Latest / Bent on Education / Multimodal Analgesia...is it worth the hype?

Transcript

Multimodal Analgesia...is it worth the hype? · Bent on Education

• 0:00
  SPEAKER_00: Welcome to Bent on Education Podcast, a podcast focusing on evidence-based review of physiology, pharmacology, pathophysiology, and other anesthesia-related topics.
• 0:12
  SPEAKER_00: I'll discuss being a clinical preceptor, a mentor, and a leader.
• 0:16
  SPEAKER_00: This podcast is by CRNA for SRNAs and others seeking to build their basic knowledge base.
• 0:22
  SPEAKER_00: So let's get bent on education.
• 0:37
  SPEAKER_00: So, you know, the reason for this podcast, of course, is to simplify some of the most complex anesthesia concepts and as students, bridging the gap between what you hear in the classroom and what happens in the operating room.
• 0:53
  SPEAKER_00: Today we're going to talk about multimodal analogesia.
• 0:56
  SPEAKER_00: And with that, there is a science of better pain control without relying on opioids or solely relying on opioids.
• 1:05
  SPEAKER_00: So we'll talk about those things.
• 1:08
  SPEAKER_00: Whether you're studying for your C or NCE or just preparing for clinical or just adding to your regular knowledge base, multimodal analogesia is no longer just a recommendation.
• 1:23
  SPEAKER_00: It's kind of becoming a standard of care, and we'll talk about what that means.
• 1:28
  SPEAKER_00: Now, what are some of the things that we're going to discuss?
• 1:31
  SPEAKER_00: We will discuss what multimodal analogesia actually means.
• 1:36
  SPEAKER_00: We'll talk a little bit about the physiology of pain and why opioids alone are sometimes no longer enough for the patients that we take care of.
• 1:45
  SPEAKER_00: Each of the major classes of analgesia, we'll talk about that a little bit.
• 1:50
  SPEAKER_00: Some regional anesthesia and local anesthetics.
• 1:54
  SPEAKER_00: And we'll get into ERAS protocols as well.
• 1:56
  SPEAKER_00: And I know that, you know, you guys are in clinical, or some of you are in clinical, or some of you again are just learning, but we'll talk about what ERAS protocols are.
• 2:06
  SPEAKER_00: Other things is how to build a multimodal analogesia plan for a variety of surgeries that you might see, or a variety of patients that you might see.
• 2:18
  SPEAKER_00: So always the best thing is to start at what defines multimodal analogesia.
• 2:26
  SPEAKER_00: It's basically the use of two or more analogesic medications or techniques that work through different mechanisms of action.
• 2:38
  SPEAKER_00: And what this does is that it improves pain control while also minimizing the use of opioids or the opioid requirement for each patient.
• 2:49
  SPEAKER_00: So the goal here isn't simply to eliminate pain because we can't always do that.
• 2:56
  SPEAKER_00: And keeping pain under control is what we're trying to do.
• 3:00
  SPEAKER_00: But the goal is to reduce pain enough so that the patient can take nice deep breaths.
• 3:07
  SPEAKER_00: They can walk around when it's feasible for them.
• 3:11
  SPEAKER_00: They can participate in physical therapy because we know we like to get patients up and moving after surgery.
• 3:18
  SPEAKER_00: They essentially can recover faster and hopefully experience less side effects than they normally would if we were using a solely opioid or opiate-based analogesic plan.
• 3:34
  SPEAKER_00: So instead of depending on just one medication, morphine, diluted, whatever your opioid or opiate of choice is, we're going to start attacking pain from different locations within the nervous system.
• 3:51
  SPEAKER_00: So what you want to do is think of pain as a relay race, right?
• 3:57
  SPEAKER_00: The baton gets handed off to the next thing.
• 4:01
  SPEAKER_00: So when your pain signal travels, it starts at the peripheral tissues where the injury occurs.
• 4:08
  SPEAKER_00: After that, it gets into, you know, it hands off the pain signal to the peripheral nerves and finally to the spinal cord and the ascending pathways and then the brain.
• 4:19
  SPEAKER_00: So what we want to do along the way is use multimodal analoggesia to interrupt that baton handoff at multiple checkpoints and kind of simultaneously, they're all working at the same time.
• 4:33
  SPEAKER_00: What happens with this is that it creates a synergistic analoggesia or synergistic analogesic plan in that we're attacking pain from all different levels so that the patient can experience hopefully some degree of comfort, you know, along the way while there's still some pain but not excruciating.
• 4:56
  SPEAKER_00: In order to get what I think is a decent handle on pain and how to attack pain from a patient's perspective, we kind of have to understand pain physiology.
• 5:09
  SPEAKER_00: So let's just review it ever so slightly so that we have something to build upon as we move forward.
• 5:16
  SPEAKER_00: Remember that pain begins with that tissue injury.
• 5:20
  SPEAKER_00: And once it, you know, peripheral tissues are injured, um, the inflammatory mediators are released.
• 5:27
  SPEAKER_00: And what are those mediators?
• 5:29
  SPEAKER_00: Uh, prostaglandins, histamine, substance P, cytokines.
• 5:35
  SPEAKER_00: Some of you who have been in our interview process at my school may have heard these words before.
• 5:43
  SPEAKER_00: Um, also serotonin and braidokinins.
• 5:46
  SPEAKER_00: So you have to kind of keep in mind what those inflammatory mediators are.
• 5:51
  SPEAKER_00: What happens when they are released is that these chemicals then lower the threshold of nociceptors.
• 5:59
  SPEAKER_00: So now those pain receptors fire a little bit more easily, like right away, right away.
• 6:06
  SPEAKER_00: So this is what's called peripheral sensitization.
• 6:10
  SPEAKER_00: The pain signal then travels through our A delta fibers.
• 6:15
  SPEAKER_00: And when we're looking at A delta fibers, what they carry are sharp pain, localized pain, fast pain.
• 6:23
  SPEAKER_00: So this is you stub your toe, you burn your hand.
• 6:26
  SPEAKER_00: You've probably seen this example before.
• 6:28
  SPEAKER_00: Um, that's through your A delta fibers.
• 6:32
  SPEAKER_00: Our C fibers, um, you know, that's where the pain signal travels as well.
• 6:38
  SPEAKER_00: Our C fibers carry dull pain, that aching pain, that burning pain.
• 6:43
  SPEAKER_00: So once, you know, we're inside the dorsal horn of the spinal cord, the neurotransmitters like uh glutamate or substance P then activate the NMDA receptor sites.
• 6:58
  SPEAKER_00: And when there's repeated stimulation, what happens is central sensitization.
• 7:04
  SPEAKER_00: This is commonly referred to as windup.
• 7:08
  SPEAKER_00: So windup happens uh with patients.
• 7:12
  SPEAKER_00: So for many years, anesthesia relied heavily on opioids, and opioids are an excellent analogesic.
• 7:21
  SPEAKER_00: We use them every day, we see how they work and all of those things.
• 7:25
  SPEAKER_00: But we also have to keep in mind that there are some drawbacks that come with the administration or using opioids.
• 7:32
  SPEAKER_00: Um, some of the side effects we already know, respiratory depression, of course, a sedated patient.
• 7:40
  SPEAKER_00: Um, some of the things that we don't see right away, but patients might see once they go home, uh, constipation and retention of urine, things like that.
• 7:49
  SPEAKER_00: And of course, you know, the big push on postoperative nausea and vomiting, of course, itching and things of that nature.
• 7:57
  SPEAKER_00: We could go on and on down the list.
• 8:00
  SPEAKER_00: Um, so opioid-induced hyperalgesia is something as well.
• 8:05
  SPEAKER_00: And this is particularly important.
• 8:08
  SPEAKER_00: Uh, when we give our patients large doses of an opioid or an opia, we can actually increase postoperative pain sensitivity sometimes.
• 8:20
  SPEAKER_00: Um, so that's one of the many reasons why ERAS protocols emphasize opioid-sparing anesthesia.
• 8:28
  SPEAKER_00: And also remember that the best multimodal plan isn't opioid-free.
• 8:34
  SPEAKER_00: It's actually being opioid smart, if you think about it in that way.
• 8:39
  SPEAKER_00: We're going to review a couple different medication classes just to kind of keep us on the same page as to medications that we're going to use for opioid sparing or multimodal analogesia protocols and things like that.
• 8:53
  SPEAKER_00: So we'll just dive into it with acetamenophen.
• 8:56
  SPEAKER_00: The mechanism of action of acetamenophil is not 100% understood.
• 9:01
  SPEAKER_00: It likely inhibits central cox enzymes, um, and it also affects uh seratogenic uh pathways too.
• 9:10
  SPEAKER_00: So some of the advantages we see with the use of acetamenophil is that it does have minimal side effects.
• 9:17
  SPEAKER_00: Really good for opioid sparing.
• 9:20
  SPEAKER_00: We can give it in multi, I mean, an abundance of ways.
• 9:23
  SPEAKER_00: We can give it by mouth, we can give it IV, four little ones we can give per rectum.
• 9:29
  SPEAKER_00: When we're looking at some of the daily doses or the maximum daily dose that we want to give patients when we're using acetaminophen, a healthy patient, four grams total for the day, divided, you know, typically over Q4 hours, sometimes every six hours, um, three grams or less in patients who are elderly or who have some sort of liver disease.
• 9:56
  SPEAKER_00: The other thing that we want to understand as well is that IV Tylenol or IV acetamen reaches its peak concentration much faster than the oral dosing of the medication.
• 10:09
  SPEAKER_00: So keep that in mind when we are dosing our patients or giving patients acetamenophen.
• 10:16
  SPEAKER_00: How quickly do we want it to work?
• 10:17
  SPEAKER_00: I mean, you're gonna give it IV, of course.
• 10:20
  SPEAKER_00: Non-steroidal anti-inflammatories, uh, Cotorillac, ibuprofen, um, celebrex, for example, maloxicam, those things are maloxicam and celebrex for the most part are making a little bit of a bigger uh splash into um, you know, pain control for patients.
• 10:39
  SPEAKER_00: These do act as COX uh inhibitors.
• 10:43
  SPEAKER_00: Um, and so when we give an NSAED, it reduces prostaglandin synthesis so that the patient uh winds up with less peripheral inflammation.
• 10:55
  SPEAKER_00: Now, what are some of the advantages of giving an NSAID?
• 10:59
  SPEAKER_00: It's great for the inflammatory process or inflammatory pain.
• 11:03
  SPEAKER_00: It does reduce our opioid requirement.
• 11:06
  SPEAKER_00: We love Cotorolac intraoperatively for cases that warrant Cotorelac.
• 11:12
  SPEAKER_00: Of course, there are some cases that you do want to stay away from Cotorolac with.
• 11:16
  SPEAKER_00: Um, but some of our potential concerns uh are bleeding, uh, of course, any kind of renal dysfunction, and patients who have gastric ulcerations too.
• 11:28
  SPEAKER_00: Remember that it does inhibit platelets, um, so that is something to keep in mind.
• 11:36
  SPEAKER_00: And selective COX2 inhibitors like Celebrex reduce platelet effect.
• 11:42
  SPEAKER_00: So, again, something to keep in mind when we're giving them to patients.
• 11:46
  SPEAKER_00: Like any kind of medication you're giving, you always want to know the patient's history first.
• 11:52
  SPEAKER_00: Gabapentinoids are another class of medication that makes a resurgence when we talk about multimodal analogesia.
• 12:01
  SPEAKER_00: So, gabapentin, um pregavalin, for example, how do these work?
• 12:07
  SPEAKER_00: They bind um alpha 2 delta calcium channels and they decrease the excitatory neurotransmitter release.
• 12:16
  SPEAKER_00: Um, what are they really helpful for?
• 12:20
  SPEAKER_00: Is neuropathic pain.
• 12:22
  SPEAKER_00: Spine surgery is, you know, another one.
• 12:24
  SPEAKER_00: We tend to give the uh you know gabapentin to patients in the preoperative area, or they come in having taken a dose of gabapentin.
• 12:34
  SPEAKER_00: Also great for chronic pain patients, but we want to look at what are potentially some of the side effects you might be seeing.
• 12:43
  SPEAKER_00: Sedation, uh dizziness in these patients.
• 12:46
  SPEAKER_00: So you want to make sure that if they're staying in the hospital while they're on that medication, they may be a fall risk.
• 12:54
  SPEAKER_00: Of course, if we're combining gabapentin with an opioid, we can see some respiratory depression with patients.
• 13:03
  SPEAKER_00: So recent evidence suggests that these medications should be used selectively rather than routinely for patients.
• 13:13
  SPEAKER_00: Ketamine is probably hands down one of the most important multimodal drugs that we have in anesthesia.
• 13:20
  SPEAKER_00: There's so many different uses for ketamine.
• 13:23
  SPEAKER_00: When we look at the mechanism of action of ketamine, it is an NMDA receptor antagonist.
• 13:30
  SPEAKER_00: So the benefit of using this medication is that it does help to prevent that wind-up phenomenon that we talked about a little bit earlier.
• 13:38
  SPEAKER_00: Also prevents opioid-induced hyperalgesia, and it's really excellent for opioid sparing.
• 13:45
  SPEAKER_00: So it works pretty good or excellent in patients who are opioid tolerant already.
• 13:53
  SPEAKER_00: Usually will give ketamine in an infusion for patients 0.1 to 0.3 milligrams per kilogram per hour, especially in bigger cases that you're using, any kind of Tiva cases.
• 14:06
  SPEAKER_00: And low-dose ketamine does provide really nice analgesia without significant anesthesia for patients.
• 14:14
  SPEAKER_00: Um lidocaine.
• 14:16
  SPEAKER_00: Lidocaine is making a bit of a resurgence as well when we're looking at multimodal analgesia.
• 14:23
  SPEAKER_00: The mechanism of action is that it does block sodium channels and reduces inflammatory signaling, which is great.
• 14:31
  SPEAKER_00: So, what are some of the benefits of using lidocaine?
• 14:34
  SPEAKER_00: I do a whole talk on multimodal analoggesia, and we in that talk I discuss the benefits because it reduces ileus.
• 14:43
  SPEAKER_00: So when we think about using opioids, one of the things we worry about is a patient developing an ileus, and lidocaine really just helps reduce that.
• 14:53
  SPEAKER_00: Let's move on to uh dexmedatomidine.
• 14:56
  SPEAKER_00: So we all know that dexmedatomidine is an alpha-2 agonist.
• 15:00
  SPEAKER_00: What happens with that is it produces sedation, some analogesia, um, some patholysis as well.
• 15:09
  SPEAKER_00: Uh, the nice thing about dexmedatomidine is that patients end up with minimal respiratory depression, so that works really well.
• 15:18
  SPEAKER_00: Now, some of the things that you need to be concerned about when you're using a dexmedatomidine uh push or infusion or anything like that is bradycardia, right?
• 15:28
  SPEAKER_00: Um, we also look at a little bit of hypotension and how this medication plays nicely into a multimodal effect is that it's great for spine surgery, um, really good for bariatric surgery, and patients that are at high risk for opioid complications and you want to stay away from opioids, uh, dexmenatomidine is a great drug to use.
• 15:54
  SPEAKER_00: Now we're going to go to a tried and true magnesium.
• 15:58
  SPEAKER_00: And I don't think we think about this as often or as much when we're doing multimodal analoggesia, but you know, it's a great medication to kind of pull out of your back pocket if you need to.
• 16:12
  SPEAKER_00: It is an NMDA receptor antagonist.
• 16:16
  SPEAKER_00: Um, and so it does have some calcium channel effects as well.
• 16:19
  SPEAKER_00: What are some of the benefits of utilizing magnesium, magnesium sulfate into your uh multimodal um, you know, toolbox, if you will?
• 16:30
  SPEAKER_00: Um, it does reduce postoperative opioid requirement.
• 16:34
  SPEAKER_00: So you're giving patients less opioid, which is kind of the goal here.
• 16:38
  SPEAKER_00: It may reduce chronic pain development.
• 16:41
  SPEAKER_00: Um, and it's often forgotten, but you know, again, it's one of those things that you want to think way back and pull it out if necessary.
• 16:50
  SPEAKER_00: Now, we don't think about corticosteroids in a way of pain management, but there is evidence that suggests that your corticosteroids or uh dexamethasone is a decent enough pain management um medication.
• 17:09
  SPEAKER_00: Of course, not solely, but definitely something to keep in mind.
• 17:13
  SPEAKER_00: What are some of the benefits of using uh dexamethasone or decadron?
• 17:19
  SPEAKER_00: It's an anti-inflammatory.
• 17:20
  SPEAKER_00: We already know that.
• 17:21
  SPEAKER_00: We use it for airway things for to decrease inflammation.
• 17:25
  SPEAKER_00: So a great anti-inflammatory.
• 17:28
  SPEAKER_00: It is wonderful for the reduction of postoperative nausea.
• 17:32
  SPEAKER_00: Um, and it does, you know, when you use it in like your nerve blocks and things of that nature, it does prolong the duration of that nerve block.
• 17:42
  SPEAKER_00: Um, your common intra-operative doses of your corticosteroid or deximethasone is four to ten milligrams IV.
• 17:51
  SPEAKER_00: You know, there are patient populations that you want to stay away from uh using this medication, someone who has uncontrolled diabetes with you know elevated blood sugars.
• 18:02
  SPEAKER_00: Um, you want to be very cautious with this.
• 18:05
  SPEAKER_00: There are also some side effects that we don't talk about, um tumor lysis syndrome and and so on.
• 18:11
  SPEAKER_00: So make sure that the patient that you want to use um decadron with is appropriate uh, you know, in the utilization of that medication.
• 18:22
  SPEAKER_00: So regional anesthesia, um, we talk about it a lot.
• 18:27
  SPEAKER_00: And it's becoming almost commonplace in anesthesia delivery.
• 18:34
  SPEAKER_00: So it's perhaps one of the most powerful components of multimodal analoggesia.
• 18:40
  SPEAKER_00: And those who are really good at it, man, they're they're great.
• 18:45
  SPEAKER_00: I work with some anesthesiologists that they do blocks, and I'm just like, wow, like how did you just, you know, learn that and and develop a great technique and things like that?
• 18:56
  SPEAKER_00: But it takes practice.
• 18:57
  SPEAKER_00: So it's not one of those techniques that you just want to walk into and say, okay, I saw a couple YouTube videos and things.
• 19:04
  SPEAKER_00: Um, and if you don't know how to identify anatomy and where the nerves are and where the nerve bundles are and vessels and things like that, it's probably something you want to get to know how to do prior to delivering a nerve block, right?
• 19:20
  SPEAKER_00: That just makes sense.
• 19:21
  SPEAKER_00: So the nice thing about regional techniques is that they actually interrupt pain before it reaches the spinal cord.
• 19:31
  SPEAKER_00: So that's great.
• 19:32
  SPEAKER_00: We take care of things for the patient before they, you know, experience that pain.
• 19:37
  SPEAKER_00: Some of the examples, and we're not going to go into each block, of course.
• 19:41
  SPEAKER_00: Um, maybe we could do that in a later podcast, but some of the examples of uh regional techniques that are super helpful, of course, are spinal anesthesia, um, epidural anesthesia, any of your peripheral nerve blocks and your fascial plane blocks, too.
• 19:58
  SPEAKER_00: Some of the examples of those specifically are like your adductor canal blocks, your ESP blocks, um, your tap blocks, and so on and so forth.
• 20:08
  SPEAKER_00: Uh, what are the benefits?
• 20:10
  SPEAKER_00: The benefits are vast, and the benefits are great.
• 20:13
  SPEAKER_00: Um, they provide superior pain control when they're done properly, right?
• 20:18
  SPEAKER_00: We have seen failed blocks, but um if they're done in the right manner, in the right place, in the right nerve bundle, and all of that, they do provide superior pain control.
• 20:29
  SPEAKER_00: Patients have earlier ambulation, so they're allowed to walk around or they they walk around sooner because they still have that numbness.
• 20:38
  SPEAKER_00: But of course, patients need to be educated that, hey, this is numb, so you want to be very careful in the things that you do because you won't be able to feel it.
• 20:48
  SPEAKER_00: Um, lower opioid use.
• 20:50
  SPEAKER_00: Of course, we want to make sure that the patient understands once this nerve block is starting to wear off, that you do want to control that pain because then they may have that wind-up, and we don't want that for our patients.
• 21:03
  SPEAKER_00: Of course, a shorter hospital stay, um, pretty high patient satisfaction, and with the addition of a liposomal bupivacaine, this may further prolong the block in selected cases.
• 21:19
  SPEAKER_00: So when we look at ERAS and multimodal analogesia, so ERAS, big name, you know, we've been talking about it for years, but enhanced recovery after surgery programs rely heavily on a multimodal approach to our analogesics.
• 21:36
  SPEAKER_00: So typical ERAS pathways when we look at the preoperative course is patient education.
• 21:43
  SPEAKER_00: We want to make sure that our patients are well educated on what this all means for them.
• 21:49
  SPEAKER_00: Typically, acetamenophen or celibrax, those medications are utilized.
• 21:55
  SPEAKER_00: Gabapentin for selected patients is another medication.
• 22:00
  SPEAKER_00: That we utilize preoperatively for the patient.
• 22:03
  SPEAKER_00: Now, we talked about some of these medications and infusions just a few minutes ago, but intraoperatively, regional anesthesia techniques are superior, like I said.
• 22:14
  SPEAKER_00: Of course, the ketamine infusion, the utilization of dexmetatomidine, lidocaine infusions, and so on.
• 22:22
  SPEAKER_00: We talked a little bit about using magsulfate too.
• 22:25
  SPEAKER_00: And postoperatively, we want to make sure that the patient, like I said, that they have their scheduled analgesic approach, because if they're just relying on the nerve block, eventually that nerve block is going to wear off.
• 22:39
  SPEAKER_00: So having scheduled acetamenophen, NSAIDs, whether it's Celebrex or you know, Motrin slash ibuprofen, a regional catheter if that's indicated.
• 22:50
  SPEAKER_00: So if a patient is staying in the hospital, having a catheter in that's delivering local anesthetic on a continual basis is helpful.
• 23:00
  SPEAKER_00: Using opioids as a breakthrough only.
• 23:03
  SPEAKER_00: So patient has breakthrough pain.
• 23:06
  SPEAKER_00: Yes, maybe they do need an opioid-based solution.
• 23:10
  SPEAKER_00: And the nice thing again is that patients recover faster because pain control supports them moving around rather than causing sedation, and pain control helps them get ambulated quicker if they, you know, were using just a pure opioid-based uh type of analogesic approach.
• 23:32
  SPEAKER_00: So let's talk about or go over like two cases that may be cases we look at as far as utilization of a multimodal approach.
• 23:44
  SPEAKER_00: Um, an open colon resection, for example.
• 23:47
  SPEAKER_00: Um preoperatively, perhaps this patient, and this is just a, hey, this is what you can do.
• 23:52
  SPEAKER_00: It's not saying this is what you're going to do, but these things kind of work out pretty well for these patients.
• 23:58
  SPEAKER_00: Um, preoperatively, looking at giving acetametaphen, um celabrax if the patient can tolerate either or intraoperatively for an open colon resection, a lidocaine refuse infusion would be great.
• 24:12
  SPEAKER_00: Maybe a tap block and a dexmedatomidine infusion.
• 24:16
  SPEAKER_00: Now, when we're looking at something like a dexmedatomidine infusion or lidocaine infusion, of course, we all know that you have to make sure the patient isn't allergic to certain things or that they hadn't had a bad reaction to them.
• 24:28
  SPEAKER_00: But those are two really good medications to use for this patient.
• 24:32
  SPEAKER_00: One of the reasons why lidocaine is really helpful is because it, with the prevention, like I talked about previously, um, you know, it helps with the prevention of an ileus, just because you're not just dumping all this opioid into this patient.
• 24:48
  SPEAKER_00: And thinking of the colon, we want to make sure peristalsis and all of those things are working nicely.
• 24:54
  SPEAKER_00: Um, so just minimum opioids during the procedure, super helpful.
• 24:59
  SPEAKER_00: And post-operatively, like I said, scheduling NSAIDs, uh, acetamenophen or Tylenol, and using opioids as a rescue for this patient.
• 25:09
  SPEAKER_00: Now, there are some patients we're gonna run into that are chronic opioid use patients.
• 25:18
  SPEAKER_00: Okay, so the thing that's special or that makes sense with these patients is that you are gonna continue their baseline opioids.
• 25:26
  SPEAKER_00: We don't want a situation where the patient's gonna go through withdrawal or anything like that.
• 25:31
  SPEAKER_00: Some of the additions that we might use uh with this patient might be ketamine.
• 25:36
  SPEAKER_00: Of course, I mean I can't speak any more highly of regional anesthesia, acetamenophen and NSADS if they're appropriate.
• 25:45
  SPEAKER_00: With these patients who have chronic opioid use, we must, as providers, expect higher postoperative opioid needs while still employing some kind of opioid sparing strategy.
• 25:57
  SPEAKER_00: So we don't want to throw these patients into a situation where they have withdrawal symptoms, but we want to spare opioids as much as we possibly can.
• 26:08
  SPEAKER_00: Now let's go over a couple NCE clinical kind of things to keep in mind.
• 26:14
  SPEAKER_00: For those of you who don't know or who are not sRNAs, um NCE is our national certification exam.
• 26:20
  SPEAKER_00: So if you're listening and you are a nurse or just an avid healthcare buff or someone who's just interested in pharmacology, these are helpful for you as well.
• 26:31
  SPEAKER_00: So here's a couple uh high yield, if you will, points that students might want to take home as far as preparation for their national certification exam.
• 26:41
  SPEAKER_00: Remember that ketamine prevents central sensitization through NMDA antagonism.
• 26:47
  SPEAKER_00: That's one point.
• 26:48
  SPEAKER_00: Um NSAIDs inhibit prostaglandin production by the by their COX inhibition.
• 26:54
  SPEAKER_00: Um dexmetatomidine, great for analogesia without significant respiratory depression.
• 27:01
  SPEAKER_00: And remember that with regional anesthesia, it often provides the greatest uh ability for us to reduce opioids of any single intervention.
• 27:12
  SPEAKER_00: Keep in mind that ERAS protocols depend on multimodal analoggesia to improve our patient's recovery and reduce complications that our patient might experience in relationship to opioid use.
• 27:27
  SPEAKER_00: And last but not least, our multimodal analoggesia.
• 27:32
  SPEAKER_00: What's the purpose?
• 27:34
  SPEAKER_00: It's about combining complementary mechanisms, not simply adding more medication, but using medication that complement each other to help the patient have less pain during and after a procedure.
• 27:49
  SPEAKER_00: So that's the end of that.
• 27:51
  SPEAKER_00: We explored reasons why multimodal analoggesia has sort of transformed perioperative care for patients.
• 27:58
  SPEAKER_00: So rather than depending on a single drug, we understand that the effective or that effective pain management comes from targeting multiple points along the pain pathway.
• 28:11
  SPEAKER_00: We want to target points from peripheral inflammatory to our spinal transmission and subsequently central perception of pain as well.
• 28:19
  SPEAKER_00: So this is how we're going to help our patient throughout that process.
• 28:23
  SPEAKER_00: As a future or practicing nurse anesthetist, your role really isn't just to keep patients asleep during surgery.
• 28:30
  SPEAKER_00: It's also to help them recover safely, get mobile sooner, return to life as they knew it, and the use of fewer opioid-related complications.
• 28:43
  SPEAKER_00: And in order to do that, using fewer opioids is going to be key.
• 28:48
  SPEAKER_00: So every anesthetic plan should include, you know, very thoughtful consideration of non-opioid medication.
• 28:56
  SPEAKER_00: We have our students do anesthesia management plans.
• 28:59
  SPEAKER_00: And when they're going through that, part of it is like, what's your goal for pain control for this patient and how are you going to accomplish this?
• 29:07
  SPEAKER_00: So the use of non-opioid medication is good, regional anesthesia when it's appropriate.
• 29:14
  SPEAKER_00: We all know there are reasons why patients cannot get regional anesthesia.
• 29:18
  SPEAKER_00: And definitely patient-specific factors such as their comorbidities, um, chronic opioid use, which we talked about a little bit, and the surgical procedure.
• 29:28
  SPEAKER_00: So the next time you're building your anesthesia plan, you want to ask yourself like, am I relying on just one medication to do all of the work, or am I using multiple evidence-based strategies to kind of complement each other for the patient's health and safety and all of those things?
• 29:47
  SPEAKER_00: So, as usual, thank you for joining me on another episode of Bent on Education.
• 29:53
  SPEAKER_00: If you found today's discussion or talk helpful, make sure you subscribe so you don't miss the next one.
• 30:01
  SPEAKER_00: Share this episode with a classmate, sRNA, or colleague that's preparing for their C or N CE.
• 30:08
  SPEAKER_00: Until the next time, keep learning, keep asking questions, and stay bent on education.