In this 108th episode I welcome Dr. Mike Grant and Dr. Mark Bicket to the show to discuss various non-opioid adjuncts such as esmolol, ketamine, dexmedetomidine, lidocaine, and magnesium, and the role they may play in multimodal anesthesia. In this episode, part 1, we discuss pre and post-op use. Intraop use will be discussed in episode 109.
Wick EC, Grant MC and Wu CL. Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques A Review. JAMA Surg. 2017;152(7):691-697.
Bahr MP, Williams BA. Esmolol, Antinociception, and Its Potential Opioid-Sparing Role in Routine Anesthesia Care. Regional Anesthesia and Pain Medicine. 2018:43(8):815-818.
Grant MC, Ouanes JP, Joshi BL. Perioperative Esmolol and Opioids: Is More Really Less? Regional Anesthesia and Pain Medicine. 2018:43(8):813-814.
IV Lidocaine: https://academic.oup.com/bjaed/article/16/9/292/1743710
Dextramethorphan: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755866/ R
12 thoughts on “Episode 108: Non-opioid adjuncts with Drs. Grant and Bicket Part 1”
I work in Melbourne, Australia, and we frequently use clonidine as an adjunct if the BP can tolerate.
Would love to hear some discussions on the evidence out there.
Not a lot of data on its IV use that we are aware of. The concern would be rebound hypertension when stopped. For neuraxial and block use there is some data, see below. Hope that helps!
Do you have any literature on preoperative Gabapentin?
Thanks in advance, Thomas
Here you go:
Thank you 👍
Thank you for a great episode! What if the patient is already on Gabapentin at home at less than 600mg- continue scheduled dosing or give PO bolus (600mg) in pre-op? Appreciate recommendations.
You would want to know if they had had a bad reaction to a higher dose. If not, giving them the usual 600 should be fine, or, if they took their home 300 (for example) that morning, giving them an additional 300 in preop.
I’ve got a lot of interest in the use of Mg as a possible adjunct in MAC anesthetics to possibly reduce opioid use. I’m having some difficulty finding exactly what was referenced in this episode. Would you or your guests happen to have any references you could share? Thanks so much!
Dr Grant recommends this meta analysis with tons of great references De Oliveira GS, Jr., Castro-Alves LJ, Khan JH, McCarthy RJ. Perioperative systemic magnesium to minimize postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology. 2013;119(1):178-190.
Thank you so much!
Hi! I just came across this podcast, and I really enjoyed it, as I am interested in OFA. When you give esmolol for induction instead of fentanyl, I am wondering if you typically give it with the same timing that you would give fentanyl in the induction sequence, or if you give it after the propofol. And do you have thoughts on whether a smaller dose of fentanyl, such as 25 mcg, on induction, in addition to esmolol, would be appropriate? Thanks in advance!
The nice thing about esmolol is it is very fast acting and lasts about 5-8 minutes so you can give it with your propofol or with your roc and it will cover you for intubation. You don’t need to give fentanyl in addition to your esmolol but you certainly could if you felt it was needed for some reason. In general I don’t think it adds anything to your esmolol.