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

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 institution's 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.

[1]  Christopher L. Wu,et al.  American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1—from the preoperative period to PACU , 2017, Perioperative Medicine.

[2]  P. L. Petersen,et al.  Gabapentin for post‐operative pain management – a systematic review with meta‐analyses and trial sequential analyses , 2016, Acta anaesthesiologica Scandinavica.

[3]  Christine S. M. Lau,et al.  Use of preoperative gabapentin significantly reduces postoperative opioid consumption: a meta-analysis , 2016, Journal of pain research.

[4]  R. Urman,et al.  Role of ketamine for analgesia in adults and children , 2016, Journal of anaesthesiology, clinical pharmacology.

[5]  K. Wilby,et al.  Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making. , 2015, The Canadian journal of hospital pharmacy.

[6]  R. Urman,et al.  Perioperative analgesia outcomes and strategies. , 2014, Best practice & research. Clinical anaesthesiology.

[7]  M. Hankins,et al.  Oral vs intravenous paracetamol for lower third molar extractions under general anaesthesia: is oral administration inferior? , 2013, British journal of anaesthesia.

[8]  K. Fearon,et al.  Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery after Surgery (eras Clinical Nutrition , 2022 .

[9]  T. Gan,et al.  Perioperative Systemic Lidocaine for Postoperative Analgesia and Recovery after Abdominal Surgery: A Meta-analysis of Randomized Controlled Trials , 2012, Diseases of the colon and rectum.

[10]  J. Lutz,et al.  Anesthesia and perioperative management of colorectal surgical patients – specific issues (part 2) , 2012, Journal of anaesthesiology, clinical pharmacology.

[11]  A. Habib,et al.  Impact of Intravenous Lidocaine Infusion on Postoperative Analgesia and Recovery from Surgery , 2010, Drugs.

[12]  A. Rawlinson,et al.  A systematic review of enhanced recovery protocols in colorectal surgery. , 2011, Annals of the Royal College of Surgeons of England.

[13]  W. McKay,et al.  A systematic review of intravenous ketamine for postoperative analgesia , 2011, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[14]  A. Merry,et al.  Combining Paracetamol (Acetaminophen) with Nonsteroidal Antiinflammatory Drugs: A Qualitative Systematic Review of Analgesic Efficacy for Acute Postoperative Pain , 2010, Anesthesia and analgesia.

[15]  P. Bampton,et al.  Clinical trial: the impact of cyclooxygenase inhibitors on gastrointestinal recovery after major surgery – a randomized double blind controlled trial of celecoxib or diclofenac vs. placebo , 2009, Alimentary pharmacology & therapeutics.

[16]  C. Kuo,et al.  Opioid-sparing Effects of Ketorolac and Its Correlation With the Recovery of Postoperative Bowel Function in Colorectal Surgery Patients: A Prospective Randomized Double-blinded Study , 2009, The Clinical journal of pain.

[17]  M. Koch,et al.  Meta‐analysis of standard, restrictive and supplemental fluid administration in colorectal surgery , 2009, The British journal of surgery.

[18]  M. Beaussier,et al.  Meta‐analysis of intravenous lidocaine and postoperative recovery after abdominal surgery , 2008, The British journal of surgery.

[19]  M. Durieux,et al.  A brief review of innovative uses for local anesthetics , 2008, Current opinion in anaesthesiology.

[20]  H. Dupont,et al.  Postoperative Ketamine Administration Decreases Morphine Consumption in Major Abdominal Surgery: A Prospective, Randomized, Double-Blind, Controlled Study , 2008, Anesthesia and analgesia.

[21]  M. B. Ben Ammar,et al.  Clinical benefits related to the combination of ketamine with morphine for patient controlled analgesia after major abdominal surgery. , 2008, La Tunisie medicale.

[22]  Katri Hamunen,et al.  Do Surgical Patients Benefit from Perioperative Gabapentin/Pregabalin? A Systematic Review of Efficacy and Safety , 2007, Anesthesia and analgesia.

[23]  C. Schlachta,et al.  Optimizing recovery after laparoscopic colon surgery (ORAL-CS) , 2007, Surgical Endoscopy.

[24]  Q. Liew,et al.  Prospective randomized, double‐blind, placebo‐controlled study of pre‐ and postoperative administration of a COX‐2‐specific inhibitor as opioid‐sparing analgesia in major colorectal surgery , 2007 .

[25]  M. Mok,et al.  Effect of adding ketorolac to intravenous morphine patient‐controlled analgesia on bowel function in colorectal surgery patients – a prospective, randomized, double‐blind study , 2005, Acta anaesthesiologica Scandinavica.

[26]  S. Pocock,et al.  Ketorolac, diclofenac, and ketoprofen are equally safe for pain relief after major surgery. , 2002, British journal of anaesthesia.

[27]  S. Pocock,et al.  POINT INVESTIGATORS. KETOROLAC, DICLOFENAC, AND KETOPROFEN ARE EQUALLY SAFE FOR PAIN RELIEF AFTER MAJOR SURGERY , 2002 .