ment patients receive adductor canal or femoral blocks, or local infil-
tration of bupivacaine at the incision site.
Even patients at high risk for morbidity and mortality benefit from
multimodal techniques. Take, for example, knee fistula repairs on
patients with major cardiovascular, peripheral vascular and renal dis-
ease. You could place supraclavicular or interscalene ultrasound-guid-
ed nerve blocks, and augment with a periarticular injection of long-
acting liposomal bupivacaine at the surgical site.
"These patients have no pain intraoperatively and are discharged
from the recovery room without any pain medications," says Alan
Kaye, MD, PhD, FASA, a professor in the department of anesthesiolo-
gy and pharmacology, toxicology and neurosciences at Louisiana
State University School of Medicine in Shreveport.
Drug cocktails
Administering numerous pain-relieving medications with various
mechanisms of action treats pain at several sources and minimizes
doses of the individual medications to limit potential side effects.
All total joint, GYN and spine patients without contraindications at
Thomas Jefferson University Hospital receive a pre-op cocktail con-
sisting of acetaminophen, a nonsteroidal anti-inflammatory drug
(NSAID) and a gabapentinoid. "Each non-opioid agent that's added to
the mix provides an incremental analgesic benefit," says Dr. Schwenk.
Dr. Schwenk points to agents in the developmental pipeline,
including a novel formulation of bupivacaine and the anti-inflamma-
tory meloxicam that promises to provide long-lasting pain relief, and
newer opioid formulations, including sublingual sufentanil, that rap-
idly treat pain without the lasting impact of traditional opioids like
morphine and hydromorphone.
Short-acting opioids are useful for managing post-op pain, notes Dr.
J A N U A R Y 2 0 2 0 • O U T PA T I E N T S U R G E R Y. N E T • 2 1
