Title: The Opioid-Free/Sparing Revolution
Historically, opioid administration has permeated anesthetic education and practice. Mu receptor modulation quickly and effectively treats various pain syndromes, but at a price. We now know the short- and long-term consequences and side effects of narcotic utilization and abuse, and society is demanding better outcomes. Unfortunately, pain and pain syndromes persist. These include acute surgical pain, chronic regional pain syndrome, phantom limb pain, fibromyalgia, and many other chronic pain syndromes. However, we are in a renaissance of analgesia therapy and are realizing increased desires for improved treatments and outcomes.
Dr. Parker has been practicing anesthesia for almost 15 years. After graduating from Gannon University, he then went on to obtain his doctorate in anesthesia from the University of Michigan-Flint. He actively pursues research opportunities, mostly focusing on pediatric emergence delirium, advanced anesthetic monitoring modalities, pain treatment, and Ketamine therapies. Furthermore, he is a member of the Society for Opioid Free Anesthesia (SOFA) and the American Society of Ketamine Physicians, Psychotherapists, and Practitioners (ASKP3). His anesthetic practice is almost entirely narcotic free, and he further treats psychiatric and chronic pain states with Ketamine therapies.
Title: EXPANDING THE DURATION OF SAFE PEDATRIC OUTPATIENT GENERAL ENDOTRACHEAL ANESTHESIC CARE PAST 7 HOURS
The maximum duration of pediatric outpatient anesthetics has been previously limited to 4 hours. Advances in anesthesia care now make pediatric ambulatory surgery of over 7 hours duration medically feasible. A retrospective analysis was conducted of 585 consecutive successful combined atresia/microtia reconstruction surgeries performed in the years 2008 to 2022 on an outpatient basis. These anesthetics, exceeding 7 hours in length, expanded the scope of ambulatory pediatric anesthetics to a duration previously deemed unwise or unsafe. Each surgical procedure was a combined cosmetic external ear reconstruction, otologic external auditory canal, and middle ear reconstruction. The general endotracheal anesthetic and surgery were followed by patient discharge to a home or hotel setting. Anesthetic challenges included: 1) appropriate preoperative evaluation and medical clearance of each patient; 2) intraoperative care designed for both safety and quick recovery; and 3) postoperative care designed for both safety and quick recovery. Ear reconstruction surgery is ideal for freestanding ambulatory centers because it involves limited surgical trauma, blood loss, perioperative fluid shifts, postoperative pain, or need for complex postoperative care. Patient disqualifiers included age under 3 years, significant cardiac or pulmonary disease, morbid obesity, sleep apnea, or the presence of dyspnea, productive cough, or fever. The anesthetic technique included sevoflurane, propofol, and fentanyl. The surgical team contributed to the anesthetic management by infiltrating surgical fields with lidocaine and bupivacaine throughout the procedure. Patients had minimal recovery room pain. Narcotics in the recovery room were rarely required. Post-anesthesia care unit stays averaged less than one hour. Only one patient required inpatient admission, due to an anaphylactic reaction to an intravenous antibiotic. This series of 7-hour-plus general endotracheal anesthetics for pediatric ambulatory surgery shows evidence that a lengthy duration of pediatric general anesthesia is both medically feasible and safe for healthy children, providing the surgical procedure causes limited surgical trauma, blood loss, perioperative fluid shifts, postoperative pain, or need for complex postoperative care.
Richard Novak MD is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University. Dr. Novak is board-certified in anesthesiology and internal medicine, and is also the Medical Director at Waverley Surgery Center in Palo Alto, California and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
Title: Regional Anesthesia and Pain Management
Pain is the 5th vital sign. Every patient has right to be pain free. Untreated or poorly treated acute pain may lead to chronic pain and long term physical and psychological effects. Multimodal analgesia is best approach to treat pain. In certain clinical conditions, pharmacological options become very limited to manage pain, i.e., in patients with renal impairment, COPD, Obesity, obstructive sleep apnea, old age, altered mental status etc, use of NSAIDs, opiates, PCA is not appropriate. Regional anesthesia, may replace not only general anesthesia for certain surgical procedures, but provides excellent intraoperative and postoperative analgesia as well. Duration of analgesia can be increased with addition of additives to local anesthetics and placement of catheters for continuous infusions. Intraoperative period:- Peripheral nerve blocks reduce use of narcotics, early recovery from general anesthesia and help in reducing operating room occupancy. Postoperative period:- Better pain control and lesser chances of nausea and vomiting help in early discharge from post anesthesia care unit, and early discharge from day care units. ICU:- Paravertebral blocks or serratus plane blocks provide greater pain relief related to ribs fractures and help to wean off ventilation and early discharge from ICU. Specialty of regional anesthesia has got significant popularity after introduction of ultrasound and relatively safer local anesthetic drugs. Newer regional block techniques and introduction of new peripheral blocks have added more popularity to regional anesthesia practice.
Dr. Tahir Akbar is specialist pain physician and anesthesiologist at Tawam Hospital, Al Ain, UAE. Holding fellowship in anesthesiology and post-graduation in regional anesthesia, he has special interest in ultrasound guided regional anesthesia, acute and chronic pain management. He is lead member of APS team. He is actively involved in educational activities and teaching his juniors and nursing staff.