6 8
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 | S E P T E M B E R 2 0 1 4
important to realize that pain does not easily fit onto a 0-to-10 scale.
It's also unrealistic for a post-surgical patient to have pain as a 0 to 1 on
the pain scale."
The goal is not to eradicate pain, he says, but to manage it as best as
possible, which often means using different modalities, one on top of
the other, to eliminate gaps in pain relief and extend by minutes or
hours the time patients are recovering at home in relative comfort. For
example, rather than waiting for a regional block to wear off before
patients get pain medication into their systems, Dr. Mundey instructs
them to take a loading dose of opioids while the block is still working.
Overlapping a block with an opioid means a patient will feel as well in
your recovery room as he will hours later in his living room.
For his mastery over the mystery that is surgical pain, Dr. Mundey is
the winner of the OR Excellence Award for Pain Management. Here are
the pillars to Dr. Mundey's pain management.
Multimodal approach
Morphine and other narcotics remain the gold standard for the treat-
ment of acute pain, while regional nerve blocks, both single
-shot blocks and nerve block catheters, are gaining popularity, says
Dr. Mundey. Other adjuncts he commonly uses include muscle relax-
ants like metaxalone or cyclobenzaprine, NSAIDs, anticonvulsants
like gabapentin or pregablin, and tricyclic antidepressants, including
amitriptyline or nortriptyline.
As an example, he says a narcotic-naïve patient coming for a routine
shoulder or knee procedure will get oral medicines in pre-op that
include a long acting narcotic, an NSAID and possibly gabapentin. The
patient will then get a nerve block 30 to 45 minutes before the proce-
dure for adequate pre-emptive analgesia. In the PACU, he'll give short-
acting narcotics for breakthrough pain and often another dose of oral
