places 10 CRNAs and 5 physician-anesthesiologists throughout
Florida.
The maxim — general never fails but regional is iffy — no longer
holds true, says Dr. Lawson. It helps that he no longer relies on anatom-
ical landmarks and patient cooperation to place blocks. Now he places
blocks with the precision of dual guidance: nerve stimulation and high-
resolution ultrasound.
For orthopedic cases, his go-to anesthetic consists of motor-sparing
peripheral nerve blocks, such as the iPACK (interspaced between the
popliteal artery and the capsule of the posterior knee) and adductor
canal block, as well as oral diclofenac, gabapentin and acetamino-
phen.
For abdominal cases, it's oral diclofenac, gabapentin and acetamino-
phen, as well as a TAP (transverse abdominis plane) block. The TAP
block was initially used for such lower abdominal surgeries as prosta-
tectomies and hysterectomies, but providers are now applying it to
other locations, including the upper abdomen for patients who have
laparoscopic cholecystectomy or other upper abdominal minimally
invasive procedures.
"You have to try to find and promote techniques that not only have
clinical benefits, but are also fairly easy for providers to perform.
Otherwise, it's difficult to get them to the point to apply them consis-
tently," says Ed Mariano, MD, MAS, chief of anesthesiology and peri-
operative care at the Veterans Affairs Palo Alto (Calif.) Health Care
System.
Opioid-sparing movement
These days, you can't discuss post-surgical pain management without
first talking about the opioid crisis. Few would disagree that opioid-
sparing pain relief is desperately needed, so how is it that from 2010
J U N E 2 0 1 9 • O U T PA T I E N T S U R G E R Y. N E T • 5 1
