5 3
M O N T H 2 0 1 4 | 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
The time to use opioids in small doses, says Dr. Hickman, is before the pain
ratchets up, not after. He gives select patients a small dose of fentanyl (100
mics), which works on the mu receptors in the spinal cord and the brain.
"I'm a big believer in preemptive analgesia. You want to prevent spinal wind-
up," says Dr. Hickman, whose facility is well known for repairing some of the
biggest names in sports. "That's where nerve fibers send a message to the spinal
cord and the spinal cord sends it up to the brain. Pain gets the spinal cord
wound up. If you prevent that from getting going, that keeps it from getting
bad."
Or as Dr. Dombrowski puts it, why not control the horses before they get out
of the barn?
"Doing everything you can beforehand is really important," he says. "It's a lot
better to give people pre-medications before surgery, like pregabalin or
gabapentin. You can even start people 24 hours beforehand on these medications,
or with a non-steroidal or Cox-2 inhibitor. There's some concern about how that's
going to affect bleeding, but it's at least worth considering. An anesthesiologist
P A I N M A N A G E M E N T
T
he multimodal
approach appears
to catching on.
When we surveyed readers
3 years ago, only 12% said
they used more than 2 non-
opioid analgesics in their
multimodal regimens. That
number was up to 35% in a
survey conducted last
month. Meanwhile, 50% say
they now use 2 non-opioids,
compared with 45% in our
previous survey. The per-
centage using only 1 non-
opioid alternative has
declined from 43% to 15%.
Also on the rise is the
percentage of readers who
administer non-opioids pre-
operatively. Three years
ago, only 35% said they do
so at least 50% of the time.
In our more recent survey,
that number stood at 55%.
The percentage of
respondents who say they
administer non-opioids
post-operatively at least
50% of the time declined
from 51% to 41%, possibly
because the added pre-
operative steps help reduce
the need.
— Jim Burger
READER
SURVEY
Multimodal Approaches Catching On
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