5 8 S U P P L E M E N T T O O U T P A T I E N T S U R G E R Y M A G A Z I N E A U G U S T 2 0 1 6
• During surgery. Our surgical "cocktail" includes several medications
designed to work in different ways on different levels. We inject a steroid-contain-
ing local anesthetic into the soft tissues that surround joints. The steroid helps
prevent local inflammation, and is combined with just enough morphine to stimu-
late all 3 opiate receptors in the joint with fewer adverse systemic effects.
The cocktail also includes an antibiotic, bupivacaine, epinephrine, clonidine
and a little saline. Bupivacaine works as a sodium channel blocker and numbs
the area. Epinephrine inhibits capillary distribution, which helps keep all the
medications we administer in the area of the planned operation. Clonidine helps
promote the synergistic action of the local anesthetic and local steroids. Applying
clonidine transdermally, via a patch, allows sustained action for several days
while minimizing potential adverse effects, including abnormally slow heart rate
or blood pressure. We consider these medications the most important and effec-
tive component of our pain protocol.
• In post-op. We administer a variety of agents with different mechanisms of
action, with a goal of providing both local and systemic pain relief. They include
agents that combine anti-inflammatory and analgesic properties, such as aceta-
minophen and steroids, and in some cases, ketorolac. We also convert patients
to oral agents and try to minimize or completely avoid parenteral opioids. If the
regimen is deemed ineffective, we augment it with 2 or 4 mg doses of morphine
sulfate at 15-minute intervals. Once the patient can tolerate oral medication, we
administer oxycodone on a PRN basis. Discharged patients also take 1,000 mg
of acetaminophen orally every 6 hours, Celebrex (200 mg once daily) for 10
days total and pantoprazole (40 mg orally) for gastrointestinal prophylaxis.
Setting expectations
The goal of pain management is to keep patients comfortable, but cognitively
aware, which lets them stand up in the recovery room an hour or so after sur-
gery, and, if all goes well, be ready for same-day discharge. The multimodal
approach is a game-changer in that regard.
