Good afternoon. I am Dr. Ann Schreier and it is my privilege to welcome you today to today's webinar. This is sponsored by the Providers Clinical Support System for Opioids and is provided through the American Society for Pain Management Nursing. Today's session is approved for nursing CEU credits. In order to receive the credits, you must attend the entire live session and in about a couple of hours after the session is over, you will receive a survey. You must complete the survey in order to receive the CEUs. The slides in today's session will be available on the PCSS.NOW website in the near future. Usually it's about two weeks. You will be able to ask questions in the Q&A at the bottom of your screen. Today's session is titled, Just a Fad, You Decide, Opioid-Free Anesthesia. Our speaker today is a board-certified CRNA. She graduated from anesthesia school in 2009 and worked at one of Omaha's level one trauma centers before moving to Colorado. Her experience in caring for trauma patients fueled her desire to find better ways to manage pain. Then she began her journey into opioid-free anesthesia and ultrasound guided regional anesthesia. For six years, she worked as the solo anesthesia provider in Grand and Jackson counties. Her multimodal opioid-free approach earned national recognition. Welcome Katie Hornbaker. Go ahead. Good afternoon, everyone. Thanks for joining us today. I have to admit, this is my first time speaking on Zoom and since I don't see people's faces and their reactions, you'll have to bear with me because I sometimes think I'm funnier than I am. So not getting anybody's responses is going to be a little bit of an adjustment for me. As Ms. Ann mentioned, we will save the questions to the end as that has been better for their flow of these webinars. So as Ann said, I'm going to be talking about opioid-free anesthesia. And there's a lot of more recent talk about opioid-free anesthesia. I also want to give one other title because the term opioid-free anesthesia can be a little bit intimidating. And so we like to approach it from the way of opioid sparing, meaning you're using a multimodal approach. And if you have to end up giving a little bit of opioid, it's still better in the long run than using the traditional approach of just straight opioid as one of your main analgesics for the duration of the surgery. So we can interchange opioid-free anesthesia and opioid sparing. Very similar, opioid-free obviously is when no opioid is given whatsoever. And opioid sparing, once again, a multimodal approach just as opioid-free is, but a small amount of opioid is given. And with all of the talk, there's a lot of different providers that think it is just a fad and that it doesn't provide any benefits to the patients or the hospital system. And once again, it's just a fad. It's the cool thing to do. I can start off by saying it's not just the cool thing to do because it is a harder thing to do. It's not a cookie cutter anesthesia where during this time you give this, it involves a lot more titration. So if it was, I'm not sure it's just the fad because if it didn't really work, people wouldn't be willing to put in the extra effort. But the proof is in the recovery of the patients. I have no disclosures. I do my disclosures. I consider superpowers, which are ketamine, my ultrasound, Expiril, which is a long-acting local anesthetic, and then Presidex, an alpha-2 agonist. And people would swear that I was sponsored by these drugs and by the ultrasound company. It's just because I love them and they work so great for my patients. So I have nothing to disclose. But if you hear me raving about one of these items, it's just because they work so well. Target audience. The goal of PCSS is to train healthcare professionals and evidence-based practices for the prevention and treatment of opioid use disorders, particularly when it comes to prescribing medications, as well as the prevention and treatment of substance use disorders. The objectives today, hopefully being able to identify the alternatives to opioids in the surgical and anesthesia setting, understanding the importance of pain management and the perioperative period, and being able to describe the hyperalgesia, which hyperalgesia means a heightened intensity of pain of something that wouldn't be normally painful. Hyperalgesia is caused with any typical surgery. So you have to have surgery. Do you need to receive opioids? Absolutely not. People do need to be afraid that, okay, I'm going to have surgery. I'm not going to get any opioids. Is my pain going to be controlled? Well, we'll find out. So the importance of pain management. The goal of postoperative pain management is to maintain pain at a tolerable level, allowing the patient to recover and get back to everyday activities. Pain, especially the hyperalgesia from surgery, affects multiple body systems, and if not prevented or treated, will cause delay in recovery and can also lead to postoperative complications. Uncontrolled surgical pain causes a lot of distress. It actually can slow healing times, increases the risk for blood clots, pneumonia, and the incidence of chronic pain following a typical surgery. So going back to the hyperalgesia, hopefully we can understand a little bit better what exactly I'm talking about when I say hyperalgesia. So three things occur during a surgery. The inflammatory process from the surgery itself, from the surgical incision, causes peripheral nerves to fire repeatedly even after that insult has stopped, even after the surgery has stopped. Central sensitization, which occurs from the continuous release of pain neurotransmitters, this causes upregulation in our pain receptors, therefore intensifying pain. So we're trying to combat the pain and blocking all of these pain receptors, but as there's an increase in the neurotransmitters, we're only creating more receptors that we need to block. And so this process of central sensitization actually causes perception of a gentle touch as painful. We can all think back to a patient that we've taken care of when we've put on their blood pressure cuff and they're already screaming in pain and we're thinking, oh my goodness, this is going to be a tough go. But it's real. Central sensitization does cause mechanisms where generally they do not cause any pain, but it's painful and the blood pressure cuff is a perfect example. And sometimes a blood pressure cuff actually does really, really hurt when it comes up to 250. That isn't comfortable. Opioid induced as the pain receptors upregulate from the central sensitization, they become to only be partially blocked. So a tolerance to opioids results, meaning that we have to increase our standard doses to control their pain. But as these doses increased, the opioids induce pain itself called opioid induced hyperalgesia. So will opioid free anesthesia control my pain, your pain, anybody's pain that is having surgery? Yes. It is a highly specialized service that not only controls pain, but has multiple other benefits, including increased patient satisfaction, enhanced recovery, reduced need for overnight stay, big one that hospitals love, decrease overall costs, risk reduction of post-operative complications, combats opioid epidemic and reduces the risk of addiction, decreases risk of chronic pain when utilized for hernia repair. That's mentioned specifically because that's been studied most with opioid free anesthesia. But it reduces the the risk of chronic pain from a multitude of surgery. A heavy hitter that a lot of people don't realize is decreased breast cancer recurrence rate when utilized during a mastectomy and also reduces the risk of cancer metastasis. So how does this actually work? Or as a lot of surgeons that I've worked with that were initially tough cells on the whole idea, they just nicknamed it Katie Voodoo. Are you going to do your Katie Voodoo on this patient or what's going to happen? And after they saw the results in the recovery room and started understanding the different mechanisms of action from all the different medications used in combination, excuse me, once again, that multimodal approach, not only did they call it Katie Voodoo, but they started requesting it for all of their patients. So starting with some really simple common drugs that we see on a day to day basis, dexamethasone, decadron, it inhibits prostaglandins, histamines and leukotrienes, which yields analgesia, a pretty significant anti-inflammatory effect and also anti-emetic effect. So reducing inflammation and the chance for post-op nausea and vomiting, that leads back to quickened recovery room times and reducing the risk for overnight stays. Because following an elective surgery, the two reasons why a patient may have an unplanned overnight stay is uncontrolled pain or intractable nausea and vomiting, both of which can be induced from your traditional anesthesia using opioids. Ketamine blocks the NMDA receptor, which are similar to mu receptors without all of the negative side effects. It prevents the hyperalgesia from that central sensitization. It causes bronchodilation. And who doesn't want that? Because with anesthesia, there can be a heightened airway reactivity. So causing bronchodilation while we're also controlling pain is just a nice side benefit. Minimal to no respiratory depression and profound analgesia. So ketamine has a best friend or a cousin, and that's magnesium. Ketamine works great by itself, but even better, adding a little bit of magnesium, because the magnesium actually prevents the loss of the magnesium plug on the NMDA receptor. And so it potentiates the analgesic effect of ketamine for up to 24 hours. So while getting four to six hours before of analgesic effect with ketamine, now with the addition of magnesium, it's much more profound and up to 24 hours. Alpha-2 agonists, which is your clonidine and your dexmedetomidine, also known as prosteducts. This is a big one. It blocks substance P and increases norepinephrine in the dorsal root horn and locus through us, causing decreased post-op delirium, shivering, anxiety and profound analgesia. So I can't share all of my magic tricks because then I wouldn't have anything to talk about next time. So this is just kind of opens the door for a multimodal approach or opioid free anesthesia. I know you guys are like this girl's nuts, but when I can't see your faces, it makes it so much harder to talk. Yes, I'll share all of my magic tricks with you today. Gabapentin prevents the release of glutamate and substance P by blocking presynaptic calcium channel, causing analgesia and preventing chronic post-surgical pain. Celebrex, also meloxicam is in the same category, which are COX-2 inhibitors, which are really nice because your standard over-the-counter NSAIDs are COX-2 and COX-1 inhibitors, which COX-1 has most of the negative side effects, where we really want the COX-2, which prevents the release of histamine, prostaglandin and bradykinin, causing anti-inflammatory and analgesic effects. Acetaminophen, oddly enough, we've gotten some more information on the mechanism of action in the last couple of years, but it's not real well known on how it actually works. It may reduce prostaglandins, but lately we've heard that it actually binds to the cannabinoid receptor, causing pain relief. So that makes a lot of sense of why Tylenol actually works. But what we do know is that the analgesic properties, when used in a multimodal approach, it may prolong the analgesic effects of the other medications. And so that's very common in a post-surgical state, is to alternate your NSAID and acetaminophen, and both of them seem to work a little bit better when used together. Esmolol, a common blood pressure medication, it's pretty fast acting, which is really nice to use during anesthesia. It can be used similarly to how fentanyl would be used. Fentanyl is generally used at induction when you're putting the patient off to sleep to manage their airway. And you want to blunt that sympathetic response prior to laryngoscopy, because that's very stimulating and can cause a pretty big increase in blood pressure and heart rate. But the Esmolol, being a selective beta-1 agonist, will blunt that sympathetic response and also inhibit the neurotransmitter release, so reducing pain as well as blunting the sympathetic response. The wonder drug, lidocaine, it's honestly a best-kept secret, and why I don't list that on my superpowers, I don't know, because I should. But as we know, lidocaine is a sodium channel blocker and prostaglandin inhibitor, so that yields pretty significant anti-inflammatory effects and bronchodilation. It also is cardioprotective and is used in cardiac ischemia, ARDS, and sepsis. You have to be really careful, though, in your epileptic and your protein-poor patients. So protein-poor patients are those with alcoholism or you're people of extreme age, so you have to be very careful in potentially protein-poor patients and must be avoided in patients with a high-level AV block. Lidocaine also, if that's not enough, has antifungal, antiviral, and antibacterial properties, which actually promote wound healing, so it seems like why wouldn't you use lidocaine? So in combination with that list of medications, plus or minus a few, depending on the patient-specific plan, ultrasound-guided nerve blocks and fascial pain box makes a lot of this possible. Can you do opioid-free anesthesia without doing nerve blocks? Absolutely. But when you use these nerve blocks, it's almost like cheating. Being able to blunt that sympathetic response and prevent all of that central sensitization before we even start the surgery is very beneficial. Since the ultrasound has come out, now almost all blocks are done under ultrasound guidance. It increases the margin of safety, especially when performing these nerve and fascial plane blocks. It allows the anesthesia provider to identify the selected nerve and surrounding structures. And this really reduces the risk as you can see all of the vascular structures and the nerves right where you need to be. Plus things like bowel and kidney and lung that you do not want to venture into. So being able to avoid needle misadventures is very beneficial. And also since you're doing everything in real time under ultrasound guidance, you can see where your anesthetic is being injected and making sure that it's not going vascular and that you're enveloping that nerve or anatomy of interest with local anesthetic. As I mentioned, it does play a huge role in a multimodal approach and often the success of an opioid-free anesthetic. So just some things that you can block using ultrasound guided regional anesthesia. Neck surgery, you can block that using a cervical plexus block with a clavicle. You can also block using a cervical plexus block. Doing a shoulder surgery, I like to isolate the C5 nerve root. That way they still have some motor ability in their hand. You can also use a supraclavicular block for a shoulder. Elbow, forearm, wrist, or hand surgery can be done with several different blocks. Supraclavicular, infraclavicular, axillary. You can also just select the nerve if you're doing fingers to selective radial, median, and ulnar nerve blocks. For breast surgery, which this is really important in the prevention of, not in the prevention, but yes, preventing further metastasis, but also being able to use an opioid-free approach, as I mentioned earlier. And we'll talk about a little bit later about opioid-free anesthesia and reducing the reoccurrence for breast cancer. But PECS 1 and 2, intrapec, or an erector spinae plane block, as mentioned before, these, along with opioid-free anesthesia, greatly reduce the reoccurrence and metastasis of breast cancer. Rib fractures, this block is how I probably make the most friends. I live in a pretty active community, a lot of skiing, mountain biking, and motor sports. So I see a lot of rib fractures, and instead of these patients having to be admitted and on a dilated PCA, drop in a quick erector spinae plane block with a long-acting local anesthetic, that Expiril that I mentioned earlier on, gives relief for anywhere from three to five days. I've had as long as seven. It gets these people over the hump without having to stay in the hospital. They can go home, they can do their incentive spirometer, and not have to take any opioids during that period, let alone be in the hospital on a dilated pump. Gallbladders, yes, there's blocks for that as well. Keeping it simple with just subcostal tap blocks, or more complex, which not only covers the surgical pain, but it also covers the visual pain, and that's the quadriceps lumborum block. Appendectomies, mid-axillary tap, or quadriceps lumborum, also just short-term is, not short-term, but abbreviated as the QL block. Ventral hernias, tap blocks, ESP blocks, or QL blocks. Umbilical hernia, same thing. Subcostal tap, mid-axillary tap, ESP, or QL. Inguinal hernias, you can isolate those even further with the ilioinguinal, iliohypogastric block. Bowery sections, QLs, taps, or ESPs. C-sections, mid-axillary tap, quadratus lumborum, ilioinguinal hypogastric, or ESP. So as you can see, in most situations, there's several block options, depending on skill level and patient selection. Hip fractures, these blocks have changed the way we are able to care for patients. The fascia iliaca gets sensory and motor. So if the surgeon is okay with no motor movement, then that's an okay option. That was a great option before the PANG block came out, and I'll explain why. But fascia iliaca, we do hip replacements, but we are at 9,000 feet in a very rural area, and often the pass is closed. And so if we couldn't get the equipment, then we couldn't fix all of these hip fractures and would have to fly them out. And so riding in a helicopter, going over a mountain pass in an ambulance was really uncomfortable for these patients. So being able to block them and send them was really nice. So they want another patient that doesn't have to be on high-dose opioids in the preoperative period before they can even get fixed. The PANG block is a pericapsular nerve group block, and that is awesome because it is sensory only block. So they have all motor function and motor strength following that surgery. So they're able to do all of the appropriate checks. Doing a total hip arthroplasty PANG block is the way to go. It spares that femoral nerve, which that's what the fascia iliaca blocks, unfortunately, and that's where the muscle weakness comes from. And with total hip arthroplasties, most surgeons these days want their patients fast-tracked. And as soon as they hit the recovery room and that spinal is worn off, they want them up walking in the hall. Some of them even go home same day. So being able to have a block that's sensory only, promoting early ambulation also reduces the risk for other post-op complications. Tibial plateau fractures used to be kind of a bone of contention because tibial plateau fractures are often at risk for compartment syndrome. And the surgeons would be afraid that our blocks would mask the compartment syndrome. Blocks do not mask compartment syndrome because ischemic pain cannot be blocked. And those of you that are familiar with surgery involving tourniquets that are used and we leave them up for anywhere from 60 to 120 minutes, we don't exceed that because that's when severe tissue ischemia can occur. However, when you hit that 60 to 90 minute mark, you start seeing increase in blood pressure, increase in heart rate that doesn't really respond to opioids or any blood pressure agents because the ischemic pain, the only way you can reduce the blood pressure and heart rate is to reduce the ischemia. So letting that tourniquet down, then everything returns to normal. So even with a block, if you develop compartment syndrome, you will still have symptoms that are diagnosable to treat that compartment syndrome appropriately. Total knee arthroplasty is done with a adductor canal block. They used to be done in the past with femoral nerve blocks, but once again, you have quad weakness so that does not allow the early ambulation that the surgeons want to see for the best recovery. So adductor canal block works great sensory only, and then touch it up with a couple other just nerve specific genicular blocks to get full coverage that are also sensory only. ACL surgery, this is one where a femoral nerve block comes into play because they often want their leg locked in extension and they want that quad weakness. However, the newer standards are coming out where they're being asked for less because they've found when they're, if it is a autograft harvest from the quad tendon that the action of the quad tendon harvest along with the femoral nerve block is causing prolonged quad weakness. And so they're starting more recently, especially in the athletes with autografts requesting adductor canal, which is that sensory only. That way we can ensure they can fire their quad right when they're waking up. And we know if they're unable to, it's from the weakness from the harvest, not the block. Ankle surgeries can be done with a popliteal sciatic nerve block and then for foot surgeries, ankle blocks. So we have lots of options for almost every body part. And I know that was a pretty quick crash course and it does seem overwhelming and like, okay, yeah, it sounds great. Is this a fad? Why are we doing it? Well, a big reason is, is that opioid related deaths exceed the number of deaths from firearm and motor vehicle accidents combined. And if you're between the ages of 35 and 50 years old, you are in the age group that has the highest risk for addiction following an elective surgery. 80% of heroin users started with prescription opioids and the two big ones are from females and that age range from ACL surgery and also from the dentist. And I'm not saying anything bad about ACL surgeries or dentists, but we all know how bad, teeth pain can occur, how bad it is if you've had any dental trauma, that it is very painful and does need to be treated. But that's often how people are started out, that they're started out following their ACL or a dental procedure. And they're given more than three to five days of opioid prescription and then it's much more difficult to get off. In a study of over 300,000 opioid naive patients, opioid naive refers to patients that have not had opioid therapy in the past they've had a short stay surgery, meaning 24 hours. And 7.7% were still prescribed opioids after one year of surgery, which is quite alarming. And then 44% of those were more likely to be opioid dependent at one year if prescribed more than seven days of opioid postoperatively. So that's the kicker of the length of opioid prescriptions. I've worked closely with my surgeons and that they will write for three days of opioid therapy following a surgery. However, with the opioid free technique along with the blocks, the pharmacists are very happy because only about 10% of our patients were picking up their opioid prescription. We talked about earlier this other really big piece of opioids and cancer and that using opioid free anesthesia helps reduce that breast cancer reoccurrence rate and also metastasis when doing surgery on other cancers. Opioids can reduce as much as 50% reduction in killer T cells during the course of an anesthetic. Opioids have shown to also decrease the immune response therefore promoting metastasis. To utilize an opioid free anesthetic during tumor resection, it will prevent the reduction of killer T cells and decreased immune response so that the cancer cells can be potentially left behind and will not be able to migrate through the vessel wall and adhere in a different location. So it's really important to maintain the amount of killer T cells and without that immune response because when you get that immune response then all of the cancer cells that are now floating through the bloodstream through a surgery, they can actually migrate through the vessel walls and as it says, attach somewhere else. So preventing the blood vessels from that immune response will keep those cancer cells where they need to be and also where the killer T cells can go get them. The local anesthetic used in ultrasound guided nerve blocks work on the voltage gate sodium channels in which cancer cells are dependent. Cancer cells rely on those voltage gated sodium channels. So we just pretty much put, as we put the nerve and the fascial planes to sleep, we also promote anti-proliferation of the cancer cells too, which is huge. Often people are just afraid to request an opioid free anesthetic because they're worried about being judged or labeled. But as it's becoming more popular, when I first started this eight years ago, people thought I was nuts. And when they would request this type of anesthesia, people weren't aware that this was an option at that time. But now it's becoming so much more popular and at most facilities, there should be at least one anesthesia provider that is proficient in this technique as it's gaining popularity. Multiple body systems are significantly affected and contribute to postoperative pain. And so it is very beneficial to receive a multimodal opioid free anesthetic, even a multimodal opioid sparing because it will still reduce the overall total amount of opioids that you would need postoperatively and maybe not even at all. The approach blocks pain from multiple different pathways without the negative side effects that opioids can cause. And opioids given during anesthesia, we all know they cause significant respiratory depression. They can cause dysphoria, constipation, post-op illness, urinary retention, nausea, vomiting, prolonged recovery stay, increased risk of dependence and opioid naive patient and increased overall cost. Just some recent patients to give kind of some, you know, anecdotal evidence and examples which helps tie everything together. I had a 70 year old female chronic pain patient who was on methadone and she needed a total shoulder arthroplasty. She actually came from a neighboring town because they were just, that facility was really concerned that they wouldn't be able to manage her pain and they wanted to wean her off her methadone prior to the surgery so that they could ensure they could manage her pain. She was sent over to me by a surgeon that worked at my facility as well as the one that this lady had hoped to have her surgery. And so what I did is I blocked her with Expro, that long acting local anesthetic. I kept her on her routine methadone which is really important because we need to consider that, yes, not only are we needing to manage her surgical pain but also her everyday pain that is, you know, only managed for her while on this methadone regimen. And her post-op surgical pain was zero to 10 throughout her stay. Her highest pain score during her admission was a four out of 10 and that was not her surgical pain, that was her overall pain. Prior to her surgery, her pain was a six to eight out of 10 on a daily basis. So we were able to reduce her overall everyday pain by a couple of points, and also not cause any further pain from the surgery as she had zero pain and did not take anything addition following her discharge other than her methadone. I also had a 20 year old female with a history of alcohol and THC abuse for an exploratory laparotomy due to a small bowel resection. This gal was done with bilateral quadratus lumborum blocks with that long acting local, along with the full gamut of prosodex, ketamine, magnesium, and she was discharged under 48 hours and she was required to stay just for, you know, the surgical reasons of observation and relieving, you know, that bowel obstruction. No opioids during her admission, and she did not need to take any as she went home. 70 year old male for an exploratory laparoscopy, once again, for a bowel obstruction. He was discharged under 24 hours and also received no opioids during his stay. The surgeons really love opioid free or opioid sparing anesthesia on their bowel cases because one of the big things that opioids can cause in these bowel obstruction patients is further constipation. It does increase their stay because they have to wait for them to have a bowel movement. And so not causing any constipation so that they can move their bowels. It actually increases gastric emptying along with the enhanced recovery after surgery protocol. So the general surgeons are generally pretty quickly to jump on board with opioid free anesthesia in their bowel cases. And once they realize the efficacy for their bowel cases, then they want it for all of them. 65 year old male with a history of COPD sleep apnea presented to the clinic with two fractured ribs. His oxygen saturations are 78 to 82, his respiratory rate high 30s. He also had some other comorbidities, but also his blood pressure was through the roof and very guarded movements. Rib fractures just hurt really bad. You can't breathe, you can't, sometimes you feel like you can't even think without it hurting. He rated his pain 100 out of 10. They were going to admit this gentleman and thankfully they gave me a call. They transferred the individual from the clinic over to the emergency room and they were going to keep him, but thankfully they gave me a call. Did an erector spinae plane block and the patient was discharged 30 minutes later with zero pain, oxygen saturation in the 90s, no guarded movements. He was now normotensive and I think I got a hug out of that deal. 55-year-old frequent flyer for kidney stones. This woman would typically come into our ER three to four times a year and we would on average require a four-day stay on a dilated PCA. An erector spinae plane block was performed for her as well, 10 out of 10 pain down to a zero and that women got to go home instead of having to stay in the hospital. So with everything that we've learned, I know that together we can provide superior care and combat the opioid epidemic all at the same time, one patient at a time. PCSS has a mentoring program. For more information, I believe that that link is provided along with the links to the lectures I could be misspeaking. So if I did, I apologize. And now it's time for some question and answer. Yeah, thank you very much for the presentation. We have some questions and you still have time to put a couple of questions in. If you want to, it's in the question and answer box. The first question is this individual confirmed that the KD voodoo side with medications, that all these medications were administered intravenously, is that correct? Yes, these medications I need to, some of them are taken orally prior to surgery. So Celebrex and Gabapentin are taken orally before surgery. The rest are intravenously. The Ketamine, Decadron, Prosodex and Magnesium are all administered intravenously. And there are every provider that you speak to that does opioid-free anesthesia has a slightly different cocktail and technique. With my facility, I didn't have an IV pump that got to stay in the ER. So I did everything by hand. I bolused everything, just over time titrated it in where one of my colleagues, some of you may have heard of a mix called the McLaupin mix and actually he combines Ketamine and all approved by pharmacy. This is gonna sound scary now, but Ketamine, Magnesium, some Prosodex all into a bag and then he has it down to a drip rate based on weight. So there's a hundred different ways to administer opioid-free anesthesia. People develop their own technique over time. There's no really wrong or right way to do it as long as you're following the guidelines. And that's why the McLaupin mix had to be approved by pharmacy. That's not something that we just go willy-nilly throw a bunch of medications in a bag and slam them in. There is an art to it with, you know, science obviously on the forefront. The other question that this person had was how often do you administer the Magnesium and the Ketamine? Is it, and I guess that would vary by the surgery I would assume. That is very patient specific and surgery specific. And so I will say that the Ketamine doses are what we would consider club subclinical not anesthetic doses on what you would use to put somebody to sleep. So on average 10 to 30 milligrams for an hour or two case occasionally up to 50 milligrams may be used. And then depending on weight and other comorbidities one to two grams, excuse me, grams of Magnesium. Right. I have another comment and this is from June Oliver. Actually a publication by Muhuri says that only 4% of people who misuse opioids advanced to heroin use. And that 4% number of heroin users start with prescription opioids is misleading as it is misuse not prescribed use that is associated with opioid use disorder. And I think that there's a lot of variation depending on the references you look at in terms of what you see in terms of statistics. And I was wondering, Katie, as I read through this if you could provide some of the references you using I particularly was interested in your references about the cancer recurrences. So if you could provide us some references I can make sure people get them. I'd appreciate it. Absolutely. There's another question. Is there evidence that the opioid free anesthesia reduces postoperative pain or opioid use in the weeks following surgery after the opioid free effects are gone? So I guess I'm saying, I guess part of this is bringing the instance, if you had a block and the block wore off, would people then start taking more opioids after that's gone or is there any evidence on that? Yes, I can provide studies on that. So I spoke a little bit about Expiril a long acting local anesthetic and the blocks that I administer with the Expiril lasts on average, depending on the body part there are a few outliers, three to five days. And so a re-block is an option when their block wears off they come back in and get a re-block. The other thing is, is that generally after the third day you are over the hump and are generally able to be managed on opioid alternatives, alternating Tylenol and ibuprofen. And so I understand where this question is coming from using a short acting local anesthetic for a block when that, before the Expiril was readily available I would tell all of my patients that the block is going to wear off between eight and 14 hours. I need you to take your pain medicine every four hours whether you're having pain or not because you're gonna go from zero to a hundred when that block wears off. Since having the Expiril, the block wearing off days later they do not get that intense rebound pain. They do not have to have opioids in their system because by the time that block wears off they're over that surgical hump of when post-operative pain is the worst. So it was rare that patients even picked up their opioids. And that's why the surgeons, they used to give them two weeks worth and now the surgeons are three to five days. So, but the patients have an option to come back for a re-block as well if they're wanting to avoid opioids altogether. Okay, here's another one. Great information. If providers get ketamine, particularly in the PACU as rescue for intractable pain how much magnesium should be ordered and when and how often? Putting a, because that magnesium plugs up the magnesium plug on the NMDA receptor. You really only need to give it once for that 24 hour effect to, you know, potentiate that. So based on the patient, you know, one to two grams hopefully that's been given preemptively though. And that if you're giving ketamine during the surgery that hopefully magnesium has already been given. Great, another question. Are these medications given in the outpatient or strictly inpatient? It seems like you were talking about EDs. So I'm thinking. No, this other than the rib fractures, all of these are, I don't say all, 90% of them are for outpatient surgeries. So the majority are given preemptively and pre-op and during the course of the anesthetic and then go to the recovery room. And generally speaking, they're pretty comfortable. May need another small dose of ketamine or prosteducts but then they're discharged home. This person wants to know where you got their regional training because she works for an international pain fellowship and their docs don't do half of these blocks. So where'd you get your training for the blocks? I actually am an instructor for regional anesthesia through Twin Oaks Anesthesia. Okay, and they wanted to know about the dosing for the lidocaine. So that's pretty variable and you know, it's so patient specific. That I generally keep it under 200 milligrams for the length of a surgery, usually not even that much but since it is so patient specific, I always, I don't wanna say I hesitate but you have to use the clinical and judgment of the scenario and the patient in front of you. And another, yeah, the other question she wanted to know is if, is the FDA approval for Expirel for other sites than just the tap block? Yes, so Expirel is currently FDA approved for tap blocks and brachial plexus blocks. They are working on getting FDA approval for the others. Since brachial plexus specifically the inner scalene is one of the more, has a higher risk for needle misadventure. It's interesting that they approved that one first because if it's one of the more dangerous blocks that we do as far as injecting into a vessel but Expirel is actually encapsulated in liposome. And so even if it's a little bit different than other local anesthetic and while they've never attempted or at least on purpose on a human and animal studies injecting Expirel into a blood vessel does not have the same risk as other local with cardiovascular collapse from local anesthetic toxicity because with the liposome they dissolve at a completely different rate and your serum concentration does not peak for 48 hours. And so I think the FDA approval will come sooner. Can't give you an exact time but it's not gonna be long before they approve it for use for all blocks. It is finally approved for the pediatric population that happened two years ago. But as far as FDA approval, a lot of the medications that are used in anesthesia are off label anyhow. So it kind of goes, I'm not saying you should do it but I'm giving an example that most of anesthesia, the medications aren't given in how they were originally intended for. Right, that's very common, isn't it? Sarah wanted to correct that it was an international pain fellowship but an interventional pain fellowship. She had mistyped it or auto-correct. Thank you. Well, that seems to be all the questions we have right now, Katie. So I really wanna thank you for this presentation and I want to remind the audience that this presentation was recorded and it'll be available on the PCSS.now website. You can see that on your slide here that is currently up. I also want to remind you that you will need to complete the survey that is sent to you in order to get your CEU credits. And we look forward to seeing you again at another webinar. Thank you so much.

opioid-free anesthesia

multimodal approach

pain management

ultrasound-guided nerve blocks

patient satisfaction

reduced need for overnight stays

decreased risk of post-operative complications

addiction

opioid epidemic