O C T O B E R 2 0 1 9 • O U T PA T I E N T S U R G E R Y. N E T • 8 1
by 50 mg of IV ketamine given 2 to 5 minutes before the incision
and then a pre-incision subcutaneous injection of lidocaine with
epinephrine, which Dr. Friedberg says acts faster than bupivacaine.
The incremental propofol induction and maintenance protects
against ketamine's negative side effects.
The timing of the ketamine dose is key because failure to preemp-
tively saturate the NMDA receptors causes the wind-up phenome-
non, which eliminates the effectiveness of your opioid-free efforts
to control post-op pain. Dr. Friedberg says giving the low dosage of
ketamine in that 2- to 5-minute window doesn't merely "block" or
close the door on the NMDA receptors, it slams that door shut.
That's how patients wake up pain free.
If you're skeptical about Dr. Friedberg's method, he urges you to
try one part of his analgesic cocktail. "Administer 50 mg of keta-
mine 3 minutes before the incision," he says, "and you'll see a dra-
matic improvement in your patients' post-op [pain levels]."
OSM
patients once they return home, often mere hours after surgery,
you have to make sure they know exactly how to manage pain on
their own. In addition to strategic pain management instructions
(go around the clock with your NSAIDS to stay ahead of the pain,
for example), the EMR at Montefiore Hutchinson Metro ASC is
set to flag any patient who gets a nerve block, so they receive
additional discharge instructions.
"The directions cover everything patients might encounter,"
says Curtis Choice, MD, MS, Montefiore's director of anesthesi-
ology. "It lets patients know things like when their block will
wear off, say, at 2 a.m., and tells them not to be alarmed if they
wake up in the morning with their arm still numb."
—Jared Bilski