Anesthesia Student Survival Guide.pdf - Index of

PhArmAColoGy of AdjunCt AGents ● 81
short-acting analgesic just prior to infiltration by the surgeon that will provide
3–5 min of sedation and analgesia. Remifentanil, 1 mcg/kg, given 75 s
before the painful stimulus, offers such an effect and is very rapidly eliminated
by ester hydrolysis shortly thereafter. Alfentanil, 1,000–1,500 mcg, is
an alternative with a similar but slightly slower elimination.
What strategy will you follow to control her pain?
This procedure should not cause much postoperative pain, so there is no
need for large doses of opioids, which could contribute to both nausea
and somnolence. A multimodal approach is therefore indicated, including
careful use of local anesthetic by the surgeon both before incision (which
may reduce postoperative pain) and at the end of the procedure with a longacting
local anesthetic such as bupivacaine. If bleeding risk is not high, as it
should not be in this case, a dose of an NSAID such as ketorolac, will help
postoperatively and has an additional benefit of being anti-inflammatory,
which may reduce pain even after its immediate analgesic effect has dissipated.
Finally, some drugs considered for sedation, notably dexmedetomidine,
have some analgesic properties themselves. In selected cases, patients have
been discharged with a mechanical, nonelectronic pump that slowly infuses
local anesthetic under the skin via a multihole “soaker hose” catheter placed
during the operation. An example is the On-Q Painbuster system. This case
should feature a very small incision, so this may not be feasible, but it could
be considered in consultation with the surgeon. Finally, long-lasting pain
control nerve blocks can be offered. In breast surgery, a popular option is
a paravertebral block, usually performed preoperatively at several levels
covering the breast (upper thoracic dermatomes). In this limited operation,
this may be overly aggressive, but consultation with the surgeon, regarding
the extent of the resection, and with the patient, regarding her expectations
and experiences with postoperative pain, are needed to decide.
What strategy will you follow to avoid postoperative nausea?
This healthy, nonsmoking woman, with a history of PONV, is at high risk
of recurrent symptoms. By one popular risk assessment scale, she would
be expected to have a 60% chance of PONV after outpatient general
anesthesia. The use of the MAC technique should reduce her risk somewhat,
particularly if opioids are avoided. Should she need general anesthesia,