Can We Minimize Narcotics Use Intra-Op?

This is a topic that I have been wanting to discuss with you guys. I feel that it is a learning process for me to understand that we don’t always have to give narcotics intraoperatively. I remembered when I was a student, I was doing my cardiac rotation at a university medical center, the attending would only allow maximum 250mcg of fentanyl to be given for the entire CABG case. His reasoning was that patient doesn’t really need that much narcotics as other ajuncts can be used to promote fast recovery and minimize the side effects of narcotics. The attending further explained his rational that pain is a perception and under general anesthesia, sympathetic response is elicited. Hence, adjuncts that can reduce sympathetic response may be effective to reduce the postop opioid consumption and pain perception. I didn’t fully understand his reasoning as a student as our norm practice is to give yellow (propofol), blue (nartotics), and red (muscle relaxant) for surgical cases. As I gained more clinical experiences as a practitioner, I started to understand the attending’s rational and accordingly changed my practice to minimize giving narcotics intraop. I am not against giving narcotics and I believe it does have its place in managing patient’s pain. But I feel that sometimes we give narcotics because we are so used to give it. I am guilty as charged as well. So I would like to share my learned experiences with you guys and would love to hear what you think about this.

As most of the hospitals promote ERAS for faster recovery, less amount of opioids is desired intraop and postop because there was less chance for respiratory depression, over-sedation, nausea/vomiting, constipation, and ileus. In addition, hospitals start to modify opioid prescribing practices/policies on discharge after surgery to reduce the likelihood of opioid addiction. Opioidfree anesthesia and multimodal analgesia have gained popularity as evidence showed lower narcotics consumption and faster recovery compared to the traditional pathway. Multimodal analgesia include lidocaine, IV tylenol, toradol, ketamine, gabapentin, magnesium, precedex, beta-blockers, all of which can facilitate opioid sparing. ERAS protocol often includes lidocaine, IV tylenol, toradol, and gabapentin. Other adjuncts may have been under-used are magnesium, precedex, ketamine,  especially for chronic pain patients and morbidly obese patients who may either need too much narcotics to adequately control the pain or may not be a good candidate to receive narcotics due to severe sleep apnea. For instance,  intraoperative magnesium administration has found to improve postoperative pain control, and is similar to the effects of ketorolac 30 mg administered in the beginning of surgery.  For patients who are unable to receive toradol, Mg could be used as an adjunct to reduce opioid consumption. IV Mg is also useful in managing chronic pain patient intraoperatively. Similarly, dexmedetomidine is a great adjunct to reduce narcotic consumption and pain perception particularly useful in the morbidly obese population  during the perioperative period. Ketamine is another drug that we love to use that has great opioid sparing effects.

I guess, if you have read this far, you know my point. We don’t have to be so boring with yellow, blue and red only to managing our patients (the drug label colors of propofol, narcotics, and muscle relaxants). Let’s make a rainbow instead so our patients can benefit from the multi-modal analgesia approach.

 

References:
Sousa AM1Rosado GM2Neto Jde S3Guimarães GM4Ashmawi HAMagnesium sulfate improves postoperative analgesia in laparoscopic gynecologic surgeries: a double-blind randomized controlled trial. J Clin Anesth. 2016 Nov;34:379-84. doi: 10.1016/j.jclinane.2016.05.006. Epub 2016 Jun 5.
Vaughns JD1Martin C2Nelson J2Nadler E3Quezado ZM. Dexmedetomidine as an adjuvant for perioperative pain management in adolescents undergoing bariatric surgery: An observational cohort study. J Pediatr Surg. 2017 Apr 19. pii: S0022-3468(17)30246-4. doi: 10.1016/j.jpedsurg.2017.04.007.
Haryalchi K, Abedinzade M, Khanaki K, Mansour Ghanaie M, Mohammad Zadeh F. Whether preventive low dose magnesium sulphate infusion has an influence on postoperative pain perception and the level of serum beta-endorphin throughout the total abdominal hysterectomy. Rev Esp Anestesiol Reanim. 2017 Aug – Sep;64(7):384-390. doi: 10.1016/j.redar.2016.11.009. Epub 2017 Feb 14.

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