Analgesic Aspects of ERAS

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Analgesic Aspects of ERAS

• Dr Susan Nimmo
• Consultant Anaesthetist
• Western General Hospital
• Edinburgh
• Age Anaesthesia Association
• Annual Scientific Meeting
• May 2008

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Why is Acute Pain a Problem ?
Pulmonary function
Thrombo embolic events
Cardiovasc. stress
Mobilisation
Ileus
Acute Pain
Postoperative confusional states
Stress response/ catabolism
Well being/sleep/ anxiety
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Analgesia and Enhanced Recovery
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Ideal Analgesia

• Safe and acceptable to patients (and surgeons!)
• No/low failure rate
• Near complete dynamic pain relief
• No gastrointestinal side effects
• No limitation of movement (side effects or
  equipment)
• Absence of other problem side effects
• May be multimodal

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Benefits of Epidural Analgesia

• Dynamic pain control
• Obtunds stress response
• Reduction of ileus
• Reduced post-operative pulmonary complications
• Reduced myocardial ischaemia/infarction
• Reduced incidence of DVT and pulmonary embolism

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Dynamic Analgesia/Mobilisation
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Causes of Ileus

• Degree of surgical manipulation
• Magnitude of inflammatory and stress response
• Sympathetic reflexes
• Opioids
• Salt and water overload/bowel oedema

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Outcome

• 64 patients randomised to epidural analgesia or
  PCA opioid
• Elective colonic resection
• Equivalent peri-operative care early nutrition
  and assisted mobilisation as able
• Carli et al. Am Soc Anesth 2002

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Results

• Epidural group
• Lower pain and fatigue scores
• Earlier return of bowel function
• Significantly better 6 min walking test distance
  at 3 and 6 weeks
• Significantly better health related quality of
  life scoring at 3 and 6 weeks

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Our practice.

• EPIDURAL FOR 72 HOURS
• T10/11 for left sided and anterior resections
• T8/9 for right hemicolectomy
• diamorphine or p/f morphine and 0.1-0.25
  bupivacaine bolus
• bupivacaine 0.1 and fentanyl 2 micrograms/ml
  infusion
• Plus paracetamol
• STEP DOWN
• oral tramadol (or fentanyl patch/ oral oxycontin)
• paracetamol
• ? ibuprofen/celecoxib

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Master Trial

• 915 high risk patients undergoing major surgery
• Only respiratory failure less frequent
• No effect on mortality
• But
• Better dynamic analgesia
• No significant adverse consequences
• ??end points
• ??utilising analgesia to enhance recovery

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Success of Epidural Analgesia

• 640 patients over 6 years
• 1/3 excellent analgesia (80 of time with no pain
  on movement no pain at rest)
• 1/3 good analgesia (single occurrence of pain at
  rest)
• 1/3 poor quality analgesia
• McLeod et al Anaesthesia 2001

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How can we make our epidurals more effective?

• Correct placement
• Insertion preop with block check
• Facilities to resite
• Adequate securing of catheter (and filter)

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Epidural ComplicationsInsertion and Catheter
in situ(RCOA Audit)
Complication
Estimated Incidence
Dural puncture
0.32-1.23
Neurological damage Haematoma Abscess Catheter
migration
0.016-0.56 0.03-0.0004 0.01-0.05 0.15-0.18

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Epidural Complications Drugs

• Complication
• Drug errors
• Respiratory depression
• CNS toxicity
• Hypotension
• Motor blockade

Estimated Incidence ? 0.13-0.4 0.01-0.12 3-30
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Epidurals and colonic blood flowFluids versus
vasopressors

• 15 patients anterior resection for rectal
  carcinoma
• Inferior mesenteric artery blood flow (Doppler)
• Arterial line, oesophageal doppler cardiac output
• Epidural induced hypotension reduced mesenteric A
  flow, which did not recover with fluid therapy
  alone but required the use of vasopressors.
• Gould et al BJA 2002

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BUT the Anastomosis.

• Sympathetic block may increase colonic blood flow
  and minimise colonic distension
• Early feeding may enhance gut blood flow
• OR
• Early motility may increase anastomotic
  disruption
• Hypotension may compromise colonic blood flow, as
  may vasoconstrictors
• Studies to date (small nos) do not tend to show
  convincing risk or benefit
• ERAS results no increase in anastomotic leak
  rate with epidurals and feeding (and laxative)

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Hypotension

• Limit block height
• Optimal fluid management
• Haemoglobin
• Vasoactive drugs (noradrenaline, phenylephrine)
• Oral ephedrine for prophylaxis of postural
  hypotension on mobilising
• Early mobilisation

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Contraindications to Epidural Analgesia

• Patient refusal
• Anticoagulation
• High risk of abscess
• High risk of serious cardiovascular instability
• (And failed epidural analgesia)

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Its not just analgesia..

• How else do we provide?
• Attenuation of the stress response
• Dynamic analgesia
• Reduction of ileus
• Multimodal analgesia/opioid sparing
• Intraop remifentanil
• ??NSAIDs/COX 2s
• Local anaesthetic
• Adjuvants eg ketamine, gabapentin

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Local Anaesthetic Alternatives

• Wound catheters
• 20mls levobupivacaine
• x 4/ day
• Improved analgesia and opioid sparing
• (elastomeric pump systems)

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Our practice.

• Wound catheters levobupivacaine
• PCA opioid (morphine or fentanyl)
• Regular paracetamol
• ? Ibuprofen/celecoxib
• ? Ketamine

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Conclusions

• Thoracic epidural analgesia is currently the gold
  standard room for improvement
• Systemic multimodal analgesia can be a good
  alternative
• Effective analgesia is a pivotal requirement for
  enhanced recovery

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ERAS(Enhanced Recovery After Surgery)

• An international collaboration group
• Prof Henrik Kehlet
• (Denmark, Netherlands, Norway, Scotland, Sweden)

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Aims of ERAS

• To establish evidence-based ERAS protocol
• To document outcomes and compliance when core
  protocol applied in 5 different centres
  (prospective study) current
• To examine individual elements of core protocol
  (randomised trials)

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Discharge Criteria

• patient has good pain control on oral analgesics
• patient is independently mobile, reached pre-op
  level
• patient takes solid foods and has no IV fluids
• all 3 criteria reached and patient willing to go
  home

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Length of Stay - ? A Useful Endpoint
1 2 d
Patient goes home
1 2 d
Patient willing to go home
Discharge criteria fulfilled able to go home
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ERAS results
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Results

• 80-99 years (3/02-11/05)
• 32 patients (elective resection with primary
  anastomosis no stoma)
• Mean LOS 12.8 days
• Discharge criteria fulfilled 6.4 days
• Deaths 1
• Anastomotic leak rate 9

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Achievable in the elderly ?

• 74 patients over 70
• Epidural analgesia/early feeding and mobilisation
• Patients discharged at 5d
• 3 anastomotic leak rate
• 1 mortality
• ? Reduced general periop complications
• Scarfenberg et al Int J Colorectal Disease 2007

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Achievable in the elderly ?

• 87 patients mean age 77
• Open colectomy ( 53 right)
• Clear fluids POD 2, diet POD 3
• PCA morphine
• 89.6 tolerated early feeding
• Mean hospital stay 3.9 days, no anastomotic
  leaks, no deaths
• Di Fronzo et al Am Coll Surgeons 2003
• No advantage from thoracic epidural
• Zutshi et al Am J Surg 2005

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Any Questions

• ?