Teaming Up to Improve Post-op Pain Control

Enhanced Recovery After Surgery (ERAS) protocols involve standardized care pathways that limit post-op pain with minimal use of opioids. Patients who enter the pathways often experience less discomfort, require limited narcotics and are able to move through the surgical experience faster, comfortably and with fewer side effects. That sounds good on paper, but how does it play out in practice?

"There are so many success stories," says Brooke Chidgey, MD, an associate professor of anesthesiology and a pain management specialist at University of North Carolina School of Medicine in Chapel Hill. "I remember the positive impact ERAS protocols had on a patient who underwent a complex procedure to remove cancerous growths from his pancreas." The patient was instructed to drink a carbohydrate supplement two hours before surgery and arrived hydrated, which made starting the IV easier. In pre-op, he received an epidural and was given acetaminophen, pregabalin and celecoxib to preemptively reduce tissue inflammation and post-op pain.

During surgery, Dr. Chidgey closely monitored the patient's fluid levels and managed his pain without the use of opioids. A day after the procedure, the patient experienced little pain and was able to ambulate. "His ability to get up and moving soon after such a significant procedure helped to prevent blood clots and pneumonia," says Dr. Chidgey. "Not having to administer IV opioids to manage pain levels also helped his intestines respond quickly, which is important after a big abdominal procedure."

Surgery causes physiological stress, and the body responds to the physical trauma by trying to protect itself and working to heal, notes Dr. Chidgey. "These responses release stress hormones and inflammatory mediators that can cause swelling, nerve irritation and pain," she says. "If we can blunt that response, by decreasing inflammation or nerve excitability, the result is often better pain control postoperatively."

Getting ahead of pain with a targeted and multidisciplinary approach makes sense for complex cases, but are ERAS protocols worth implementing for less invasive surgeries? Absolutely, says Susan Hukill, DNAP, MSNA, CRNA. "Even a single pre-op dose of acetaminophen before a 'minor' surgery is beneficial," explains Dr. Hukill, chief nurse anesthetist at St. David's South Austin (Texas) Medical Center. "Regardless of how big or small the procedure, ERAS pathways benefit the outpatient population."

There's been a big push to implement enhanced recovery protocols in hospitals and surgery centers over the past couple of years, according to Dr. Hukill. "Members of the anesthesia community talk about the benefits of practicing opioid-free anesthesia," she says. "The ability to potentially eliminate opioids from surgical care is partly dependent on the successful implementation of ERAS protocols."

The increasing numbers of surgeons who are publishing studies that report successes with ERAS pathways are inspiring others to add the protocols in their practices. However, says Dr. Chidgey, ERAS programs remain difficult to implement. "It takes a true multidisciplinary approach to develop a comprehensive plan," she points out.

"Implementing ERAS protocols also requires disrupting 'the way it has always been done' mentality."

Here are a few ways to overcome the inertia that prevents improved patient care:

• Collaborate and communicate. Practices designed to enhance recoveries can improve post-op pain management, but determining how to implement them consistently and effectively requires a coordinated effort from a team of committed providers. ERAS pathways are generally made with a collaborative effort among surgeons, anesthesiologists, pain specialists and nurses. ?"Together they can voice their concerns and goals regarding their specific areas of focus," says Dr. Chidgey. "They discuss care plans and make revisions based on evidence in the literature and specific circumstances with their facility-specific processes."

Promote closed-loop communication among providers along the continuum of care, notes Dr. Hukill. "Strategies must be in place to make sure the medications used are appropriate for each individual patient," she explains. "The documentation of what medications were given must be available for all providers to access in a timely manner. It's essential that anesthesia providers and pre-operative staff keep the lines of communication open so that additional medication doses are not inadvertently administered."

Lynda Schoppe, MSN, RN, CNOR, CAPA, CNEcl, quality and process improvement supervisor of surgical services at St. David's South Austin, believes clear communication among providers is particularly important when administering acetaminophen, which has a 4000mg dosing limit per 24 hours. "Have pre-op nurses, anesthesia providers and PACU nurses note the meds given and times of administration on a perioperative communication form, which provides for clear communication and easily accessible continuity of care," she says.

Implementing ERAS protocols requires disrupting 'the way it has always been done' mentality.

• Start early. Make sure ERAS pathways are initiated in the clinic at the time the decision to proceed with surgery is made and tailored to specific procedures, notes Dr. Chidgey. She says pathways should be broken down into specific aspects of care: pre-op patient education; medications and regional blocks administered before surgery; intraoperative fluid management and administration of pain-relieving medications; and guidelines for postoperative pain control measures, diet and physical activity.
• Get buy-in. Set realistic expectations with patients about the pain-relieving measures you'll implement and ensure that the messaging aligns with the efforts of providers along the continuum of care, suggests Elizabeth Wick, MD. "For instance, surgeons tend to be hesitant about using NSAIDs because of a perceived increased risk of post-op bleeding, but, in reality, this risk is very low," says Dr. Wick, a professor of surgery at University of California San Francisco. "Providers need to gain consensus around multimodal analgesia for all eligible patients."