Have you all been using multimodal anesthesia? If so, what? My current choices are listed below.
In pre-op holding:
- Acetaminophen 975 mg PO
- Celebrex 400 mg PO
- Gabapentin 600 mg PO
At the start of anesthesia:
On certain cases I will add 10 mg dexamethasone to the bupivacaine for the local.
Patients complained about nausea when I've used OxyContin pre-op so I stopped.
I think what's made the most noticeable drop in post-op pain has been the addition of the MgSO4. The last several bunionectomies, hallux rigidus repairs, and neuroma excisions have said they only took one or two opioids but had minimal pain.
What's been your experience?
Excellent question for a guy who works part time!! Seriously, anesthesia at the hosptial where I bring cases have suggested various protocols to reduce opioid use. However, I’m old school and have never had an issue with patients needing narcotics post operatively.
Yes, I do prescribe a limited amount of a narcotic post op, and in all my years of practice I renewed a narcotic RX once for a post op patient.
Many years ago, I noticed a few foot and ankle orthopedists patients seemed to have more post op pain than my patients or the other docs in the practice. Then I realized that most orthopedists do not use local blocks, but use general anesthesia and may inject some local before bandaging.
And THAT is the issue. Even if you are using general anesthesia in a case, ALWAYS inject the local before the incision. Yes, I know that sounds intuitive and basic but it’s a point that will make a huge difference in your post op patients.
The pain process begins at the incision. Performing a block after the procedure will result in significantly more post op pain, even if the surgery was under general.
Using a long acting local before the incision is paramount in limiting post op pain. The patient doesn’t experience that “breakthrough pain”.
Two factors often overlooked include surgical time and tissue handling. Over the years I became much more efficient with my movements in the OR. Without compromising quality, I was in and out quickly. I made sure everything I needed was up and ready and that the power equipment was functioning prior to tourniquet inflation. I also had minimal tension free retraction. Those two factors alone decrease post op pain. The shorter the tourniquet time the less pain patients experience. Overly tight or awkward dressings also contribute to post op pain.
Excluding any contra indications, I often give an injection of Toradol in recovery. I’m a huge believer in ice 20/min an hour when not contraindicated and also have patients take an NSAID (when not contraindicated) for 1-2 weeks. I know the bad press regarding NSAIDs and cardiac issues, and discuss this with the patient and PCP.
I believe strongly in this regimen and over the years kept a log regarding post op pain meds. 85% of my patients took less than 5 narcotic doses in the entire post op period and 90% of those 85% took 0-2 doses.
I only used in dwelling catheter anesthetic for heavy duty cases.
And I believe that patient confidence in their doctors makes a huge difference. I always assure patients NOT to expect a lot of pain and encourage them to call me at any time with any concerns. And I always call my post op patients within 24 hours to see how they are doing and reassure them I’m there if needed. When you reduce anxiety you reduce their concern of pain.
Although I always call within 24 hours (me, not my staff), in my opinion the most effective time to call is that evening. It makes the patient feel at ease and let’s the patient know you care.
This formula has worked for me for over 25 years, without any fancy or elaborate pre op or intra op or post op medication protocol.
Yep, it’s simple and it’s common sense. But it’s often overlooked.
