Clinical Benchmarks Regarding Multimodal Peripheral Nerve Blocks for Postoperative Analgesia: Observations Regarding Combined Perineural Midazolam-Clonidine-Buprenorphine-Dexamethasone

In a separate commentary [1] , we reported on potential clinical research priorities with respect to multimodal perineural anesthesia and analgesia (MMPNA). This was based on our group's review of institutional quality assurance/improvement (QA/QI) data routinely using this technique for over 1,300 patients from late 2011 to the present at the Veterans Affairs Pittsburgh Healthcare System. This previous commentary addressed the four-drug combination of bupivacaine, clonidine, buprenorphine, and dexamethasone (BPV-CBD) used for postoperative perineural analgesia (e.g., combined with intraoperative spinal anesthesia), or for the dual role of intraoperative perineural anesthesia and postoperative analgesia. The average block duration (block insertion time until peak rebound pain score on a 0 to 10 scale) in this previous commentary was 33 to 37 hours, depending on the context. We believe that this clinical observation warrants high-priority research for the specialty, especially in the context of the effects of buprenorphine dose response and the parameters of block duration and rebound pain. In this current commentary, we will direct separate attention toward the four-drug combination of midazolam (MDZ) with CBD used for specific contexts of motor-sparing perineural analgesia.