Professor Narinder Rawal, MD, PhD, FRCA (Hon) Department of Clinical Medicine Division of Anaesthesiology and Intensive Care University Hospital

Transcription

1 Professor Narinder Rawal, MD, PhD, FRCA (Hon) Department of Clinical Medicine Division of Anaesthesiology and Intensive Care University Hospital Örebro, Sweden

2 Multicomponent techniques to improve postoperative outcome Multimodal analgesia Enhanced Recovery (ER), Fast-track protocols for a variety of surgical procedures (in particular colorectal surgery) Local Infiltration Anesthesia (LIA)

3 Rationale for analgesic combinations To improve efficacy and reduce toxicity Combining analgesics that act at different locations along the pain pathway centrally acting (opioid) with peripherally acting (NSAID s) centrally acting with centrally acting but different mode of action, e.g. opioid and clonidine ( 2 -agonist) three types of combination: tramadol (central opioid and monoaminergic effects) and peripheral (paracetamol or NSAID) To increase duration and widen the spectrum of efficacy: l.a. + epinephrine opioids + NMDA-receptor antagonists (ketamine, dextromethorphan to efficacy, tolerance, prevent central sensitization and hyperalgesia) To improve compliance (specially elderly patients) Reduce risk of abuse (e.g. combining opioid with antagonist)

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6 Multimodal analgesia The evidence I 26 articles (21 articles rejected) 5 articles (3 meta-analyses, 2 systematic reviews) 1 st meta-analysis 22 RCTs, 2 nd 7 RCTs, 3 rd 57 RCTs 1 st systematic review 22 RCTs, 2 nd 9 RCTs Comparison between addition of paracetamol or NSAIDs or coxibs versus placebo to i.v. PCA morphine Evaluation of a) efficacy of analgesia b) reduction of opioid-related adverse effects Rathmell JP et al. Reg Anesth Pain Med 2006;31:1-42

7 Multimodal analgesia The evidence II NSAID-based multimodal analgesia improves pain control only for multidose, non-specific NSAIDs and coxibs (level A) Paracetamol and single dose NSAID (level E) NSAID-based multimodal analgesia reduces opioid-related adverse effects (level E*) Evidence for other forms of multimodal analgesia limited * Reduced relative risk of some opioid-related AE (PONV, sedation) but not others (pruritus, urinary retention, resp. dep.) but only with non-selective NSAID Rathmell JP et al. Reg Anesth Pain Med 2006;31:1-42

8 J Clin Anesth 2001;13: No mention of possible risks of combining multiple drugs and modalities

9 11 RCT`s, n= 887 Ketamine + iv opioid PCA vs iv PCA alone Improvement= 6 RCT`s, no improvement= 5 RCT`s 18 diff. surgical procedures, heterogeniety of studies, small sample size, 5 diff. dosages Improvement- thoracic surgery, unclear- orthopedic, abdominal surgery Opioid-related side effects decreased in 7 RCT s, no difference in 4 RCT s Ketmine side effects - psychotomimetic side effects in 2 RCT s - cognitive impairment 1 RCT - overall increase in AE (dysphoria, nausea, pruritus) 1 RCT

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11 Anesthesiology 2012;116: Multimodal techniques for pain management The following drugs should be considered: COX-2 selective NSAID s(coxibs) Nonselective NSAID s Acetaminophen (paracetamol) Calcium channel antagonists (gabapentin/pregabalin) Unless contraindicated,all patients should receive an around-the-clock regimen of NSAID, Coxibs or acetaminophen Regional blockade with local anesthetics-part of multimodal analgesia Individualize the choice of medication, dose, route,and duration of therapy

12 LIA technique (knee, hip replacement) Intraoperative infiltration of surgical area ropivacaine 0.2 % 150 ml (300 mg) ketolorac 30 mg adrenaline 0.5 mg Intraarticular catheter (withdrawn morning after surgery) Pressure bandage + icepack for 4-6 h (to prolong analgesia) Anaesthesia: spinal with high GA Surgical technique: conventional Early mobilization within 3-5 h 50 % discharged day after surgery (almost all others on day 2) Pain management: paracetamol, NSAID s, weak opioids Antithrombotic treatment: only aspirin!

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15 RCT, TKA, n=102, surgery under spinal anaesthesia EDA group: bupi 0.1% + fentanyl + epinephrine for 48h vs LIA group: ropi 150mg + epinephrine 0.5mg (150ml), intraarticular catheter (lateral side, epidural 18G) - LIA group: intraarticular ketolorac 30mg + morphine 5mg - LIAiv group: intravenous ketorolac 30mg + morphine 5mg LIA group: injections repeated at 22-24h, rescue PCA, oxycodone after PCA stopped LIA with intraarticular ketorolac and morphine (vs EDA) associated with: - lower pain scores at rest from 24h after surgery until discharge - lower cumulated morphine consumption (80mg vs 101mg) - superior knee function - faster mobilization - earlier discharge (3.5 vs 5.5 days) LIA with local adjuvants compared with epidural analgesia results in reduced opioid consumption, faster mobilization, and earlier readiness for hospital discharge. Ketolorac and morphine are more efficient when given locally than systemically.

16 CWI vs other regional techniques 1. CWI vs Neuraxial techniques - vs epidural c.section equally effective Ranta PO Int J Obstet Anesth vs epidural THA CWI better, LOS Andersen KV Acta Orthop vs epidural TKA CWI better Andersen KV Acta Orthop vs epidural TKA CWI better, LOS Spreng KJ Br J Anaesth vs i.t morphine TKA CWI better Essving P Anesth Analg vs i.t morphine THA CWI better Rikalanen-Salmi R Acta Anaesth Scand vs epidural prostatectomy epidural better Fant F Br J Anaesth vs epidural for c.section CWI better, LOS O Neill P Anesth Analg vs epidural open colorectal CWI better, LOS Bertoglio S Anesth Analg vs epidural open colorectal EDA better, LOS Jouve P Anesthesiology CWI vs Femoral nerve block for TKA - CWI better (not blinded) Toftdahl K Acta Orthop Femoral better Carli F Br J Anaesth Equally effective Affas F Acta Orthop Equally effective (analgesia,rehab, satisfaction) Ng F Y J Arthroplasty CWI vs paravertebral block - radical mastectomy CWI better Sidiropoulou T Anesth Analg CWI vs interscalene block for arthroscopic shoulder surgery - 4/6 studies- interscalene better (in 1 study analgesia lasted 6h)

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18 LIA unanswered questions Which drugs or drug combinations are essential? Is intraarticular catheter necessary? for THA? TKA? Is there a local NSAID effect? Is LIA more effective for TKA vs THA? Role of surgical and infiltration technique, ice packs, pressure bandage etc?

19 Recommended interventions for ERAS open colorectal surgery Preoperative counselling Preoperative feeding Synbiotics No bowel preparation No premedication Fluid restriction Perioperative high oxygen concentrations Active prevention of hypothermia Epidural analgesia Short transverse incision No routine use of drains Enforced postoperative mobilization Enforced postoperative oral feeding No systemic morphine (opioid) use Standard laxatives Early removal of bladder catheter

20 6 RCTs, n= 452 Number of ERAS elements 4-12 (12, 4, 12, 8, 10, 9) Number of recommended evidence-based elements = 17 Epidural technique used in 5/6 studies The results from the present meta-analysis suggest that the implementation of four or more elements of the ERAS pathway leads to a reduction in length of hospital stay by more than 2 days and an almost 50% reduction in complication rates in patients undergoing major open colonic/colorectal surgery

21 Problems with ER programs for colorectal surgery 17 components recommended but hardly any 2 protocols similar Several metaanalyses, no clear answers to following questions: - How many components essential? - 4 or more components adequate - which 4? - Are all components equally beneficial? - Is epidural technique necessary?

22 Fast-track surgery versus conventional recovery strategies for colorectal surgery The (low) quality of the trials and lack of sufficient other outcome parameters do not justify implementation of fast-track surgery as a standard of care Spanjerberg WR et al Cochrane Database Syst Rev 2011;2;CD

23 Evidence-based methods* to reduce postoperative ileus 1. Thoracic epidural analgesia- reduces postoperative ileus by h Liu SS,Wu CL Anesth Analg 2007;104: Marret E et al Br J Surg 2007;94: Intravenous lidocaine Sun Y et al Dis Colon Rectum 2012;2012;55: Vigneault L et al Can J Anesth 2011;58:22-37 Mccarthy GC et al Drugs 2010;18: Marret E et al Br J Surg 2008;95: Chewing gum therapy Fitzgerald JEF, et al World J Surg 2009;33: De Castro SM et al Dig Surg 2008;25:39-45 Chan MK et al Dis Colon Rect 2007;50: Systemic prokinetic drugs ( Alvimopan- peripheral mu receptor antagonist) *Traut U et al Cochrane Database of Systematic Reviews 2008 issue 1 *Metaanalysis or systematic reviews

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25 Epidural technique for postoperative pain the evidence (PROSPECT Surgical procedure PROSPECT recommendation Thoracotomy Yes (or paravertebral -grade A) Breast surgery No Lap. cholecystectomy No Lap. colon resection No (yes for open resection) Abdominal hysterectomy No Hip replacement No Knee replacement No Abdominal prostatectomy No

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27 Audits are performed annually and the results presented at meetings of different surgery sections (picture: department of general surgery)