Erik M. Helander

A Comparison of Multimodal Analgesic Approaches in Institutional Enhanced Recovery After Surgery Protocols for Colorectal Surgery: Pharmacological Agents

Abstract Introduction: Enhanced recovery after surgery (ERAS®) protocols are the cornerstone of improved recovery after colorectal surgery. Their implementation leads to reduced morbidity and shorter hospital stays while attenuating the surgical stress response. Multimodal analgesia is an important part of ERAS protocols. We compared and contrasted protocols from 15 institutions to test our hypothesis that there is a fundamental consensus among them. Materials and Methods: ERAS protocols for open and laparoscopic colorectal surgery were compared from 15 different healthcare facilities. We examined each institutions approach to multimodal analgesia related to the use of oral and intravenous analgesics. Preoperative, intraoperative, and postoperative management was examined. Results: All but three protocols used preoperative multimodal analgesics, with acetaminophen, celecoxib, and gabapentin being the most common. Intraoperative recommendations included the use of ketamine, lidocaine, magnesium, and ketor...INTRODUCTION Enhanced Recovery After Surgery (ERAS®) protocols are the cornerstone of improved recovery after colorectal surgery. Their implementation leads to reduced morbidity and shorter hospital stays while attenuating the surgical stress response. Multimodal analgesia is an important part of ERAS protocols. We compared and contrasted protocols from 15 institutions to test our hypothesis that there is a fundamental consensus among them. MATERIALS AND METHODS ERAS protocols for open and laparoscopic colorectal surgery were compared from 15 different healthcare facilities. We examined each institutions approach to multimodal analgesia related to the use of oral and intravenous analgesics. Preoperative, intraoperative, and postoperative management was examined. RESULTS All but three protocols used preoperative multimodal analgesics, with acetaminophen, celecoxib, and gabapentin being the most common. Intraoperative recommendations included the use of ketamine, lidocaine, magnesium, and ketorolac. Some protocols advocated for the use of opiates, while others aimed to minimize total opioid dose. In the postoperative period, the three most utilized agents were acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. CONCLUSIONS There were many similarities and some significant differences among ERAS protocols examined. Acetaminophen was the most widely used nonopioid agent and along with NSAIDs offers a benefit with respect to postoperative analgesia, opioid-sparing effects, earlier ambulation, and reduction in postoperative ileus. Gabapentin was widely used as it may reduce opioid consumption within the first 24 hours postoperatively. Lidocaine infusion was recommended if there were contraindications to or failure of epidural anesthesia. Ketamine is frequently recommended due to its analgesic, antihyperalgesic, antiallodynic, and antitolerance properties. Differences in approaches may be due to both institutional- and provider-level factors.

Multimodal analgesia, current concepts, and acute pain considerations

Purpose of ReviewManagement of acute pain following surgery using a multimodal approach is recommended by the American Society of Anesthesiologists whenever possible. In addition to opioids, drugs with differing mechanisms of actions target pain pathways resulting in additive and/or synergistic effects. Some of these agents include alpha 2 agonists, NMDA receptor antagonists, gabapentinoids, dexamethasone, NSAIDs, acetaminophen, and duloxetine.Recent FindingsAlpha 2 agonists have been shown to have opioid-sparing effects, but can cause hypotension and bradycardia and must be taken into consideration when administered. Acetaminophen is commonly used in a multimodal approach, with recent evidence lacking for the use of IV over oral formulations in patients able to take medications by mouth. Studies involving gabapentinoids have been mixed with some showing benefit; however, future large randomized controlled trials are needed. Ketamine is known to have powerful analgesic effects and, when combined with magnesium and other agents, may have a synergistic effect. Dexamethasone reduces postoperative nausea and vomiting and has been demonstrated to be an effective adjunct in multimodal analgesia. The serotonin–norepinephrine reuptake inhibitor, duloxetine, is a novel agent, but studies are limited and further evidence is needed.SummaryOverall, a multimodal analgesic approach should be used when treating postoperative pain, as it can potentially reduce side effects and provide the benefit of treating pain through different cellular pathways.

America’s Opioid Epidemic: a Comprehensive Review and Look into the Rising Crisis

Purpose of ReviewIn the USA, there has been a sharp increase in heroin, prescription opiate, and illicitly manufactured fentanyl abuse with overdoses tripling since the 1990s. Several states have been deemed as “high-burden” abuse states where there is a greater proportion of synthetic opiate use. During the same period that prescription limitations were initially implemented throughout the country, the fentanyl epidemic started nationwide.Recent FindingsIn the setting of data demonstrating an almost fourfold increase in overdose deaths from 1999 to 2008, states began restricting access to Food and Drug Agency (FDA) approved opioid medications. Another factor further exacerbating the opioid crises is that the cost of all formulations of naloxone has increased significantly over the past several years.SummaryIn order to combat the opioid epidemic, stricter prescribing practices and prescription-monitoring programs have been instituted. Also, improvements in abuse-deterrent strategies for all opioid preparations can play an important role by increasing the safety of these medications and is a major focus of the FDA.

Multimodal Approaches to Analgesia in Enhanced Recovery After Surgery Pathways

Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway designed to decrease morbidity, length of stay, and promote faster postoperative recovery. Surgery is associated with many undesirable potential consequences, including pain, cardiopulmonary sequelae, thromboembolic events, nausea/vomiting, ileus, and fatigue. The surgical stress response related to inflammatory mediators and neurohumoral responses combined with postoperative pain, nothing by mouth status, anxiety, hypovolemia, fatigue, and sleep disturbances is primarily responsible for many of the aforementioned potential consequences after a surgical procedure. The implementation of ERAS protocols, therefore, is aimed to attenuate these processes. Current ERAS protocols involvemany techniques to promote early mobilization and attenuate the surgical stress response, and involve a collaborative effort between anesthesiologists, surgeons, the

Ketorolac, Oxymorphone, Tapentadol, and Tramadol : A Comprehensive Review

Pain remains a tremendous burden on patients and for the health care system, with uncontrolled pain being the leading cause of disability in this country. There are a variety of medications that can be used in the treatment of pain, including ketorolac, oxymorphone, tapentadol, and tramadol. Depending on the clinical situation, these drugs can be used as monotherapy or in conjunction with other types of medications in a multimodal approach. A strong appreciation of pharmacologic properties of these agents and potential side effects is warranted for clinicians.

Preoperative Assessment for Ambulatory Surgery

Purpose of ReviewAmbulatory surgery has grown in recent decades in volume and represents a significant number of anesthetics delivered throughout the USA. Preoperative anesthetic assessment in the ambulatory setting has become important because patients with numerous complex comorbidities are now commonplace in this arena. Disease states involving the lungs, the heart, the kidneys, and subpopulations including those who are obese and the elderly commonly receive anesthetics in an ambulatory setting.Recent FindingsThis review presents key aspects of current thinking with regard to preoperative assessment and considerations for different critical disease states and subpopulations that are now being managed under ambulatory surgery. Same day surgery centers require patient safety, and expectations are high for patient satisfaction. Advancements in surgical and anesthetic technique have allowed for more complex patients to partake in ambulatory surgery.SummaryAnesthesiologists must be familiar with guidelines, state-of-the-art pain management, and standards of preoperative patient evaluation to accurately stratify patient risk and to advocate for patient safety.

Tanezumab: a selective humanized mAb for chronic lower back pain

Chronic lower back pain is a significant disease that affects nearly 20% of the worldwide population. Along with hindering patients’ quality of life, chronic lower back pain is considered to be the second most common cause of disability among Americans. Treating chronic lower back pain is often a challenge for providers, especially in light of our current opioid epidemic. With this epidemic and an increased aging population, there is an imminent need for development of new pharmacologic therapeutic options, which are not only effective but also pose minimal adverse effects to the patient. With these considerations, a novel therapeutic agent called tanezumab has been developed and studied. Tanezumab is a humanized monoclonal immunoglobulin G2 antibody that works by inhibiting the binding of NGF to its receptors. NGF is involved in the function of sensory neurons and fibers involved in nociceptive transduction. It is commonly seen in excess in inflammatory joint conditions and in chronic pain patients. Nociceptors are dependent on NGF for growth and ongoing function. The inhibition of NGF binding to its receptors is a mechanism by which pain pathways can be interrupted. In this article, a number of recent randomized controlled trials are examined relating to the efficacy and safety of tanezumab in the treatment of chronic lower back pain. Although tanezumab was shown to be an effective pain modulator in major trials, several adverse effects were seen among different doses of the medication, one of which led to a clinical hold placed by the US Food and Drug Administration. In summary, tanezumab is a promising agent that warrants further investigation into its analgesic properties and safety profile.

Preemptive Analgesia, Regional Anesthesia, and Prevention of Chronic Postoperative Pain

Preemptive analgesia is focused on both the prevention and treatment of postoperative pain. There are several factors at play related to postoperative pain and the individual patient. Furthermore, sensitization is an important aspect to consider when determining an appropriate analgesic plan for patients. Similarly, exposure to noxious stimuli for prolonged periods or of high frequency in the periphery can lead to changes in the central nervous system pain processing centers, which can affect the appropriate analgesic plan for patients. Pain can be controlled in several phases of perioperative care including pre-, peri-, and postoperative periods, and many agents can be used as preemptive analgesic treatments such as NSAIDs, local anesthetics, opioids, and NMDA receptor antagonists. Local wound infiltration is being used in conjunction with nerve blocks and is becoming an efficient method of postoperative pain control. Regional anesthesia is also continuing to grow and is used for a wide variety of procedures in the treatment of chronic pain. Several complex pain syndromes are discussed in this chapter, as well as the diagnostic criteria and how to treat them. Overall, the value of comprehensive pain control for surgical patients should not be underestimated and is likely to be best addressed with a multimodal, patient-specific approach.

Preoperative Assessment of the Pregnant Patient Undergoing Nonobstetric Surgery

The anesthetic management of pregnant patients can present a variety of challenges and a thorough preoperative assessment is necessary before initiating any anesthetic services. Both the mother and the fetus need to be considered when formulating an anesthetic plan and discussing informed consent. The overall aims in assessing a pregnant patient are to identity potential issues that can lead to catastrophic complications, provide adequate information allowing the mother to make informed decisions, and to obtain knowledge for tailoring an anesthetic that maintains maternal and fetal homeostasis.