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Taming pain and PONV
The 2 things patients are most likely to remember are how much they
hurt and how queasy they felt. Years back, the assumption was that you
couldn't have the best of both worlds: You loaded up the narcotics to numb the
pain, and you crossed your fingers, hoping the side effects wouldn't be too grim.
Not anymore. As anesthesia providers embrace multimodal pain management
— combining strategically mixed and perfectly timed pain-relief cocktails with
new techniques — patients can experience minimal pain and no gastric distress.
"When possible, and it's almost always possible with outpatient cases, you
shouldn't have to give any narcotics at all — zero opiates," says Adam Dorin,
MD, MBA, an independent consulting anesthesiologist in Southern California and
EmCare team member at Palmdale (Calif.) Regional Medical Center.
He often tells patients to avoid taking the opiate pills they're prescribed once
they're discharged. The pills are stronger than over-the-counter pain remedies,
but they can also cause nausea, itching and constipation, which no patient
wants to experience.
Of course, opioid-free recoveries start with advance planning. Dr. Dorin sug-
gests patients receive 4 mg of ondansetron (to prevent nausea) at the beginning
of the case, before anything else. Next, administer 4 to 8 mg (for a typical adult)
of the anti-inflammatory dexamethasone. He says you should avoid nitrous
oxide, which causes nausea, and use an orogastric tube, even if it's just to quick-
ly suction the stomach.
From there, propofol is effective, but not always necessary. "If you don't want
to do general under total intravenous anesthesia, there are other approaches,"
says Dr. Dorin. "You can use a lighter, lower propofol drip — 25 to 75
mcg/kg/min — which allows you to decrease the inhalation anesthetic below 1.0
MAC."
If you don't want to completely avoid propofol, placing a local block lets you
administer inhalation anesthetic at the lowest possible flow. Blocks are increas-
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