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S U P P L E M E N T T O O U T P AT 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 | M O N T H 2 0 1 4
something really simple like a carpal tunnel or a
trigger finger."
When you add up all the elements of strategi-
cally executed multimodal pain management,
something remarkable happens. The whole turns
out to be greater than the sum of the parts.
"You always want to use multimodal therapy,
because you get a lot more bang for your buck,"
says John Dombrowski, MD, a specialist in pain
medicine at the Center for Pain Medicine in
Washington, D.C. "People say, we just use this
and that alone. Well, that's good, but it could be
so much better."
Mixing the right cocktail
The key is to use a cocktail of drugs that work on different sites, target different
receptors and have different effects. The goal is to effectively reduce post-oper-
ative pain, opioid consumption and opioid-related adverse effects after surgery.
Dr. Hickman augments his blocks with continuous catheters, running a dilute
solution of local anesthetic for 3 or 4 days. If he doesn't do a nerve block, pre-
operatively he gives patients 200mg of pregabalin, useful for treating neuropath-
ic pain. In the operating room, right after induction but before the surgery starts,
he'll give IV acetaminophen, which works centrally in the brain. He also gives
small does of ketamine, an NMDA receptor antagonist that works in the spinal
cord and "really helps a lot with analgesia." He can also give patients the anti-
inflammatory ketorolac.
"We're doing a multimodal approach — hitting different sites with the differ-
ent drugs," he says.
The time for opioids
P A I N M A N A G E M E N T
QUICK HIT The best way to control
pain is to attack it before it starts.
Pamela
Bevelhymer,
RN,
BSN
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