“Alternative Pain Therapy For Minimizing Postoperative

“Strengthening Anesthesiologist In
Pain Service”
The 6th National Meeting Indonesian
Society of Anesthesiology for Pain
Management
Opioid Use : What Does ERAS Recommend”
dr. Farhan Ali Rahman, Sp.An
Anesthesiologist DR (H.C.) Ir. Soekarno Hospital, Bangka Belitung
Fellow of FIPM –KATI Programme
 The present interdisciplinary
consensus review proposes clinical
considerations and recommendations
for anaesthetic practice in patients
undergoing surgery with an Enhanced
Recovery after Surgery (ERAS)
programme1. Elements in the ERAS
protocol include good pain control and
“Strengthening Anesthesiologist In reducing postoperative pain.
Pain Service”
 Enhanced Recovery after Surgery
(ERAS)
“ERAS is a multimodal perioperative care
pathway designed to achieve early recovery for
patients undergoing major surgery. Involving
IASP, 2010 several medical professions to re-examine its
traditional practices and replacing them with
evidence based best practices. When
implemented, proven results show, improved
quality of care.”
OBJECTIVE : PAIN FREE HOSPITAL

1. 2.
evidence-based and optimal analgesia
multidisciplinary with minimal side
team effects

Multimodal, achievement of
procedure-specific important ERAS
analgesic regimens milestones such as
should be standard of early mobilization
care and oral feeding2
What we can do as Anesthesiologist ?
ERAS AND ANAESTHESIA CONSIDERATIONS :
PAIN MANAGEMENT

a Thoracic epidural analgesia (TEA)3

b Intrathecal (IT) analgesia4,5

c Intravenous lidocaine (IVL) infusion6,7

continuous wound infusion (CWI) of local

d
anaesthetic8,9
e Transversus abdominis plane (TAP) block10
Multimodal analgesia (MMA)11 regimen based on routine use of
f NSAIDs, COX-2 and acetaminophen (paracetamol)
A. Thoracic Epidural Analgesia (TEA)3

TEA (T6-T11) remains the gold standard for postoperative pain control in patients
undergoing open abdominal surgery

Epidural blockade should be tested before surgery or in the immediate

postoperative period (post-anaesthesia care unit) to avoid non-functioning
epidurals and unnecessary opioid administration. The addition of opioids to local
anaesthetic has shown to improve postoperative analgesia. Institutional policies
on how to manage epidural side effects, terminate epidural infusions, and how
transition to oral multimodal analgesia are recommended

Use of low dose of local anaesthetics (bupivacaine 0.1 mg/ml) and lipophilic opioids (e.g.
fentanyl 3 lg/ml) seem to provide optimal analgesia with minimal side effects.
Placement of epidural with contrast
B. Intrathecal (IT) Analgesia4,5

IT morphine is a valuable analgesic technique to improve early postoperative

analgesia and facilitates surgical recovery. Behind providing excellent analgesia, IT
morphine seems an appealing technique to shorten hospital stay in low-risk patients
undergoing laparoscopic colorectal surgery with an ERAS protocol.

Clinical management
Reported IT morphine dosage range between 200 and 250 lg in patients aged ≤ 75 years to lg
150 in patients > 75 years of age. Isobaric or hyperbaric bupivacaine (10–12.5 mg) have been
used in conjunction with IT morphine.

In the light of side effects, in the context of an multimodal analgesic regimen other
regional anaesthesia technique could be favoured especially in elderly patients.
C. Intravenous Lidocaine (IVL) Infusion6,7

In view of its antinociceptive and anti-inflammatory properties, systemic administration of

IVL as adjuvant to systemic opioids has been shown to improve postoperative analgesia,
reduce opioid consumption and speed surgical recovery

Clinical management
A loading dose of 1.5 mg/kg (IBW) should be initiated 30 min before or at the induction of
anaesthesia and continued until the end of surgery or in the recovery room (2 mg/kg/h
IBW). The exact duration of the infusion providing optimal analgesia and facilitating also
recovery remains unknown.

Systemic toxicity is rare, but continuous cardiovascular monitoring is required

D. Continuous Wound Infusion (CWI) of Local Anaesthetic8,9

CWI of local anaesthetic after open abdominal surgery has been shown to improve
postoperative analgesia and reduce opioid consumption, however the effect on the
recovery of bowel function is unclear.

Clinical management
Preperitoneal continuous infusion of ropivacaine 0.2% (10 ml/h) for 48–72 h has been
used in the majority of the studies. Other amide-local anaesthetics have also been used.
Systemic opioids are still required to control visceral pain.

Despite promising results the analgesic efficacy of CWI of local anaesthetic remains inconclusive
and several aspects related to this techniques need to be clarified. For example, the anatomical location
associated with optimal recovery remains undetermined. Furthermore, it remains to be established if the
analgesic effect observed in different trials is mainly driven by the bolus of local anaesthetic commonly given at
the end of surgery or by the infusion of local anaesthetic during the postoperative period
E. Transversus Abdominis Plane (TAP) block10

TAP block Significant reduction of pain intensity and opioid consumption

after ultrasound-guided single-shot TAP blocks has been observed but it is limited to the
first 24 h after surgery

Clinical management
Optimal timing, choice of local anaesthetic, dosing and volumes remain unknown. However,
it seems that a minimal volume of 15 ml is required to achieve satisfactory analgesia with
single-shot TAP block. Ropivacaine 0.2% (8– 10 ml/h) can be infused for 48–72 h trough a
multihole catheter. A bilateral infusion (8–10 ml/h each side) is required with a midline
incision. Systemic opioids are needed to control visceral pain.

A recent RCT has shown that the analgesic efficacy of four-quadrant TAP blocks
in adjunct to bilateral posterior continuous TAP blocks, was not inferior to TEA after
laparoscopic colorectal surgery
F. Multimodal analgesia (MMA)11 regimen based on routine use of
NSAIDs, COX-2 and acetaminophen (paracetamol)

A MMA regimen based on routine use of NSAIDs, COX-2 and acetaminophen (paracetamol)
(PO or intravenously when available) should adopted if not contraindicated in patients
undergoing open and laparoscopic abdominal procedures with the aim to reduce opioid
consumption and their dose-dependent side effects that impair recovery.

NSAIDs and COX-2 inhibitors have been shown to improve postoperative analgesia,
reduce opioid consumption and some of their side effects by 30%. Perioperative intravenous
ketamine and gabapentinoids have also shown opioid sparing properties. However, the risk of
side effects such as dizziness and sedation should be considered

It might be possible that the well-proven benefits of ERAS programmes might offset the
reported advantages of different analgesic techniques. The synergistic effect of combining
different analgesic medications remains unknown and the impact of MMA on long- term
outcomes still remains to be determined.
 Persistent post-surgical pain (PPSP, also referred
to as ‘chronic post-surgical pain’)
is common, causes disability, lowers quality of life
and has economic consequences.
1 Reviews of its prevalence report that
22–67% of persons who underwent thoracotomy,
30–81% of persons who had a limb amputated,
11–51% of women who had breast surgery,
3–56% of persons who had a cholecystectomy and
0–37% of persons who had an inguinal hernia
“Strengthening Anesthesiologist In repair
developed PPSP.12
Pain Service”
 REFERENCES
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Thank You dr. Farhan Ali Rahman, Sp.An
farhanalirahman@yahoo.com