Jason McLott, MSN, CRNA developed a mix of medications for doing opioid-free anesthesia that came to be know as the McLott Mix. It’s a combination of dexmedetomidine, lidocaine, ketamine and magnesium.
Jason completed his anesthesia training at Oakland University’s Beaumont Nurse Anesthesia program and works in a CRNA-only practice at Blue Ridge Hospital in rural North Carolina. He regularly mentors SRNAs from Western Carolina University, giving them exposure to a CRNA-only practice, extensive regional anesthesia experience and opioid-free anesthesia techniques. Jason also instructs regional anesthesia courses with Twin Oaks Anesthesia.
If you’ve followed Anesthesia Guidebook for any amount of time, you’ll probably remember that Western Carolina University is my alma mater. I would highly recommend WCU as a premier school for becoming a CRNA. The faculty & clinical sites are top notch and you can’t beat the location down in Asheville, North Carolina.
In Part 1 of this conversation, we talked about Jason’s background, what led him to get into opioid-free anesthesia and the details of the McLott Mix and how he suggests it be used. In Part 2 of our conversation, we come back to talk in more detail on the nuances of how Jason uses the McLott Mix in his practice and how providers can instigate change in moving their practices and groups towards opioid-free anesthesia. Part 2 is a prime example of what Randy Moore & Desirée Chappell & I talked about in episode 82 on change management in healthcare. Hopefully these 2 shows with Jason McLott get you thinking about real ways that you can build opioid-free techniques into your anesthesia practice.
Jason McLott, MSN, CRNA developed a mix of medications for doing opioid-free anesthesia that came to be know as the McLott Mix. It’s a combination of dexmedetomidine, lidocaine, ketamine and magnesium. In this episode, Mr McLott himself unpacks the story of the mix’s development, efficacy and principles for opioid-free anesthesia. He’s clear that this mix helps achieve opioid-free anesthesia, not opioid-free analgesia, recognizing the role of opiates, if needed, in post-operative analgesia plans.
Jason completed his anesthesia training at Oakland University’s Beaumont Nurse Anesthesia program and works in a CRNA-only practice at Blue Ridge Hospital in rural North Carolina. He regularly mentors SRNAs from Western Carolina University, giving them exposure to a CRNA-only practice, extensive regional anesthesia experience and opioid-free anesthesia techniques. Jason also instructs regional anesthesia courses with Twin Oaks Anesthesia.
If you’ve followed Anesthesia Guidebook for any amount of time, you’ll probably remember that Western Carolina University is my alma mater. I would highly recommend WCU as a premier school for becoming a CRNA. The faculty & clinical sites are top notch and you can’t beat the location down in Asheville, North Carolina.
In Part 1 of this conversation, we talk about Jason’s background, what led him to get into opioid-free anesthesia and the details of the McLott Mix and how he suggests it be used. In Part 2 of our conversation, we come back to talk in more detail on the nuances of how Jason uses the McLott Mix in his practice and how providers can instigate change in moving their practices and groups towards opioid-free anesthesia. Part 2 is a prime example of what Randy Moore & Desirée Chappell & I talked about in episode 82 on change management in healthcare. Hopefully these 2 shows with Jason McLott get you thinking about real ways that you can build opioid-free techniques into your anesthesia practice.
This episode was originally published in April 2019 on From the Head of the Bed… a podcast for the anesthesia community. In this podcast, Skyler provides a thorough overview of local anesthetics including relevant anatomy and physiology (i.e. nerve fibers, sodium channels, pKa, etc), types of local anesthetics and factors that effect onset, potency, duration of action and absorption. We touch on methemoglobinemia, Local Anesthetic Systemic Toxicity (LAST) and common dosing and max dosing for local anesthetics. This is a great run down for anyone wanting to brush up on local anesthetics!
At the time of this recording, Skyler Rouhselang was a second-year SRNA at Marian University in Indianapolis, IN. She attended Ball State University for her undergraduate education where she earned her BSN in 2013. Skyler went on to work in the medical ICU at a level 1 trauma center in downtown Indianapolis for 5 years before returning to school to complete her Doctor of Nursing Practice degree. Skyler has married and changed her name to Skyler Williams, DNP, CRNA. As of September 2021, Dr Williams practices anesthesia as a CRNA at IU Health Arnett Hospital in Lafayette, IN.
Resources
Butterworth, J. F., Mackey, D. C., & Wasnick, J. D. (2018). Morgan and Mikhail’s clinical anesthesiology. McGraw-Hill Education.
Miller, R. D. (2014). Miller’s anesthesia. Philadelphia, PA: Elsevier.
Nagelhout, J. J., Elisha, S., & Plaus, K. (2017). Nurse anesthesia. Elsevier Health Sciences.
This episode was originally released on From the Head of the Bed on March 3, 2019 and recorded in Scottsdale, Arizona. Tom Baribeault, DNP, CRNA and Jayme Reuter, MS, CRNA talk with me about opioid free anesthesia.
We discuss the progression to opioid free anesthesia (OFA), where OFA fits into enhanced recovery programs and the specific techniques of how to provide a comfortable, opioid-free perioperative experience for our patients.
Find out more about the Society for Opioid Free Anesthesia, including a resource-filled members-only section of their website which includes overviews of pharmacological alternatives to opioids and specific opioid-free anesthetic plans.
At the time of this recording, Tom Baribeault was the Chief CRNA at Lexington Surgery Center in Lexington, Kentucky. He completed his anesthesia training at Case Western Reserve University. Tom has a passion for teaching anesthesia providers and others on opioid-free anesthesia, enhanced recovery after surgery, ultrasound guided regional anesthesia and point of care ultrasound. He is the president and founder of the Society for Opioid Free Anesthesia and is a member of the American Association of Nurse Anesthetists and the Kentucky Association of Nurse Anesthetists. Since this recording, Tom completed his Doctor of Nursing Practice
Jayme Reuter, MS, CRNA is the Program Director and founder of Cornerstone Anesthesia Conferences. She completed her anesthesia training at Baylor College of Medicine and practices at Houston Methodist Hospital, which is part of Texas Medical Center. She created Cornerstone Anesthesia Conferences in 2017 with a mission to be the foundation for excellence in continuing anesthesia education.
This episode was originally released in April of 2020 on From the Head of the Bed… a podcast for the anesthesia community and is being re-released on 5 September 2021 on Anesthesia Guidebook.
In this episode, I speak with Shane Garner, MS, CRNA, NSPM-C about an introduction & overview of regional anesthesia. We discuss:
opioid-free anesthesia
how to gain experience in regional anesthesia as a SRNA or CRNA
fellowships in pain management available to CRNAs
the Non-Surgical Pain Management (NSPM) board examination
how to start a block program and gain surgeon buy-in
when to use regional anesthesia catheters and more!
Shane Garner, MS, CRNA, NSPM-C
Shane Garner is a CRNA who works in Ripon, Wisconsin and is passionate about teaching anesthesia providers on personal finance as well as regional anesthesia. He has a Bachelor of Science in Nursing from the University of Minnesota and graduated from Rosalind Franklin University with his Master of Science in Nurse Anesthesia in 2012. He went on to complete a fellowship in Advanced Pain Management at the University of South Florida before becoming board certified in Nonsurgical Pain Management through the NBCRNA. Shane is an adjunct faculty member at the University of Alabama at Birmingham’s nurse anesthesia program and regularly instructs with Twin Oaks Anesthesia & Cornerstone Anesthesia Conferences.
This episode outlines the overnight transition to same-day surgery & discharge for total knee patients at Maine Medical Center. Surgeon Adam Rana, MD was informed on a Tuesday afternoon in December 2020 that elective cases requiring overnight hospital stays were being canceled effective immediately. He reached out to physician anesthesiologist Ryan Mountjoy, MD, along with others, and the very next day they implemented a new anesthesia plan that got patients discharged safely the same-day of surgery. These patients experienced equivalent pain scores post-operatively while remarkably requiring less opioid refills. The length of stay was slashed from 42 hours to 12 hours.
These physicians, along with physician anesthesiology resident and lead author Derek Bunch, DO and others, have submitted this story as a proof of concept for the American Society of Regional Anesthesia and Pain Medicine (ASRA) and will present this story at other national anesthesia and surgical meetings. Dr Bunch was unfortunately unable to join us on the podcast due to working overnight call during the wee-hours of the morning when we recorded this episode but hopefully he’ll agree to come on the show in the future to talk about this or other regional anesthesia topics as he prepares to head off for his regional fellowship later this summer.
Dr Bunch’s write up is provided below courtesy of the authors with select table data following:
Posterior injection by surgeon (bupivacaine 120mg, epinephrine 300mcg, morphine 8mg)
Posterior injection by surgeon (bupivacaine 50mg, epinephrine 100mcg)
Propofol sedation
Propofol sedation
Table 2 highlights the differences between the standard practice and the new anesthesia protocol for same-day discharge for total knee arthroplasty at Maine Medical Center.
Table 3: Demographics and Outcomes
Next day knee
Same day Knee
Number of patients
48
49
Average LOS (hrs)
42
12
Number of patients needing IV hydromorphone post op
15
11
Number of patients needing oral opioids post op
41
32
Average pain score in hospital
3.9
3.8
Average pain score at 2 weeks
3.3
3
Number of patients filling narcotics following surgery
25
20
Total number of narcotics refills following surgery
49
27
Table 3 highlights preliminary data comparing a cohort of patients from one year prior to the study period when patients were shifted to same-day discharge from total knee surgery. “Average age was 63 for both groups and average ASA scores were comparable (2.3 for next day knee patients and 2.2 for same day knee patients).” D. Bunch.
Dr Adam Rana’s bio as quoted from his website: “Dr. Adam Rana is a Board Certified, Fellowship-Trained Orthopedic Surgeon who specializes in minimally invasive hip and knee replacement surgery with specific training in the anterolateral muscle sparring approach to the hip, custom partial and total knee replacement surgery as well as revision hip and knee replacement surgery… Dr. Rana earned his Bachelor’s degree with Honors in Economics and Biology from Colby College where he graduated Cum Laude. While at Colby, Dr. Rana spent two summers in Minneapolis, MN at the Hennepin County Orthopedic Biomechanics Laboratory… [and] was actively involved in research projects relating to biomechanics in hip and knee replacement systems.” He attended SUNY Downstate Medical Center for medical school and “subsequently completed his Orthopedic Surgical Residency at the Boston Medical Center… After residency, he completed a fellowship in Adult Reconstruction, Arthritis, and Joint Replacement Surgery at the Hospital for Special Surgery (HSS) in New York City.” Dr Rana is widely published in peer-reviewed journals as well as medical text chapters and frequently presents on orthopedic surgery at state and national meetings. He is actively involved in the American Academy of Orthopedic Surgeons, the American Association of Hip and Knee Surgeons and the New England and Maine Orthopedic Associations. He currently serves as the director of the Joint Replacement Center at Maine Medical Center.
You may remember Dr Ryan Mountjoy, MD, who joined us for episode 11 of Anesthesia Guidebook to talk about the use of cognitive aids in emergencies. He is a board-certified physician anesthesiologist with Spectrum Healthcare Partners in Portland, Maine. He is the Co-Director of Orthopedic Trauma and Total Joint Anesthesia and the Co-Director of Regional Anesthesia and Acute Pain Medicine at Maine Medical Center and the Site Chief of Anesthesia at MaineHealth’s Scarborough Surgery Center. He completed his anesthesia residency at Stanford University and then pursued a Regional and Ambulatory Anesthesia fellowship at Duke University, where he worked prior to moving to Maine.
Aurora Quaye, MD is an anesthesiologist who specializes in regional anesthesia and pain medicine at Maine Medical Center in Portland, Maine. She completed her residency at Massachusetts General Hospital and a fellowship in Regional Anesthesia at Brigham and Women’s Hospital. Dr. Quaye’s clinical interests include decreasing the use of opioids for pain management, in improving provider education on non-opioid analgesic strategies, and in identifying analgesic techniques that decrease the potential for opioid misuse, dependence and addiction. Dr Quaye has led committees to establish institutional guidelines for perioperative continuation of buprenorphine at analgesic dosing for patients with history of Opioid Use Disorder. These guidelines have been incorporated in acute pain management protocols at Massachusetts General Hospital and Maine Medical Center. This change from the prior practice of discontinuing buprenorphine has shown early promise in facilitating postoperative pain relief while limiting opioid prescribing.
Resources:
Quaye, A. N. A., et. al. (2020) Perioperative Continuation of Buprenorphine at Low–Moderate Doses Was Associated with Lower Postoperative Pain Scores and Decreased Outpatient Opioid Dispensing Compared with Buprenorphine Discontinuation, Pain Medicine, Volume 21, Issue 9, Pages 1955–1960, https://doi.org/10.1093/pm/pnaa020
Quaye, A. N. A., & Zhang, Y. (2019). Perioperative management of buprenorphine: solving the conundrum. Pain Medicine, 20(7), 1395-1408.
Ward, E. N., Quaye, A. N. A., & Wilens, T. E. (2018). Opioid use disorders: perioperative management of a special population. Anesthesia and analgesia, 127(2), 539.
Anderson, T. A., Quaye, A. N., Ward, E. N., Wilens, T. E., Hilliard, P. E., & Brummett, C. M. (2017). To Stop or Not, That Is the QuestionAcute Pain Management for the Patient on Chronic Buprenorphine. Anesthesiology: The Journal of the American Society of Anesthesiologists, 126(6), 1180-1186.
