ERAS Reduces Reliance on Opioids

It’s fitting that our pathway began with colorectal patients, because the first ERAS protocol, which began in Denmark, was used on colorectal patients. It was outlined in 1995 by a Danish surgeon named Henrik Kehlet for colonic resections; he was known to walk around the PACU and wonder why his patients were still at the hospital. Usually, it was because they weren’t eating or ambulating and didn’t have bowel function due to the opioids they were prescribed — all issues that are addressed in an ERAS protocol.

We noticed that our laparoscopic living donor nephrectomy patients were in a lot of pain following their procedures, which made them good candidates for the pathway. These patients used to receive a two-quadrant transversus abdominis plane (TAP) block, which is a regional technique for analgesia of the anterolateral abdominal wall. They would receive intravenous opioids intraoperatively and an opioid patient-controlled analgesia (PCA) option postoperatively to help manage their pain.

With the implementation of our directed ERAS protocol — combined with a targeted and multimodal approach to medication administration — we can get ahead of the pain that a patient will experience. We focused on five major principles in our ERAS protocol: optimizing perioperative nutrition; standardizing anesthetic management, including fluid/intravascular volume administration; controlling perioperative pain by emphasizing non-opioid analgesia; mitigating the physiologic stress response to surgery; and promoting early mobilization and oral intake.

• Preoperatively. Patients are offered clear liquids up to two hours before surgery to optimize their perioperative nutrition, and they receive a carbohydrate-rich drink, which helps to decrease insulin resistance that can occur after major surgery. Normally, patients who fast prior to surgery could have insulin resistance up to a week after their procedure. Patients who develop insulin resistance often take longer to recover after surgery, so the carbohydrate-rich drink reduces their insulin resistance and helps them feel better postoperatively.

Patients now consistently receive standardized multimodal adjuncts preoperatively, including acetaminophen 1,000 mg PO, pregabalin 75 mg PO and tramadol 50 mg PO (celecoxib 200 mg PO replaces tramadol in other pathways). Intraoperatively, instead of a two-quadrant TAP block, patients receive a four-quadrant TAP block prior to the start of surgery and a multimodal anesthetic regimen that includes a propofol infusion administered at a rate dependent on bispectral index (BIS) readings, dexmedetomidine infusion beginning at 0.6 mcg/kg/hr and an esmolol infusion (20 to 50 mcg/kg/min) after a bolus of esmolol on induction of anesthesia. We also give a bolus of magnesium 2g IV and ketamine 0.5 mg/kg on induction with repeat doses. By using propofol infusions instead of inhalation gases, along with prophylactic ondansetron and dexamethasone, we’re able to greatly reduce rates of PONV.

Non-opioid analgesia blocks the patient’s pain pathways — as well as their surgical stress response. We use medications that block different areas of the pain pathways within the periphery, spinal cord and the brain, along with fascial plane blocks. Opioids, which block mu pain receptors in the central nervous system and are associated with a higher side effect profile, aren’t often needed intraoperatively with this protocol.

The beauty of ERAS protocols is that you can use them effectively for a variety of service lines.

• Intraoperatively. Abdominal cases such as colorectal surgery and laparoscopic donor nephrectomy can have different fluid administration requirements because these patients had a bowel prep the day before surgery and may be dehydrated. We use non-invasive cardiac output monitoring to assess how the heart is responding to fluid levels. We might administer a fluid bolus to see if this extra fluid increases the stroke volume or the amount of blood that they’re pumping out, thus increasing the heart function and/or blood pressure. If it does, the patient might need another fluid bolus to get them at a normal volume status. Patients might not require as much fluid perioperatively as we once thought for this type of surgery but with goal-directed fluid therapy we have more information to guide fluid administration. We’ve also noticed that patients who drink fluids prior to surgery are often better hydrated.

• Postoperatively. We administer scheduled doses of acetaminophen 1,000 mg every eight hours and pregabalin 75 mg every 12 hours. Patients are offered tramadol for moderate pain (scores between four and seven on a 10-point scale) or hydromorphone for severe pain (scores between eight and 10). By continuing this multimodal regimen post-op, patients are able to eat, drink, get out of bed and ambulate more quickly.

The beauty of ERAS protocols is that you can use them effectively for a variety of service lines. I worked out a protocol for mastectomy patients, and some were able to go home the same day of their surgeries. With these patients, we administer the same pre-op medications and let them drink fluids up to two hours before surgery. We use the same opioid-free IV drips and place regional blocks.

A recent mastectomy patient who was treated through the ERAS pathway told us she didn’t feel any pain. She took one acetaminophen during the day of her surgery and another dose at night, but only because she was told to take them. These procedures can be performed without a block, but adding regional anesthesia makes a big difference in managing a patient’s pain. Patients who are in pain after surgery can still take opioids, but they will require a much smaller dose to get relief than they would’ve needed otherwise.

Before implementing ERAS protocols, we developed a multidisciplinary committee to get everyone involved in patient care on board with the program. You need buy-in from surgeons, anesthesia providers, pre- and post-op nurses as well as any other staff members who interact with patients. Our transplant department has a coordinator who speaks to patients preoperatively and educates them about the program’s elements. This ensures they know exactly what to expect before, during and after their procedure.

It’s crucial for all patients to have realistic expectations going into surgery. No one has no pain after surgery. Patients need to know they will experience some pain, but at a manageable level, which is usually a tolerable type of discomfort. They need to know and trust that their care team will treat intolerable pain. It needs to be stressed to patients to continue to take their prescribed multimodal medications even if they are having no pain. Educate them thoroughly on this aspect of care because the multimodal medications are going to help keep their pain at a manageable level. I make it a point to mention this point to patients in pre-op and reemphasize it postoperatively.

I call our ERAS pathway an opioid-sparing program because I don’t want patients to think that if they have severe pain, they aren’t going to get opioids. If multimodal analgesia and regional blocks fail to make a patient feel comfortable, we will treat their pain appropriately. But again, they will usually require much smaller doses of opioids than they would receive if we treated them with narcotics intraoperatively. They will experience pain relief with small doses, and their side effects won’t be as extreme. We’re also able to avoid opioid-induced hyperalgesia, which is an increased sensitivity to a painful stimulus because of opioid use.

One in 15 surgical patients can develop an opioid addiction or dependence, so providers need to institute better methods of acute pain control. The evidence is out there to support alternate methods, such as a multimodal approach with the addition of some type of regional block. An ERAS protocol can pay dividends for your facility and lead to multiple direct and indirect benefits. It’s an emerging care model that facilities can implement across most service lines to help patients recover from their procedures quickly and in less pain. OSM