Views on Containing Post-op Pain 
Pre-emptive analgesia starts before the surgical incision and before the injection of the local analgesia ("
New Ways to Contain Post-op Pain," August, p. 24). Titrating a BIS-monitored propofol infusion to 70-75 before administering a 50-mg dissociative dose of ketamine is the critical component missing in all previous Level I studies of preemptive analgesia. Blocking the NMDA receptors with a dissociative dose of ketamine not only produces an immobile patient for the local analgesia injection but also sets the stage for genuine pre-emptive analgesia. My patients are routinely pre-oped with oral clonidine 0.2 mg and rofecoxib 50 mg 30-60 mg before induction. I have not used any opioids in my practice since December 1997 (without inflicting suffering in my patients).
The key to managing post-op pain is similar to managing post-op PONV - don't cause it in the first place! Avoid emetogenic opioids for analgesia and precede the local anesthetic injection with a 50 mg dissociative dose of ketamine under adequate propofol hypnosis.
Barry L. Friedberg, MD
Cosmetic Surgery Anesthesia
Corona del Mar, Calif.
drfriedberg@doctorfriedberg.com As a healthcare provider and the champion of our institution's pain team, I was certainly shocked to read that Dr. Rathmell ("Pain Assessment: Don't Just Treat a Number," August, p. 26) feels that healthcare providers should "use their judgment" to assess patient's pain levels rather than rely on the patient's self-report of pain. This does not coincide with the current standard of care for pain management. According to the Agency for Health Care Policy and Research and the American Pain Society, "the single most reliable indicator of the existence and intensity of pain is the patient's self-report." In the future, please print the current factual information regarding pain management and not merely a healthcare provider's opinion.
Diane Betz RN, BSN
Director of Education
In "Which Consciousness Monitor Is Right For You?" (September 2002), we erroneously stated that the SNAP module from Nicolet Biomedical lists for $450. The actual list price of the module is $4,500. Outpatient Surgery regrets the error.
