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Chapter 29: Postoperative Period

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Whenever possible, it is recommended to use multimodal analgesia for postoperative pain management. Following total knee arthroplasty, which multimodal technique for postoperative pain management is most effective?

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(A) postincisional infiltration of bupivacaine

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(B) epidural morphine

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(C) IV opioids and pregabalin

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(D) IV opioids and ketamine

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(E) IV opioids and acetaminophen

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The answer is C. Meta-analysis data shows that intravenous (IV) opioids with calcium channel blockers (gabapentin or pregabalin) are a useful multimodal technique that improves analgesia, compared to IV opioids alone.

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Multimodal pain management is defined as the administration of two or more analgesic drugs (each with a distinct mechanism of action). Therefore, although epidural morphine and postincisional infiltration of bupivacaine can both improve postoperative analgesia, in and of themselves they are not multimodal techniques.

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IV opioids with ketamine and IV opioids with acetaminophen are both multimodal techniques, but current evidence is inconsistent as to whether they are superior to IV opioids alone. However, it is currently recommended, except when contraindicated, that all surgical patients receive multimodal pain management including around-the-clock NSAIDs, COX-2 selective NSAIDs, or acetaminophen.

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Refs: American Society of Anesthesiologists Task Force on Acute Pain Management, Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management, Anesthesiology 2012;116:248–273.

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Miller RD. Miller's Anesthesia, 8th ed. Philadelphia, PA: Elsevier; 2015.

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In an attempt to reduce the incidence of chronic postsurgical pain (CPSP), nonopioid adjuvant analgesics are often administered. Best evidence suggests which of the following adjuvants may modify the risk of CPSP?

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(A) ketamine

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(B) gabapentin

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(C) dexmedetomidine

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(D) magnesium

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(E) amitriptyline

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The answer is B. Best evidence suggests that gabapentin (and pregabalin) can prevent CPSP. CPSP is defined as the presence of unexplained pain more than 2 months postoperatively. Depending on the type of surgery, the incidence of CPSP can range from ~10% to >50%. A number of different nonopioid adjuvants have been studied to reduce the incidence of CPSP. Studies of ketamine, dexmedetomidine, magnesium infusions, lidocaine infusions, and various antidepressants (TCAs—amitriptyline, SSRIs, and SNRIs) are unfortunately either limited or sometimes contradictory.

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Refs: Miller RD. Miller's Anesthesia, 8th ed. Philadelphia, PA: Elsevier; 2015.

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Ramaswamy S, Wilson JA, Colvin L. Non-opioid-based adjuvant analgesia in perioperative care. Contin Educ ...

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