Multimodal Approaches to Analgesia in Enhanced Recovery After Surgery Pathways

Helander, Erik; Billeaud, Craig B.; Kline, Ryan J.; Emelife, Patrick I.; Harmon, Chris M.; Prabhakar, Amit; Urman, Richard D.; Kaye, Alan D.

doi:10.1097/aia.0000000000000165

Cited by 32 publications

(14 citation statements)

References 112 publications

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“…Enhanced Recovery After Surgery (ERAS), firstly proposed by Kehlet[22], is now applied to most surgery fields. ERAS is a multimodal perioperative care pathway designed to decrease morbidity, length of hospital stay, and promote postoperative recovery[23]. However, postoperative pain is one of the most undesirable consequences for the patients[24].…”

Section: Discussionmentioning

confidence: 99%

Dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plain (TAP) block for analgesia after abdominal surgery: A systematic review and meta-analysis of randomized controlled trials

et al. 2019

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ObjectiveTo evaluate the analgesic efficacy of dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plane (TAP) block for the patients after abdominal surgery.MethodsPubMed, CENTRAL, EMBASE, Web of science were searched to identify eligible randomized controlled trials (RCTs) that compared dexamethasone added to local anesthetics in ultrasound-guided TAP block with control for postoperative analgesia in adult patients undergoing abdominal surgery. Primary outcomes included postoperative pain intensity, the time to the first request for additional analgesics, and opioid consumption over 24 h after surgery. Secondary outcome was the incidence of postoperative nausea and vomiting. Analysis was performed by RevMan 5.3 software and the quality of evidence was rated using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.ResultsNine RCTs involving 575 patients were included. Compared to the control, dexamethasone added to local anesthetics in ultrasound-guided TAP block significantly decreased visual analogue scale (VAS) scores at rest at 4h (mean difference [MD] = -1.01; 95% confidence intervals [CI], -1.29 to -0.73; P<0.00001; moderate quality of evidence), 6h (MD = -1.21; 95% CI, -1.74 to -0.69; P<0.00001; low quality of evidence), and 12h after surgery (MD = -0.79; 95% CI, -0.97 to -0.60; P<0.00001; moderate quality of evidence). No difference was found at 2h (MD = -0.64; 95% CI, -1.35 to 0.08; P = 0.08; low quality of evidence) and 24 h (MD = -0.41; 95% CI, -0.91 to 0.09; P = 0.11; moderate quality of evidence) in VAS scores. The time to the first request for additional analgesics was prolonged in the dexamethasone group (MD = 3.08; 95% CI, 2.37 to 3.78; P<0.00001; moderate quality of evidence). Opioid consumption over 24 h after surgery was also reduced (MD = -5.42; 95% CI, -8.20 to -2.63; P = 0.0001; low quality of evidence). Meanwhile, the incidence of postoperative nausea and vomiting was significantly decreased in the dexamethasone group (risk ratios [RR] = 0.40; 95% CI, 0.28 to 0.58; P<0.00001; high quality of evidence). No complications were reported in all the included studies.ConclusionsDexamethasone added to local anesthetics in ultrasound-guided TAP block was a safe and effective strategy for postoperative analgesia in adult patients undergoing abdominal surgery.

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Section: Discussionmentioning

confidence: 99%

Dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plain (TAP) block for analgesia after abdominal surgery: A systematic review and meta-analysis of randomized controlled trials

et al. 2019

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“…One of the most important and influential items in all ERAS programs is effective pain management. TEA has been acknowledged as the gold standard for years for its benefits in decreasing bowel paralysis and stress response [ 18 – 20 ]. For elective colorectal surgery, this issue has been widely studied and discussed in diverging settings [ 10 , 21 , 22 ].…”

Section: Discussionmentioning

confidence: 99%

Purely ropivacaine-based TEA vs single TAP block in pain management after elective laparoscopic colon surgery within an upgraded institutional ERAS program

et al. 2021

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Background The aim of this study was to compare thoracic epidural analgesia (TEA) with transversus abdominis plane (TAP) block in post-operative pain management after laparoscopic colon surgery. Methods One hundred thirty-six patients undergoing laparoscopic colon resection randomly received either TEA or TAP with ropivacaine only. The primary endpoint was opioid requirement up to 48 h postoperatively. Intensity of pain, time to onset of bowel function, time to mobilization, postoperative complications, length of hospital stay, and patients’ satisfaction with pain management were also assessed. Results We observed a significant decrease in opioid consumption on the day of surgery with TEA compared with TAP block (30 mg vs 14 mg, p < 0.001). On the first two postoperative days (POD), the balance shifted to opioid consumption being smaller in the TAP group: on POD 1 (15.2 mg vs 10.6 mg; p = 0.086) and on POD 2 (9.2 mg vs 4.6 mg; p = 0.021). There were no differences in postoperative nausea/vomiting or time to first postoperative bowel movement between the groups. No direct blockade-related complications were observed and the length of stay was similar between TEA and TAP groups. Conclusion TEA is more efficient for acute postoperative pain than TAP block on day of surgery, but not on the first two PODs. No differences in pain management-related complications were detected.

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“…This dashboard can be applied as a benchmarking tool for hospitals to compare local performance against national trends and as a starting point for quality improvement initiatives to reduce opioid-related events and emphasize multimodal analgesic approaches to postsurgical pain. 27-30 Hospital leadership could harness this dashboard as a monitoring program for ORADEs. It gives hospital leadership the ability to detect an ORADEs problem without devoting large amounts of resources in terms of staff time or expenses, and provides preliminary data to justify devoting more resources to further explore solutions for specific local drivers of increased ORADEs.…”

Section: Discussionmentioning

confidence: 99%

A Dashboard for Monitoring Opioid-Related Adverse Drug Events Following Surgery Using a National Administrative Database

Stone

Jones

Rao³

et al. 2018

Am J Med Qual

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Opioid-related adverse drug events (ORADEs) include a range of complications, from respiratory arrest to ileus and urinary retention. ORADEs correlate to morbidity, mortality, and increased costs. The Centers for Medicare & Medicaid Services database, which represents approximately 35% of hospital discharges. The authors searched for previously published ICD-9 codes that defined ORADEs. A group of surgical diagnosis-related groups (DRGs) were selected. Recurring queries were programmed using these ICD codes and DRGs and used to update an online dashboard. The dashboard presents an estimate of the burden of ORADEs to frontline clinicians and hospital leadership and allows users to compare local data on ORADEs rates to other hospitals. Users are able to refine their search by surgery type or ORADE type. An interface was created, using national administrative claims data, to allow hospitals to access their ORADEs and benchmark local data against national trends.

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Multimodal Approaches to Analgesia in Enhanced Recovery After Surgery Pathways

Cited by 32 publications

References 112 publications

Dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plain (TAP) block for analgesia after abdominal surgery: A systematic review and meta-analysis of randomized controlled trials

Dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plain (TAP) block for analgesia after abdominal surgery: A systematic review and meta-analysis of randomized controlled trials

Purely ropivacaine-based TEA vs single TAP block in pain management after elective laparoscopic colon surgery within an upgraded institutional ERAS program

A Dashboard for Monitoring Opioid-Related Adverse Drug Events Following Surgery Using a National Administrative Database

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