Conquest of pain - the 'nifty fifty'

Date Published: 
May 2011

'Slip me some skin,' said the beatniks of the 1950s.

What do we really know about the skin?

1. It is the largest organ in the body.

2. It generates the greatest amount of neural traffic to the brain.

3. It is the major barrier between self & the outside world of danger.

4. The brain does not 'like' to be warned of danger.

5. The vast majority of surgery involves a scalpel or trocar puncturing the skin, setting off an alarm to the brain: 'Invasion, danger!

6. Although poorly understood, acupuncture (needle stimulation of skin meridians) has persisted for thousands of years. Must be some positive evidence based outcomes to account for this success.

Many of you on this list have dismissed my propofol ketamine paradigm as only being relevant for cosmetic, not 'real' surgery.

Only after the floor nurses at St. John's of Santa Monica validated my personal post total hip outcomes* as identical to the thousands of my cosmetic surgery patients' did I feel I finally had an answer to the criticism above.

The use of 50 mg ketamine 3 minutes prior to surgical stimulation is a universally desirable paradigm if one truly desires to improve patient outcomes.

*My account posted in a NY Times blog follows below.*

Comment #20 @ http://well.blogs.nytimes.com/2009/09/22/when-pain-goes-beyond-words/?hp...

By the fall of 1992, I observed that none of my patients were experiencing either PONV or pain.

Failure to give this 'nifty fifty' meant I was merely aiding and abetting my surgeon inflicting painful signals to the patients' brains.

Being an accomplice to the infliction of pain is decidedly not what I went into anesthesia to be.

Since adopting routine BIS monitoring in late 1997, none of my more than 2500 patients have required opioids, either during or after surgery.

If your patients still require postop opioids for pain, I am clearly doing something that improves patient outcomes.

Postoperative pain comes from intra-operative pain.

You have nothing to lose by giving the 'nifty fifty,' but your patients (PACU RNs & facility) have everything to gain.

Seriously, what is your downside risk?

Wouldn't you rather be perceived as the 'hero' instead of the 'scapegoat?'

PS Some papers to 'chew' on:

Hudetz JA, Iqbal Z, Gandi SD, et al: Ketamine attenuates post-operative cognitive dysfunction after cardiac surgery. Acta Scand Anesthesiol 2009; 53: 864–872.

Klopman MA, Sebel PS: Cost-effectiveness of bispectral index monitoring. Curr Op Anesthesiol 2011;24: 177-81.

It’s more fun to be the hero instead of the perpetual goat.

Ortho anes: http://www.youtube.com/user/narkose3535?feature=mhum#p/a/u/1/r6O-stIHlgo

Carpe diem!

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