1. Presented by: Paul Stechschulte, MD General Surgery PGY 2
Pain Management in Surgical Procedures Before and After Introduction of an Enhanced Recovery Protocol at an Ambulatory Surgery Center
Emma Alden, M.D., Paul Stechschulte, M.D., Cameron Black, M.D., Conor Holland, Steven Reitz, M.D., Lowell Chambers, M.D., Lynn Shaffer, Ph.D., Mark Stanley, M.D., Jason Keith, M.D.,
1 Intro, Thank you, Title
2 Not only
3 The concepts of multimodal and preventative analgesia focus on the basics of the physiology of surgical pain - surgical stimulus releases Inflammatory mediators causing increased nociceptor signaling to CNS (primary hyperalgesia) which causes changes in neurophysiology resulting in secondary hyperalgesia – the pathway for acute pain to transition into chronic pain
By using a multimodal attack on all the steps in this pathway, acute surgical pain is reduced, preventing chronic pain its related morbidity and costs
11 The ERP group was younger by 3 years and had fewer patients on chronic opioids which had to be factored into the statistical analysis
14 Females, younger patients, patients with higher BMI, and those on home opioids demonstrated higher levels of cumulative opioid use.
15 Hosmer-Lemeshow goodness of fit p-value
17 You can make a significant improvement in outpatient surgery patients’ pain control by applying a systematic pain treatment regimen
Presented by:
Paul Stechschulte, MD
General Surgery PGY 2

2. Background
Minimizing acute post-operative pain and use of narcotic pain medication is a prerequisite for optimizing post-operative recovery and reducing morbidity
An association has been noted between acute post-operative pain intensity and subsequent development of chronic pain, specifically in studies after breast surgery1, thoracotomy2 and inguinal hernia repair3.
Not only

3. Background (cont.) Multimodal analgesia and preventive analgesia 4
The concepts of multimodal and preventative analgesia focus on the basics of the physiology of surgical pain - surgical stimulus releases Inflammatory mediators causing increased nociceptor signaling to CNS (primary hyperalgesia) which causes changes in neurophysiology resulting in secondary hyperalgesia – the pathway for acute pain to transition into chronic pain

4. Background (cont.)
Enhanced recovery after surgery (ERAS) pathways5,6,7,8
Reduce perioperative morbidity
Enhance functional recovery after surgery
Shorten the duration of inpatient hospital stays

5. Background (cont.)
ERPs are now common in practice and the literature for major surgical procedures such as colectomies, spinal decompression and knee replacements
There is not as much literature on ERPs for minor to moderate surgical procedures, despite some of these surgeries having higher reported pain scores recorded than more major surgeries9

6. Objective
The objective of this study is to compare pain management in patients before and after the institution of an enhanced recovery protocol (ERP) at an ambulatory surgery center.

7. Methods Inclusion Criteria: Exclusion Criteria:
Patients undergoing outpatient general surgery procedure at Taylor Station Surgical Center
Exclusion Criteria:
Pregnancy
Under 18 years of age

8. Methods (cont.)
The traditional group (TRD) was comprised of patients from 7/1/ /1/2014
The enhanced recovery pathway group (ERP) was comprised of patients from 9/1/2015 – 12/31/2015

9. Methods (cont.) ERP Protocol: Pre-operative: Intra-operative:
Infusion of 1 Liter Lactated Ringers or 0.9 Normal Saline
Acetaminophen 1gram IV
Oxycontin 20mg PO
Ibuprofen 800mg IV
For females ≤ 60 years old, Scopolamine Transdermal Patch 1.5mg behind ear.
Intra-operative:
Zofran 4mg IV
Decadron 8mg IV

10. Methods (cont.) Outcomes: Subjective pain score (0-10)
Post-operative opioid or anti-emetic use
Cumulative post-operative opioid dose
PACU length of stay
PACU complication rates

11. Results 981 patients enrolled in study 449 (45.8%) in TRD group
532 (54.2%) in ERP group

12. Results (cont.)

14. Results (cont.)
Females, younger patients, patients with higher BMI, and those on home opioids demonstrated higher levels of cumulative opioid use.

15. Results (cont.)
Logistic regression model supports the effect of the ERP is fairly constant across subgroups
After controlling for other key factors, patients in the ERP group had a 63% lower odds of using opioids in the PACU after their procedure, compared to "traditional" patients.
Hosmer-Lemeshow goodness of fit p-value

16. Results (cont.)
Among patients who took any opioids, ERP patients took a lower amount [n=72, mean (SD) = 8.7 (3.5)] than did "traditional" patients [n=127, mean (SD) = 18.0 (9.3)] (p<0.0001).
Cumulative opioid use was significantly and positively correlated with all three pain measures: 1st pain score, highest pain score and pain at discharge (all p<0.0001)

17. Conclusion
Implementation of an enhanced recovery pathway can decrease pain scores and post-operative opioid use in the ambulatory surgery setting.
You can make a significant improvement in outpatient surgery patients’ pain control by applying a systematic pain treatment regimen

18. Limitations and Future Research
Non-randomized retrospective chart review
Procedure-specific pain management
Cost analysis, patient satisfaction

19. References
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2 Katz J, Jackson M, Kavanagh BP, Sandier AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain 1996;12:
3 Callesen T, Bech K, Kehlet H. Prospective study of chronic pain after groin hernia repair. Br J Surg 1999; 86:
4 Gritsenko, K., Khelemsky, Y., Kaye, A., Vadivelu, N., Urman, R. Multimodal therapy in perioperative analgesia. Best Practice & Research Clinical Anaesthesiology, Published March 1, Volume 28, Issue 1. pages
5 Kehlet H., and Wilmore D.W.: Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008; 248: pp
6 Kehlet H.: Fast-track colorectal surgery. Lancet 2008; 371: pp
7 Adamina M., Kehlet H., Tomlinson G.A., et al: Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 2011; 149: pp
8 Kehlet H.: Fast-track hip and knee arthroplasty. Lancet 2013; 381: pp
9 Gerbershagen H.J., Aduckathil S., van Wijck A.J.M., et al: Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology 2013; 118: pp