night mandates helps to clear up the confusion. "It eliminates the vari-
ables that can cause providers to wonder whether they're dealing with
a pain issue or a failure to optimize fluid levels before surgery," says
Dr. Luke. "Evidence shows drinking clear fluids before surgery pro-
vides more benefit in terms of absorption into the body than intraop-
erative administration of IV fluids and positively impacts the body's
fluid volume status."
3. Attack pain from every angle
Dr. Luke champions opioid-free anesthesia and strongly urges the
use of regional anesthesia — he calls it the cornerstone of UPMC's
perioperative pain management program — whenever it's deemed
appropriate.
Nerve blocks can function as the primary anesthetic absent any opi-
oids, says Michael Kim, MD, medical director of the value improve-
ment office and clinical assistant professor of anesthesiology at Keck
School of Medicine. Anesthesia providers there routinely administer
retrobulbar, superficial cervical plexus and sphenopalatine blocks for
surgeries involving the head and neck. They rely on the "big 5" —
interscalene, supraclavicular, femoral, popliteal and adductor canal
nerve blocks — to provide analgesia for the majority of patients who
undergo orthopedic procedures.
As an adjunct to nerve blocks, the right multimodal cocktail is
invaluable in curbing post-op opioid usage. "Each patient gets 1g of
PO Tylenol to start," says Dr. Dickerson. "They also get celecoxib or
intraoperative ketorolac, with or without gabapentinoids, which have
been shown to reduce opioid requirements and aid in preventing
chronic post-surgical pain.
"We also employ a multimodal general anesthetic in the OR, which
includes NMDA antagonists like magnesium and ketamine, and anti-
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