Buprenorphine perioperatively

Probably continue for less painful surgery and stop for major surgery, replacing with oral opioids, anticipating the need for higher dose opioids in a monitored setting. Multimodal analgesia techniques – PCA, acetaminophen, NSAIDs, regional techniques, gabapentinoids, Ketamine, Dexmedetomidine. Liaison with addiction specialist is advised

Anesthesiology article

Now if someone had their extended release Naltrexone there’s another conundrum!

periop Naltrexone

Chronic Post Surgical Pain Prediction

A summary of risk factors :- genetic, age (young), female, pain sensitivity (like fibromyalgia), psychosocial (e.g. anxiety, depression, late return to work), pre-op pain, acute post-op pain, surgery/nerve injury.

The hypothesis is if we can identify and manage and treat promptly, we may prevent transition to chronic pain. A frequent problem is determining if these are just markers for chronic pain development or risk factors causally related to future pain. Nonetheless multimodal analgesia is the least we can do.

Pain

Hypotension, MI and Death

Intra or post op hypotension increases myocardial infarction and death. Various definitions – often cited as 40% drop in MAP or MAP below 55, and duration figures as a factor. I prefer minimum MAP 65-70 and systolic 90-100.

A big array of studies trying to define the magic figure. The important message is to treat it promptly.

Here defined as systolic < 90  Anesthesiology article

 

Prehabilitation

Yes it’s a word. Although the evidence is still just coming in, enhanced recovery after surgery may begin preoperatively for major surgery. It’s a “combination of aerobic training, resistance training and inspiratory muscle training to promote positive adaptations in cardiorespiratory fitness, muscular strength and endurance and respiratory muscle function, respectively”.

Anaesthesia guidelines

Cricothyrotomy (FONA)

The wire guided Seldinger technique (that was easy enough for an anesthesiologist to understand!) is no longer recommended. If the membrane is palpable, one full thickness transverse incision into the trachea; if not palpable an initial vertical incision so you don’t end up above the larynx.

A FONA (front of neck airway) Difficult Airway Society video that we all hope never to re-enact!

Front of Neck Airway