A Treatment Protocol for Opioid-Minimal Postoperative Pain Management

James Price, MD

Today, James Price, MD, an anesthesiologist and perioperative pain specialist with the Arctic Surgical Group in Anchorage, AK, shared his perspectives on how a full-length, multimodal practice to treat postsurgical pain could minimize patient reliance on opioids—and therefore aid in the prevention of opioid addiction risk.

In alignment with the multimodal approach plan, Price has shared with MD Magazine® his surgical group’s treatment protocol, posted step-by-step below.

1. Preoperative Multimodal Analgesia Program

• Gabapentin 300 mg orally (PO) 5 times a day for 2 weeks preoperatively as tolerated (gabapentin 300 mg each day if glomerular filtration rate (GFR) is greater than 70) (100 mg on prescription 3 times daily [TID] if GFR is less than 50)
• Celecoxib (Celebrex) 200 mg PO twice daily (BID) (caution in renal patients).
• Methadone 20 mg intravaneously (IV) preoperatively (preoperative electrocardiogram [EKG] must be performed to measure QT interval less than 0.45 and the patient denies any cardiac disease, arrhythmias, obstructive sleep apnea, or liver insufficiency)
• Acetaminophen (Tylenol) 1000 mg PO
• Melatonin 5 mg PO for angiolysis
• Dexamethasone 10 mg IV
• Ketorolac (Toradol) 30 mg IV
• Prehydration with carbohydrate load, 40 ounces of sports drink (Gatorade) at bedtime, 10 ounces morning of surgery 2 hours before surgery.
• Dexamethasone 10 mg IV

2. Intraoperative: Induction with TIVA Anesthesia

1. Propofol 100 - 150 mg
2. Dexmedetomidine 20 mcg
3. (If methadone is not used) Remifentanil 50 mcg then .125 mcg/kg/minute for maintenance

3. Maintenance of Total Intravenous Anesthesia (TIVA)

• Ketamine 0.5 mg/kilo bullous before incision is made, then 0.2 mg/kg/hour.
• Dexmedetomidine 0.2 mcg/kilo/hour
• Propofol 120 mg/kg/minute. Maintain this at 30 to 40 range
• Magnesium 2 gm over 2 hours IV

4. Closing

• 0.25% bupivacaine with clonidine and ketamine

5. Postoperative

• Continue outpatient dosing for gabapentin to a goal of 1500 mg to 2400 mg a day. Caution in renal patients and elderly.
• Tylenol 1 gm q. eight hours.
• Celebrex 100 mg PO BID. (caution in renal patients)
• Oxycodone 5 - 10 mg PO q 4 - 6 hours as needed for pain

6. Postoperative in the PACU:

• Continue ketamine infusion 0.2 mg/kg/hour for 1 - 2 hours with dedicated anesthesiologist to the PACU theater

7. Discharge Medications:

• Tylenol 1 gm PO q 8 hours
• Celebrex 100 mg PO BID
• Gabapentin 300 mg PO 5 times a day
• Oxycodone 5 to 10 mg PO q 4 - 6 hours
• Melatonin 5 mg PO at bedtime (QHS)
• Magnesium 1 to 2 gm PO QH

James Price, MD, is a board-certified Anesthesiologist and Perioperative Pain Specialist with the Arctic Surgical Group in Anchorage, AK. He is a diplomat of the American Board of Anesthesiology and a delegate to the American Society of Anesthesiologists.The piece reflects his views, not necessarily those of the publication. Healthcare professionals and researchers interested in responding to this piece or contributing to MD Magazine® can reach the editorial staff here.