April FY20

[sarahrollison]

This months Journal Club is presented by Katya Podin. She chose an article that discusses the necessity of multimodal analgesia for patients undergoing thoracic spine surgery. The article reviews evidenced-based, literature-supported methods of analgesia that anesthesia providers can use in the management of pain for these patients. 

Here is a link to the article. 

Questions to engage discussion:
1. Have you used Magnesium supplementation with Ketamine, and in what cases have you used both drugs?
2. Did you see surgeons using morphine/duramorph nerve paste intraoperatively, and if so, what cases?

[Christine Velarde]

1. I have not used magnesium supplementation with ketamine.
2, I have seen some duramorph injected in the joint space of knees in the past but not in a paste. I have not given anesthesia for thoracic spine cases, now I kmow there are other options for multimodal methods for anesthesia.

[Amy Swank]

1) Yes, I have used Magnesium gtts with Propofol and Ketamine gtt supplementations particularly in the outpatient surgery population before coming here to Hopkins.

2) No, I have not yet been involved with the care of a patient where the surgeon has prescribed or utilized Morphine or Duromorph nerve paste intra-operatively - although it sounds like an intriguing component for multimodal analgesia.

[kristenhorsman]

1. No I have not purposefully used magnesium with ketamine
2. I don't think I have seen a paste used ever

[Anne McNulty CRNA]

Prior to the ERA development , MDA antagonists were used frequently in ortho and spine cases. It works very well in long ortho cases especially ex-fix devices. Intra articular and intrathecal injections of Duramorph are often used. You need to be sure you are aware of what the surgeon is up to on the field. I have worked in an institution that had me draw 20cc of blood , which they mixed with other substances and injected into total knees, frequently re-do total joints. As long as you know what they are up to on the field you should be OK. This article offers a protocol very similar to ERAS except nitrous oxide is added

[aileenm4]

there are so many protocols on doing spine cases plus each team also changes up their methods
I have used Ketamine plus the Magnesium in an adult spine protocol, in peds we use Ketamine on chronic pain or as an infusion intraop for spine large scoliosis fusions and in the post op period but no magnesium is given.We use Methadone for our opioid often.
we rarely use intrathecal Duramorph, never have I seen the paste used.

[A Schutter]

1. I have used Magnesium with Ketamine gtts in another institution for not only spine cases but also Hips and gastric bypass cases.
2. I have never worked with a surgeon that used the morphine/duramorph nerve paste.

[Jackie Howell]

1. I like to administer Magnesium with Ketamine unless there is a contraindication (severe renal disease or baseline neuromuscular weakness). I utilize this combination primarily with chronic pain patients and ERAS (colorectal, orthopedics).
2. At Bayview, we have a surgeon that routinely uses epidural duramorph on lumbar spine cases. I haven't seen it utilized as much for the thoracic spine surgeries. My patients require less intraoperative and postoperative narcotics.

[Vania Milnes]

1. I have administered magnesium infusions in the past, but it has been 4+ years. I do think it worked well along with ketamine. I have never run one on a pediatric patient for this purpose.
2. I have never seen the paste, so this is an interesting option...

[Dahlia Rouchon, CRNA]

1. I have used magnesium infusions for ERAS cases, typically abdominal procedures, not for orthopedic/spine. I have also used ketamine gtt with magnesium for these ERAS procedures. I have used ketamine for spinal procedures in addition to propofol gtt or low dose IA where monitoring is in progress.
2. I have not seen intrathecal paste being used but have seen intrathecal duramorph injected by surgery into surgical site.

[Patricia Brissett, CRNA]

1: I have used both Mag and Ketamine infusions on various ERAS cases mostly spine and GYN specialties here at JH and outside the institution.
2:I have witnessed Duramorph injections in total joints as a cocktail mix the surgeon injects directly to site but not as a paste.

[Jocelyn Datud]

1. For ERAS cases (ex.:colo-rectal, spine) and cases where I want to avoid narcotics and maximize pain control, I would utilize Magnesium and Ketamine. I haven't done much cases yet though to compare the difference of incorporating Magnesium.
2. I haven't seen surgeons using morphine/duramorph nerve paste intraoperatively yet.

[kels]

I have used Magnesium supplementation with Ketamine for a few colon ERAS cases
2.I have never seen surgeons using morphine/duramorph nerve paste intraoperatively

[clawry]

Questions to engage discussion:

1. Have you used Magnesium supplementation with Ketamine, and in what cases have you used both drugs?

2. Did you see surgeons using morphine/duramorph nerve paste intraoperatively, and if so, what cases?

1. I have used Magnesium with ketamine in ERAS cases at York and Johns Hopkins. I typically do not use Magnesium in spine cases although it would be a nice adjunct for multimodal analgesia.

2. I have never seen surgeons using morphine/duramorph nerve paste intraoperatively. It sounds like an interesting concept that could definitely help as an adunct for multimodal analgesia for spine patients.

[emedina1]

No I have not use magnesium supplementation with Ketamine in thoracic cases. I had used this combination in other eras procedure in another facility
way back when I used to work in other hospital.


I have not seen morphine /duramorph paste intraoperatively. I have used duramorph epidural for post pain after c-section.