Jon Wilton DNAP, CRNA, shares his experience of converting to an opioid-free practice in part 2 of 2 of our Opioid Free Anesthesia Series. Below you can find some of the impressive data Jon has collected since going opioid-free, and a guide to what he uses in his practice for different surgeries.
Mercy Mount Shasta Acute Pain Anesthesia Guidelines
Pre-Op
All patients receive acetaminophen, gabapentin, and celecoxib preop if not contraindicated. Opioids are avoided if possible
Intra-op
TIVA will be utilized as much as possible. If regional anesthesia is not an option and or case involves cancer, a lidocaine infusion will be utilized. Additionally, Esmolol and Mag Sulfate will be utilized as needed. Dexamethasone and methocarbamol will be given unless contraindicated. Clonidine or dexmedetomidine will also be used as needed.
Post-OP
All order sets will include acetaminophen scheduled around the clock, not PRN unless contraindicated. Ketorolac or NSAID of choice will be planned around the clock depending on renal function. Methocarbamol or muscle relaxant of choice will be scheduled around the clock. Gabapentin or equivalent will be scheduled around the clock depending on age.
Regional Anesthesia Blocks
Catheters
1. If possible, each catheter will be limited in place to 3-5 days. Refills of OnQ will be provided if needed and if Risk vs. Benefit warrants, the catheter may be run for seven days, pulled and then replaced.
2. If the block is being utilized for spinal fusion in the presence of neuromonitoring, the catheter may be placed preop but will not be dosed until neuromonitoring is complete.
3. Blocks are routinely performed in the ER for trauma and or uncontrolled pain. This regularly prevents admissions for pain control.
Concern for Compartment syndrome
Consult with the surgeon but regional will be utilized with a lower concentration to allow for breakthrough pain. This will usually be 0.125% Marcaine as an initial bolus, and then OnQ pump with 0.2% ropivacaine titrated to effect. If a surgical blockade is necessary, the catheter will be bolused with lido for a short-acting dense blockade.
Posterior cervical surgery.
Occipital blocks or high Erector Spinae.
ACDF
Cervical plexus block and Greater Occipital/ Third Occipital Block as needed.
Shoulder
Interscalene block single shot or Catheter depending on indications and patient preference. Superficial cervical plexus as needed. If Biceps Tendonitis is performed, a PECS block will also be done.
With any significant Pulmonary issues and or as rescue, Suprascapular single shot vs. catheter plus a Selective Axillary nerve block single shot. A high erector spinae catheter has also been successfully used.
Clavicle
Superficial Cervical Plexus catheter and or interscalene block as indicated.
Proximal Humerus and occasionally shoulder
Supraclavicular block single shot or catheter. If patient is a pulmonary cripple we place catheter and bolus a few milliliters at a time until effective.
Distal humerus/Elbow to hand
Infraclavicular block or costoclavicular single shot or catheter.
If anatomy requires:
Axillary block/Musculocutaneous single shot only for elbow and distal.
Breast
Single shot PECS 1 and two blocks. If catheter indicated or as a rescue an additional Erector Spinae block would be utilized.
Intrapec Block will be used for pectoralis muscle repairs.
Thoracic surgery and or Thoracic Spine surgery
Erector Spinae block. Will be utilized for rib fractures, spinous process fractures, kyphoplasty, thoracic spine surgery as well as epigastric hernias and break through abdominal pain.
Abdominal and lumbar spine surgery
Quadratus Lumborum blocks or Erector Spinae Blocks single shot vs. catheter. This includes a standard of single shot for lap Cholecystectomy, inguinal hernia, and catheters for a colon resection and cesarean section or any other abdominal surgery. Spine surgery will get QL catheters preferentially over ES. Type of QL is dependent on time available. QL1/2 is most common with QL 3 if time available and or as a rescue.
Hip
PENG block is the current standard. This block is implemented ASAP, preferably in the ER. Additionally, a Quadratus Lumborum Block type 3 or fascia illiaca block has been implemented if other blocks are contraindicated.
Pelvic Fracture
Quadratus Lumborum type 3 with catheters
Total Knee
Adductor Canal block with Catheter and then single shot IPACK.
Genicular vs. anterior local infiltration in PACU only if indicated which is extremely rare.
Knee arthroscopy
Intraarticular knee block with port site infiltration. Adductor canal block if chronic pain and or if otherwise indicated. Genicular blocks as rescue.
Distal to the knee including ankle and feet
Lateral Popliteal Block and Adductor Canal block single shot versus catheter.
CTR
Local per surgeon
This list is continually updated and adapted to new and emerging evidence and blocks.
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