2. For the appropriately selected patient, how much oral gabapentin should be administered to help treat PONV and post-operative surgical pain?
- a. 300mg
- b. 600mg
- c. 1,000mg
- Reveal
Answer: b
When anesthesiologists at the Surgery Center of Oklahoma started giving patients 600 mg of oral gabapentin preoperatively to reduce the risk of PONV, they noticed it also decreased post-op pain,
particularly for patients with a history of nerve pain. "We’re very impressed with it so far," says anesthesiologist Keith Smith, MD, the Oklahoma City facility’s medical director. "It almost eradicates PONV and
has a nice post-op analgesic effect as well."
Gabapentin is used routinely as part of a cocktail that can include a mix or pregabalin, steroids, anti-inflammatories and diazepam. This non-narcotic mix doesn’t depress
patients’ nervous systems as opioids do and results in less sedation overall, which means they can be discharged sooner.
Dr. Mariano says the jury is still out on routinely using gabapentin after surgery, saying
some evidence has emerged questioning its pain management benefits and ability to prescribe less opioids for patients when used arbitrarily. "I think gabapentinoids should be restricted to indications when they make the most
sense, such as patients who have pre-existing neuropathic pain or develop it after surgery," he says. "It really shouldn’t be used routinely for surgical pain control."
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3. Rather than learning dozens of nerve blocks, a group of anesthesiologists in 2020 recommended teaching outpatient providers five versatile blocks that could result in widespread implementation of regional anesthesia in ASCs. Which one is not on the list?
- a. Adductor canal
- b. Interscalene brachial plexus
- c. Popliteal sciatic
- d. Infraclavicular brachial plexus
- e. Transversus abdominis plane (TAP)
- f. Pericapsular nerve group block (PENG)
- Reveal
Answer: f
Dr. Mariano, who was part of the 2020 group to suggest the back-to-basics approach to nerve blocks, notes regional anesthesia isn’t regularly used by most anesthesia providers. Dr. Mariano
says it’s used in only 3% of outpatient surgeries in which it would be appropriate. Furthermore, nerve blocks are used only 41% of the time during shoulder arthroscopies, a procedure perfectly suited for them.
While
it’s understandable for newer and more complex blocks to be created, Dr. Mariano says a larger number of patients would be better served if more anesthesia providers would learn five basic blocks for use in outpatient
arenas. The interscalene brachial plexus is the gold standard for shoulder procedures; infraclavicular brachial plexus blocks do the job for elbow, wrist and hand surgeries; adductor canal blocks are perfect for knee replacements;
popliteal sciatic blocks provide great relief for foot and ankle surgeries; and the TAP is the most common interfascial block used in abdominal and pelvic surgeries. "While the increasing use of ultrasound guidance has increased
our options as far as how many blocks we can use," says Dr. Marino, "it’s really in many ways to the detriment of developing competence in the select few techniques that can be of the most help."
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Cryoanalgesia, which targets and freezes nerves with carbon dioxide or nitrous oxide, provides _____ to _____ of pain relief.
- a. days to weeks
- b. weeks to months
- c. months to years
- Reveal
Answer: b
A long-established pain management intervention for chronic pain often used for individuals who are trying to delay surgery, cryoanalgesia is very new for acute pain that patients experience after
surgeries. It freezes the nerves near the surgical site, then the nerves regenerate weeks to months later when function is restored. Providers use anatomical landmarks or ultrasound guidance to target the nerves for freezing,
and it’s a procedure that doesn’t require a surgeon to perform. Often, a physician’s assistant will do the work. "I think there may be a role for cryoanalgesia in select cases when used very close to the surgical
site," says Dr. Mariano. "Unlike the medicine in pain pumps, you can’t titrate the amount of anesthetic a patient receives, so it’s really an all-or-nothing proposition, and patients need to understand that the
treated nerves are going to be out of commission for several weeks or months."
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5. Opioid-sparing pain control regimens are designed to moderate the amounts of narcotics prescribed to patients. The guidelines for how many 5mg oxycodone pills to give range from up to __ pills for a hernia repair, up to __ pills for a hip replacement and up to __ pills for a knee replacement.
- a. three, seven and 10
- b. five, 15 and 25
- c. 10, 30 and 50
- Reveal
Answer: c
These recommendations come from the Michigan Opioid Prescribing Engagement Network (Michigan OPEN), created by the state government, Blue Cross Blue Shield of Michigan and the University of Michigan
to tailor postoperative prescribing in an effort to decrease addiction rates. Dr. Mariano says Michigan OPEN’s recommendations are among the best he’s seen and provide a good starting point for physicians.
He recommends that patients who are prescribed opioids also receive a sheet containing explicit instructions on how and when to taper off the drug. Doing that has been shown shown to decrease the dosage of opioids prescribed
to patients by two-thirds without an increase in refills for six weeks.
"There’s fairly convincing data that shows you can put together a simple patient-specific discharge opioid prescribing and tapering protocol
based on the patient’s own use and then send them home with the right amount of pills," says Dr. Marino.
Michigan OPEN’s recommendations for surgical providers include not providing opioid prescriptions for
post-op use before the surgery date, using nerve blocks, local anesthetics and non-opioid medications when appropriate and never using meperidine for outpatient cases.
That said, Shakeel Ahmed, MD, founder and CEO of
Atlas Surgical Group, which consists of 10 privately owned surgery centers in the Midwest, says opioids remain an important part of post-op care. "The indications are strong for their use after many surgeries, such as orthopedic,
ENT, gynecologic and urologic cases," he says.
Dr. Smith agrees, saying, "Narcotics have their place, as does moderation. Just as we shouldn’t overprescribe, we should never deny patients adequate pain relief.
We should always use our improved ultrasound skills and regional anesthesia techniques to reduce intraoperative opioids, because they are barriers to fast and safe discharges."
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