Chapter 48: Enhanced Recovery Protocols & Optimization of Perioperative Outcomes

Major advances in surgical and anesthetic management have progressively decreased risk-adjusted perioperative mortality and morbidity. Continued improvement in perioperative outcomes, including accelerated postoperative convalescence and decreased perioperative complications, depends upon the continued evolution of integrated, multidisciplinary team approaches to perioperative care. The goal of team-based care is to combine individual evidence-based elements of perioperative care (eg, analgesic regimens, nutritional interventions, and physical therapy), each of which may have modest benefits when used in isolation into a tightly coordinated effort that has significant synergistic, beneficial effects upon surgical outcomes (the theory of aggregation of marginal gains).

Such coordinated, multidisciplinary perioperative care programs are termed enhanced recovery programs (ERPs), fast-track surgery, or enhanced recovery after surgery (ERAS) (Figure 48–1). A well-functioning ERP uses evidence-based practices that ensure continuity of care, decrease variation in clinical management, minimize organ dysfunction, decrease postoperative complications, and accelerate convalescence (Figure 48–2). The success of ERPs relies upon the additive or synergistic effects of the interventions included in these programs. Adherence to ERP pathways is associated with better postoperative outcomes, accelerated convalescence, and lower costs.

Assessing outcomes following ERP adoption is critical. Hospital length of stay is a commonly used measure of success, although in many health care systems the timing of hospital discharge is more directly related to administrative and organizational issues than to discrete surgical and medical milestones in the patient’s postoperative recovery. Little research has been undertaken to define the process of postoperative recovery, and few outcome measures are currently available to confirm that postoperative recovery has been accomplished for a given surgical disease. Other measures of successful implementation of ERPs include reduced rates of hospital readmission and reduced rates and severity of perioperative complications. Promising data suggest that ERPs may improve oncologic outcomes after surgery.

Anesthetic interventions that reduce pain, facilitate earlier postoperative mobilization, and allow earlier resumption of oral feeding accelerate the pace of perioperative recovery. In this context, the anesthesia provider must not only provide ideal anesthetic management throughout the procedure, but must also help improve overall perioperative care. These goals are achieved through optimizing the patient’s preoperative medical condition, avoiding prolonged fasting, moderating the adverse effects of the intraoperative neuroendocrine stress response, and providing multimodal pain and symptom management to accelerate postoperative recovery.

Initially developed for patients undergoing colorectal and cardiac surgery, ERPs have also been developed for patients undergoing esophageal, bariatric, pancreatic, liver, head and neck, breast, orthopedic, bariatric, and pediatric abdominal surgery. Many ERP guidelines and consensus statements are available from the various specialty societies.

The perioperative surgical home (PSH) has been defined as a “patient centered, innovative model of delivering health care during the entire patient surgical/procedural experience; from the time of the decision for surgery until the patient has recovered and returned to the care of his or her patient centered medical home or primary health care provider.” The PSH “provides coordination of care throughout all of the clinical microsystems of care.” PSH programs can be considered an evolution of ERPs, because they include several perioperative ERP elements but are adapted to the local clinical environment. Based on their unique clinical skills, anesthesiologists are called to play a pivotal, coordinating care role in the PSH. To accomplish this, anesthesia providers must integrate with the surgical and medical teams with whom they jointly provide perioperative care. Accordingly, anesthesiology training programs must expand their curricula to include the entire continuum of perioperative care.

Persistent postsurgical pain (chronic pain that continues beyond the typical healing period of 1–2 months following surgery) is increasingly acknowledged as a common and significant issue following surgery. The incidence of persistent postsurgical pain may exceed 30% after some operations, especially amputations, thoracotomy, mastectomy, and inguinal herniorrhaphy. Although the cause is unclear, several risk factors have been identified (Figure 48–3). Multimodal perioperative pain control is often suggested as a fundamental preemptive strategy to reduce the incidence of persistent postsurgical pain (see Chapter 47).

PREOPERATIVE PERIOD

Patient Education

Cooperation from the patient and family is essential if an ERP is to be effectively implemented. Preoperative teaching must use plain language and avoid medical jargon. Well-designed print, video, and online materials presented in the patient’s native language are useful to introduce ERPs. Smartphone text messaging and patient navigation apps are increasingly utilized to help organize and coordinate the patient’s perioperative care continuum.

Preoperative Risk Assessment & Optimization of Functional Status

Reducing the likelihood of perioperative complications improves surgical recovery. Preoperative assessment is discussed in detail in Chapter 18. Although international guidelines evaluating the risk for developing cardiovascular, respiratory, or metabolic complications have been extensively reviewed and published, less attention has been given to assessment and optimization of preoperative functional and physiological status. Nonetheless, some recommendations can be made. For example, perioperative β-blockers should be continued in patients already receiving this therapy. Perioperative statins appear to decrease postoperative cardiovascular complications and should not be abruptly discontinued perioperatively. Several procedure-specific scoring systems based on patient comorbidity, type of surgery, and biochemical data are being used to predict postoperative mortality and morbidity. In addition, risk-adjusted scoring systems, such as the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) and the Society of Thoracic Surgeons’ National Database, can be used to compare outcomes among institutions.

Smoking & Alcohol Cessation

Preoperative evaluation of surgical risk and optimization of medical comorbidities also provides opportunity to modify habits that may significantly impact the patient’s short-term and long-term health and quality of life. Smoking, drug abuse, and excessive alcohol use are risk factors for the development of postoperative complications. Perioperative interventions aimed at risk modification can reduce risks of complications, accelerate surgical recovery, and reduce perioperative costs. A recent meta-analysis found that preoperative smoking cessation, for any type of surgery, reduced postoperative complications by 41%, especially those related to wound healing and the lungs. Intense preoperative smoking cessation programs of 3 to 4 weeks’ duration that include pharmacological interventions (eg, nicotine replacement therapy) and patient counseling produce better results than brief and isolated preoperative smoking cessation interventions. Many psychological and pharmacological strategies are also available to help patients stop excessive alcohol consumption and reduce the risk of alcohol withdrawal.

Guidelines for Food & Fluid Intake

Preoperative fasting and surgical stress induce insulin resistance. Furthermore, patients who are not allowed to drink fluids after an overnight fast and those who receive a mechanical bowel preparation experience dehydration, which may increase discomfort and cause drowsiness and orthostatic lightheadedness. Although fasting has been advocated as a preoperative strategy to minimize the risk of pulmonary aspiration during induction of anesthesia, this benefit must be weighed against the detrimental aspects of this practice.

Research suggests that avoiding preoperative fasting and ensuring adequate hydration and energy supply may moderate postoperative insulin resistance. Preliminary evidence has shown that preoperative administration of carbohydrate (CHO) drinks (eg, 50 g of maltodextrin 2–3 h before induction of anesthesia) is safe and reduces insulin resistance, hunger, fatigue, and postoperative nausea and vomiting (PONV). Moreover, CHO drinks positively influence recovery of bowel and immune function. However, these results have been achieved mainly with maltodextrin CHO drinks, and the metabolic and clinical impacts of simple sugar CHO drinks are unknown. It is important to educate patients to drink preoperative CHO over a short time, as sipping these beverages over hours does not induce a sufficient insulin response to reduce insulin resistance.

Contemporary international fasting guidelines allow clear fluids up to 2 h prior to induction of anesthesia in patients at low risk for pulmonary aspiration (see Chapter 18). The safety of allowing clear fluids, CHO drinks, or both, 2 h before induction of anesthesia has been demonstrated by magnetic resonance imaging studies in healthy volunteers. Residual gastric volume 2 h after 400 mL of oral carbohydrate (12.5% maltodextrins) was found to be similar to the residual gastric volume following an overnight fast (mean volume 21 mL). The safety of this practice has been tested in patients with uncomplicated type 2 diabetes mellitus, none of whom showed evidence of worsened risk of aspiration. Despite several clinical trials demonstrating that prolonged fasting impairs postoperative recovery, compliance with evidence-based fasting guidelines remains low, as physicians continue to order nil per os (NPO) after midnight.

INTRAOPERATIVE PERIOD

Antithrombotic Prophylaxis

Antithrombotic prophylaxis reduces perioperative venous thromboembolism risk and related morbidity and mortality. Both pneumatic compression devices and anticoagulant medications are now commonly used. Because neuraxial anesthesia techniques are commonly employed for many patients undergoing major abdominal, vascular, thoracic, and orthopedic procedures, appropriate timing and administration of antithrombotic agents in these cases is of critical importance in order to avoid the risk of epidural hematoma. International recommendations on the management of anticoagulated patients receiving regional anesthesia are discussed in Chapter 45.

Antibiotic Prophylaxis

Appropriate selection and timing of preoperative antibiotic prophylaxis reduces the risk of surgical site infections. Antibiotics should be administered intravenously within 1 h before skin incision and, based on their plasma half-life and estimated blood loss, should be repeated during lengthy surgeries to ensure adequate tissue concentrations. Recent data from large national databases have demonstrated that administration of oral antibiotics 24 h prior to colorectal surgery in patients receiving mechanical bowel preparation (MBP) reduces the risk of surgical site infections, when compared with patients receiving MBP alone or those not receiving MBP. Antibiotic prophylaxis for surgical site infections should be discontinued within 24 h following surgery, although current guidelines permit cardiothoracic patients to receive antibiotics for 48 h following surgery.

Strategies to Minimize the Surgical Stress Response

The surgical stress response is characterized by neuroendocrine, metabolic, inflammatory, and immunological changes initiated by the physiological trespass of the surgical incision and subsequent invasive procedures. The stress response can adversely affect organ function and perioperative outcomes, and may include induction of a catabolic state as well as a transient, but reversible, state of insulin resistance, characterized by decreased peripheral glucose uptake and increased endogenous glucose production. The magnitude of the surgical stress response is related to the intensity of the surgical stimulus, hypothermia, and psychological stress. It can be moderated by perioperative interventions, including neural blockade and reduction in procedural invasiveness. Much recent effort has focused on developing surgical and anesthetic techniques that reduce the surgical stress response, with the goal of lowering the risk of stress-related organ dysfunction and perioperative complications. An overview of several techniques that have proved effective in ERP protocols follows.

A. Minimally Invasive Surgery

It is well established that minimally invasive surgical procedures are associated with significantly less surgical stress when compared with corresponding “open” procedures. Published data highlight the safety of minimally invasive procedures in the hands of adequately trained and experienced surgeons. Moreover, a longer term salutary impact is achieved when laparoscopic techniques are included in ERPs. For example, laparoscopic procedures are associated with a reduced incidence of surgical complications, especially surgical site infections, when compared with the same procedures performed in “open” fashion. A laparoscopic approach is also associated with less postoperative surgical pain, better postoperative respiratory function, and less morbidity in elderly surgical patients. Over the past 15 years, further advancements in surgical care, such as robotic surgery, natural orifice specimen extraction during laparoscopic surgery, endoscopic surgical approaches, and minimally invasive orthopedic surgery, have further moderated the impact of surgery on surgical stress, and such progress is expected to continue.

B. Regional Anesthesia/Analgesia Techniques

A variety of fast-track surgical procedures have taken advantage of the beneficial clinical and metabolic effects of regional anesthesia/analgesia techniques (Table 48–1). Neuraxial blockade of nociceptive stimuli by epidural and spinal local anesthetics has been shown to blunt the metabolic, inflammatory, and neuroendocrine stress responses to surgery. In major open abdominal and thoracic procedures, thoracic epidural blockade with local anesthetic is a recommended anesthetic component of a postoperative ERP, providing excellent analgesia, facilitating mobilization and physical therapy, and decreasing the incidence and severity of ileus. However, the advantages of epidural blockade in such cases are not as evident when minimally invasive surgical techniques are used, and in certain cases, epidural blockade has even been shown to delay recovery and prolong hospital stay. Lumbar epidural anesthesia/analgesia should be discouraged for abdominal surgery because it often does not provide adequate segmental analgesia for an abdominal incision. In addition, it frequently causes urinary retention and lower limb sensory and motor blockade, increasing the need for urinary drainage catheters (with accompanying increased risk of urinary tract infection), delaying mobilization and recovery, and increasing the risk of falls.

Epidural blockade using a solution of local anesthetic and low-dose opioid provides better postoperative analgesia at rest and with movement than systemic opioids (Figure 48–4 and Table 48–2). By sparing opioid use and minimizing the incidence of systemic opioid-related side effects, epidural analgesia facilitates both earlier mobilization and earlier resumption of oral nutrition, expediting exercise activity and attenuating loss of body mass. It minimizes postoperative insulin resistance by attenuating the postoperative hyperglycemic response and by facilitating utilization of exogenous glucose, thereby preventing postoperative loss of amino acids and conserving lean body mass.

If spinal anesthesia is used for fast-track (and especially ambulatory) surgery, attention must be paid to delayed recovery due to prolonged motor blockade. The use of smaller doses of intrathecal local anesthetics (lidocaine, 30–40 mg; bupivacaine, 3–10 mg; or ropivacaine, 5–10 mg) with lipophilic intrathecal opioids (fentanyl, 10–25 mcg, or sufentanil, 5–10 mcg) can prolong postoperative analgesia and minimize motor block without delaying recovery from anesthesia. The introduction of ultra-short-acting intrathecal agents such as 2-chloroprocaine (still controversial at present) may further speed the fast-track process. Spinal opioids are associated with side effects such as nausea, pruritus, and postoperative urinary retention. Adjuvants such as clonidine are effective alternatives to intrathecal opioids, with the goal of avoiding opioid side effects that may delay hospital discharge. For example, intrathecal clonidine added to spinal local anesthetic provides effective analgesia with less urinary retention than intrathecal morphine. In a recent study, lower cortisol and glucose levels were observed in colorectal patients receiving spinal anesthesia with intrathecal local anesthetic and morphine compared with patients receiving systemic opioids; however, the inflammatory response did not differ between the two analgesic techniques. Further studies are needed to define the safety and efficacy of regional anesthesia techniques in fast-track cardiac surgery. Although some cardiac surgery studies have shown that spinal analgesia with intrathecal morphine decreases extubation time, decreases length of stay in the intensive care unit (ICU), reduces pulmonary complications and arrhythmias, and provides analgesia with less respiratory depression, other studies have shown no benefit to this approach.

Peripheral nerve blocks (PNBs) with local anesthetics (single-shot or continuous infusion) block afferent nociceptive pathways and are an excellent way to minimize the need for systemic opioids and thereby reduce the incidence of opioid-related side effects and facilitate recovery (see Chapter 46). The choice of local anesthetic, dosage, and concentration should be made with the goal of avoiding prolonged motor blockade and delayed mobilization and discharge.

C. Intravenous Lidocaine Infusion

Lidocaine (intravenous bolus of 100 mg or 1.5–2 mg/kg, followed by continuous intravenous infusion of 1.5–3 mg/kg/h or 2–3 mg/min) has analgesic, antihyperalgesic, and antiinflammatory properties. In patients undergoing colorectal and radical retropubic prostate surgeries, intravenous lidocaine has been shown to reduce requirements for opioids and general anesthetic agents, provide satisfactory analgesia, facilitate early return of bowel function, and accelerate hospital discharge. Although lidocaine infusion potentially may replace neuraxial blockade and regional anesthesia in some circumstances, more studies are needed to confirm the advantage of this technique in the context of ERPs. The most effective dose and duration of infusion for various surgical procedures remains to be determined; even short duration of lidocaine infusion may have benefit.

D. Beta-Blockade Therapy

β-Blockers have been used to blunt the sympathetic response during laryngoscopy and intubation and to attenuate the surgical stress-induced increase in circulating catecholamines. They also have been shown to prevent perioperative cardiovascular events in at-risk patients undergoing noncardiac surgery and to help maintain hemodynamic stability during the intraoperative period and during emergence from anesthesia. They possess anticatabolic properties, which may be explained by reduced energy requirements associated with decreased adrenergic stimulation. Intravenous esmolol reduces the requirement of volatile anesthetic agents and decreases minimum alveolar concentration values; it has also been shown to reduce postoperative pain intensity, opioid consumption, and PONV. A positive protein balance has been reported in critically ill patients when β-blockade is combined with parenteral nutrition. However, the precise role of β-blockers as adjuvant analgesics in the context of ERPs remains undetermined.

E. Intravenous Alpha₂-Agonist Therapy

Both clonidine and dexmedetomidine have anesthetic and analgesic properties. Clonidine decreases postoperative pain, reduces opioid consumption and opioid-related side effects, and prolongs neuraxial and peripheral nerve local anesthetic blockade. In patients undergoing cardiovascular fast-track surgery, spinal morphine with clonidine decreases extubation time, provides effective analgesia, and improves quality of recovery. The role of dexmedetomidine in ERP pathways has not been extensively studied.

Use of Short-Acting Intravenous & Inhalation Agents

A. Intravenous Anesthetics

Intravenous propofol is the deep sedation and general anesthesia induction agent of choice for most surgical procedures. Propofol total intravenous anesthesia (TIVA) is often used as part of a multimodal regimen for patients at high risk for PONV.

B. Inhalational Anesthetics

When compared with other volatile anesthetic agents, desflurane and sevoflurane may shorten anesthesia emergence, reduce postanesthesia care unit (PACU) length of stay, and decrease recovery-associated costs. There is evidence that avoidance of deep general anesthesia by use of bispectral index (BIS) monitoring may improve outcomes, including a reduction of the incidence of postoperative delirium and cognitive dysfunction. Nitrous oxide, because of its anesthetic- and analgesic-sparing effects, rapid pharmacokinetic profile, and low cost, is sometimes administered with other inhalation agents. However, routine administration of nitrous oxide has declined recently, as it may cause bowel distention and impair the laparoscopic surgeon’s view of anatomic structures, and may increase the risk of PONV (see Chapter 8).

C. Opioids

Short-acting opioids such as fentanyl, alfentanil, and remifentanil are commonly used during fast-track surgery in combination with inhalation agents or propofol, and with regional or local anesthesia/analgesia techniques. However, intraoperative administration of remifentanil to patients who will experience extensive postoperative pain has been associated with opioid-induced hyperalgesia, acute opioid tolerance, and increased analgesic requirements during the postoperative period. There is increasing evidence that the use of opioids should be minimized in all phases of the perioperative course as part of a multimodal analgesia technique to reduce opioid side effects and optimize recovery. Opioid-free anesthesia has been shown to reduce PONV and postoperative opioid use when compared with opioid-based anesthesia and may be an alternative technique, especially in patients at high risk for PONV, sleep apnea, or respiratory depression.

Maintenance of Normothermia

The inhibitory effects of anesthetic agents on thermoregulation, exposure to the relatively cool surgical environment, and intraoperative heat loss can lead to hypothermia in all patients undergoing surgical procedures. The duration and extent of the surgical procedure directly correlates with hypothermia risk. Perioperative hypothermia increases cardiovascular morbidity and wound infection risk by increasing sympathetic discharge and inhibiting the immune cellular response. A decrease in core body temperature of 1.9°C triples the incidence of surgical wound infection. The risk of bleeding and blood transfusion requirement are also increased with hypothermia. Furthermore, by impairing the metabolism of many anesthetic agents, hypothermia may significantly prolong anesthesia recovery (see Chapter 52).

Maintenance of Adequate Tissue Oxygenation

Surgical stress leads to impaired pulmonary function and to peripheral vasoconstriction, resulting in arterial and local tissue hypoxemia, respectively. Perioperative hypoxia can increase cardiovascular and cerebral complications, and many strategies should be adopted during the perioperative period to prevent its development.

Maintenance of adequate perioperative oxygenation by oxygen supplementation has been associated with the improvement of some clinically relevant outcomes. Intraoperative and postoperative (for 2 h) inspired oxygen concentration of 80% increases arterial and subcutaneous oxygen tension and may decrease the rate of wound infection and lower the incidence of PONV, without increasing potential complications associated with high inspired oxygen fraction, such as atelectasis and hypercapnia. Regional anesthesia techniques decrease vascular resistance and may improve peripheral tissue perfusion and oxygenation. Finally, early mobilization and avoidance of bedrest improve postoperative central and peripheral tissue oxygenation.

Postoperative Nausea & Vomiting Prophylaxis

PONV is a frequent complication that delays early feeding and postoperative recovery. Preemptive strategies minimizing the risk of PONV are strongly advocated for any type of surgery, and consensus guidelines for prevention and management of PONV are available in the current literature (see Chapters 17 and 56).

Goal-Directed Fluid & Hemodynamic Therapy

There is increasing evidence that perioperative fluid administration affects patient outcome following major surgery, with the quantity of fluid administered—either too restrictive or too liberal—being associated with increased incidence of postoperative complications. Observational studies reveal large variation in practitioners’ fluid management strategies. Most attention is focused on avoiding hypovolemia, whereas excessively liberal fluid administration and its attendant adverse effects, though more difficult to observe in the operating room, are probably more common. Fluid overload, especially of crystalloid, has been associated with reduced tissue oxygenation, anastomotic leakage, pulmonary edema, pneumonia, wound infection, postoperative ileus, and prolonged hospitalization. Furthermore, excess fluids commonly increase body weight by 3 to 6 kg and may impair postoperative mobilization.

The concept of goal-directed fluid therapy (GDFT) is based on optimization of hemodynamic measures such as heart rate, blood pressure, stroke volume, pulse pressure variation, and stroke volume variation obtained by noninvasive cardiac output devices such as pulse-contour arterial waveform analysis, transesophageal echocardiography, or esophageal Doppler (see Chapter 5). GDFT aims to avoid both hypovolemia and fluid excess, and has been shown to be the optimal approach for fluid administration in high-risk surgical patients.

The type of fluid infused is also important: isotonic balanced crystalloid should be used to replace extracellular losses, whereas iso-oncotic colloids are commonly used to replace intravascular volume (Table 48–3).

POSTOPERATIVE PERIOD

Immediate Postoperative Care

A. Strategies to Minimize Postoperative Shivering

The primary cause of postoperative shivering is perioperative hypothermia, although other, non-thermoregulatory, mechanisms may be involved. Postoperative shivering can greatly increase oxygen consumption, catecholamine release, cardiac output, heart rate, blood pressure, and intracranial and intraocular pressure. It increases cardiovascular morbidity, especially in elderly patients, and increases PACU length of stay and cost. Shivering is uncommon in elderly and hypoxic patients: the efficacy of thermoregulation decreases with aging, and hypoxia can directly inhibit shivering. Many drugs, notably meperidine, clonidine, and tramadol, can be used to reduce postoperative shivering; however, prevention via strategies intended to minimize thermal loss is optimal (see Chapter 52).

B. PONV Treatment

Pharmacological treatment of PONV should be promptly initiated once medical or surgical causes of PONV have been ruled out (see Chapters 17 and 56).

C. Multimodal Analgesia

Multimodal analgesia combines different classes of medications that have different (multimodal) pharmacological mechanisms of action, resulting in additive or synergistic effects to reduce postoperative pain and its sequelae. Such an approach may achieve desired analgesic effects while reducing analgesic dosage and associated side effects. Multimodal pain management often includes utilization of regional analgesic techniques, including local anesthetic wound infusion, epidural/intrathecal analgesia, or single-shot/continuous peripheral nerve blockade. Multimodal analgesia is routinely utilized in ERPs to improve postoperative outcomes. Discussion here focuses on principal analgesic interventions used in perioperative multimodal analgesia regimens.

1. NSAIDs

The addition of nonsteroidal antiinflammatory drugs (NSAIDs) to systemic opioid analgesia diminishes postoperative pain intensity, reduces opioid requirements, and decreases opioid-related side effects such as PONV, sedation, and urinary retention. However, NSAIDs may increase the risk of gastrointestinal and wound bleeding, decrease kidney function, and impair wound healing. There is also a concern that NSAIDs may have a detrimental effect on anastomotic healing of the gastrointestinal tract and increase the risk of anastomotic leak, although this is controversial and further research is needed.

Perioperative administration of selective cyclooxygenase-2 (COX-2) inhibitor NSAIDs likewise reduces postoperative pain and decreases both opioid consumption and opioid-related side effects, and although their use reduces the incidence of NSAID-related platelet dysfunction and gastrointestinal bleeding, the potential adverse effects of COX-2 inhibitors on kidney function remain controversial. Concerns have also been raised, primarily with rofecoxib and valdecoxib, regarding COX-2 safety for patients undergoing cardiovascular surgery. Increased cardiovascular risk associated with the perioperative use of celecoxib or valdecoxib in patients with minimal cardiovascular risk factors and undergoing nonvascular surgery is unproven. Further studies are needed to establish the analgesic efficacy and safety of COX-2 inhibitors, their clinical impact on postoperative outcomes, and their precise role in ERPs.

2. Acetaminophen (paracetamol)

Oral, rectal, and parenteral acetaminophen is a common component of multimodal analgesia. Acetaminophen’s analgesic effect is 20% to 30% less than that of NSAIDs, but its pharmacological profile is safer. Analgesic efficacy improves when the drug is administered together with NSAIDs, and it significantly reduces pain intensity and spares opioid consumption after orthopedic and abdominal surgery. However, acetaminophen may not reduce opioid-related side effects. Routine administration of acetaminophen in combination with regional anesthesia and analgesia techniques may allow NSAIDs to be reserved for control of breakthrough pain, thus limiting the incidence of NSAID-related side effects.

3. Gabapentinoids

Oral gabapentin and pregabalin given as a single dose preoperatively have been shown to decrease postoperative pain and opioid consumption in the first 24 h following surgery. There is debate about the dose and duration of perioperative use of these drugs, and whether they may potentially alter the incidence of chronic pain after surgery. Common side effects include sedation and dizziness, especially in elderly patients.

4. N-methyl-D-aspartate (NMDA) receptor antagonists

• Ketamine: Perioperative low-dose ketamine (bolus, infusion) has been associated with significant reduction in pain, opioid consumption, and PONV. Ketamine has also been shown to be of particular benefit in patients on chronic opioids.

• Magnesium: Magnesium may also reduce postoperative pain and opioid consumption, although the optimal dosing is uncertain. Side effects include hypotension and potentiation of neuromuscular blockade.

5. Intravenous lidocaine

Intravenous lidocaine infusion analgesia has recently increased in popularity because there is good evidence to support its use as a component of multimodal analgesia. In major abdominal surgery, it is associated with faster return of bowel function and decreased hospital length of stay. Continuous cardiovascular monitoring is frequently advocated for patients receiving intravenous lidocaine, and therefore its use is currently limited to settings such as the PACU, ICU, or a monitored hospital ward. However, several centers have developed and implemented perioperative protocols to safely use intravenous lidocaine on surgical wards without continuous cardiovascular monitoring.

6. Opioids

Despite the increasing use of new, nonopioid analgesic medications and adjuvants and of regional anesthesia and analgesia techniques intended to minimize opioid requirements and opioid-related side effects (Table 48–4), the use of systemic opioids remains a cornerstone in the management of surgical pain. Parenteral opioids are frequently prescribed in the postoperative period during the transitional phase to oral analgesia. Opioid administration by patient-controlled analgesia (PCA) provides better pain control, greater patient satisfaction, and fewer opioid side effects when compared to nurse-administered, on-request (PRN) parenteral opioid administration. Oral administration of opioids, such as oxycodone or hydrocodone, in combination with NSAIDs or acetaminophen, or both, is common in the perioperative period.

7. Epidural analgesia

In addition to providing excellent analgesia, epidural blockade blunts the stress response associated with surgery, decreases postoperative morbidity, attenuates catabolism, and accelerates postoperative functional recovery. Compared with systemic opioid analgesia, thoracic epidural analgesia provides better static and dynamic pain relief. However, these benefits have mainly been observed in patients undergoing open abdominal and thoracic surgery; its usefulness in patients undergoing minimally invasive abdominal and thoracic surgery is questionable, as recent trials have suggested it may actually prolong in-hospital recovery in such cases. Long-acting local anesthetics such as ropivacaine (0.2%), bupivacaine (0.0625–0.125%), and levobupivacaine (0.1–0.125%) are commonly administered together with lipophilic opioids by continuous epidural infusion or by patient-controlled epidural analgesia (PCEA). As previously noted, administering low doses of local anesthetic via thoracic epidural infusion instead of lumbar levels avoids lower extremity motor blockade that may delay postoperative mobilization and recovery and will increase the risk of patient falls. Adding opioids to epidural local anesthetics improves the quality of postoperative analgesia without delaying recovery of bowel function.

8. Paravertebral nerve blocks

Paravertebral nerve blocks provide similar parietal analgesia to epidural blockade but without the risk of epidural-related side effects. However, they have been poorly studied in the context of ERPs.

9. Peripheral nerve blockade

Single-shot and continuous peripheral nerve blockade is frequently utilized for fast-track ambulatory and inpatient orthopedic surgery, and can accelerate recovery from surgery and improve both analgesia and patient satisfaction (see Chapters 38 and 46). For some procedures, blocking multiple nerves can provide analgesic benefits superior to blockade of a single nerve. The opioid-sparing effect of nerve blocks minimizes the risk of systemic opioid-related side effects. Appropriate patient selection and strict adherence to institutional clinical pathways helps ensure the success of peripheral nerve blockade as a fast-track orthopedic analgesia technique and also helps minimize its risks.

Advances in ultrasound imaging technology and techniques have accelerated interest in abdominal wall blockade, facilitating the selective localization of specific nerves and the direct deposition of local anesthetic solutions in proximity to the compartments where specific nerves are located (see Chapters 38 and 46).

Single-shot perineural administration of liposomal bupivacaine has been used recently to extend the analgesic duration of peripheral nerve blocks to up to 72 h after surgery. However, preliminary studies have not consistently shown expected benefits, and the role of liposomal local anesthetic preparations in postoperative analgesia and ERPs has, therefore, yet to be precisely defined.

10. High-volume local anesthetic infiltration analgesia and wound infusion

High-volume local anesthetic infiltration analgesia with a mixture of local anesthetic and epinephrine, with or without systemic NSAIDs, has recently gained popularity in patients undergoing total hip and knee replacements, and is currently replacing peripheral nerve blocks in many institutions, especially in the context of an ERP (see Chapter 38). However, supporting evidence demonstrating that this technique is superior to peripheral nerve blockade is currently lacking. Moreover, its impact on metabolic and inflammatory responses and on non–analgesic-related outcomes remains unknown. The impact of peripheral nerve blocks and rehabilitation therapy on functional outcomes also remains incompletely studied.

Local anesthetic wound infusions can be used to improve postoperative pain control and reduce the necessity for opioids, especially in patients undergoing open abdominal surgery and in whom epidural analgesia is contraindicated. The analgesic efficacy of local anesthetic wound infusion has been also established for multiple other surgical procedures. Inconsistent results from wound infusion may be secondary to type, concentration, and dose of local anesthetic employed; catheter placement; and mode of local anesthetic delivery.

11. Intraperitoneal instillation and nebulization of local anesthetic

Instillation and nebulization of intraperitoneal local anesthetic decreases pain intensity and decreases opioid consumption following open abdominal and laparoscopic surgery. However, the precise roles of these techniques in multimodal management remain to be determined.

Strategies to Facilitate Recovery on the Surgical Unit

A. Organization of Multidisciplinary Surgical Care

The multidisciplinary aspect of postoperative care should bring together the surgeon, anesthesia care team, nurses, nutritionist, physiotherapist, pharmacist, and case manager/social worker in an interdisciplinary team effort to optimize each patient’s care based upon standardized, procedure-specific protocols. Comfortable chairs and walkers should be made readily available near each patient bed to encourage patients to sit, stand, and walk. Routine bedrest after surgery should be avoided. Patients should be encouraged to sit in a chair the afternoon or evening following surgery, with ambulation starting the same or next day. If patients are unable to get out of bed, they should be instructed and encouraged to perform physical and deep breathing exercises in their beds.

B. Optimization of Analgesia to Facilitate Functional Recovery

A well-organized, well-trained, acute pain service (APS) utilizing procedure-specific clinical protocols to optimally manage analgesia and related side effects helps drive ERPs. The quality of pain relief and symptom control heavily influences postoperative recovery; optimal mobilization and dietary intake depend upon adequate analgesia with minimal analgesic-related side effects. The surgeon and the APS must identify and employ optimal analgesic techniques tailored to the specific surgical procedure, and the quality of analgesia and risk of analgesic-related side effects must be closely and continuously assessed. The goal is not to achieve “zero pain,” but to make patients comfortable while walking and performing physiotherapy, with minimal side effects such as lightheadedness, sedation, nausea and vomiting, urinary retention, ileus, and leg weakness. It should be noted that opioid-related PONV is the most common cause of unplanned hospital admission following ambulatory surgery, and opioid-related ileus is one of the most common causes of extended hospital length of stay. Both of these problems significantly increase perioperative costs.

C. Strategies to Minimize Postoperative Ileus

Postoperative ileus delays postoperative resumption of enteral feeding, is often a source of considerable patient discomfort, and is one of the most common causes of prolonged postoperative hospital length of stay and preventable hospitalization costs. Because early enteral nutrition is associated with decreased postoperative morbidity, interventions and strategies aimed at minimizing the risk and severity of postoperative ileus are essential for patients in an ERP. Four main mechanisms contribute to ileus: sympathetic inhibitory reflexes, local inflammation initiated by the operative procedure, intraoperatively- and postoperatively-administered systemic opioids, and bowel edema caused by administration of excess intravenous fluid. Nasogastric tubes, frequently inserted after abdominal surgery, do not speed the recovery of bowel function and may increase pulmonary morbidity by increasing the risk of aspiration. Therefore, nasogastric tubes should be discouraged whenever possible or used for only a very short period of time, even with gastrointestinal surgery.

The opioid-sparing effects of multimodal analgesia with minimal or non–opioid analgesia techniques shorten the duration of postoperative ileus or may preempt it entirely. Minimally invasive surgical techniques are associated with less surgical stress and inflammation than open procedures, resulting in more rapid return of bowel function. For open abdominal procedures, thoracic epidural local anesthetic infusions not only provide superior analgesia, but also speed recovery of bowel function by suppressing inhibitory sympathetic spinal cord reflexes that promote the development and severity of postoperative ileus. Epidural analgesia does not appear to have the same impact following laparoscopic procedures. Laxatives, such as milk of magnesia and bisacodyl, reduce postoperative ileus duration. Prokinetic medications such as metoclopramide are ineffective. Neostigmine increases peristalsis but may also increase the incidence of PONV.

Postoperative chewing gum, by stimulating gastrointestinal reflexes, may decrease ileus duration. Although its effect has not been evaluated in ERP patients, postoperative chewing gum may be included in multimodal interventions to decrease postoperative ileus because of its safety and low cost. Peripheral opioid μ-receptor antagonists methylnaltrexone (Relistor) and alvimopan (Entereg) minimize the adverse effects of opioids on bowel function without antagonizing systemic opioid analgesia because of their limited ability to cross the blood–brain barrier. In laparotomy patients receiving high-dose intravenous morphine analgesia, alvimopan decreases the duration of postoperative ileus by 16 to 18 h, decreases the incidence of nasogastric tube reinsertion, shortens hospital length of stay, and lowers hospital readmission rates, especially in patients undergoing bowel resection. Nevertheless, recovery of postoperative bowel function in such alvimopan-treated, high-dose systemic morphine analgesia patients remains slower than that of patients utilizing opioid-sparing, multimodal ERPs.

Excessive perioperative fluid administration commonly causes bowel mucosal edema and delays postoperative return of bowel function. Because either excessive, or excessively restricted, perioperative fluid therapy increases the incidence and severity of postoperative ileus, a goal-directed fluid administration strategy may be beneficial, especially in patients undergoing major surgery associated with large fluid shifts and patients at high risk of developing postoperative gastrointestinal complications (see Chapter 51). However, results from a recent randomized double-blind study of liberal versus restricted fluid administration showed no differences with regard to recovery of bowel function in patients undergoing fast-track abdominal surgery.

The success of ERPs depends upon the ability and willingness of perioperative team stakeholders to reach evidence-based interdisciplinary consensus. Many traditional aspects of perioperative care, such as use of drains, dietary and activity restrictions, excessive or excessively restrictive fluid management, and bedrest, must be extensively revised in ERPs. Patient involvement and patient and family expectations are fundamentally important, but frequently overlooked, aspects of these programs. New surgical techniques, such as transverse incisions or minimally invasive surgery, may require surgeons to acquire and perfect new skills. Similarly, the emphasis on thoracic epidural blockade or peripheral nerve blocks, pharmacological modulation of the neuroendocrine stress response to surgery, goal-directed fluid and hemodynamic therapy, and integral involvement of a well-organized and managed APS requires a substantial expansion of the traditional roles of anesthesiologists and of the anesthesia care team. Aggressive analgesia and symptom management, early ambulation and physiotherapy, early nutrition protocols, and early removal or total avoidance of urinary drainage catheters significantly change the way patients are cared for in the postanesthesia recovery unit and on the surgical unit and require a well-organized, highly trained, highly motivated nursing staff.

Although there are published studies of successful ERPs, there are no “off-the-shelf” protocols with universal application: Local differences in goals, expertise, experience, resources, and politics markedly influence the development, implementation, and management of ERPs for each institution or health care system. Each family of similar surgical procedures requires a standardized interdisciplinary clinical protocol or pathway, with specialized input from a team with experience in caring for those patients. Such an interdisciplinary team should include representation from surgery, anesthesiology, nursing, pharmacy, physiotherapy, nutrition, and administration, and it should be responsible not only for each clinical protocol’s creation, but also for continuously monitoring its efficacy and cost, and for instituting continuous improvement-related protocol modifications and provider feedback as indicated by outcomes data (Figure 48–5).

Optimal perioperative care requires the anesthesia provider to be an integral part of the perioperative surgical care team leadership and management. The skill sets of the anesthesiologist and anesthesia care team are essential for the success of ERPs and have potential benefits for surgical care delivery on a global basis, from initial surgical diagnosis, preoperative evaluation, and presurgical preparation through postoperative recovery and return of the patient to his or her primary healthcare provider. The perioperative surgical home concept represents an accumulation of developments derived from ambulatory, minimally invasive, fast-track, enhanced recovery, and interdisciplinary, team-based surgical care and allows both quality- and cost-related variables to be analyzed and optimized from the patient’s perspective (eg, incidence and severity of perioperative complications, hospital length of stay, hospital readmission rate, return to work, and return to chemotherapy). By optimizing these many variables, the PSH contributes to delivering a higher value surgical experience to the patient. This will require new standards for clinical education and training.