gesics that target different pain pathways to provide synergistic pain
relief.
"But those strategies are underutilized in facilities where providers
aren't aware of the advantages they bring or lack the expertise to
administer them properly," says Dr. Chou.
Dr. Wu notes that the typical classes of medications included in multi-
modal cocktails include acetaminophen, non-steroidal anti-inflammatory
agents (NSAIDs), local anesthetics and gabapentinoids, which are typi-
cally used as anticonvulsants, but, at lower doses, have proven effective
in treating post-op nerve pain. NSAIDs are terrific options for managing
pain after surgeries with big inflammatory components, says Dr. Carr,
but they also have their issues.
"Conventional NSAIDs that don't differentiate between Cox 1 and
Cox 2 can interfere with the clotting that prevents post-op bleeding,"
he says. That's why providers have turned to short-term administra-
tion of Cox-2 inhibitors, which don't interfere with post-op clotting, to
provide pain relief. NSAIDs might not be appropriate for very frail
patients, such as the elderly, who have kidney insufficiency or heart
disease. "Even a brief exposure can have adverse consequences," says
Dr. Carr.
There's also been increased interest in administering ketamine
acutely during surgery. "The higher the dose, the greater the psycho-
logical effect, which can be significant, so there's a limitation to
what's feasible for outpatient use," says Dr. Carr. He says small doses
— the analgesic range is a .25 to .50 mg/kg — are used so the medica-
tion clears before discharge.
Ultrasound guidance lets providers of all skill levels place targeted
regional blocks, says Dr. Carr. He says combining regional blocks with
non-steroidal therapy before and after surgery can reduce pain scores by
2 to 3 points.
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