Appendix: 24-hour Background Analgesic Infusion

Based on an 80 kg patient over 24 hours (multiplication factor for each drug = 24 x 80 = 1 920).

Amounts are rounded off to available ampoule sizes.

Hours	Total/24 h	Volume
Drug: Ketamine; Dose/kg/hr: 0.05 mg; kg: 80 kg
24	100 mg	2 ml of 50 mg/ml
Drug: Lignocaine; Dose/kg/hr: 1 mg; kg: 80 kg
24	2 000 mg	20 ml (10%; 100 mg/ml)
Drug: Dexmedetomidine; Dose/kg/hr: 0.1 μg; kg: 80 kg
24	200 μg	2 ml (100 μg/ml)
Drug: MgSO4; Dose/kg/hr: 2.5 mg; kg: 80 kg
24	5 g	10 ml (50%; 0.5 g/ml)

Dextrose 5% volume: 500 ml
Total volume: 534 ml
Infusion rate: 534/24 = 22 ml/hour

(Remark: As far as the author knows, DW5% 500 ml is not available in South Africa. Therefore, the total drug volumes (34 ml) can be added to 200 ml of DW5% = 234 ml and administered at 234 ml/24 hours = 9.75 ml/h ≈ 10 ml/h).)

Reviews

1. Tick H, Nielsen A, Pelletier PR. Evidence-based nonpharmacologic strategies for comprehensive pain care: the consortium pain task force white paper. Academic Consortium for Integrative Medicine & Health [Internet]; 2018. Available from: http://www.nonpharmpaincare.org.
2. Mitra S, Carlyle D, Kodumudi G, et al. New advances in acute postoperative pain management. Curr Pain Headache Rep. 2018;22:34-45. https://doi.org/10.1007/s11916-018-0690-8.
3. Tan M, Law LS-C, Gan TJ. Optimizing pain management to facilitate enhanced recovery. Can J Anesth. 2015;62:203-21. https://doi. org/10.1007/s12630-014-0275-x.
4. Ramirez MF, Kamdar BB, Cata JP. Optimizing perioperative use of opioids: a multimodal approach. Curr Anestesiol Rep. 2020;10(4):404-15. https://doi.org/10.1007/s40140-020-00413-6.

Bibliography

• Chester SJ, Stockton K, De Young A, et al. Effectiveness of medical hypnosis for pain reduction and faster wound healing in pediatric acute burn injury: study protocol for a randomized controlled trial. Trials. 2016;17:223-34. https://doi.org/10.1186/s13063-016-1346-9.
• Chooi CS, White AM, Tan SG, Dowling K, Cyna AM. Pain vs. comfort scores after caesarean section: a randomized trial. Br J Anaesth. 2013;110(5):780-7. https://doi.org/10.1093/bja/aes517.
• De Oliveira GS Jr, Castro-Alves LJ, Khan JH, McCarthy RJ. Perioperative systemic magnesium to minimize postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology. 2013;119(1):178-90. https://doi.org/10.1097/ALN.0b013e318297630d.
• Dhasmana CS. Nasotracheal fiberoptic intubation: patient comfort, inubating conditions and hemodynamic stability during conscious sedation with different doses of dexmedetomidine. J Maxillofac Oral Surg. 2014;13(1):53-8. https://doi.org/10.1007/s12663-012-0469-0.
• Duggan EW, Patel GP. Commentary on: bilateral breast reduction without opioid analgesics: a comparative study. Aesthetic Surg J. 2017;37(8):900-3. https://doi.org/10.1093/asj/sjx092.
• Gami AS, Caples SM, Somers VK. Obesity and obstructive sleep apnea. Endocrinol Metab Clin N Am. 2003;32:869-4. https://doi. org/10.1016/S0889-8529(03)00069-0.
• Gelineau AM, King MR, Ladna KS, et al. Intraoperative esmolol as an adjunct for perioperative opioid and postoperative pain reduction: a systematic review, meta-analysis, and meta-regression. Anesth Analg. 2018;126:1035-49. https://doi.org/10.1213/ANE.0000000000002469.
• Jehan S, Zizi F, Pandi-Perumal SR, et al. Obstructive sleep apnea and obesity: implications for public health. Sleep Med Disord. 2017;1(4):00019. https://doi.org/10.15406/smdij.2017.01.00019.
• Johnson MI. Transcutaneous electrical nerve stimulation (TENS) as an adjunct for pain management in perioperative settings: a critical review. Expert Rev Neurother. 2017;27(10):1013-27. https://doi.org/10.1080/14737175.2017.1364158.
• Jouguelet-Lacoste J, La Colla L, Schilling D, Chelly JE. The use of intravenous infusion or single dose of low-dose ketamine for postoperative analgesia: a review of the current literature. Pain Med. 2015;16(2):383-403. https://doi.org/10.1111/pme.12619.
• Kaye AD, Chernobylsky DJ, Thakur P, et al. Dexmedetomidine in enhanced recovery after surgery (ERAS): protocols for postoperative pain. Curr Pain Headache Rep. 2020;24:21-34. https://doi.org/10.1007/s11916-020-00853-z.
• Kranke P, Jokinen J, Pace NL, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev. 2015;7:CD009642. https://doi.org/10.1002/14651858.CD009642.pub2.
• Krish B, Patel V, Baldawi M, et al. Traditional acupuncture and battlefield acupuncture use in mutimodal perioperative anesthesia care for our veteran patients. American Soc Anaesthesiologists Congress Abstract A3091. American Soc Anaesthesiologists; 2020.
• Lee JH. The effects of music on pain: a meta-analysis. J Music Ther. 2016;54(4):430-77. https://doi.org/10.1093/jmt/thw012.
• Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician. 2010;13:401-35. https://doi.org/10.36076/ppj.2010/13/401.
• Manchikanti L, Helm SII, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012;15:ES9-ES38. https://doi.org/10.36076/ ppj.2012/15/ES9.
• Mulier JP. Is opioid-free general anesthesia for breast and gynecological surgery a viable option? Curr Opin Anesthesiol. 2019;32:257-62. https://doi.org/10.1097/ACO.0000000000000716.
• Parsa FD, Cheng D, Stephan B, et al. Bilateral breast reduction without opioid analgesics: a comparative study. Aesthetic Surg J. 2017;37(8):892-9. https://doi.org/10.1093/asj/sjx038.
• Ramirez MF, Kamdar BB, Cata JP. Optimizing perioperative use of opioids: a multimodal approach. Curr Anestesiol Rep. 2020;10(4):404-15. https://doi.org/10.1007/s40140-020-00413-6.
• Rovling N, Nielsen CV, Christensen FB, et al. Preoperative cognitive-behavioural intervention improves in-hospital mobilisation and analgesic use for lumbar spinal fusion patients. BMC Musculoskelet Disord. 2016:17:217-24. https://doi.org/10.1186/s12891-016-1078-8.
• Sanketh R, Katie M, Amy DY, Azeem A, Daqing M. Postoperative sleep disorders and their potential impacts on surgical outcomes. J Biomed Res. 2019;34(4):271-80. https://doi.org/10.7555/JBR.33.20190054.
• Schwenk ES, Viscusi ER, Buvanendran A, et al. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018;43(5):456-66. https://doi.org/10.1097/AAP.0000000000000806.
• Tefikow S, Barth J, Maichrowitz S, Strauss B, Rosendahl J. Efficacy of hypnosis in adults undergoing surgery or medical procedures: A meta-analysis of randomized controlled trials. Clin Psychol Rev. 2013;33:623-36. https://doi.org/10.1016/j.cpr.2013.03.005.
• Vigneault L, Turgeon AF, Côte D, et al. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth. 2011;58(1):22-37. https://doi.org/10.1007/s12630-010-9407-0.
• White PF, Kehlet H. Improving pain management: have we jumped from the frying pan into the fire? Anesth Analg. 2007;105(1):10-2. https://doi.org/10.1213/01.ane.0000268392.05157.a8.
• Xiang A, Cheng K, Shen X, Xu P, Liu S. The immediate analgesic effect of acupuncture for pain: a systematic review and meta-analysis. Evid Based Complement Alternat Med. 2017;3837194. https://doi.org/10.1155/2017/3837194.

Click here for the pdf

---

South African Society of Anaesthesiologists (SASA) Guidelines for the Management of Acute Pain in Specific Scenarios 2022