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Chapter 48. Perioperative Pain Management & Enhanced Outcomes

Francesco Carli, MD, MPhil; Gabriele Baldini, MD, MSc

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    AMA Citation
    Carli F, Baldini G. Carli F, Baldini G Carli, Francesco, and Gabriele Baldini.Chapter 48. Perioperative Pain Management & Enhanced Outcomes. In: Butterworth JF, IV, Mackey DC, Wasnick JD. Butterworth J.F., IV, Mackey D.C., Wasnick J.D. Eds. John F. Butterworth, IV, et al.eds. Morgan & Mikhail's Clinical Anesthesiology, 5e New York, NY: McGraw-Hill; 2013. http://accessmedicine.mhmedical.com/content.aspx?bookid=564&sectionid=42800581. Accessed June 07, 2020.
    MLA Citation
    Carli F, Baldini G. Carli F, Baldini G Carli, Francesco, and Gabriele Baldini.. "Chapter 48. Perioperative Pain Management & Enhanced Outcomes." Morgan & Mikhail's Clinical Anesthesiology, 5e Butterworth JF, IV, Mackey DC, Wasnick JD. Butterworth J.F., IV, Mackey D.C., Wasnick J.D. Eds. John F. Butterworth, IV, et al. New York, NY: McGraw-Hill, 2013, http://accessmedicine.mhmedical.com/content.aspx?bookid=564&sectionid=42800581.

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  • image A well-functioning enhanced recovery program (ERP) uses evidence-based practices to decrease variation in clinical management, minimize organ dysfunction, and accelerate convalescence; it requires adjustments in multiple aspects of care, including surgical and anesthetic techniques, nursing care, physiotherapy, and nutrition support.
  • image Persistent postsurgical pain—chronic pain that continues beyond the typical healing period of 1-2 months following surgery, or well past the normal period for postoperative follow-up—is increasingly acknowledged as a common and significant problem following surgery.
  • image The magnitude of the surgical stress response is related to the intensity of the surgical stimulus, can be amplified by other factors, including hypothermia and psychological stress, and can be moderated by perioperative interventions, including deeper planes of general anesthesia, neural blockade, and reduction in the degree of surgical invasiveness.
  • image Neuraxial blockade of nociceptive stimuli by epidural and spinal local anesthetics has been shown to blunt the metabolic 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 physical therapy, and decreases the incidence and severity of ileus.
  • image By sparing opioid use and minimizing the incidence of systemic opioid-related side effects, epidural analgesia facilitates earlier mobilization and earlier resumption of oral nutrition, expediting exercise activity and attenuating loss of body mass.
  • image Continuous peripheral nerve blocks with local anesthetics block afferent nociceptive pathways and are an excellent way to reduce the incidence of opioid-related side effects and facilitate recovery.
  • image 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.
  • image Multimodal analgesia combines different classes of medications, having different (multimodal) pharmacological mechanisms of action and additive or synergistic effects, to control multiple perioperative pathophysiological factors that lead to postoperative pain and its sequelae.
  • image The addition of nonsteroidal antiinflammatory drugs (NSAIDs) to systemic opioids diminishes postoperative pain intensity, reduces the opioid requirement by approximately 30%, and decreases opioid-related side effects such as postoperative nausea and vomiting and sedation. However, NSAIDs may increase the risk of gastrointestinal and postoperative bleeding, decrease kidney function, and impair wound healing.
  • image Opioid administration by patient-controlled analgesia provides better pain control, greater patient satisfaction, and fewer opioid side effects when compared with on-request parenteral opioid administration.
  • image 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.
  • image Postoperative ileus delays enteral feeding, causes patient discomfort, and is one of the most common causes of prolonged postoperative hospital stay. Nasogastric tubes should be discouraged whenever possible or used for only a very short period of time, even in gastric and hepatic surgery. Multimodal analgesia and nonopioid analgesia techniques shorten the duration of postoperative ileus.
  • image Because either excessive, or excessively restricted, perioperative fluid therapy may increase the ...

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