Acute Pain Service

-suggested pre/intraop strategies for best post-op pain outcomes-

Preop:
pregabalin 150mg (25-75mg for older patients)
scopolamine patch (hold for older patients or concern for post op delirium)

Intra-op:
minimize opioid use intra-op if possible
high dose intra-op opioids cause some degree of post-op hyperalgesia
ketamine 0.5mg-1mg/kg bolus near beginning of case (no infusion unless chronic pain)
prevents post-op hyperalgesia, reduces post-op opioid requirements
dexmedetomidine 0.2mcg/kg/hr
reduces post-op opioid requirements, reduces PONV
lidocaine infusion 1.5mg/kg/hr
reduces post-op opioid requirements, reduces PONV
(no need to use dex and lido infusions, either is fine)
acetaminophen IV optional, if used please give early as it will also be used post-op
dexamethasone 4-8mg hold for poorly controlled diabetic pts
reduces post-op opioid requirements, reduces PONV
No Toradol due epidural contraindication NSAIDS + Lovenox

Discontinue infusions at least 1hr prior to end of case to prevent delayed emergence
15 min prior to anticipated extubation dose epidural:
100mcg fentanyl in the epidural
15ml 0.125% bupivacaine with epi in divided doses

References:
British Journal of Anaesthesia 112 (6): 9911004 (2014). Opioid-induced hyperalgesia in patients after surgery: a
systematic review and a meta-analysis

Eur J Pain. 2013 Apr;17(4):562-70. The impact of intra-operative sufentanil dosing on post-operative pain,
hyperalgesia and morphine consumption after cardiac surgery.

Br J Anaesth. 2014 Sep 10. Impact of pregabalin on acute and persistent postoperative pain: a systematic review and
meta-analysis.

Br J Surg. 2008 Nov;95(11):1331-8. Meta-analysis of intravenous lidocaine and postoperative recovery after
abdominal surgery.

Anesth Analg. 2012 Aug;115(2):262-7. Systemic lidocaine to improve postoperative quality of recovery after
ambulatory laparoscopic surgery.

Anesthesiology. 2012 Jun;116(6):1312-22. Effect of perioperative systemic 2 agonists on postoperative morphine

consumption and pain intensity: systematic review and meta-analysis of randomized controlled trials.

Br J Anaesth. 2013 Feb;110(2):191-200. Impact of perioperative dexamethasone on postoperative analgesia and

side-effects: systematic review and meta-analysis.