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

Abstract

BackgroundWithin an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver “optimal analgesia,” which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects.MethodsWith input from a multi-disciplinary, international group of clinicians, and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients.DiscussionAs a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery ERP. The goal was two-fold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus from the preoperative period to the post-anesthesia care unit. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of optimal analgesia as set forth in this document.

ERAS—Anticipated outcomes and realistic goals

“…Although opiates still appear as a cornerstone in multiple analgesic regimens all around the world, their deleterious side effects in general, and specific to the surgical patient, have been well documented . Most successful enhanced recovery programs place a great emphasis on the ability to avoid opiates through a multimodal narcotic sparing approach.…”

“…By decreasing or eliminating opiates, dry mouth, dysphoria, and organ dysfunction (including ileus) can be attenuated, facilitating early feeding and ambulation. When optimized, narcotic‐sparing analgesia significantly accelerates functional recovery …”

“…specific to the surgical patient, have been well documented. [9][10][11][12] Most successful enhanced recovery programs place a great emphasis on the ability to avoid opiates through a multimodal narcotic sparing approach. This kind of regimen aims to not only optimize patient comfort, but also to reduce surgical stress.…”

“…When optimized, narcotic-sparing analgesia significantly accelerates functional recovery. [10][11][12][13] The concept of multimodal analgesia is not new and is based on the assumption that different kinds of agents and techniques will exert their effects in different parts of the pain cascade, acting in a synergetic way. This integration of effects is possible to maximize their efficacy while minimizing side effects.…”

Economic Considerations of Acute Pain Medicine Programs

“…Multiple studies from countries including Taiwan, India, and the US have all consistently found that regional anesthesia-based approaches to operations as diverse as colorectal surgery, anterior cruciate ligament repair, total knee and hip arthroplasties, breast surgery, and carotid endarterectomy demonstrated faster recoveries, decreased side effects such as post-operative nausea, shorter hospital stays, and decreased overall costs when compared to general anesthesia and opioid-based approaches. 23–29 Similarly, the public has great interest in containing the evolving disaster that is the US opioid epidemic. With approximately 10 million Americans reporting using opioids for non-medical reasons, nearly 2 million meeting substance abuse diagnostic criteria for opioids, and as many as 91 deaths every day due to opioid overdose, it is imperative that effective methods for opioid-sparing pain control be employed whenever possible.…”