Preop opioid sparing meds

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Do other people use preopedative meds significantly and feel it offers much? We routinely use Tylenol preop, plus or minus some Lyrica or gabapentin, I can’t say anecdotely I think it offers much though. Thoughts?
 
I like it for ortho- unless contraindication, a combo of tylenol, celebrex and gabapentin. I know other places also use clonidine patch.
 
I think po Tylenol is underused, and if you supervise it's a good way to save money and stop your trainees/anesthetists from overusing the IV form. Gabapentin or lyrica seem decent for spines and big ortho cases too.
 
Lyrics/gabapentin, Celebrex, Tylenol and ibuprofen all show efficacy. Also studies being done on cymbalta and some other SNRIs.
 
IV Clonidine works well but sometimes you get refractory hypotension. It’s great for kids getting cleft palate repairs.

Intraop esmolol and metoprolol too.
 
nimbus said:
IV Clonidine works well but sometimes you get refractory hypotension. It’s great for kids getting cleft palate repairs.

Intraop esmolol and metoprolol too.
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I use dexmedetomidine, but same idea. I bolus 10mcgs at a time in adults q5ish minutes and monitor hemodynamics. Cuts down on my opioid use (anecdotally) by a bunch. I really need to start ordering the other three and rolling with it.
 
For those who use transdermal clonidine, how do you go about it and to what degree do you worry about worsening intraoperative hypotension in combination with other medications?
 
zizzer said:
For those who use transdermal clonidine, how do you go about it and to what degree do you worry about worsening intraoperative hypotension in combination with other medications?
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0.1 mg per 24 hr. Remove after 24 hr.
 
ambiturner said:
I think po Tylenol is underused, and if you supervise it's a good way to save money and stop your trainees/anesthetists from overusing the IV form. Gabapentin or lyrica seem decent for spines and big ortho cases too.
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We've been very happy with IV tylenol - obviously it's more expensive than PO, but in the quantities we purchase, it's one of our cheaper drugs. In our experience, PO tylenol in pre-op doesn't do much.
 
dipriMAN said:
Do other people use preopedative meds significantly and feel it offers much? We routinely use Tylenol preop, plus or minus some Lyrica or gabapentin, I can’t say anecdotely I think it offers much though. Thoughts?
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This plus ketamine/ketorolac/dexamethasone/diphenhydramine + SAB in the OR and the bulk of our THA/TKA done as outpatients go home not having needed any narcs at all.
 
jwk said:
This plus ketamine/ketorolac/dexamethasone/diphenhydramine + SAB in the OR and the bulk of our THA/TKA done as outpatients go home not having needed any narcs at all.
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What's the optimal dose for decadron?

Anybody move to toradol 15?

If you use them, what are you running your lidocaine and esmol at?
 
fill in Or add to or modify this list of preop pain meds based on literature:

Decadron 4
Clonidine patch 0.1
Tylenol 1000 po
Toradol 15
Lyrica 100
Esmolol ?
Lidocaine gtt 1.5mg/kg/hr
Precedex?
 
anes121508 said:
What's the optimal dose for decadron?

Anybody move to toradol 15?

If you use them, what are you running your lidocaine and esmol at?
Click to expand...
We're using 0.15mg/kg of decadron with a max dose of 15mg.

I don't know anyone in our group doing esmolol infusions - just bolus dose PRN. We do some lidocaine infusions - we load at 1.5 mg/kg and run the infusion at 33mcg/kg/min.
 
Do that, then during the case run some lido, ketamine, precedex and you wont need opioids
 
I've been ordering preop tylenol, gabapentin, +/- celebrex depending on if its going to be a blood case or something. I've been replacing fentanyl on induction with esmolol bolus and running keta/lido gtt, and prn fentanyl that i haven't drawn up yet, in pacu if pacu nurses wake up the patient to demand pain score.

Would you be wrong to order celebrex on an anticipated more bloody case?
 
A few folks above have mentioned esmolol- looking around, it looks like there's some good evidence to support this. I might give it a try...
 
2Fast2Des said:
I've been ordering preop tylenol, gabapentin, +/- celebrex depending on if its going to be a blood case or something. I've been replacing fentanyl on induction with esmolol bolus and running keta/lido gtt, and prn fentanyl that i haven't drawn up yet, in pacu if pacu nurses wake up the patient to demand pain score.

Would you be wrong to order celebrex on an anticipated more bloody case?
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The only things I've read about peri-op esmolol indicated a bolus and drip started immediately pre-induction, and continued throughout the entirety of the case. Not sure how much it helps in single dose? Have you felt like it was helpful?

I presented some of the data supporting esmolol for analgesia in our conference a couple months ago and people definitely thought I was out of my mind. Some attendings approached me after and said "it doesn't make sense so I'm never going to try it" and others came up and said "cool, I'm going to try it!"
 
I used to do esmolol gtts in academics with some success. I think the point is cut down on fentanyl and use esmolol boluses instead and you should be ok.
 
Paracoxib, paracetamol, other boring things...
 
Lecithin5 said:
On a related topic, I don't know if any of you read Sibert's article on fentanyl on kevinmd. A bit extreme in my estimation, but her point is well taken.

Why this anesthesiologist says "no" to fentanyl
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Oh dear God!
Suddenly everyone wants to be an opponent to opiates since it is the cool thing to do these days!
The medical profession in this country has always been reactionary and is notorious for going from one concept to the absolute opposite overnight to accommodate political and marketing changes.
20 years ago we were told by politicians and pharmaceutical companies that we need to give everyone opiates since "people in pain don't get addicted" and since the pharma industry needs to make lots of money so their CEO's can continue to enjoy their handsome bonuses. So we did, and we started the prescription drug addiction epidemic.
Now after the politicians realized the enormity of the disaster they encouraged us to create, they want us to fix it by giving no one opiates and by giving instead other medications that will continue to guarantee the Pharma companies their ongoing flow of cash and make the politicians look good while we go crazy trying to eliminate opiates from daily practice.
Opiates are not all evil and they do have a place in anesthesia practice, they are another tool that we as experts should know when and how to use based on science and experience not based on political rhetoric.
And for someone like the author of the article above to claim being an expert and an educator then come up with such a strange attack on one opioid as if it is the cause of all evil, is nothing but a cheap silly attempt to jump on the public panic and paranoia wagon that has been going around lately.
 
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For those using simultaneous ketamine and esmolol infusions: do you ever witness the oft-cited direct myocardial depressant effects of ketamine when you block its indirect beta-1 receptor mediated positive inotropic effect?
 
I'm a little cautious about bb's in non cardiac patients, especially longer acting ones (poise trial). Mainly lingering hypotension in the post op period while on the floor with the surgery team being the primary culprit for stroke.

Maybe an esmolol here or there would be fine for analgesia.
 
ethilo said:
I'm a little cautious about bb's in non cardiac patients, especially longer acting ones (poise trial). Mainly lingering hypotension in the post op period while on the floor with the surgery team being the primary culprit for stroke.

Maybe an esmolol here or there would be fine for analgesia.
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Even when I think I need a beta blocker for things other than blunting the sympathetic response to nociception, I start with esmolol. Maybe it's more expensive to use two drugs, but if esmolol ends up being a bad decision, it isn't a bad decision for very long.
 
zizzer said:
For those using simultaneous ketamine and esmolol infusions: do you ever witness the oft-cited direct myocardial depressant effects of ketamine when you block its indirect beta-1 receptor mediated positive inotropic effect?
Click to expand...
Nope. I even used to use low-dose ketamine in patients with poor LV function/chronic failure without seeing this.

Sent from my SM-G930V using SDN mobile
 
abolt18 said:
The only things I've read about peri-op esmolol indicated a bolus and drip started immediately pre-induction, and continued throughout the entirety of the case. Not sure how much it helps in single dose? Have you felt like it was helpful?

I presented some of the data supporting esmolol for analgesia in our conference a couple months ago and people definitely thought I was out of my mind. Some attendings approached me after and said "it doesn't make sense so I'm never going to try it" and others came up and said "cool, I'm going to try it!"
Click to expand...

I would love to try an esmolol infusion. I just give the 1-2mg/kg dose on induction and watch them start bradying down from the anxious 110 they start off from down to a 70. With combination of 0.5mg/kg ketamine on induction, it seems to provide a stable hemodynamic/analgesic pattern without having to push any fentanyl. And yes many attendings here are convinced that ketamine is the most evil hallucinogenic drug known to man even though I tell them that many institutions do this this regularly without issue, but can't teach an old dog new tricks. I do use esmolol/nitro/labetalol prn throughout the case to maintain any spike in hemodynamics, and if no dice than an extra bolus of 20mg ketamine on top of the infusion for analgesia/stimulation. Yes for painful surgeries they will need some opioid adjunct after extubation if they don't have a regional but its a lot better to titrate to effect when awake than giving a ton of narcotics intraop.
 
ethilo said:
I'm a little cautious about bb's in non cardiac patients, especially longer acting ones (poise trial). Mainly lingering hypotension in the post op period while on the floor with the surgery team being the primary culprit for stroke.

Maybe an esmolol here or there would be fine for analgesia.
Click to expand...
The doses in the POISE trial were huge. I believe 50mg was the dose. We are coming close to this dosing.
 
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