the posterior capsule, the medial periosteum and medial capsule, the
lateral periosteum and lateral capsule, and the surrounding soft tissue
— gave patients immediate pain relief after a total knee replacement
(osmag.net/Yq8KTb).
While soft tissue injections of local anesthesia can be a good adjunct
to regional blocks, they still don't provide the same lasting relief of
continuous nerve blocks, says Dr. Hickman. However, more manufac-
turers are attempting to create stronger formulas that could change
that in the future, he says.
4. Non-opioid analgesics
One thing that has really driven the multimodal approach in recent
years is the growing list of non-opioid analgesics, says Dr. Settles.
More providers are using combinations of these medications before,
during and after surgery in an effort to keep patients comfortable with-
out the side effects of opioids.
Non-steroidal anti-inflammatory drugs (NSAIDs) delivered intra-
venously can be a powerful addition to your multimodal plan. "You
get much higher blood levels and CNS (central nervous system) levels
with the IV NSAIDs over PO versions," says Dr. Hickman. "The CNS
levels show the drug is actually working in the brain."
You have plenty of options in IV NSAIDs, including a new diclofenac
sodium injection that can be delivered in a small-volume IV bolus
much more quickly than its alternative, ketorolac. However, Dr.
Hickman notes that ketorolac offers the same analgesic effect at a
lower cost. "The new option has the same complications and issues as
ketorolac, but it's much more expensive," he says.
IV acetaminophen offers similar advantages over oral versions of
the drug, but an uptick in its cost has limited its use in some facilities.
"The cost doubled a year or so ago for IV acetaminophen," adds Dr.
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