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At "normal" doses, ketamine can have numerous undesirable side
effects, but Dr. Lawson is a strong proponent of its analgesic properties at subhypnotic doses (0.1mg/kg vs. the commonly prescribed
10 to 60mg doses). "At those (smaller) levels, it's not going to have
side effects," he says. "It's only going to have an intense analgesic
effect. People have forgotten it and abandoned it, because of its
side effects, but you don't get them at such small doses."
Ketorolac (Toradol) is an NSAID that provides equivalent pain
relief to morphine, says Dr. Lawson. Dr. Ballantyne agrees, calling
ketorolac "incredibly useful" for moderate pain, and equal to morphine in terms of analgesic efficacy.
Not that Dr. Lawson flat-out refuses to use opioids. "The goal," he
says, "should be balanced anesthesia: just the right amount of opioids
and just the right amount of non-opioids."
For one group of his patients, however, opioids are off limits. "We take
care of about 80 pediatric patients a month with no narcotics," he says.
"It's challenging, because with kids, you have 2 patients — the parent
and the child. Naturally, parents want their children to be comfortable,
and we make sure they are by having them alternate between acetaminophen and ibuprofen every 2 hours. It controls the pain without the side
effects of opiates. And that way also — considering the growing obesity
problem with children — undiagnosed sleep apnea isn't an issue."
Regional emphasis
At the Andrews Orthopaedic & Sports Medicine Center in Gulf
Breeze, Fla., an ongoing initiative to minimize opioids has achieved
remarkable success. The center has steadily reduced the percentage
of patients given opioids post-operatively — to 11.7% in 2010, 9.4% in
2011 and 7.0% in 2012.
"It's really a pretty simple mindset we have in that we approach
N O V E M B E R 2013 | O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E
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