Analgesia for ERAS programs. Dr Igor Lemech VMO Anaesthetist Wagga Wagga Base Hospital

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1 Analgesia for ERAS programs Dr Igor Lemech VMO Anaesthetist Wagga Wagga Base Hospital

2 Disclosure I have received honoraria from Mundipharma and MSD

3 The new Wagga Wagga Rural Referral Centre

4 Scope Analgesic principles behind ERAS programs The evidence behind TAP v LAI v epidurals Lignocaine infusions Tramadol infusions What I do Analgesia as a component of ERAS for joint replacements

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7 Analgesic principles Multimodal Regular IV/PO Panadol NSAIDS if not contra-indicated Use regional anaesthesia Wound infiltration or catheters Transversus abdominis plane blocks Epidurals Spinals with intrathecal morphine Minimise opioids to minimise adverse effects to gain earlier return of bowel function and early discharge

8 The Bendigo ERAS pathway

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10 Regional anaesthesia A few options Classical thoracic epidural (rate varies from 12% locally to 70-80% in Europe) TAP blocks either 4 quadrant, subcostal, or low abdominal Rectus sheath catheters Continuous wound infiltration Spinal with intrathecal morphine Results seem to depend on How your local hospital system handles regional analgesic techniques Laparoscopic versus open as well as degree of complexity of case, whether it be redo surgery, surgery for inflammatory bowel disease or involving pouch or stoma formation

11 Regional anaesthesia Most studies are single centre with single main trial investigator producing recurrent papers on a single theme. There are studies supporting all major options.

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13 To the left is their normal protocol The addition of regular IV Panadol and TAP blocks (laparoscopically inserted) Case matched study

14 RESULTS: Two hundred eight elective major laparoscopic cases were evaluated. Both groups were similar in demographics and comorbidities. Length of stay was significantly shorter once transverse abdominus plane blocks and acetaminophen were introduced (p < 0.01), dropping from 3.7 to 2.6 days. There were significantly more complications in the prechange group (p = 0.02), but no significant differences in readmissions or mortality. Direct costs were similar, but there was a $500 increase in total margin per case (p = 0.004) with the pathway changes. With the use of statistical process control to examine the effect on outliers, there was significantly less variation in the mean length of stay (2.29 vs 1.90 days, p < 0.01) after the addition of transverse abdominus plane blocks and intravenous acetaminophen.

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21 So which regional anaesthetic option? I like epidurals but they have their limitations Don t always work Can be mismanaged if not looked after May need vasopressor and associated ICU bed May prolong discharge as patients are tied to their bed Can have a nasty day when they stop More inclined for their use with upper abdominal midline or hockey stick incision in patients with respiratory disease TAP catheters, rectus sheath catheters or CWI Use if contraindication to epidural or Pt declines epidural or not appropriate Surgeon dislikes epidural Last option is local wound infiltration this may become a better option with liposomal local anaesthetics Intrathecal morphine sounds promising I have little experience as it is not used at Wagga

22 Lignocaine infusion Analgesic, anti-hyperalgesic and anti-inflammatory Potential benefits Improved analgesia Earlier return of bowel function Decrease inflammatory response Disadvantage Potential for infusion errors Will need ECG monitoring if infusion continued postoperatively Unfamiliarity by nursing staff

23 Lignocaine infusion Evidence is grade II. There are studies supporting its use and other studies which show no improvement. However, most studies have relatively small numbers, done in single institutions with varying infusion protocols. What I do 1.5 mg/kg bolus intraoperatively followed by 2 mg/kg/hr infusion for 48 hours through dedicated IVC

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27 Tramadol infusions Some evidence to support the notion but, in my experience, an infusion seems to be associated with less side effects, particularly nausea and vomiting When combined with morphine PCA, leads to less morphine use with no increase in side effect profile. Infusion rate is either 0.2 mg/kg/hr or 12 mg/hr (i.e. 360 mg in 24 hr period) Hartjen K, Fischer MV, Mewes R, et al. Preventive pain therapy: preventive tramadol infusion versus bolus application in the early postoperative phase. Anaesthesist 1996; 45 (6): Rud U, Fischer MV, Mewes R, et al. Postoperative analgesia with tramadol: continuous infusion versus repetitive bolus. Anaesthesist 1994; 43 (5):

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29 Ketamine NMDA antagonist Little evidence of its use in the ERAS setting. May lead to slower mobilisation with psychoactive adverse effects However, in the general postoperative period, use of the ketamine leads to less morphine consumption with less PONV with minimal adverse effects when used at low doses ( mg/kg/hr)

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32 What I do for abdominal surgery Regular Panadol NSAIDS if not contraindicated if PO intake an issue, then consider Parecoxib intraoperatively and celecoxib postoperatively Preferably laparoscopic rather than open procedure Preferably epidural with open upper abdominal cases or those with high risk of postoperative pain issues but use any other local anaesthetic option. If no epidural, add Morphine PCA +/- tramal infusion +/- ketamine infusion. If epidural fails and no local has been injected, consider TAP blocks in recovery or lignocaine infusion If laparoscopic, may use tramadol infusion for hours and straight onto PO endone. No PCA unless worsening pain on the ward.

33 ERAS for joint replacements Aim is to allow early mobilisation. The patient should be sitting out of bed on day 0 and mobilising day 1. Thus, we need to provide good analgesia with minimal side effects. This is mainly achieved through appropriate use of local anaesthesia while trying to achieve opioid sparing Options for TKR include Femoral n blocks Adductor canal blocks LAI by surgeon Options for THR Lumbar plexus blocks LAI by surgeon These can be combined with short courses of a gabapentinoid Constipation after joint replacement is often neglected. Remember to chart aperients

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36 FOR TKR

37 Total Knee Replacement More painful operation than THR Need return of quadriceps function to enable early mobilisation. Thus, there has been a tendency away from femoral nerve blocks and femoral nerve catheters which will cause a quadriceps weakness, preventing early mobilisation. However, for local infiltration by the orthopod, it needs to be placed in the correct area. This is unclear from the literature and, in my experience, sometimes it is done well and sometimes not. My preferred option is low concentration femoral or adductor canal to conserve motor function. This is combined with regular IV paracetamol, NSAIDS (usually celecoxib), and a gabapentinoid if the surgeon agrees.

38 Total Hip Replacement Local anaesthetic options are less important. There may be slight improvement in analgesic efficacy with local anaesthetic infiltration by the surgeon Multimodal analgesia is the mainstay Paracetamol NSAIDS Gabapentinoids

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41 Future developments Depodur extended release morphine for epidural use Liposomal bupivicaine for CWI or TAP blocks Tapentadol Evidence base is currently with non-surgical chronic pain, normally of a mixed nature There is anecdotal evidence of 5 days of Tapentadol 50mg ER helping as part of a multimodal analgesia approach in the acute pain setting, with lower pain scores at 3 months

42 Thank you