Richard D. Urman

Multimodal therapy in perioperative analgesia

This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.

Liposomal bupivacaine and clinical outcomes

In the multimodal approach to the management of postoperative pain, local infiltration and regional blocks have been increasingly utilized for pain control. One of the limitations of local anesthetics in the postoperative setting is its relatively short duration of action. Multivesicular liposomes containing bupivacaine have been increasingly utilized for their increased duration of action. Compared with bupivacaine HCl, local infiltration of liposomal bupivacaine has shown to have an increase in duration of action and causes delay in peak plasma concentration. In this article, we attempt to review the clinical literature surrounding liposomal bupivacaine and its evolving role in perioperative analgesia. This new bupivacaine formation may have promising implications in postoperative pain control, resulting in increased patient satisfaction and a decrease in both hospital stay and opioid-induced adverse events (AEs). Although more studies are needed, the preliminary clinical trials suggest that liposomal bupivacaine has predictable pharmacokinetics, a similar side effect profile compared with bupivacaine HCl, and is effective in providing increased postoperative pain control.

Preventive analgesia for postoperative pain control: a broader concept

Pain from surgical procedures occurs as a consequence of tissue trauma and may result in physical, cognitive, and emotional discomfort. Almost a century ago, researchers first described a possible relationship between intraoperative tissue damage and an intensification of acute pain and long-term postoperative pain, now referred to as central sensitization. Nociceptor activation is mediated by chemicals that are released in response to cellular or tissue damage. Pre-emptive analgesia is an important concept in understanding treatment strategies for postoperative analgesia. Pre-emptive analgesia focuses on postoperative pain control and the prevention of central sensitization and chronic neuropathic pain by providing analgesia administered preoperatively but not after surgical incision. Additional research in pre-emptive analgesia is warranted to better determine good outcome measurements and a better appreciation with regard to treatment optimization. Preventive analgesia reduces postoperative pain and consumption of analgesics, and this appears to be the most effective means of decreasing postoperative pain. Preventive analgesia, which includes multimodal preoperative and postoperative analgesic therapies, results in decreased postoperative pain and less postoperative consumption of analgesics.

Perioperative analgesia and challenges in the drug-addicted and drug-dependent patient

The epidemic use of illicit drugs has led to an increasing number of patients with drug addiction and dependence presenting for perioperative care. There are a wide variety of drugs commonly abused including opioids, such as heroin and prescription drugs; stimulants, such as amphetamine and cocaine; depressant drugs, such as alprazolam and diazepam; and hallucinogens, such as lysergic acid diethylamide, phencyclidine, and marijuana. Treatment of opioid dependence by office-based buprenorphine and methadone maintenance programs has expanded opportunities for therapy. Treatment of these patients in the perioperative period is challenging. In addition to pain control, management of anxiety, psychological states, and hemodynamic control are the factors to be considered to provide optimum treatment. Although opioids are the mainstay for the control of acute pain, other therapeutic options include alternative routes of administration of local anesthetic, ketamine infusion, and the use of regional anesthesia. We discuss optimum perioperative management, the role of perioperative urine testing, and special considerations in patients on methadone and buprenorphine.

Capnography during cardiopulmonary resuscitation: Current evidence and future directions

Capnography continues to be an important tool in measuring expired carbon dioxide (CO2). Most recent Advanced Cardiac Life Support (ACLS) guidelines now recommend using capnography to ascertain the effectiveness of chest compressions and duration of cardiopulmonary resuscitation (CPR). Based on an extensive review of available published literature, we selected all available peer-reviewed research investigations and case reports. Available evidence suggests that there is significant correlation between partial pressure of end-tidal CO2 (PETCO2) and cardiac output that can indicate the return of spontaneous circulation (ROSC). Additional evidence favoring the use of capnography during CPR includes definitive proof of correct placement of the endotracheal tube and possible prediction of patient survival following cardiac arrest, although the latter will require further investigations. There is emerging evidence that PETCO2 values can guide the initiation of extracorporeal life support (ECLS) in refractory cardiac arrest (RCA). There is also increasing recognition of the value of capnography in intensive care settings in intubated patients. Future directions include determining the outcomes based on capnography waveforms PETCO2 values and determining a reasonable duration of CPR. In the future, given increasing use of capnography during CPR large databases can be analyzed to predict outcomes.

Operating Room Metrics Score Card--Creating a Prototype for Individualized Feedback

The balance between reducing costs and inefficiencies with that of patient safety is a challenging problem faced in the operating room suite. An ongoing challenge is the creation of effective strategies that reduce these inefficiencies and provide real-time personalized metrics and electronic feedback to anesthesia practitioners. We created a sample report card structure, utilizing existing informatics systems. This system allows to gather and analyze operating room metrics for each anesthesia provider and offer personalized feedback. To accomplish this task, we identified key metrics that represented time and quality parameters. We collected these data for individual anesthesiologists and compared performance to the overall group average. Data were presented as an electronic score card and made available to individual clinicians on a real-time basis in an effort to provide effective feedback. These metrics included number of cancelled cases, average turnover time, average time to operating room ready and patient in room, number of delayed first case starts, average induction time, average extubation time, average time to recovery room arrival to discharge, performance feedback from other providers, compliance to various protocols, and total anesthetic costs. The concept we propose can easily be generalized to a variety of operating room settings, types of facilities and OR health care professionals. Such a scorecard can be created using content that is important for operating room efficiency, research, and practice improvement for anesthesia providers.

The role of analgesics in cancer propagation.

The treatment of cancer pain is paramount to both medical practitioner and patient in order to maximize quality of life. Cancer pain results from direct tumor effects as well as from surgical and medical treatments. Despite therapeutic advancements, morbidity and mortality in cancer care remains high, often from local recurrence or metastasis. Increasing evidence suggests analgesics affect the cellular milieu of malignant and nonmalignant cells and may influence cancer outcomes by directly stimulating tumor growth and inhibiting immune surveillance. Opioids have been shown to cause immunosuppression and stimulate malignant cells in vitro, though adjunct analgesics may additionally promote tumor cell growth. These results have led many to hypothesize that regional analgesic techniques may offer survival advantages to systemic analgesics. Thus far, the data do not support specific analgesic recommendations for the cancer patient, though ongoing prospective, randomized clinical trials are under way to better characterize the safest analgesic regimens for cancer patients.

Evolution of the transversus abdominis plane block and its role in postoperative analgesia.

Since it was first described by Rafi in 2001, the transversus abdominis plane (TAP) block can be best described as a peripheral nerve block to the anterior abdominal wall (T6 to L1). The TAP block is specifically a local anesthetic injection into the fascial plane superficial to the transversus abdominis muscle and deep to the internal oblique muscle. The TAP block has been a subject of controversy with regard to utility, to indications, and more fundamentally, how best to place the block and its precise mechanism of action. The evolution of thinking with regard to this block, or more correctly family of interrelated blocks, includes knowledge of underlying anatomy, as well as an appreciation of its varied approaches. The TAP block affords excellent analgesia for abdominal procedures. In summary, the TAP block affords effective analgesia with opioid sparing effects, technical simplicity, and long duration of action. Some disadvantages include the need for bilateral block for midline incisions and absence of effectiveness for visceral pain.

Office-based anesthesia: safety and outcomes

The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.

Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines

Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.