J. Pisini April 2014

Below are recommendations to consider when caring for an opioid-tolerant patient undergoing spinal fusion surgery:


1)     Continuation of preoperative (home) opioid regimen on day of surgery.

2)     Preop cocktail (to be ordered by surgery)

       PO acetaminophen 1g TID day prior to surgery and 1g PO morning of surgery (please ensure that patients dont take more than 3 gm/day if also taking other acetaminophen containing products). Consider IV Ofirmev 1g q 8hr if NPO.

       PO pregabalin (Lyrica) 150mg preop (if not contraindicated) and BID X 5 days.

3)     After induction, Ketamine (0.5mg/kg IV bolus), followed by continuous infusion at 0.1-0.2mg/kg/hr until POD #2 (as per Ketamine protocol).

4)     Intraop opioids as needed, larger doses may be required secondary to tolerance.

5)     Local infiltration of Bupivacaine (3mg/kg) by surgeon into wound.

6)     To smooth emergence, consider dexmedetomidine (Precedex) 20-30 mcg IV over 10 minutes at start of wound closure (use pre-prepared 1ml syringes of 4mcg/ml in Anesthesia fridge).

7)     IV PCA for postoperative use.

8)     Discuss epidural placement by surgeon intraoperatively if extremely high likelihood or history of post op pain. Recommend straight local anesthetic epidural infusion.



APMS will order ketamine, PCA, and epidural if indicated until POD#2 and transition to POs.

Neurosurgery team will order: preop home meds, Tylenol, Lyrica for day of surgery and hospital course and will take over pain management once on POs. We will continue to be available for assistance as needed.

Flexeril PO by neurosurgery is fine. Benzodiazepines should be discussed with APMS.


4/2014  JVP/PM