5. Multimodal pain protocols
The ingredients and doses vary from provider to provider and from
procedure to procedure, but the goal is the same: Attack the various
ways pain is perceived in the spinal cord, the peripheral nerves, the
central nervous system and the brain, and do so with an eye toward
minimizing opioids and the issues that surround them.
Regional anesthesia is a good starting point, and the long list of
potential ingredients may include IV acetaminophen, bupivacaine, IV
ibuprofen, IV diclofenac, epinephrine, clonidine, saline, steroids,
NSAIDs, ketorolac, ketamine, celecoxib and gabapentinoids, among
others.
Anesthesia providers have become skilled mixologists, with many
actively seeking feedback and data that can help them standardize
their approaches. Avoiding the knee-jerk tendency to lean too heavily
on opioids is the key. "All of these multimodal pain protocols can real-
ly work," says Mr. deSouza. "But only if the support staff has the time
to honestly implement them."
6. Ultrasound guidance
"It's always amazing to me why people don't use ultrasound more,"
says Merlin Wehling, MD, director of anesthesia at the Kearney (Neb.)
Regional Medical Center. "I've never seen a downside." He and others
say it's indispensable once you get the hang of it. "You can use it any-
where on anything in the body — not just for nerve blocks and pain
injections. The only reason we don't use it more is the lack of
machines available, but they're not terribly expensive."
A little education goes a long way, says Dr. Wehling: "We recently
instructed nurses to use ultrasound with peripheral IV starts. Their
reaction was, Are we allowed to? Is that within the scope of practice?
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