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Optimizing Analgesia  to Enhance the Recovery After Surgery

Francesco Carli, M.D.. McGill University, Montreal, QC, Canada.

ASPMN, Baltimore, 2012

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

CME FACULTY DISCLOSURE

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.

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Il‐1, TNF‐, IL‐6

Perioperative Immunosuppression

• Perioperative factors that activate HPA/SNS

– Hypotension

– Hypothermia

– Pain

– Surgical trauma

– Psychological stress

Perioperative Immunosuppression

IL-6IL-1,TNF-α

Kurosawa, J Anesth. 2008;22(3):263-77

IL-4, IL-10

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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 200195: 578‐84

Pain management and proinflammatory cytokines

• Pain and immune mediators (proinflammatory cytokines) mutually interact and influence each other

• Analgesia attenuates surgery‐induced PGE2production 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)

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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

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Opioid side-effects

Wheeler et al. 2002. J Pain; 3(3):159-180

31%

30%

31%

30%

Dose-dependent !!

Non opioid analgesics

• Local anesthetics

• Nonsteroidal anti‐inflammatory drugs

• Acetaminophen

• Ketamine

• Clonidine

• Gabapentin

• Beta‐blockers

Epidural for surgery

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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

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thoracic epidural

local anesthetics

‐

sympatheticinnervation

parasympathetic innervation

blood flow

+

peristalsis

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 

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• 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”

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Somatic Pain Inflammation

Visceral Pain Shoulder Pain Neuropathic Pain

Incisional pain Open > Laparoscopic

Rectal procedures Thoracic surgery

Surgical manipulation Pneumoperitoneum (distension)

CO2 irritation Surgical manipulation Open > Laparoscopic

Laparoscopic Diaphragmatic irritation

Pain after abdominal

surgery

Conduction blockadeGabapentinoids

‐

Conduction blockade

α2 agonists

Opioid

IV Lidocaine

NSAIDs/Coxibs

Tylenol

Steroids ‐ ‐

‐

‐

‐

NMDA antagonists

‐

SurgeryPain

Fatigue

Time out of bed

Increased functional walking capacity

Analgesic intervention

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Beyond analgesia

Sedation

IleusUrinary

Retention Respiratory depression

Nausea/Vomiting

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

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Enhanced Enhanced Recovery

After Surgery

Sedation

IleusUrinary

Retention Respiratory depression

Nausea/Vomiting

Stress attenuation

Nociceptive stress thermal stress

metabolic stress inflammation

Ann Surg, 2008

Stress reduction

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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

Enhanced Recovery After Surgery =

Integration of Care

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ERAS meta analysisLength of stay

Decreased by 2 days

Varadhan et al, Clin Nutr, 2010

ERAS meta analysiscomplications

Down by 50%

Varadhan et al, Clin Nutr, 2010

Enhanced Recovery Program for colorectal surgery at McGill

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Enhanced Recovery Program for colorectal surgery at McGill

Enhancedrecoverycarepathway(n=290)

Standardcare(n=841)

pvalue

Lengthofstay† 4[5] 6[5] <0.001*

Oneormorecomplication 50.3% 58.6% 0.016*

Oneormoremajorcomplication

8.6% 14.4% 0.011*

OneormoreERvisit 5.9% 7.0% 0.586

Readmission 11.1% 9.4% 0.423

†Dataaremedian[IQR]*p<0.05

The Perioperative Collaborative Group

Patient andfamily

Anesthesiologist

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