I give fentanyl on induction because most surgeries are at least somewhat painful and require a touch of narcotic. It's like why give esmolol, just to give fentanyl later anyway.
Why give fenratnyl when another medication can blunt the sympathetic response which is what we’re targeting?
Why not reserve fentanyl until emergence and resumption of consciousness?
I ask these to elicit discussion.
Why not give a longer acting agent for more of a “tail”? In the wrong hands it’ll snow the patient. Someone who may have a better feel for it may make it a smoother emergence, time in Pacu and even on the floor/ride home.
I'm a multimodal proponent, but if I'm not mistaken I think the benefit from throwing the kitchen sink of lido, mag, ketamine, precedex, GABA, nsaid (and even some regional) is modest at best. Most of the time early opioid usage is slightly reduced but then catches up to controls a couple days to a week after major abdominal or TJ surgery.
I view multimodal analgesia as a paradigm shift away from “pushing some stuff labeled in a blue syringe” to a more thoughtful approach about receptors of action and pharmacodynamics.
Now, other factors certainly take into account opioid use: surgeon technique, longer acting local infiltration by surgeon, pre op MME, associated mental heath issues etc.
Recent JAMA article about opioid use in knee and shoulder arthroscopy suggesting (not proving) multimodal technique may spare post op opioid use.
There was exactly one post in the entire thread "hating on pain". Seems like a red herring to focus on that and ignore the entire gist of this thread while questioning anesthesiologist pain practices.
I never questioned canceling the case.
Questioning them? Not in that sense. Did I ask questions? Sure. Was it in the spirit of sharing ideas and opinions? Yes. Could someone maybe pick up a tip that improves their technique or allows them to defend and support what they’re doing? I hope so.
Well I give fentanyl not just to blunt the sympathetic reflex but also logic would tell me that placing an ett down my throat would be quite painful.
The patient is not conscious. So I respectfully disagree.
Are you using lidocaine on the tube? Are topicalizing while DLing?
Esmolol would treat the heart rate secondary to that action not address the initiating stimulus.
Secondly I’m all for multimodal analgesia but everything is patient and situation dependent. It’s dependent on cost effectiveness and what exactly is the goal of that particular situation.
Throwing a bunch of gabapebtin lidocaine ketamine and precedex may work, may not work, or may work better. It depends on the situation.
Plenty of patients delay they’re discharge from pacu after they’re snowed by these overkill multimodal drugs.
Agree it depends on the situation.
Agree multimodal is not a cure all. Never said it was.
A blanket “multimodal cocktail” may be well meaning but unless the anesthesiologist understands the agents you may see what you’re suggesting in PACU.
And for that matter I don’t blame the medications. It’s the person pushing them. A good carpenter doesn’t blame their tools.
Secondly, opioid dependence leading to addiction is a complex phenomenon. It’s not “just” from perioperative opioid use.
Opioids are only truly indicated for cancer pain and acute pain (surgery would be one of these situations). When they’re used for chronic non malignant pain then that’s the issue.
As anesthesiologists, our first goal is to get the patient through surgery in a safe manner - and if opioids are part of that balanced anesthetic plan, then sure why not.
To be clear I’m not a fanatic against the use of opioids intraop and post op. They have their place sure. However indiscriminate use or to cover up for lack of effort does our patients no favors.
Again, why aren’t we placing catheters and still doing single shots? Not everyone needs a catheter sure. There are logistic problems, institutional challenges, reimbursement issue set. I get it.
Why aren’t we using medications like methadone or suboxone for some post op care instead of fentanyl for painful surgeries in those at a higher risk of developing pain?
Do some anesthesiologists know these high risk surgeries that show up in a pain clinic with chronic pain?
Would you consider introducing a plastic tube into someone's trachea noxious or painful? Honest question.
Would the hospital make more money having that OR reserved for one SCS or true spine cases? This is rhetorical. There is no way a day of SCS implants is a profitable endeavor in comparison to other cases that are reimbursed more favorably.
There is a limit to non-opioid multimodal analgesia. Each of those aforementioned medications have risks and side effects that aren't always appreciated. How many times have I seen someone shotgunned with a hefty dose of preoperative gabapentin only to sit in the PACU snowed unnecessarily with a GCS of 3 in the PACU for a lengthy period of time. Once they leave the PACU, if the surgeon is exclusively prescribing opioids, what good have you done in minimizing opioids in the OR and PACU?
No I wouldn’t. I’m unconscious.
I don’t work in the hospital. As you probably already know baller pain people don’t do cases in the hospital. Not saying I’m a baller bc I’m not. The ones that do cases in the hospital may get a cut of the SOS but still don’t kill it financially. In my opinion I’d say most pain procedures are better suited for the outpatient setting. Pain cases in the hospital are way too slow. The overhead is waaaaaay too high - gotta pay the cafeteria workers, 8th floor, subsidize the ID department, pay for some endowed char, cover someone’s research time, pay for OT for that nurse taking care of the rock etc.
I’d take a room full of full spine cases vs SCS all day in terms of profitability. But SCS don’t need to be in the hospital and IMHO shouldn’t be in the hospital.
I’m hesitant to tell you what a full day of pain cases can net. You can ask a local rep the reimbursement on a SCS trial in terms of pro fees and facility fees. In the hospital the hospital gets the squeeze. In the ASC the owners get it.
In my community small ASC there wouldn’t be spine surgeons every day of the week. As you know most spine cases usually undergo some conservative blocks before they get surgery. In addition in order to increase EBIDTA its better to have a multi speciality practice. So I’d argue if we look at one day of cases it would be nice to optimize it with spine cases all day. But in terms of practice management, increasing business evaluation, and responding to community needs it is better long term and on a macro level to include other lesser paying specialities.
Whoever is shotgunning the meds needs to do a better job of understanding the meds. It’s not Gabapentins fault. To be fair I’m not a huge fan of Gabapentin and I find it in many cases to have more downsides than benefits in certain cases. Hence the appreciation for celebrex, blocks, local infiltration, ketamine bolus, lido, mag, precedex in certain cases, etc. of course not every case gets these. Just saying there are options
If the surgeon will just prescribe opioids then sit down with her, explain your concerns, offer to develop a pathway, explain your reasoning, get buy in etc. Again, indiscriminate use of opioids by us (anesthesiologists) or surgeons isn’t doing our patient any favors.
I don’t know if I agree. Respectfully.
I mean i understand what you’re saying, ie, general anesthesia is by definition “doesn’t respond to painful stimuli” therefore if there is a response then they aren’t under a deep enough anesthetic. So in reality we run all of our patients “light”
But we both know in practice, we’re treating and trying to minimize the pain that arrives on emergence.
Agreed.
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