Analgesia After Open Abdominal Surgery in the Setting of Enhanced Recovery Surgery

Hughes, Michael; Ventham, NT; McNally, Steve; Harrison, Ewen M; Wigmore, Stephen J.

doi:10.1001/jamasurg.2014.210

Cited by 155 publications

(110 citation statements)

References 40 publications

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“…Until recently, pain management in ERAS has been studied mainly in open abdominal surgeries [27]. As studies on the best methods of pain control in LCRC surgeries emerged, few studies described a local anesthetics wound infusion catheter at the extraction wound of the specimen [1219].…”

Section: Discussionmentioning

confidence: 99%

Randomized trial of subfascial infusion of ropivacaine for early recovery in laparoscopic colorectal cancer surgery

Lee

Sim

Kim

et al. 2016

Korean J Anesthesiol

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BackgroundThere is a need for investigating the analgesic method as part of early recovery after surgery tailored for laparoscopic colorectal cancer (LCRC) surgery. In this randomized trial, we aimed to investigate the analgesic efficacy of an inverse ‘v’ shaped bilateral, subfascial ropivacaine continuous infusion in LCRC surgery.MethodsForty two patients undergoing elective LCRC surgery were randomly allocated to one of two groups to receive either 0.5% ropivacaine continuous infusion at the subfascial plane (n = 20, R group) or fentanyl intravenous patient controlled analgesia (IV PCA) (n = 22, F group) for postoperative 72 hours. The primary endpoint was the visual analogue scores (VAS) when coughing at postoperative 24 hours. Secondary end points were the VAS at 1, 6, 48, and 72 hours, time to first flatus, time to first rescue meperidine requirement, rescue meperidine consumption, length of hospital stay, postoperative nausea and vomiting, sedation, hypotension, dizziness, headache, and wound complications.ResultsThe VAS at rest and when coughing were similar between the groups throughout the study. The time to first gas passage and time to first rescue meperidine at ward were significantly shorter in the R group compared to the F group (P = 0.010). Rescue meperidine was administered less in the R group; however, without statistical significance. Other study parameters were not different between the groups.ConclusionsRopivacaine continuous infusion with an inverse ‘v ’ shaped bilateral, subfascial catheter placement showed significantly enhanced bowel recovery and analgesic efficacy was not different from IV PCA in LCRC surgery.

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Section: Discussionmentioning

confidence: 99%

Randomized trial of subfascial infusion of ropivacaine for early recovery in laparoscopic colorectal cancer surgery

Lee

Sim

Kim

et al. 2016

Korean J Anesthesiol

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“…It is widely perceived that epidural analgesia alters the stress response after surgery, improves pain control, and consequently reduces cardiovascular and infectious complications [2]. However, a recent meta-analysis on the role of epidural analgesia within an enhanced recovery after surgery (ERAS) program in open surgery has reported better pain control but no reduction in postoperative stay and in complications rates with epidural analgesia compared to other analgesic techniques [3]. …”

Section: Introductionmentioning

confidence: 99%

Role of Epidural Analgesia within an ERAS Program after Laparoscopic Colorectal Surgery: A Review and Meta-Analysis of Randomised Controlled Studies

Borzellino

Francis

Chapuis³

et al. 2016

Surgery Research and Practice

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Introduction. Epidural analgesia has been a cornerstone of any ERAS program for open colorectal surgery. With the improvements in anesthetic and analgesic techniques as well as the introduction of the laparoscopy for colorectal resection, the role of epidural analgesia has been questioned. The aim of the review was to assess through a meta-analysis the impact of epidural analgesia compared to other analgesic techniques for colorectal laparoscopic surgery within an ERAS program. Methods. Literature research was performed on PubMed, Embase, and the Cochrane Library. All randomised clinical trials that reported data on hospital stay, postoperative complications, and readmissions rates within an ERAS program with and without an epidural analgesia after a colorectal laparoscopic resection were included. Results. Five randomised clinical trials were selected and a total of 168 patients submitted to epidural analgesia were compared to 163 patients treated by an alternative analgesic technique. Pooled data show a longer hospital stay in the epidural group with a mean difference of 1.07 (95% CI 0.06–2.08) without any significant differences in postoperative complications and readmissions rates. Conclusion. Epidural analgesia does not seem to offer any additional clinical benefits to patients undergoing laparoscopic colorectal surgery within an ERAS program.

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“…Such an approach matches well with initiatives such as the perioperative surgical home 16,17 and enhanced recovery after surgery. 18,19 …”

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confidence: 99%

Postoperative Pulmonary Complications, Early Mortality, and Hospital Stay Following Noncardiothoracic Surgery

et al. 2017

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IMPORTANCE Postoperative pulmonary complications (PPCs), a leading cause of poor surgical outcomes, are heterogeneous in their pathophysiology, severity, and reporting accuracy. OBJECTIVE To prospectively study clinical and radiological PPCs and respiratory insufficiency therapies in a high-risk surgical population. DESIGN, SETTING, AND PARTICIPANTS We performed a multicenter prospective observational study in 7 US academic institutions. American Society of Anesthesiologists physical status 3 patients who presented for noncardiothoracic surgery requiring 2 hours or more of general anesthesia with mechanical ventilation from May to November 2014 were included in the study. We hypothesized that PPCs, even mild, would be associated with early postoperative mortality and use of hospital resources. We analyzed their association with modifiable perioperative variables. EXPOSURE Noncardiothoracic surgery. MAIN OUTCOMES AND MEASURES Predefined PPCs occurring within the first 7 postoperative days were prospectively identified. We used bivariable and logistic regression analyses to study the association of PPCs with ventilatory and other perioperative variables. RESULTS This study included 1202 patients who underwent predominantly abdominal, orthopedic, and neurological procedures. The mean (SD) age of patients was 62.1 (13.8) years, and 636 (52.9%) were men. At least 1 PPC occurred in 401 patients (33.4%), mainly the need for prolonged oxygen therapy by nasal cannula (n = 235; 19.6%) and atelectasis (n = 206; 17.1%). Patients with 1 or more PPCs, even mild, had significantly increased early postoperative mortality, intensive care unit (ICU) admission, and ICU/hospital length of stay. Significant PPC risk factors included nonmodifiable (emergency [yes vs no]: odds ratio [OR], 4.47, 95% CI, 1.59–12.56; surgical site [abdominal/pelvic vs nonabdominal/pelvic]: OR, 2.54, 95% CI, 1.67–3.89; and age [in years]: OR, 1.03, 95% CI, 1.02–1.05) and potentially modifiable (colloid administration [yes vs no]: OR, 1.75, 95% CI, 1.03–2.97; preoperative oxygenation: OR, 0.86, 95% CI, 0.80–0.93; blood loss [in milliliters]: OR, 1.17, 95% CI, 1.05–1.30; anesthesia duration [in minutes]: OR, 1.14, 95% CI, 1.05–1.24; and tidal volume [in milliliters per kilogram of predicted body weight]: OR, 1.12, 95% CI, 1.01–1.24) factors. CONCLUSIONS AND RELEVANCE Postoperative pulmonary complications are common in patients with American Society of Anesthesiologists physical status 3, despite current protective ventilation practices. Even mild PPCs are associated with increased early postoperative mortality, ICU admission, and length of stay (ICU and hospital). Mild frequent PPCs (eg, atelectasis and prolonged oxygen therapy need) deserve increased attention and intervention for improving perioperative outcomes.

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Analgesia After Open Abdominal Surgery in the Setting of Enhanced Recovery Surgery

Abstract: Epidurals may be associated with superior pain control but this does not translate into improved recovery or reduced morbidity when compared with alternative analgesic techniques when used within an enhanced recovery protocol.

Cited by 155 publications

References 40 publications

Randomized trial of subfascial infusion of ropivacaine for early recovery in laparoscopic colorectal cancer surgery

Randomized trial of subfascial infusion of ropivacaine for early recovery in laparoscopic colorectal cancer surgery

Role of Epidural Analgesia within an ERAS Program after Laparoscopic Colorectal Surgery: A Review and Meta-Analysis of Randomised Controlled Studies

Postoperative Pulmonary Complications, Early Mortality, and Hospital Stay Following Noncardiothoracic Surgery

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