A well-functioning enhanced recovery program (ERP) uses evidence-based practices that ensure continuity of care, decrease variation in clinical management, minimize organ dysfunction, decrease postoperative complications, and accelerate convalescence.
The perioperative surgical home (PSH) is defined by interdisciplinary, team-based global management of the surgical patient throughout the surgical care continuum. PSH management begins following the initial surgical diagnosis and patient preparation, and ends when the patient is returned to the care of his or her primary health care provider after full recovery. It includes several perioperative enhanced recovery program (ERP) elements that are adapted to the local clinical care environment.
Persistent postsurgical pain (chronic pain that continues beyond the typical healing period of 1 to 2 months following surgery, or well past the normal period for postoperative follow-up) is increasingly acknowledged as a common and significant problem following surgery.
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.
Neuraxial blockade of nociceptive stimuli by epidural and spinal local anesthetics has been shown to blunt the metabolic, inflammatory, and neuroendocrine stress response to surgery. In major open abdominal and thoracic procedures, thoracic epidural blockade with local anesthetic provides excellent analgesia, facilitates mobilization, and decreases the incidence and severity of ileus.
Epidural blockade using a solution of local anesthetic and low-dose opioid provides better postoperative analgesia at rest and with movement than systemic opioids. 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.
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.
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.
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.
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 postoperative nausea and vomiting (PONV), sedation, and urinary retention. However, NSAIDs may increase the risk of gastrointestinal and wound bleeding, decrease kidney function, and impair wound healing.
Opioid administration by patient-controlled analgesia provides better pain control, greater patient satisfaction, and fewer opioid side effects when compared to nurse-administered on-request (PRN) parenteral opioid administration.
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 analgesia and patient satisfaction.
Postoperative ileus delays postoperative resumption of enteral feeding, is often a ...