case - options for pain control

[mtu620]

40 yo F morbid obesity (BMI 50 w/ OSA requiring CPAP) presents for bariatric surgery - laparoscopic. H/o Chiari malformation, h/o hydrocephalus w/ ventricular-thoracic shunt and lumbar-peritoneal-shunt s/p multiple revisions for failure and optic nerve fenestration for blindness, chronic neck/headaches on Norco 10-325, gabapentin 300 once daily, flexeril, fibromyalgia.
Thoughts on pre-intra-post operative pain control options? Neuraxial? Multimodal?
How would you manage her preop opioid use?

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[Urzuz]

Am I missing something?

40 yo F morbid obesity (BMI 50 w/ OSA requiring CPAP) presents for bariatric surgery - laparoscopic. H/o Chiari malformation, h/o hydrocephalus w/ ventricular-thoracic shunt and lumbar-peritoneal-shunt s/p multiple revisions for failure and optic nerve fenestration for blindness,

Regular sized bariatric surgery patient. Rest of PMH is irrelevant since there's no way in hell you're needling this lady's back.

chronic neck/headaches on Norco 10-325, gabapentin 300 once daily, flexeril, fibromyalgia.?

Seem like normal doses for a chronic pain patient.

Thoughts on pre-intra-post operative pain control options? Neuraxial? Multimodal?
How would you manage her preop opioid use?

Neuraxial - absolutely not. Multimodal - yes. Have her continue her normal meds preoperatively (now isn't the time to titrate anything), give PO Celebrex/acetaminophen preop (pissing in the wind but you'll take whatever you can get), can consider a post-induction subcostal TAP block if her fat is semi-evenly distributed and you can make out tissue planes but no big deal if you skip it altogether, IV ketamine/IV lidocaine intraop, IV Dilaudid prn. Extubate, discharge to floor, direct all pain management calls postoperatively to the surgeon (if for nothing else than to teach him not to book elective surgeries on these kinds of patients).

 

[vector2]

continue home meds including the norco morning of. give opioids intraop. give toradol iv if no contraindication. exparel in the port sites, more opioids in pacu. next.

 

[10KHertz]

Increase the gabapentin to 300mg tid. Qd is ridiculously low dosing in this obese patient.
Increase opioid post op 10-20% as needed clinically. It’s laparoscopic, not open chevron incision.
Refer her to your pain MD for cervical MBBs and cervical RFAs for cervicogenic headaches, GON, cervical facet syndrome .
Have fun...

 

[FiO2@21]

40 yo F morbid obesity (BMI 50 w/ OSA requiring CPAP) presents for bariatric surgery - laparoscopic. H/o Chiari malformation, h/o hydrocephalus w/ ventricular-thoracic shunt and lumbar-peritoneal-shunt s/p multiple revisions for failure and optic nerve fenestration for blindness, chronic neck/headaches on Norco 10-325, gabapentin 300 once daily, flexeril, fibromyalgia.
Thoughts on pre-intra-post operative pain control options? Neuraxial? Multimodal?
How would you manage her preop opioid use?

Would throw the kitchen sink.

Pre-op acetaminophen, gabapentin/lyrica (only because she’s already on it), Celebrex. She should take her normal AM amount of norco.

Intra-op, 0.5 mg/kg ketamine just after induction with repeat boluses every hour or 0.25 mg/kg boluses q30 min.

0.1-0.15 mg/kg decadron with induction.

Precedex. Would work in at least 0.1 mcg/kg starting 30 min prior to wake up.

Wouldn’t give acetaminophen or toradol intra-op if given pre-op meds.

Definitely don’t foresee advantage to addition of epidural or spinal to GA. TAP block is +/-, I personally wouldn’t suggest it for a laparoscopic case.

I always bolus 0.5 mg dilaudid around insufflation. Would target a higher RR given her obesity and OSA at the end of the case when I’m pressure supporting her. Alternatively you could use fentanyl given her obesity or OSA but unless you’re playing catch up with the long acting opioid and overdue it, you usually don’t get burned.

Extubating awake (instead of the private practice 0.2-03 MAC) will be how I know I don’t burn myself with dilaudid.

 

[mtu620]

All great responses.

give PO Celebrex/acetaminophen preop

Say this was sleeve gastrectomy. Still give PO preop meds? Still give NSAIDs?

What if her opioid requirement was higher - say > 100 OME/day chronically? Still "continue" them preop?

 

[FiO2@21]

All great responses.

Say this was sleeve gastrectomy. Still give PO preop meds? Still give NSAIDs?

What if her opioid requirement was higher - say > 100 OME/day chronically? Still "continue" them preop?

I would not alter the course for a sleeve. Bypass would be different.

The only thing I would be concerned about is if the medication was physically within the portion excised to the left of the bougie. I would just make sure I get the eras orders in ASAP the morning of the surgery so the patient isn’t taking them as they’re rolling back.

I would still continue whatever their home regimen was. Might need a PCA afterwards depending on how long they’re leak testing. If you want to be cute you could convert one of their long acting meds to a fentanyl patch a day or two before. But where I am that level of planning and coordination probably isn’t possible.

 

[Arch Guillotti]

Thoughts on pre-intra-post operative pain control options? Neuraxial?

 

[GassYous]

Good luck trying neuraxial on this whale.

Decadron is fine. Toradol is fine. Ketamine is fine.

Fentanyl 100 and dilaudid 0.4 on induction. Subcostal tap blocks bupi 0.5% 20 each side. Next.

 

[kidthor]

Really it shouldn't be too painful. I would just do whatever you'd normally do for a small-ish laparoscopic procedure. No need to get fancy.

 

[Hork Bajir]

Tell her that life is pain. Prop sux tube.

 

[zizzer]

Mostly what others have said:

Pre-op acetaminophen, gabapentin, celecoxib, home hydrocodone dose

Pre-incision dexamethasone, ketamine, opioid

Opioids + rescue TAP if needed.


I wouldn't be concerned too much about her home opioid dose. Even if it were significantly higher, it's likely that she has developed tolerance (though I would be mindful that tolerance to pain develops to a greater extent than tolerance to respiratory effects).

For those who use intraoperative methadone a lot, how would you dose it for this case?

 

[deleted162650]

40 yo F morbid obesity (BMI 50 w/ OSA requiring CPAP) presents for bariatric surgery - laparoscopic. H/o Chiari malformation, h/o hydrocephalus w/ ventricular-thoracic shunt and lumbar-peritoneal-shunt s/p multiple revisions for failure and optic nerve fenestration for blindness, chronic neck/headaches

She single?

 

[geauxg8rs]

She single?

More like a double stack

 

[kidthor]

For those who use intraoperative methadone a lot, how would you dose it for this case?

I wouldn't give it - she should have OSA and the risk/benefit doesn't make it worth it. If it's that bad post-op then just give her a PCA for 24 hrs.

 

[Angus Avagadro]

I like methadone, but wouldnt use it on her unless her chronic narc requirements were higher.

 

[deleted875186]

Opioid dose is not very high. All the multimodal stuff mentioned above. I think the most bang for your buck is local at the port sites by the surgeon. I would give no fentanyl, and start at 0.5-1mg hydromorphone IV for the case, she will likely need more. If I were the surgeon I would definitely not put her on a PCA. IV opioids PRN the first day, and transition to PO opioids as soon as the diet allows. She should be leaving the within a couple days.

 

[Urzuz]

40 yo F morbid obesity (BMI 50 w/ OSA requiring CPAP) presents for bariatric surgery - laparoscopic. H/o Chiari malformation, h/o hydrocephalus w/ ventricular-thoracic shunt and lumbar-peritoneal-shunt s/p multiple revisions for failure and optic nerve fenestration for blindness, chronic neck/headaches on Norco 10-325, gabapentin 300 once daily, flexeril, fibromyalgia.
Thoughts on pre-intra-post operative pain control options? Neuraxial? Multimodal?
How would you manage her preop opioid use?

All great responses.

Say this was sleeve gastrectomy. Still give PO preop meds? Still give NSAIDs?

What if her opioid requirement was higher - say > 100 OME/day chronically? Still "continue" them preop?

Yes, same medications and plan for sleeve & REY unless the surgeon has some huge objection to them swallowing a pill preoperatively while they are manipulating the stomach.

NSAIDs - leave it up to the surgeon. Some don't mind periop doses of Celebrex/Toradol, but obviously others feel very strongly about it. IDC one way or another since, at the end of the day, she's a chronic pain patient and a couple doses of Celebrex/Toradol aren't going to make/break this lady's experience.

And yes, continue her medications perioperatively, regardless of the doses she is taking. Think of it this way - when a patient comes in for an elective surgery, their body should presumably be in state of homeostasis, regardless of how ****ed up their medication regimen is to achieve said homeostasis (e.g.: >100 OME/day). The last thing you want to do is start tinkering with pain medications that they've been on for ages, only to traumatize their body and acutely increase their pain needs afterward.

 

[mtu620]

Say this a more extensive abdominal surgery in a normal BMI pt with chronic pain. Would h/o Chiari and hydrocephalus w/ shunt (multiple revisions) affect your plans on epidural?

 

[MirrorTodd]

Say this a more extensive abdominal surgery in a normal BMI pt with chronic pain. Would h/o Chiari and hydrocephalus w/ shunt (multiple revisions) affect your plans on epidural?

It would for me. I'm fairly competent with a Tuohy, but that isn't the patient to get a wet tap in.

 

[jwk]

This seems like a pretty routine bariatric procedure except for the Chiari and shunts, which really aren't much of a concern.

She would get our standard bariatric protocol. Clear fluids up to four hours pre-op. ERAS/MMA opioid-sparing techniques. No PO meds pre-op, so gabapentin elixir, famotidine IV, scop patch. IV tylenol, ketorolac, des 1 MAC or less + propofol infusion. Ketamine +/- although we're tending towards not using it on these patients. Acetazolimide 500mg near the end of procedure. No TAP blocks. If narcs required, we use low dose fentanyl, although depending on how much Norco she takes normally, might consider methadone 10mg at induction. Also consider methocarbamol.

No neuraxial. We don't use it on any other laparoscopic procedures. Most of these patients are out the door POD 1.

 

[Planktonmd]

This is going to be a post-op nightmare for the surgeon who is most likely going to get called day and night to provide emotional support and to adjust her pain medications.
As for intra-op care it's just another laparoscopic procedure.

 

[ethilo]

I regularly perform a lidocaine infusion in bariatric surgery patients. It's very effective. 1.5mg/kg actual body weight bolus at induction followed by infusion at 2mg/kg/HR intraop. With 0.5mg/kg ket bolus, APAP and celebrex pre op, usually only need about 100mcg or 150 mcg of fentanyl for a sleeve.

Systemic lidocaine to improve quality of recovery after laparoscopic bariatric surgery: a randomized double-blinded placebo-controlled trial - PubMed

Systemic lidocaine improves postoperative quality of recovery in patients undergoing laparoscopic bariatric surgery. Patients who received lidocaine had a lower opioid consumption which translated to a better quality of recovery.

pubmed.ncbi.nlm.nih.gov

 

[Angus Avagadro]

I regularly perform a lidocaine infusion in bariatric surgery patients. It's very effective. 1.5mg/kg actual body weight bolus at induction followed by infusion at 2mg/kg/HR intraop. With 0.5mg/kg ket bolus, APAP and celebrex pre op, usually only need about 100mcg or 150 mcg of fentanyl for a sleeve.

Systemic lidocaine to improve quality of recovery after laparoscopic bariatric surgery: a randomized double-blinded placebo-controlled trial - PubMed

Systemic lidocaine improves postoperative quality of recovery in patients undergoing laparoscopic bariatric surgery. Patients who received lidocaine had a lower opioid consumption which translated to a better quality of recovery.

pubmed.ncbi.nlm.nih.gov

Do you have a max dose for the lidocaine if the procedure goes longer than usual?

 

[ethilo]

No, it's short acting and at low serum levels. You could run the infusion safely and easily for 24+ hours

 

[lobelsteve]

Call her outpatient pain doc. She could be violating contract if she gets an Rx form surgeon on discharge. Make outpatient doc Rx on discharge and send her home POD1. If on Norco pre-op, hit her with oxy 10mg or Dilaudid 4mg q4h prn until DC.

 

[dabears505]

a little fentanyl

 

[nimbus]

I regularly perform a lidocaine infusion in bariatric surgery patients. It's very effective. 1.5mg/kg actual body weight bolus at induction followed by infusion at 2mg/kg/HR intraop. With 0.5mg/kg ket bolus, APAP and celebrex pre op, usually only need about 100mcg or 150 mcg of fentanyl for a sleeve.

Systemic lidocaine to improve quality of recovery after laparoscopic bariatric surgery: a randomized double-blinded placebo-controlled trial - PubMed

Systemic lidocaine improves postoperative quality of recovery in patients undergoing laparoscopic bariatric surgery. Patients who received lidocaine had a lower opioid consumption which translated to a better quality of recovery.

pubmed.ncbi.nlm.nih.gov

Do you have a max dose for the lidocaine if the procedure goes longer than usual?

Related issue came up recently for one of my partners. Say the laparoscopic procedure became open and the surgeon requests a TAP block. Assuming there is consent, would you do a TAP block on a patient getting a lidocaine infusion? If so, what would you use and how much?

 

[coffeebythelake]

Related issue came up recently for one of my partners. Say the laparoscopic procedure became open and the surgeon requests a TAP block. Assuming there is consent, would you do a TAP block on a patient getting a lidocaine infusion? If so, what would you use and how much?

We've had this issue come up a few times before. I wouldnt do it right away. TAP blovks is high volume with a fair amount of systemic uptake. Depending how long IV lido running.. I would stop the IV infusion when they changed plan for open surgery, keep the patient in PACU a while longer before doing TAP.

 

[secretasianman]

100mg remimidazolam. Report back here with findings.

 

[ethilo]

Related issue came up recently for one of my partners. Say the laparoscopic procedure became open and the surgeon requests a TAP block. Assuming there is consent, would you do a TAP block on a patient getting a lidocaine infusion? If so, what would you use and how much?

2 mg/kg/hr of lidocaine is actually not that high of a dose. When you shut it off the effects are gone in around 45 mins.

I would feel comfortable performing a block but I'd suggest a rectus sheath block - uses less local than a TAP, less patchy, less variable and it gets that midline laparotomy. I'd do 10mL bupi 0.25% with epi and maybe 2mg decadron per side. You don't need a lot bc they are cutaneous nerves in a relatively small plane.

I don't really do TAP blocks anymore, I'm either a QL or rectus sheath guy. They seem to give better results in my admittedly limited experience.

 

[coffeebythelake]

2 mg/kg/hr of lidocaine is actually not that high of a dose. When you shut it off the effects are gone in around 45 mins.

I would feel comfortable performing a block but I'd suggest a rectus sheath block - uses less local than a TAP, less patchy, less variable and it gets that midline laparotomy. I'd do 10mL bupi 0.25% with epi and maybe 2mg decadron per side. You don't need a lot bc they are cutaneous nerves in a relatively small plane.

I don't really do TAP blocks anymore, I'm either a QL or rectus sheath guy. They seem to give better results in my admittedly limited experience.

Plasma half-life of lidocaine is 1.5 to 2 hrs, and some people giving IV lidocaine to fatties use TBW. Thats not a small amount of local.

 

[fakin' the funk]

40 yo F morbid obesity (BMI 50 w/ OSA requiring CPAP) presents for bariatric surgery - laparoscopic.

Laparoscopic bari case. How is this even a question? Many of these are done with zero periop opioids. Do the usual things like APAP, NSAID, can get fancy with lidocaine gtt ketamine gtt precedex mag gaba etc etc but honestly this is a not painful procedure so who cares.

 

[fakin' the funk]

2 mg/kg/hr of lidocaine is actually not that high of a dose. .

Dude what

You're telling me the maximum that anyone would ever EVER give for periop MMA is "not that high?"

 

[ethilo]

Dude what

You're telling me the maximum that anyone would ever EVER give for periop MMA is "not that high?"

The study where it was done with colorectal surgery to get that dosing regimen had these patients on the infusions on the floor for 48h+ at these rates. The rates mimic the serun concentration from that of a floor epidural. It is a lower dosing regimen to maximize the safety profile. You certainly can maximize the MMA factor of the lido infusion, at the cost of safety.

Perioperative Use of Intravenous Lidocaine

Perioperative lidocaine infusion improves analgesia and recovery after some surgical procedures, possibly through systemic antiinflammatory effects. This commentary provides the clinician with evidence for rational use of perioperative lidocaine infusion in procedures where it is of demonstrated...

anesthesiology.pubs.asahq.org

 

[coffeebythelake]

The study where it was done with colorectal surgery to get that dosing regimen had these patients on the infusions on the floor for 48h+ at these rates. The rates mimic the serun concentration from that of a floor epidural. It is a lower dosing regimen to maximize the safety profile. You certainly can maximize the MMA factor of the lido infusion, at the cost of safety.

Perioperative Use of Intravenous Lidocaine

Perioperative lidocaine infusion improves analgesia and recovery after some surgical procedures, possibly through systemic antiinflammatory effects. This commentary provides the clinician with evidence for rational use of perioperative lidocaine infusion in procedures where it is of demonstrated...

anesthesiology.pubs.asahq.org

1. Fyi, epidurals can administer a fair amount of local anesthesia especially when a patient has that PCEA button for boluses.

2. For IV lidocaine, do you dose your fatties by TBW?

Not a lot of wiggle room before you can possibly get into toxic territory. I think the conservative approach is to wait and assess.. I'm not saying you can't "get away with it" with overdosing local, but I am saying you will be scrutinized and grilled if the patient develops toxicity.

 

[secretasianman]

If you gave me this on the oral boards I would think it’s a trick question and keep looking for the pink bunny.

Laparoscopic bari case. How is this even a question? Many of these are done with zero periop opioids. Do the usual things like APAP, NSAID, can get fancy with lidocaine gtt ketamine gtt precedex mag gaba etc etc but honestly this is a not painful procedure so who cares.

 

[Norepi]

2 mg/kg/hr of lidocaine is actually not that high of a dose. When you shut it off the effects are gone in around 45 mins.

I would feel comfortable performing a block but I'd suggest a rectus sheath block - uses less local than a TAP, less patchy, less variable and it gets that midline laparotomy. I'd do 10mL bupi 0.25% with epi and maybe 2mg decadron per side. You don't need a lot bc they are cutaneous nerves in a relatively small plane.

I don't really do TAP blocks anymore, I'm either a QL or rectus sheath guy. They seem to give better results in my admittedly limited experience.

The study where it was done with colorectal surgery to get that dosing regimen had these patients on the infusions on the floor for 48h+ at these rates. The rates mimic the serun concentration from that of a floor epidural. It is a lower dosing regimen to maximize the safety profile. You certainly can maximize the MMA factor of the lido infusion, at the cost of safety.

Perioperative Use of Intravenous Lidocaine

Perioperative lidocaine infusion improves analgesia and recovery after some surgical procedures, possibly through systemic antiinflammatory effects. This commentary provides the clinician with evidence for rational use of perioperative lidocaine infusion in procedures where it is of demonstrated...

anesthesiology.pubs.asahq.org

1. Fyi, epidurals can administer a fair amount of local anesthesia especially when a patient has that PCEA button for boluses.

2. For IV lidocaine, do you dose your fatties by TBW?

Not a lot of wiggle room before you can possibly get into toxic territory. I think the conservative approach is to wait and assess.. I'm not saying you can't "get away with it" with overdosing local, but I am saying you will be scrutinized and grilled if the patient develops toxicity.

Take a look at this paper showing how long lidocaine levels remain therapeutic in plasma after boluses and infusions - something to think about regarding the block question.
I've run lidocaine infusions on patients getting blocks -lipophilic local with epinephrine makes me feel better about a lack of accumulation in plasma in concordance with a lidocaine infusion but who know's how much that'll hold up in court - not that much of this stuff is well backed by science anyway.

 

[FiO2@21]

I regularly perform a lidocaine infusion in bariatric surgery patients. It's very effective. 1.5mg/kg actual body weight bolus at induction followed by infusion at 2mg/kg/HR intraop. With 0.5mg/kg ket bolus, APAP and celebrex pre op, usually only need about 100mcg or 150 mcg of fentanyl for a sleeve.

Systemic lidocaine to improve quality of recovery after laparoscopic bariatric surgery: a randomized double-blinded placebo-controlled trial - PubMed

Systemic lidocaine improves postoperative quality of recovery in patients undergoing laparoscopic bariatric surgery. Patients who received lidocaine had a lower opioid consumption which translated to a better quality of recovery.

pubmed.ncbi.nlm.nih.gov

When do you stop the infusion?

I’ve had a couple attendings tell me they felt it slowed down the wake up. I’ve only tried it twice, had one slow wake up but attributed it to a propofol infusion I stopped too late.

 

[Norepi]

Intraoperative methadone in same-day ambulatory surgery: A randomized, double-blinded, dose-finding pilot study

Approximately 50 million US patients undergo ambulatory surgery annually. Postoperative opioid overprescribing is problematic, yet many patients report inadequate pain relief. In major inpatient surgery, intraoperative single-dose methadone produces better ...

www.ncbi.nlm.nih.gov

Intraoperative methadone in same-day ambulatory surgery: A randomized, double-blinded, dose-finding pilot study


Run methadone instead - one time dose at induction with esmolol for laryngoscopy - I have been doing this for same day surgeries without any significant post-op respiratory depression and patients leave the PACU comfortable all the same. When mentioned to the PACU nurses they are more leary about slamming them with the PACU dilaudid and the patient feels just as good.

 

[abolt18]

Intraoperative methadone in same-day ambulatory surgery: A randomized, double-blinded, dose-finding pilot study

Approximately 50 million US patients undergo ambulatory surgery annually. Postoperative opioid overprescribing is problematic, yet many patients report inadequate pain relief. In major inpatient surgery, intraoperative single-dose methadone produces better ...

www.ncbi.nlm.nih.gov

Intraoperative methadone in same-day ambulatory surgery: A randomized, double-blinded, dose-finding pilot study


Run methadone instead - one time dose at induction with esmolol for laryngoscopy - I have been doing this for same day surgeries without any significant post-op respiratory depression and patients leave the PACU comfortable all the same. When mentioned to the PACU nurses they are more leary about slamming them with the PACU dilaudid and the patient feels just as good.

Standard dose for everyone? Or weight based dose? I'm guessing something like .1-.2mg/kg depending on patient factors?

 

[anbuitachi]

2 mg/kg/hr of lidocaine is actually not that high of a dose. When you shut it off the effects are gone in around 45 mins.

I would feel comfortable performing a block but I'd suggest a rectus sheath block - uses less local than a TAP, less patchy, less variable and it gets that midline laparotomy. I'd do 10mL bupi 0.25% with epi and maybe 2mg decadron per side. You don't need a lot bc they are cutaneous nerves in a relatively small plane.

I don't really do TAP blocks anymore, I'm either a QL or rectus sheath guy. They seem to give better results in my admittedly limited experience.

seems like a high dose to me. for a obese 150kg man, 1.5mgk/kg is already 225mg lidocaine bolus. Then 2mg/kg/hr is 300mg/hr. Means in the first hour, this man received 525mg lidocaine IV. thats a lot

 

[Norepi]

Standard dose for everyone? Or weight based dose? I'm guessing something like .1-.2mg/kg depending on patient factors?

.15 per kilo ideal, this is when significant postop opioid sparing effects are seen. .1/kg doesnt cut it.

 

[deleted697127]

Intraoperative methadone in same-day ambulatory surgery: A randomized, double-blinded, dose-finding pilot study

Approximately 50 million US patients undergo ambulatory surgery annually. Postoperative opioid overprescribing is problematic, yet many patients report inadequate pain relief. In major inpatient surgery, intraoperative single-dose methadone produces better ...

www.ncbi.nlm.nih.gov

Intraoperative methadone in same-day ambulatory surgery: A randomized, double-blinded, dose-finding pilot study


Run methadone instead - one time dose at induction with esmolol for laryngoscopy - I have been doing this for same day surgeries without any significant post-op respiratory depression and patients leave the PACU comfortable all the same. When mentioned to the PACU nurses they are more leary about slamming them with the PACU dilaudid and the patient feels just as good.

I wouldn’t do this. Methadone has a long half life and will still be around after the patient leaves. You need a special license to prescribe it. Americans like to abuse drugs. If one of these patients decides to take a couple of extra oxycodone from their prescription and dies, how’s that methadone going to look?

 

[fakin' the funk]

Intraoperative methadone in same-day ambulatory surgery: A randomized, double-blinded, dose-finding pilot study

Approximately 50 million US patients undergo ambulatory surgery annually. Postoperative opioid overprescribing is problematic, yet many patients report inadequate pain relief. In major inpatient surgery, intraoperative single-dose methadone produces better ...

www.ncbi.nlm.nih.gov

Intraoperative methadone in same-day ambulatory surgery: A randomized, double-blinded, dose-finding pilot study


Run methadone instead - one time dose at induction with esmolol for laryngoscopy - I have been doing this for same day surgeries without any significant post-op respiratory depression and patients leave the PACU comfortable all the same. When mentioned to the PACU nurses they are more leary about slamming them with the PACU dilaudid and the patient feels just as good.

This is some galaxy brain s*it here
Researcher 1: hey let's try to minimize opioids in same day surgery, the US is a huge outlier in this regard
Researcher 2: hey what if instead we gave a F*CK TON of a nontitratable opioid???

 

[coffeebythelake]

I wouldn’t do this. Methadone has a long half life and will still be around after the patient leaves. You need a special license to prescribe it. Americans like to abuse drugs. If one of these patients decides to take a couple of extra oxycodone from their prescription and dies, how’s that methadone going to look?

The only times I've used methadone are for those on chronic methadone use

 

[10KHertz]

The pharmacodynamics of methadone is all over the place. The OR is not the time for initiation of this Med.

 

[Lidolover]

Agreed with Lidocaine gtt. Loooove it.
Usually I do a standard 100mg with induction and max dose of 150mg/hr thereafter. No more no less. Patients wake up beautifully. I continue gtt in the PACU at 1-1.5 mg/min. We don’t have a formal protocol in place but PACU nurses love it. If surgeon wants to use local intra op, I dictate the max amount they can use depending on the use of epi or not.
Facts:
- ideal for abdominal surgeries; decreases time to first flatus, time to first bowel movement, risk of post-op ileus, decreased opiate needs
- no statistically significant difference If you stop it in pacu vs after 48 hrs although the 48hour infusion had better trends
- study that evaluated the serum levels found most patients where under toxic threshold. There was only one outlier who despite the toxic levels, pt remained asymptomatic.
- usually I avoid lido gtt together with blocks. Gtt is enough I think.

 

[vector2]

Agreed with Lidocaine gtt. Loooove it.
Usually I do a standard 100mg with induction and max dose of 150mg/hr thereafter. No more no less. Patients wake up beautifully. I continue gtt in the PACU at 1-1.5 mg/min. We don’t have a formal protocol in place but PACU nurses love it. If surgeon wants to use local intra op, I dictate the max amount they can use depending on the use of epi or not.
Facts:
- ideal for abdominal surgeries; decreases time to first flatus, time to first bowel movement, risk of post-op ileus, decreased opiate needs
- no statistically significant difference If you stop it in pacu vs after 48 hrs although the 48hour infusion had better trends
- study that evaluated the serum levels found most patients where under toxic threshold. There was only one outlier who despite the toxic levels, pt remained asymptomatic.
- usually I avoid lido gtt together with blocks. Gtt is enough I think.

Username checks out.

 

[Lidolover]

Username checks out.

Haha no conflicts of interest