), 52-61.

YouTube: Anterior suprascapular nerve block and literature 11:43 for procedure

YouTube: Suprascapular and axillary nerve block

Anesthesia for Latissimus Dorsi Flap for Breast Reconstruction

What is a latissimus dorsi flap?

From MDAnderson.org

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. https://doi.org/10.3389/fonc.2021.598604

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.

Exparel

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.

Cardiac/Thoracic

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, https://doi.org/10.1093/icvts/ivaa083

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.

Ortho

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.

OB

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.

Intraperitoneal Chloroprocaine

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.

Intraperitoneal chloroprocaine

Chloroprocaine. StatPearls.

Intraperitoneal chloroprocaine is a useful adjunct to neuraxial block during cesarean delivery: a case series. Int J Obstet Anesth. 2018 Aug;35:33-41. doi: 10.1016/j.ijoa.2018.01.007. Epub 2018 Mar 2.

Chloroprocaine Lavage to Improve Outcomes Related to Operative Cesarean Delivery (CLOR-PRO). Clinicaltrials.gov. 2018 ongoing.

Pain Control During Cesarean Delivery. Anesthesia Experts. Jan 2020.

From Essential Clinical Anesthesia: January 2012. Chapter 47

Failed epidural

Mechanisms and management of an incomplete epidural block for cesarean section. Anesthesiology Clinics. REVIEW ARTICLE| VOLUME 21, ISSUE 1, P39-57, MARCH 01, 2003

Fascia Iliaca block for hip surgery

Why place regional blocks for surgery?

JNYSORA Volume 10 March 2009: Nerve Blocks For Postoperative Analgesia: Choices After Common Lower Extremity Procedures.

What is it?

NYSORA description

From Starship Child Health

NYSORA video describing the block

Academic Life in EM. Aug 21, 2019. Fascia iliaca nerve block: A hip fracture best-practice

EM St. John. Fascia Iliaca Nerve Block. .

From Starship Child Health

How to do it?

Suprainguinal Fascia Iliaca Plane block

MySigRA Suprainguinal Fascia Iliaca Plane block

From Highland EM Ultrasound

Literature says:

Journal of Orthopaedic Trauma: January 2020 – Volume 34 – Issue 1 – p 49-54. Fascia Iliaca Block Decreases Hip Fracture Postoperative Opioid Consumption: A Prospective Randomized Controlled Trial.

Eur J Emerg Med. 2016 Feb;23(1):12-8. Fascia iliaca compartment block for hip fractures: experience of integrating a new protocol across two hospital sites.

BJA VOLUME 120, ISSUE 6, P1368-1380, JUNE 01, 2018. Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation.

Fascia iliaca block in the emergency department for hip fracture: a randomized, controlled, double-blind trial. BMC Geriatr 19, 180 (2019).

Anesthesiology September 2018, Vol. 129, 536–543. Preoperative Fascia Iliaca Block Does Not Improve Analgesia after Arthroscopic Hip Surgery, but Causes Quadriceps Muscles Weakness: A Randomized, Double-blind Trial.

J Surg, Volume 16:2, 2020. Peripheral Nerve Blocks in Hip Arthroscopy.

Am J Orthop (Belle Mead NJ).  2018 Jun;47(6). Outcomes After Peripheral Nerve Block in Hip Arthroscopy.

Dexmedetomidine

From DrugStoreNews

What is dexmedetomidine?

Current role of dexmedetomidine in clinical anesthesia and intensive care. Anesth Essays Res. 2011 Jul-Dec; 5(2): 128–133.

Dexmedetomidine: a novel sedative-analgesic agent. Proc (Bayl Univ Med Cent). 2001 Jan; 14(1): 13–21.

Resources:

Perioperative Dexmedetomidine Improves Outcomes of Cardiac Surgery. Circulation. 2013;127:1576–1584.

Dexmedetomidine sedation reduces atrial fibrillation after cardiac surgery compared to propofol: a randomized controlled trial. Critical Care volume 20, Article number: 298 (2016).

The effect of dexmedetomidine on outcomes of cardiac surgery in elderly patients. J Cardiothorac Vasc Anesth. 2016 Dec; 30(6): 1502–1508.

Prevalence of Delirium with Dexmedetomidine Compared with Morphine Based Therapy after Cardiac Surgery: A Randomized Controlled Trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study). Anesthesiology 11 2009, Vol.111, 1075-1084.

Effects of Perioperative Dexmedetomidine on Postoperative Mortality and Morbidity: A Systematic Review and Meta-analysis. Clinical Therapeutics/Volume 41, Number 1, 2019.

Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac SurgeryThe DEXACET Randomized Clinical Trial. JAMA. 2019;321(7):686-696.

Dexmedetomidine for reduction of atrial fibrillation and delirium after cardiac surgery (DECADE): a randomised placebo-controlled trial. The Lancet. VOLUME 396, ISSUE 10245, P177-185, JULY 18, 2020.

Role of dexmedetomidine infusion after coronary artery bypass grafting. The Cardiothoracic Surgeon volume 28, Article number: 4 (2020).

Dexmedetomidine as an Option for Opioid Refractory Pain in the Hospice Setting. J Palliat Med. 2019 Nov;22(11):1478-1481.


Dexmedetomidine as an adjunct in regional anesthesia

The comparison of the effects of dexmedetomidine, fentanyl and esmolol on prevention of hemodynamic response to intubation

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: https://doi.org/10.1097/ALN.0000000000003743.
    • 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: https://doi.org/10.1097/ALN.0000000000003743.

    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.

    Buprenorphine

    Depths of Anesthesia podcast: Should buprenorphine be discontinued preoperatively?

    From the articles below (updated Feb 2021):

    • 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.

    Treatment of Acute Pain in Patients Receiving Buprenorphine/Naloxone – 2014

    CA Bridge Program Acute Pain and Buprenorphine – ED and Crit Care – Nov 2019

    A Practical Approach for the Management of the Mixed Opioid Agonist-Antagonist Buprenorphine During Acute Pain and Surgery. June 2020.

    From Mayo Clinic Proceedings. 2020.

    Treatment of Pain in Patients Taking Buprenorphine for Opioid Addiction. Jan 2018

    To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine. June 2017.

    https://pubs.asahq.org/view-large/figure/1228784/31ff01.png
    https://pubs.asahq.org/view-large/figure/1228791/31ff02.png

    Update:

    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.

    Multimodal Analgesia Pain Management

    Methadone: perioperative use; acute and chronic pain

    Buprenorphine

    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.

    Gabapentinoids

    Ketamine

    Lidocaine

    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

    Gabapentinoids

    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.

    What are gabapentinoids?

    Wikipedia

    Analgesic mechanisms of gabapentinoids and effects in experimental pain models: a narrative review. British Journal of Anaesthesia. Volume 120, Issue 6, June 2018, Pages 1315-1334.

    AAFP.org

    FDA

    ACPHospitalist.org

    Resources:

    Non-opioid IV adjuvants in the perioperative period: pharmacological and clinical aspects of ketamine and gabapentinoids. Pharmacol Res. 2012 Apr;65(4):411-29.

    Systemic analgesia and co-analgesia. Acta Anaesthesiol Belg. 2006;57(2):113-20.

    A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesth Analg. 2009 Nov;109(5):1645-50.

    Perioperative gabapentin reduces 24 h opioid consumption and improves in-hospital rehabilitation but not post-discharge outcomes after total knee arthroplasty with peripheral nerve block. Br J Anaesth. 2014 Nov;113(5):855-64.

    From BJA Anaesth 2914 Nov. Fig 2.

    Post‐operative analgesic effects of paracetamol, NSAIDs , glucocorticoids, gabapentinoids and their combinations: a topical review. Acta Anaesthesiol Scand. 2014 Nov;58(10):1165-81.

    What our patients are getting:

    • July 2020
      • Cardiac pre-op: Lyrica 150mg PO