What's the point of intraoperative narcotics?

[RxBoy]

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Lets take 1 case and provide the anesthetic 2 different ways.

Case: 45 year old elective lap colectomy, healthy with no cardiac history.

Anesthetic option #1:
Induction: prop only + paralytic.
Maintenance: Volatiles at a MAC titrated up to 1.5 with neo drip or PRN squirts.
Emergence: Drive off gas, give 100 mcg fentanyl at closure, reverse, extubate.

Anesthetic option#2
Induction: 150 mcg fentanyl, prop, paralytic.
Maintenance: Volatile at MAC 1, 50 mcg fentanyl every 30 minutes for duration of case
Emergence: Reverse, work in narcotic to RR, extubate.

Opinion: Which option is better? Will option#2 provide superior PACU pain control?

 

[urge]

Lets take 1 case and provide the anesthetic 2 different ways.

Case: 45 year old elective lap colectomy, healthy with no cardiac history.

Anesthetic option #1:
Induction: prop only + paralytic.
Maintenance: Volatiles at a MAC titrated up to 1.5 with neo drip or PRN squirts.
Emergence: Drive off gas, give 100 mcg fentanyl at closure, reverse, extubate.

Anesthetic option#2
Induction: 150 mcg fentanyl, prop, paralytic.
Maintenance: Volatile at MAC 1, 50 mcg fentanyl every 30 minutes for duration of case
Emergence: Reverse, work in narcotic to RR, extubate.

Opinion: Which option is better? Will option#2 provide superior PACU pain control?

Narcotics are used to have smoother vital signs.

Anesthetic 1 will likely need an esmolol drip instead of phenylephrine.

I suspect anesthetic 1 will have lower pain scores in pacu.

 

[Hoya11]

Lets take 1 case and provide the anesthetic 2 different ways.

Case: 45 year old elective lap colectomy, healthy with no cardiac history.

Anesthetic option #1:
Induction: prop only + paralytic.
Maintenance: Volatiles at a MAC titrated up to 1.5 with neo drip or PRN squirts.
Emergence: Drive off gas, give 100 mcg fentanyl at closure, reverse, extubate.

Anesthetic option#2
Induction: 150 mcg fentanyl, prop, paralytic.
Maintenance: Volatile at MAC 1, 50 mcg fentanyl every 30 minutes for duration of case
Emergence: Reverse, work in narcotic to RR, extubate.

Opinion: Which option is better? Will option#2 provide superior PACU pain control?

When nociceptors sense pain, there are other things that happen besides increased heart rate and bp. There is mapping of this pain in the CNS. There is and has been plenty of good data that shows this. Untreated intra-op pain just like any untreated pain leads to unrelenting pain stimulus and pain mapping in the CNS. This can and does lead to chronic pain conditions like hypersensitivity, windup, CRPS and who knows what other damage on a psychological and neurological level. Some would argue things like PTSD (on the subconcious level) may occur. For a short procedure, you have a point, just give it at the end. But for prolonged painful stimulus you give analgesics to stop pain signal transmission to higher centers in the CNS and the ensuing problems that come with that.

Also, narcotic helps with tube/lma tolerance, cough suppressant, and lets you give less BP dropping induction agent than with just a pure hypnotic.

 

[Planktonmd]

Lets take 1 case and provide the anesthetic 2 different ways.

Case: 45 year old elective lap colectomy, healthy with no cardiac history.

Anesthetic option #1:
Induction: prop only + paralytic.
Maintenance: Volatiles at a MAC titrated up to 1.5 with neo drip or PRN squirts.
Emergence: Drive off gas, give 100 mcg fentanyl at closure, reverse, extubate.

Anesthetic option#2
Induction: 150 mcg fentanyl, prop, paralytic.
Maintenance: Volatile at MAC 1, 50 mcg fentanyl every 30 minutes for duration of case
Emergence: Reverse, work in narcotic to RR, extubate.

Opinion: Which option is better? Will option#2 provide superior PACU pain control?

There is a reason why anesthesiologists switched from single agent anesthetics of the 19th century to balanced anesthesia!

 

[Urzuz]

In addition to what everyone has said above, giving intraoperative opioids also gives you much more leeway when it comes to dosing muscle relaxants. If you have no opioid on board, even if your end tidal gas is at 1.5 MAC, a lot of patients with jump with the initial surgical stimulus. I know this because I tried it for a couple weeks. The reason is because the concentrations of gases have not reached steady state yet, and though your monitor may read 1.5 MAC the actual concentration in the brain/body is less. Without opioids you really have to make sure patients have 0/4 twitches, which at times may set your patient up for residual muscle paralysis the end of a case.

That being said I DO believe that opioids are way overutilized and should be used much more judiciously and sparingly than I have seen them used.

 

[GravelRider]

A better way to avoid opioids is using local anesthetic. Option #1 would be a good option if you do a good preop TAP block. On a similar open case then an epidural works great to spare opioids. We can make everyone's hemodynamics look pretty on the monitor with vasoactive and cardiac meds, but is that really anesthesia?

 

[NICMAN]

Lets take 1 case and provide the anesthetic 2 different ways.

Case: 45 year old elective lap colectomy, healthy with no cardiac history.

Anesthetic option #1:
Induction: prop only + paralytic.
Maintenance: Volatiles at a MAC titrated up to 1.5 with neo drip or PRN squirts.
Emergence: Drive off gas, give 100 mcg fentanyl at closure, reverse, extubate.

Anesthetic option#2
Induction: 150 mcg fentanyl, prop, paralytic.
Maintenance: Volatile at MAC 1, 50 mcg fentanyl every 30 minutes for duration of case
Emergence: Reverse, work in narcotic to RR, extubate.

Opinion: Which option is better? Will option#2 provide superior PACU pain control?

Volatile anesthetics are hyperalgesic through DRG TRPV channel up regulation and spinal sensitization. Also you have the aforementioned CNS pain mapping and windup. A better approach to opioid-less balanced technique is a regional block and oral pain mess pre-op with low dose lidocaine and ketamine infusions Intraop.

 

[Orin]

Volatile anesthetics are hyperalgesic

Has that ever been shown in a human study or should I start using continuous spinals and Remimazolam on everyone?

 

[deleted162650]

Has that ever been shown in a human study or should I start using continuous spinals and Remimazolam on everyone?

Just go w/ continuous total spinal and skip the remimazolam.

Seriously though, intraop narcs allow you to run much lower volatile levels and and reduce muscle relaxant dosing which leads to quicker smoother wake-ups not to mention prettier vitals. I know it's all en vogue to hate on narcs these days but I think that just stems from a bunch of academics that need to keep publishing. Does opioid hyperalgesia, etc. really exist - sure. But I don't think it's clinically relevant to at least 95% of the pt population most of us see on a daily basis. Give a little gas, a little narc, a little relaxant, and gt on with your life. Save the fancy stuff for those few occasions when it may actually matter.

 

[ranvier]

Do you miss the vapor when you run a tiva for whatever reason (mh history etc)?

 

[deleted162650]

Do you miss the vapor when you run a tiva for whatever reason (mh history etc)?

Yes

 

[NICMAN]

Just go w/ continuous total spinal and skip the remimazolam.

Seriously though, intraop narcs allow you to run much lower volatile levels and and reduce muscle relaxant dosing which leads to quicker smoother wake-ups not to mention prettier vitals. I know it's all en vogue to hate on narcs these days but I think that just stems from a bunch of academics that need to keep publishing. Does opioid hyperalgesia, etc. really exist - sure. But I don't think it's clinically relevant to at least 95% of the pt population most of us see on a daily basis. Give a little gas, a little narc, a little relaxant, and gt on with your life. Save the fancy stuff for those few occasions when it may actually matter.

In general, I agree with you, but there is some good data to suggest improved postoperative outcomes with opioid sparing techniques. The problem is that most Anesthesiology really could not care less about what happens when the patient is on POD#2 and how that might be related to him making pretty pictures out of their vitals on the monitor (yes I am also biased to railroading the vitals).

The Vanderbilt group has shown that they have saved 100 hospital bed-days/year just by avoiding opioids for colon cases (use zero opioids for >80% of their colon cases). That comes out to hundreds of thousands of dollars. Now throw in Gyn, Thoracic, etc..

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4743367/


And to answer the previous question about volatile hyperalgesia, yes most of the evidence is in animals. Yes the effect is probably transient and only at low MAC values. Very fair question. My general point was that we need to rely on more than just volatile and think about the perioperative outcomes, not just on the time we have until they are dropped off in the PACU.

 

[Scotty_G]

A colon case with the use of an intraop epidural does not count. We know of the opiod sparing effect and overall positive effect from doing this. In pp you are not going to stick an epidural on every patient who goes in for a colon case. It just doesn't happen :/ I agree that if you look in the pacu the patients who usually require more pain medicine are the ones who receives tons of it in the OR. I support using less narcotics and using esmolol at times for bp/hr changes. I have done a handful of cases using an esmolol or gtt + narcotic on induction only. They usually wake up fine. You can than give more narcs in the recovery unit. There is some limited data on esmolol and pain.

 

[deleted162650]

Not to be overly cynical, but I've found that most "narcotic sparing" anesthetics go right out the window once the pt hits PACU and the nurse pushes mg's of dilaudid as soon as you walk away and the pt even hints they have a little pain.

I can't say I agree that more intra-op narcs = more post-op narcs. I just haven't seen that phenomenon myself, and that's not the feedback I receive from PACU nurses.

 

[fakin' the funk]

Don't throw out intraop opioids altogether.

It's a useful class of drugs that helps you give less of the others.

It's not really more complicated than that.

 

[fakin' the funk]

In pp you are not going to stick an epidural on every patient who goes in for a colon case.

Because the vast vast majority are done laparoscopically? That seems like a good reason.

 

[fakin' the funk]

I agree that if you look in the pacu the patients who usually require more pain medicine are the ones who receives tons of it in the OR.

Um, what? So high(er) intraop opioid doses predispose to high(er) postop opioid requirements? Based on what mechanism? Or are you really trying to say "patients have different opioid tolerances."

 

[fakin' the funk]

Opinion: Which option is better? Will option#2 provide superior PACU pain control?

Probably neither is superior, at least not in any way that any study could demonstrate.

Lap colectomies are seriously feasible to be done with zero opioid. Try it.

 

[ranvier]

Yes

I do too.

 

[drmwvr]

Do you miss the vapor when you run a tiva for whatever reason (mh history etc)?

Miss in what sense? Less of a set up hassle? Then yes. Otherwise, on a therapeutic level, not in the least.

 

[Mman]

Um, what? So high(er) intraop opioid doses predispose to high(er) postop opioid requirements? Based on what mechanism? Or are you really trying to say "patients have different opioid tolerances."

I think the answer is both. Different patients do have different tolerances, but in general the more opioid you give the more hyperalgesia you will induce.

 

[Orin]

In general, I agree with you, but there is some good data to suggest improved postoperative outcomes with opioid sparing techniques. The problem is that most Anesthesiology really could not care less about what happens when the patient is on POD#2 and how that might be related to him making pretty pictures out of their vitals on the monitor (yes I am also biased to railroading the vitals).

The Vanderbilt group has shown that they have saved 100 hospital bed-days/year just by avoiding opioids for colon cases (use zero opioids for >80% of their colon cases). That comes out to hundreds of thousands of dollars. Now throw in Gyn, Thoracic, etc..

And to answer the previous question about volatile hyperalgesia, yes most of the evidence is in animals. Yes the effect is probably transient and only at low MAC values. Very fair question. My general point was that we need to rely on more than just volatile and think about the perioperative outcomes, not just on the time we have until they are dropped off in the PACU.

The whole ERAS thing really isn't opioid-centric and I'm not sure why we focus so much on just that arm of it. Opioids suck for lots of reasons, so I agree with minimizing those and all agents, but any standardization protocol would likely cut LOS.

I agree with worrying about POD#2 and beyond, but in the current model, there is little to no value for outpatient same day surgery anesthesiologists to worry about it.

For example, PONV with a TIVA works great for short term, but if you look out beyond the PACU stay, it may cause an increase in nausea/vomiting. What should be more important to the patient, the surgeon, and the anesthesiologist, early or late PONV?
( http://www.ncbi.nlm.nih.gov/pubmed/21911192 )

 

[Mman]

For example, PONV with a TIVA works great for short term, but if you look out beyond the PACU stay, it may cause an increase in nausea/vomiting. What should be more important to the patient, the surgeon, and the anesthesiologist, early or late PONV?
( http://www.ncbi.nlm.nih.gov/pubmed/21911192 )

Can I ask why in a study monitoring PONV that they chose to use remifentanil as part of their TIVA protocol? They point out that those patients required more postop narcotics. Shocking that they had more PONV while taking increased narcotics postop.

 

[deansrv72]

I think the answer is both. Different patients do have different tolerances, but in general the more opioid you give the more hyperalgesia you will induce.

Are you inferring that all opioids can/do cause hyperalgesia? I've heard/read that drugs like remifentanil can cause/enhance post-op hyperalgesia, but have not heard/read that drugs like dilaudid will/can.


Sent from my iPhone using SDN mobile

 

[Mman]

Are you inferring that all opioids can/do cause hyperalgesia? I've heard/read that drugs like remifentanil can cause/enhance post-op hyperalgesia, but have not heard/read that drugs like dilaudid will/can.

Yes. They hit the same receptor and act by the same mechanism. Pain is a good thing for the body and when you get enough opioid on board, the pain signalling mechanisms are altered. Then you take that narcotic away and they hurt more. Now is remi the most obnoxious offender? Sure. We get them so deep on it and they it goes away so quickly. But it can happen to varying degrees with all of them. The bigger the dose the higher the risk. Is it clinically relevant for smaller doses? Probably not, but the effect is likely happening.

 

[Planktonmd]

Yes. They hit the same receptor and act by the same mechanism. Pain is a good thing for the body and when you get enough opioid on board, the pain signalling mechanisms are altered. Then you take that narcotic away and they hurt more. Now is remi the most obnoxious offender? Sure. We get them so deep on it and they it goes away so quickly. But it can happen to varying degrees with all of them. The bigger the dose the higher the risk. Is it clinically relevant for smaller doses? Probably not, but the effect is likely happening.

What does that mean???

 

[GravelRider]

What does that mean???

Sounds to me like he just claimed an entire subspecialty of anesthesia is not only irrelevant, but actually doing patients a disservice. (I don't necessarily disagree)

 

[pgg]

What does that mean???

I would guess he means that humans evolved "pain" because in the grand scheme of things it has a survival benefit, and messing with that system using potent synthetic receptor agonists just might possibly have unintended and undesirable effects that we should at least think about. And possibly adjust our practice to minimize.

 

[NICMAN]

The whole ERAS thing really isn't opioid-centric and I'm not sure why we focus so much on just that arm of it. Opioids suck for lots of reasons, so I agree with minimizing those and all agents, but any standardization protocol would likely cut LOS.

I agree with worrying about POD#2 and beyond, but in the current model, there is little to no value for outpatient same day surgery anesthesiologists to worry about it.

For example, PONV with a TIVA works great for short term, but if you look out beyond the PACU stay, it may cause an increase in nausea/vomiting. What should be more important to the patient, the surgeon, and the anesthesiologist, early or late PONV?
( http://www.ncbi.nlm.nih.gov/pubmed/21911192 )

I'm not a big fan of propofol/remi. I prefer the propofol/ketamine/NMB or propofol/fentanyl/NMB depending on the case. There are some patients at my place who undergo repeat urological procedures (e.g., cystodistension, repeat stents) requesting the propofol/ketamine/versed anesthetic when compared to LMA. Anecdotal, I know.

 

[deleted162650]

OIH is a problem with chronic narcotic usage and even then its relatively rare. What Mman is talking about is not real OIH. Treatment of acute surgical pain with judicious appropriate use of opioids is not a bad thing.

 

[Planktonmd]

I would guess he means that humans evolved "pain" because in the grand scheme of things it has a survival benefit, and messing with that system using potent synthetic receptor agonists just might possibly have unintended and undesirable effects that we should at least think about. And possibly adjust our practice to minimize.

So since pain is good for you maybe we should go back to doing surgery with bourbon and a bullet to bite on?
I bet you they had no hyperalgesia during the civil war!

 

[GravelRider]

So since pain is good for you maybe we should go back to doing surgery with bourbon and a bullet to bite on?
I bet you they had no hyperalgesia during the civil war!

That's my kind of anesthesia...so long as the bourbon is a good one.

 

[Planktonmd]

That's my kind of anesthesia...so long as the bourbon is a good one.

Bourbon gives me a headache... my favorite anesthetic is scotch!

 

[pgg]

So since pain is good for you maybe we should go back to doing surgery with bourbon and a bullet to bite on?
I bet you they had no hyperalgesia during the civil war!

Now you're arguing just for the sake of arguing.

I know you're smart enough to understand exactly what I meant.

 

[Mman]

OIH is a problem with chronic narcotic usage and even then its relatively rare. What Mman is talking about is not real OIH. Treatment of acute surgical pain with judicious appropriate use of opioids is not a bad thing.

I'm not saying don't treat pain. I'm not saying don't treat it with opioids. I'm saying be cognizant of the fact that every dose adds up and has consequences beyond that temporary reduction in pain. The more opioid you give to anybody the higher the degree of hyperalgesia you are inducing. I am not saying it is clinically relevant in the 99.whatever percent of situations.

So real OIH is only with chronic narcotics? Then why do we see it with remifentanil? That's as far away from chronic narcotics as we can get. Remi causes it because they drop off is so quick and steep. Chronic methadone/percocet/whatever users get it because the cumulative dose and time course is so long. The effect is identical, though.

 

[Mman]

I would guess he means that humans evolved "pain" because in the grand scheme of things it has a survival benefit, and messing with that system using potent synthetic receptor agonists just might possibly have unintended and undesirable effects that we should at least think about. And possibly adjust our practice to minimize.

Yes. Pain is a protective response for the body and when we mess with it to treat acute surgical pain we can have unintended consequences.

 

[Hoya11]

I'm not saying don't treat pain. I'm not saying don't treat it with opioids. I'm saying be cognizant of the fact that every dose adds up and has consequences beyond that temporary reduction in pain. The more opioid you give to anybody the higher the degree of hyperalgesia you are inducing. I am not saying it is clinically relevant in the 99.whatever percent of situations.

So real OIH is only with chronic narcotics? Then why do we see it with remifentanil? That's as far away from chronic narcotics as we can get. Remi causes it because they drop off is so quick and steep. Chronic methadone/percocet/whatever users get it because the cumulative dose and time course is so long. The effect is identical, though.

I dont view OIH this way. That you give a drug one time to a normal person and it somehow sensitizes the system to pain. Definitely NOT my understanding of OIH. Agree that its only with chronic opiate therapy and wonder what you are seeing with remi that makes you think OIH is happening... the remi is probably just wearing off and the person is in pain!

If you have someone on oxycontin 40 and oxycodone 20 multiple times per day for LBP and then they fall down and hurt their ankle, this person will experience OIH. Their system has been made into a big baby by the opiates and any little insult is a huge deal (again a mix of actual OIH and the person just being a wimp necessitating opiates in the first place). Many people (educated people) I have met in the pain world do NOT believe in OIH. They just think its tolerance. This makes some sense to me. I dont think OIH is clinically as relevant as we think..If your withholding opiates based on fear of OIH i would think again..

 

[Noyac]

I think there are advantages of a narcotic based approach as well as there are advantages to no narcs. When I was a young attending I had a senior partner that was very very good and respected. I was shocked to find out that he gave nearly no narcs for many cases. He did use beta blockers. His pts were comfortable in PACU and easy to manage. I thought it was crazy. Over the years I have started to appreciate his approach more and more. I'm not as narcotic free as he was but I'm much closer than I was 10 yrs ago. I do feel like a low dose narcotic anesthetic (maybe something like 50-100mcg fentanyl at the start only) and then a small dose at the end is a reasonable approach for many cases that we otherwise would give higher doses. These pts are easy to get comfortable in PACU. But prefer to bring them to PACU not needing anything and cruising through. This seems to keep PONV at bay best as well. In other words I like to spoil my PACU nurses.

 

[Noyac]

I dont view OIH this way. That you give a drug one time to a normal person and it somehow sensitizes the system to pain. Definitely NOT my understanding of OIH. Agree that its only with chronic opiate therapy and wonder what you are seeing with remi that makes you think OIH is happening... the remi is probably just wearing off and the person is in pain!

If you have someone on oxycontin 40 and oxycodone 20 multiple times per day for LBP and then they fall down and hurt their ankle, this person will experience OIH. Their system has been made into a big baby by the opiates and any little insult is a huge deal (again a mix of actual OIH and the person just being a wimp necessitating opiates in the first place). Many people (educated people) I have met in the pain world do NOT believe in OIH. They just think its tolerance. This makes some sense to me. I dont think OIH is clinically as relevant as we think..If your withholding opiates based on fear of OIH i would think again..

Your points are well taken and I believe most people think the same way here. But I also do believe that Remi seems to have a greater ability to induce OIH. We do a lot of spine and when I get a pt on high dose narcs pre-op, I make an effort to not use remi. Their opiate needs for the rest of the hospital stay IN MY OPINION is reduced and they are "possibly" somewhat easier to manage.

 

[deleted162650]

I dont view OIH this way. That you give a drug one time to a normal person and it somehow sensitizes the system to pain. Definitely NOT my understanding of OIH. Agree that its only with chronic opiate therapy and wonder what you are seeing with remi that makes you think OIH is happening... the remi is probably just wearing off and the person is in pain!

Exactly this ^^.

I don't believe Remi magically induces OIH acutely (or ever), but it does wear off quickly and completely leaving you with your pants down and the pt. in pain especially when people use it for cases with a high degree of post-op pain like big back whacks - makes no sense to me to use this drug in this situation. Remi is equipotent to regular old fentanyl (mcg for mcg). Keep it at doses </= 0.2 and you won't have problems. Thing is, since it goes away so nice people like to jack it way the hell up. This can induce acute withdrawals later that day - I know someone who was a subject for early clinical trials with Remi when it was under development. They put him on monitors (including art line) and started the drip at gradually escalating doses. He said during the infusion it was absolutely amazing, but that afternoon after going home he had complete withdrawal symptoms - N/V, shakes, goosebumps, the whole deal.

 

[Mman]

I dont view OIH this way. That you give a drug one time to a normal person and it somehow sensitizes the system to pain. Definitely NOT my understanding of OIH. Agree that its only with chronic opiate therapy and wonder what you are seeing with remi that makes you think OIH is happening... the remi is probably just wearing off and the person is in pain!

It's not just the remi wearing off and the patient being in pain. They have increased narcotic requirements days later from the exposure to the remi. The more narcotics you give someone, the more you are sensitizing their system to future painful stimuli.

 

[deleted162650]

It's not just the remi wearing off and the patient being in pain. They have increased narcotic requirements days later from the exposure to the remi.

Data please

I think remi is a terrible drug and don't use it, but I don't believe this is true.

How many pts are you rounding on days later anyways??

 

[Mman]

Data please

I think remi is a terrible drug and don't use it, but I don't believe this is true.

How many pts are you rounding on days later anyways??

You can dig the studies up yourself. There are too many to count. Patients that get remi (the more the worse) have worse pain scores and higher narcotic requirements persisting into postop days.


And please note I'm not arguing in favor of narcotic free anesthesia. Just gotta recognize the side effects and potential complications.

 

[Planktonmd]

Data please

I think remi is a terrible drug and don't use it, but I don't believe this is true.

How many pts are you rounding on days later anyways??

Remi is not a terrible drug and it has it's place in anesthesia practice if you know how and when to use it!
Remi is an elegant agent to use for cases where you need a really deep anesthetic intra-op, can't use muscle relaxants to prevent movement because of neuro monitoring, and the surgical procedure does not cause much post-op pain (carotids, thyroidectmoies...)
All that crap about hyperalgesia is mostly imaginary and consists of illusions of academic guys who have too much time on their hands!

 

[deleted162650]

Remi is not a terrible drug and it has it's place in anesthesia practice if you know how and when to use it!
Remi is an elegant agent to use for cases where you need a really deep anesthetic intra-op, can't use muscle relaxants to prevent movement because of neuro monitoring, and the surgical procedure does not cause much post-op pain (carotids, thyroidectmoies...)

I would argue it's the least elegant way to do those kinds of cases. It's a CRNA level turn it on turn it off drug, brainless way to do an anesthetic. Effective? - sure. Elegant? - not so much. Just MHO though - your mileage may vary.

 

[Ezekiel2517]

I don't use remifentanil for the patient. I use it for the surgeon. A unique drug that is great in certain situations.

 

[Planktonmd]

I would argue it's the least elegant way to do those kinds of cases. It's a CRNA level turn it on turn it off drug, brainless way to do an anesthetic. Effective? - sure. Elegant? - not so much. Just MHO though - your mileage may vary.

I think it is very elegant when you use a fool proof technique that can be employed even if you leave the janitor at the head of the table!

 

[Mman]

All that crap about hyperalgesia is mostly imaginary and consists of illusions of academic guys who have too much time on their hands!

I think remi is a great drug and has wonderful uses. I like to use it for things like carotids and thyroids and cranis and all sorts of things. But the evidence that you see increased postop pain levels and narcotic requirements is not "imaginary". It's real data. We've seen it in our own institution. We are far too lazy to try to publish our own internal reviews, but the result is fairly clear and obvious (how much it matters is a related, but separate, debate).

 

[deleted162650]

I think it is very elegant when you use a fool proof technique that can be employed even if you leave the janitor at the head of the table!

A common mistake that people make when trying to design something completely foolproof is to underestimate the ingenuity of complete fools.
-Douglas Adams

I choose to work in a fool free practice environment. 😉

And I think you basically proved my point.

 

[Planktonmd]

A common mistake that people make when trying to design something completely foolproof is to underestimate the ingenuity of complete fools.
-Douglas Adams

I choose to work in a fool free practice environment. 😉

And I think you basically proved my point.

Hey good for you... the rest of us have practice in the real world 😉