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Archive Orthopedic Surgery 2017

Maximize Multimodal Pain Management

Controlling post-op pain with fewer opioids is more important than ever.

Nabil Elkassabany, MD

BIO

total knee patients JOINT DECISION Total knee patients are given adductor canal blocks or femoral nerve blocks, depending on their pre-op condition.

Sounding alarms about the nation's opioid crisis is fairly easy. Solving it is turning out to be a lot harder. The current epidemic demands that you take a hard look at how effectively your surgical team is using multimodal post-op pain management to limit the use of addictive painkillers. Do your part to stop the overprescribing of opioids and you'll soon realize that the right mix of analgesics, regional anesthesia and continuous nerve blocks helps send joint patients home sooner, healthier and happier.

The main elements
Our multimodal perioperative pain protocol for shoulder arthroscopy — widely considered to be one of the most painful outpatient procedures — decreases the need for opioids and improves recoveries. Regional anesthesia is a key ingredient in the multimodal protocol. Most shoulder arthroscopy patients receive a brachial plexus nerve block with or without general anesthesia. Additional elements include pre-operative acetaminophen (1 gram every 8 hours) and gabapentin (starting with 300 mg 3 times a day); intraoperative ketorolac; and post-operative oral acetaminophen, gabapentin and ketorolac, with oxycodone as needed for breakthrough pain.

The dosage regimens are standard, but we provide enough wiggle room to accommodate significant variability. For example, an opioid-naive patient may do fine with a single-shot regional anesthetic or a regional block plus the multimodal analgesia. But you'd want more prolonged pain control with a patient who's been treated for opioid addiction, so we might opt for an ambulatory catheter and a continuous nerve block that lasts as long as possible.

With our multimodal shoulder arthroscopy protocol, patients have significantly better pain scores after 24 and 48 hours and significantly better quality of recovery scores at 24 and 48 hours and at 1 week, compared with equivalent patients before we instituted the protocol. Additionally, their total oxycodone requirements for breakthrough pain were less than half of what other shoulder patients required. Finally, their average PACU stays were reduced by about 20 minutes, to just under 2 hours.

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