How is surgical pain managed in enhanced recovery after surgery (ERAS) programs for emergency GI procedures?

Updated: Jan 20, 2021
  • Author: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed); Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Pain is one of the distressing factors after any surgical procedure. It has various adverse effects on the body and can trigger multiorgan dysfunction. It activates the hypothalamic-pituitary-adrenal (HPA) axis, thereby increasing the production of cortisol, which, in turn, leads to anxiety, insomnia and disorientation. Activation of the HPA axis also enhances sympathetic stimulation and increases the levels of antidiuretic hormone (ADH), aldosterone, catecholamines, angiotensin, and prostaglandins in the body, thereby reducing urine output and increasing the need for prolonged catheterization.

The increase in cortisol, glucagon, and catecholamine levels leads to insulin resistance as well. It increases the heart rate and systemic vascular resistance (SVR), thus predisposing the individual to myocardial ischemia. Postoperative pain also leads to restriction of respiratory movements, suppresses the cough reflex, and reduces vital capacity and minute volume. Postoperative atelectasis, pneumonia, and hypoxia may then develop, hindering early mobilization and recovery.

The spinal-level reflexes and hyperactivity of the sympathetic system lead to paralytic ileus. This is a most worrisome complication for a surgeon, in that it impedes early mobilization and enteral feeding; it can also cause muscle spasms and impaired fibrinolysis, thus predisposing the patient to venous thromboembolism (VTE). Nociceptive stimuli can also lead to inflammation, impairing wound healing and predisposing to systemic inflammation. [16, 17]

Managing surgical pain, thereby reducing or minimizing various complications, is one of the key components of ERAS. Opioid analgesics are known to cause prolonged ileus, as well as dependence with long-term use, and are therefore avoided in ERAS protocols. Multimodal analgesia is an effective approach that not only relieves pain but also enhances early enteral feeding, encourages early mobilization, reduces the side effects of opioids, and decreases the systemic inflammation described above, thereby facilitating a quicker recovery. [18]

The primary components of multimodal analgesia include thoracic epidural analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs). However, in view of the reservations that have been expressed regarding the use of NSAIDs in patients undergoing bowel anastomoses, transversus abdominis plane (TAP) blocks, spinal anesthesia, and IV lidocaine are currently preferred. [19, 20, 21]

The authors found lumbar epidural anesthesia to be effective in patients with perforated duodenal ulcers and patients undergoing emergency small-bowel surgery on an ERAS protocol. [1, 2] The patients received infusions of 16 mL of 1% lidocaine with 150 μg of epinephrine and short-acting opioids with anesthetic agents such as fentanyl (1 μg/kg) and sevoflurane (0.5-0.7 minimum alveolar concentration).

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