TY  - CHAP
M1  - Book, Section
TI  - Enhanced Recovery Protocols & Optimization of Perioperative Outcomes
A1  - Baldini, Gabriele
A1  - Miller, Timothy
A2  - Butterworth IV, John F.
A2  - Mackey, David C.
A2  - Wasnick, John D.
PY  - 2018
T2  - Morgan & Mikhail's Clinical Anesthesiology, 6e
AB  - KEY  CONCEPTS  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  source  of  considerable  patient  discomfort,  and  is  one  of  the  most  common  ...
SN  - 
PB  - McGraw-Hill Education
CY  - New York, NY
Y2  - 2024/04/19
UR  - accessmedicine.mhmedical.com/content.aspx?aid=1161432821
ER  -