Multi-Modal Analgesia
There exists a smorgasbord of options to manage pain. By utilizing multiple classes of medications, it is theoretically possible to reduce complications from over relying on one class (for example--gut dysmotility and opiate crisis). This is a very complex subject with a dearth of scientific data to guide optimal protocols necessary to consider unique individual patient parameters, surgical procedures and the intangibles of unknown unknowns. This is not a cookbook protocol of medications to be given but rather a menu of possible options. As always, clinical judgment supercedes anything presented on this page. Please share your thoughts and experiences with John@SaferAnesthesia.com.
These notes are no substitute for sound medical knowledge and training.
Clinicians should always use and rely upon their clinical judgment and decision making.
All information presented must first be confirmed for accuracy prior to use in patient care.
Pre-op
(Options)
Acetaminophen
500 - 1000 mg PO or IV
15 mg/kg
75 mg/kg max 24 hour dose
max 3 to 4 gram/24 hours divided dose
Cox-2 inhibitors
celecoxib
200 mg PO
Black Box Warnings:
Cardiovascular Thrombotic events
Gabapentinoids
Gabapentin
300 mg PO premed
Small dose because of sedation concerns
Not for older patients
(65 y/o cut off?)
Antiemetics
Aprepitant
40 mg PO
(3 hours prior to Induction)
(No serotonin system Effects)
Scopolamine Transdermal
Regional Anesthesia
Intra-op
(Options)
Ketamine
0.3 mg/kg IV just prior to incision
[A larger dose if sole induction agent: 1 to 5 mg/kg IV]
or
15 mg IV for women prior to incision
20 mg IV for men prior to incision
Repeat if needed
and/or
drip 1 to 5 mcg/kg/min
Dexmedetomidine
Load 0.5 mcg/kg over 20 minutes
slow IV load
May initially see tachycardia & Hypertension
May cause Heart Block and Hypotension
Reduce dose in elderly
Concern with Heart block
For Longer surgery (> 2 hours)
Consider
Drip 0.2 to 0.7 mcg/kg/hour
Dexamethasone
4 to 8 mg IV prior to Incision
Intravenous Lidocaine
Bolus 1 mg/kg
Drip: 1 to 2 mg/kg/hour
Toxicity Caution with regional blocks
Continuous EKG Monitoring
Magnesium
1 to 2 grams over 20 minutes
Ketorolac
30 mg IV prior to emergence
Antiplatelet bleeding concerns
Anastomotic Leak concerns
Discuss with Surgeon
Regional Anesthesia
Opiates
Short Acting versus Long Acting Opiates
Antiemetics
Post-op
(Options)
Regional Anesthesia
Acetaminophen
Ketorolac
PO NSAIDs
Gabapentinoids
Tramadol
Lidocaine
Opiates
