Dr. Deborah Keller has been a surgeon in Texas for nearly a year, and said her experience with the Early Recovery After Surgery program, particularly in pain management, has been “a little bit different.” During her residency, Keller had not been made aware of ERAS and used opioid-based approaches to pain management. She knew there had to be a better way to help patients.
The slowed bowel function, delayed recovery and other common issues associated with opioids were not helping her colon and rectal surgery patients. During her fellowship, she was introduced to enhanced recovery pathways in research and clinical practice. “It was like flipping on a light switch to use enhanced recovery for patients,” she recalled. Opioid-sparing pain management is a cornerstone of enhanced recovery principles, and Dr. Keller developed a specific interest in developing pathways with multimodal pain control. “Opioids do work; they are easy, but they come at a cost. And there are effective alternatives.”
Since then, Keller connected with her colleagues in Texas and have collected data on ERAS’ multimodal approach as a team. While teams like this are few and far between, they are not alone. Single-facility studies have been conducted, and multi-facility data is starting to be collected. Once this data is available, Keller says the larger control studies will be planned to provide what surgeons are demanding – data on whether these method work and consistently improve recovery.
To learn more about how other surgeons in the United States have implemented ERAS pain management practices, Surgical Products connected with Anita Gupta, D.O., Pharm.D., member ASA Committee on Pain Medicine; and Dr. Lawrence Volz, director of ERAS programs for Dunes Surgical Hospital and Mercy Medical Center-Sioux City, Iowa.
How have you seen patient outcomes affected by multimodal pain management approaches?
Gupta: Multimodal therapy or balanced analgesia was has been in existence for the past 20 years. The principle behind this mode of analgesia is combining analgesics with additive or synergistic effects in a bid to reduce the total dose of each agent when used individually and its attendant side effects. There are a limited number of well-developed and conducted RCTs which have demonstrated improved clinical outcomes with respect to analgesia and opioid related side effects when using multimodal analgesia compared to single therapy. Evidence to support improved outcomes with regards to common post-surgical side effects including bladder and bowel dysfunction, ventilator depression remains equivocal. Multimodal analgesia has a significant role in opioid sparing analgesia protocols. This is directly associated with a reduction in the incidence of post-operative nausea and vomiting, urinary retention, ileus, sedation and respiratory depression. The alternatives which include NSAIDs, APAP, and ketamine have their own unique side effect profile which includes hepatotoxicity, renal toxicity and delirium to name a few, therefore multimodal analgesic strategies need to take into account the patients underlying comorbidities in order to ensure improved outcomes.
Keller: I have seen patients less anxious about the surgical experience knowing there is an active plan to address their pain- this is a primary patient concern. In addition, with the current multimodal regimen we are using, patients look like they haven’t had surgery on the day of the operation. They’re sitting up and walking around with family members- it’s amazing- a huge departure from patients being bed-bound from nasogastric tubes, drains, foley catheters, and PCAs. Bowel function returns faster, and lengths of stay are shorted- without any increase in readmission rates.
Volz: We have now implemented multiple medications for preemptive analgesia including Tylenol, Neurontin and Celebrex. The lessons we learned from ERAS we have now applied across the board to every procedure. I now give these same medications to every patient preop and perform a TAP block on every laparoscopic case. I have now found that most of my surgical patients do not utilize narcotics after surgery. I am sending most of my patients home on scheduled Tylenol, ibuprofen and ultram as needed and they have been very comfortable without narcotics. It is rare at this point for patients to need IV narcotics in the recovery room, on the floor or the same day surgery unit before dismissal.
This is one in a five-part series. These experts also answered:
