We asked 3 nurse anesthetists to share their pain management recipes during each stage of surgery for 3 notoriously painful procedures: total knees, shoulders and total hips. There was one condition: no opioids.

Mr. Schneider explains:

Pre-op: Give the patient oral Tylenol, clonidine and gabapentin, and administer an ultrasound guided adductor canal peripheral nerve block with catheter using 15-20 cc of 0.5% ropivacaine and 4 mg decadron. The patient can still extend his leg and walk with an adductor canal nerve block so we can get him ambulating sooner.

Intra-op: Spinal anesthetic for this case is preferred. Administer the ketamine, magnesium, and lidocaine infusion together to help with surgical pain during and after the procedure for a narcotic sparing technique.

Post-op: Overall goal for pain management is to provide superior analgesia without the need for narcotics. An adductor canal nerve block catheter will keep them pain free for 3 days using a 0.2% ropivacaine infusion at 10-14 mL/hr. Depending on the patient's risk factors, schedule gabapentin or Tylenol 3 times a day for post-op pain management. You can give 15-30 mg Toradol for any break through pain. We can do a 2-hour knee replacement with no opioids using this method.

Mr. Bland explains:

Pre-op: Give the APAP IV with the celecoxib and gabapentin. Intra-op: The surgeon will initiate an Exparel infiltration and will inject the encapsulated bupivacaine into the planes of the tissue. This is usually adequate to keep the patient pain free through post-op for 3-days. If necessary, give ketamine, decadron or 2mg of magnesium sulfate.

Post-op: Repeat the APAP IV 6 hours after the procedure. Provide the patient with oral APAP for two days. If necessary, administer an ultrasound guided adductor canal block or IPACK block with 0.5% ropivacaine plus decadron for break through pain. Or you can schedule a ketorolac IV every 8 hours twice daily.

Dr. O'Con explains:

Pre-op: Administer an interscalene nerve block with ropivacaine + epi at each block site. The nerve blocks are adequate to keep the patient pain-free for 12 hours after surgery.

Intra-op: The anesthetist may administer minimal amounts of ketamine and propofol if necessary and if surgery is done with blocks as the sole anesthetic.

Post-op: Handled by surgeon.

Mr. Schneider explains:

Pre-op: Give the patient Tylenol, clonidine and gabapentin and administer an ultrasound guided interscalene brachial plexus nerve block with catheter using 10-15 cc of 0.5% ropivacaine with 4mg decadron. I use ropivacaine because it is less cardiotoxic unless there is a drug shortage; then I'll use bupivacaine.

Intra-op: General anesthesia with endotracheal tube. Administer the ketamine, magnesium and lidocaine infusion together to help with surgical pain during and after the procedure for a narcotic sparing technique. Inhaled anesthetic gas at a reduced percentage for maintenance.

Post-op: Overall goal for pain management is to provide superior analgesia without the need for opioids. An interscalene nerve block with catheter will drastically reduce pain for 3 days using a 0.2% ropivacaine infusion at 8-10 mL/hr. Depending on the patient's risk factors, schedule gabapentin or Tylenol 3 times a day for post-op pain management. 15-30 mg Toradol can be given for any break through pain. This regiment typically helps get our patients home a day sooner than expected due to superior pain control.

Mr. Bland explains:

Pre-op: Give the APAP IV with the celecoxib and gabapentin.

Intra-op: The surgeon will initiate an Exparel infiltration and will inject the encapsulated bupivacaine into the planes of the tissue. This is usually adequate to keep the patient pain free through post-op for 3 days. If necessary, give ketamine, decadron or 2mg of magnesium sulfate.

Post-op: Repeat the APAP IV 6 hours after the procedure. Provide the patient with oral APAP for 2 days. If necessary, administer an ultrasound-guided fascia iliaca block with 0.5% ropivacaine plus decadron for breakthrough pain. Or you can schedule a ketorolac IV every 8 hours twice daily.

Dr. O'Con explains:

Pre-op: Administer a fascia iliaca nerve block using ropivacaine + epi along with a subarachnoid nerve block using the tetracaine. The nerve blocks are adequate to keep the patient pain free for 12-hours after surgery.

Intra-op: The CRNA may administer minimal amounts of ketamine and propofol if necessary and if surgery is done with blocks as the sole-anesthetic.

Post-op: Handled by surgeon. OSM