analgesic aspects of eras

1. Analgesic Aspects of ERAS Dr Susan Nimmo Consultant Anaesthetist Western General Hospital Edinburgh Age Anaesthesia Association Annual Scientific Meeting May 2008

4. Analgesia and Enhanced Recovery

5. 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

7. 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

8. Dynamic Analgesia/Mobilisation

9. Causes of Ileus Degree of surgical manipulation Magnitude of inflammatory and stress response Sympathetic reflexes Opioids Salt and water overload/bowel oedema

11. 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

12. 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

13. 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

15. 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

16. 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

17. How can we make our epidurals more effective? Correct placement Insertion preop with block check Facilities to resite Adequate securing of catheter (and filter)

19. Epidural Complications: Drugs Complication Drug errors Respiratory depression CNS toxicity Hypotension Motor blockade

20. 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

21. 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)

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

23. Contraindications to Epidural Analgesia Patient refusal Anticoagulation High risk of abscess High risk of serious cardiovascular instability (And failed epidural analgesia)

24. It’s 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

25. Local Anaesthetic Alternatives Wound catheters 20mls levobupivacaine x 4/ day Improved analgesia and opioid sparing (elastomeric pump systems)

28. Our practice…. Wound catheters – levobupivacaine PCA opioid (morphine or fentanyl) Regular paracetamol ? Ibuprofen/celecoxib ? Ketamine

29. 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

31. ERAS(Enhanced Recovery After Surgery) An international collaboration group Prof Henrik Kehlet (Denmark, Netherlands, Norway, Scotland, Sweden)

32. 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)

33. 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

34. Length of Stay - ? A Useful Endpoint

35. ERAS results

36. 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%

37. 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

38. 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

39. Any Questions ?