Optimizing Analgesia to Enhance the Recovery After Surgery Francesco Carli, M.D.. McGill University, Montreal, QC, Canada. ASPMN, Baltimore, 2012 CME FACULTY DISCLOSURE Francesco Carli has no affiliation with the manufacturer of any commercial product or provider of any commercial service discussed in this CME activity. Francesco Carli is the President of Peri-Operative Programme (POP), a charitable organization which supports research on prehabilitation Objectives 1. To review the role of analgesics in attenuating the stress response 2. To discuss the principle of the enhance recovery after surgery (ERAS) program 3. To identify the role of health practictioner in facilitating patient's return to preoperative baseline functional capacity. 1
Il 1, TNF, IL 6 Perioperative Immunosuppression Perioperative factors that activate HPA/SNS Hypotension Hypothermia Pain Surgical trauma Psychological stress Perioperative Immunosuppress ion IL-1, TNF-α IL-6 IL-4, IL-10 Kurosawa, J Anesth. 2008;22(3):263-77 2
Acute Pain Induces Insulin Resistance in Humans Greisen J, Juhl CB, Vilstrup H, Jensen TS, Schmitz O Anesthesiology 2001; 95: 578 84 Greisens J, Anesthesiology 2001 95: 578 84 Pain management and proinflammatory cytokines Pain and immune mediators (proinflammatory cytokines) mutually interact and influence each other Analgesia attenuates surgery induced PGE 2 production in the amygdala and activation of the HPA axis Analgesia can improve postoperative period(body weight and food consumption) Effective postoperative pain influences immune alterations (reduced suppression of Il 2) 3
Morphine Role of HPA and SNS in release of ACTH, glucocorticoids, catecholamines Suppression of lymphocytes, NK cells, macrophage functions through opioid receptors Direct suppression of neutrophil functions via mu3 receptors (in vivo and in vitro) and T and B lymphocyte functions 4
Opioid side-effects 31% 30% Dose-dependent!! 31% 30% Wheeler et al. 2002. J Pain; 3(3):159-180 Non opioid analgesics Local anesthetics Nonsteroidal anti inflammatory drugs Acetaminophen Ketamine Clonidine Gabapentin Beta blockers Epidural for surgery 5
Epidural analgesia in major surgery Epidural local anesthetic opioid combination is the most effective technique for dynamic pain relief Jorgensen, The Cochrane Library, Issue 4, 2001 Efficacy of Postoperative Epidural Analgesia. A meta analysis (Block BM et al, JAMA 2003; 290: 2455 63) 36 years of practice, 100 papers Better analgesia than parenteral opioids Independent of the analgesic used Independent of the location (lumbar/thoracic) At rest or with movement/ coughing Local anesthetics give an advantage Anesthesiology 2011; 115: 181-8 6
thoracic epidural local anesthetics + sympathetic innervation parasympathetic innervation peristalsis blood flow Local Anesthetics Neural blockade causes ac va on of HPA and sympathetic system. Less depression of NK cells Less impact on depression of lymphocyte proliferation Effect of neural blockade or local anesthetics? Why lidocaine i.v.?? Has been used successfully for chronic neuropathic pain and cancer Has analgesic, anti hyperalgesic, antinociceptive anti inflammatory properties Small doses may be effective Unlike to have toxic effects at clinical doses Cheap and easily available 7
16 trials, 395 i.v. lidocaine and 369 controls In abdominal surgery less pain, opioid sparing, shorter LOS, earlier return of GI function No advantage in orthopedic & cardiac surgery Incisional analgesia. Wound Infiltration Advantages of incisional catheter technique: Simple, safe, inexpensive Placed under direct vision Affects only the surgical area Lack of limb numbness No damage to extremity due to motor block No vascular, neural, pleural damage Spares opioid use Decreased incidence of urinary retention Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a qualitative and quantitative systematic review of randomized controlled trials. Liu SS et al J Am Coll Surg, 2006; 203:914 32 44 RCTs, 2141 patients, cardiothoracic, orthopedics, general, gynecology urology Consistent findings improved analgesia, reduced opioid use and side effects, increased patient satisfaction and perhaps reduce hospital stay 8
NSAIDs/Coxibs Somatic Pain Inflammation Tylenol CO 2 irritation Incisional pain Surgical manipulation Open > Laparoscopic Steroids Open > Laparoscopic Conduction blockade Pain after abdominal surgery IV Lidocaine Shoulder Pain Laparoscopic Diaphragmatic irritation Neuropathic Pain Rectal procedures Thoracic surgery Gabapentinoids Opioid α 2 agonists NMDA antagonists Visceral Pain Surgical manipulation Pneumoperitoneum (distension) Conduction blockade Analgesic intervention Surgery Pain Fatigue Time out of bed Increased functional walking capacity 9
Nausea/Vo miting Sedation Beyond analgesia Ileus Respiratory depression Urinary Retention Why good pain relief Facilitates mobilization Accelerates oral feeding Enhances vitality For most anesthesia practitioners, the primary goal in trying to improve pain management is to enhance patient comfort and facilitate the recovery process after surgery, as well as minimize postoperative complications. Therefore, it is critically important to incorporate the principle of optimizing perioperative medical care by using a fast track recovery paradigm and examining the impact of pain management on patient outcomes. White P, Kehlet H, A&A 2007 10
Nausea/Vo miting Sedation Enhanced Recovery After Surgery Ileus Respiratory depression Urinary Retention Nociceptive stress thermal stress Stress attenuation metabolic stress inflammation Stress reduction Ann Surg, 2008 11
Enhanced Recovery After Surgery Fearon et al. Clin Nut 2005; 24:466-77 Enhanced Recovery After Surgery Fearon et al. Clin Nut 2005; 24:466-77 Enhanced Recovery After Surgery = Integration of Care 12
ERAS meta analysis Length of stay Decreased by 2 days Varadhan et al, Clin Nutr, 2010 ERAS meta analysis complications Down by 50% Varadhan et al, Clin Nutr, 2010 Enhanced Recovery Program for colorectal surgery at McGill 13
Enhanced Recovery Program for colorectal surgery at McGill Enhanced recovery care pathway (n=290) Standard care (n=841) p value Length of stay 4 [5] 6 [5] < 0.001 * One or more complication 50.3% 58.6% 0.016 * One or more major complication 8.6% 14.4% 0.011 * One or more ER visit 5.9% 7.0% 0.586 Readmission 11.1% 9.4% 0.423 Data are median [IQR] * p<0.05 The Perioperative Collaborative Group Anesthesiologist Patient and family Surgeon Surgical Nurse Message to take home Optimize analgesia when possible Limit the amount of opioids Use multimodal analgesia when possible Strong role of the Acute Pain Service Thinks beyond analgesia Analgesia to be evaluated in the context of Enhanced Recovery After Surgery (ERAS) Team approach to perioperative care 14