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; Dr. David B. Auyong, attending anesthesiologist, medical director at Lindeman Ambulatory Surgical Center, Virginia Mason Medical Center; and Dr. Lawrence Volz, director of ERAS programs for Dunes Surgical Hospital and Mercy Medical Center-Sioux City, Iowa.
How has ERAS program impacted your pain management practices?
Auyong: Pain management plays a huge role in how well patients recover after surgery. Managing the use of narcotics for pain defines a successful ERAS program – if pain can be adequately managed without the use of narcotics, there is less risk of dependence and adverse side effects for patients – i.e. respiratory depression, immunosuppression, sedation, nausea, vomiting, dizziness and physical dependence. Non-narcotic, post-operative pain pumps play well into these goals.
Employing multimodal methods for pain management, with an emphasis on narcotic reduction, can also increase the chances that a patient will follow through on physical therapy as they won’t be hampered down by both pain and the physical/mental setbacks often presented by narcotics.
Gupta: Enhanced recovery programs are multimodal perioperative pathways that were developed to enhance recovery following major surgery. A key component of ERAS program is pain management. This encompasses standardized strategies to reduce postoperative pain thereby, facilitating early mobilization and discharge. Traditional practice has long advocated for the use of opioids in the post-operative period particularly following colorectal, thoracic, vascular surgery and radical cystectomy, all of which currently have well established ERAS protocols available. To achieve adequate pain control as part of ERAS, there has been a shift toward multimodal analgesia with emphasis on opioid reduction to reduce complications associated with opioid use including respiratory depression and constipation which can have significant impact on recovery rates. There has also been a push to use regional techniques, for example in the setting of thoracic and colorectal surgery. Use of an epidural has been shown to reduce the risk of post-operative respiratory complications by reducing the incidence of basal atelectasis.
Keller: Enhanced Recovery Protocols have put an emphasis on pain management at every stage of the patient experience- preoperative counseling and preparation, intraoperative, and postoperative. They have also increased the number of opioid-sparing agents we use, and methods of delivery- so baseline pain thresholds, ascending and descending pain pathways, and peripheral targets are all addressed, with th end result of decreasing opioid utilization.
Volz: When our ERAS program started, I was a bit skeptical about how good of pain relief I would get utilizing the ERAS techniques. I had not even heard of TAP blocks but had not had a good experience with epidurals in my colon resection patients. Many of the patients had spotty pain control and many were not able to walk. The foley catheters stayed in longer and there seemed to be more ileus postoperatively. I had always felt narcotics were causing a lot of problems and was willing to do anything to avoid them. We initially used IV Tylenol and toradol but IV Tylenol was taken off formulary and we had to change to preop PO Tylenol. I wanted to use TAP blocks but many anesthesiologists did not do them. I started doing the TAP blocks myself in the OR with ultrasound after insufflating the abdomen for laparoscopy and eventually decided that I did not need ultrasound guidance but could do them with laparoscopy and have done them that way since.
This is one in a five-part series. These experts also answered: