1. Minimizing Opioids in the Perioperative Period
Trina M. Kleiver MD
Assistant Professor
Director of Acute Pain & Regional Anesthesia
Department of Anesthesiology
University of Arkansas for Medical Sciences

2. Disclosures
No financial disclosures

3. Objectives
Defining the opioid epidemic as it relates to perioperative opioid use
Discuss Enhanced Recovery After Surgery (ERAS) and what it encompasses
Discuss Multimodal Analgesia perioperatively
Discuss Regional Anesthesia and how it can be utilized to decrease opioid use perioperatively
Review components of ERAS and discuss how it all fits together

4. Why are opioids bad? Hyperalgesia Addiction Immunosuppression Ileus
Increased sensitivity to pain
Mins to hrs of exposure to opioids leads to this for 24 hours or more
Addiction
Immunosuppression
Ileus
Constipation
Nausea/vomiting
Hormonal Levels
Sedation
Hypotension
Respiratory depression
Death

5. The Opioid Epidemic
Millet et al, 2016 described association between initial opioid prescribing patterns and subsequent long term use in opioid-naïve patients
Looked at 536K patients
Of those 26K (5%) patients become long term users (LTU)
LTU’s were 7x more likely to be hospitalized
Increased number script fills increase likelihood to become LTU
Single script for long acting opioid increased likelihood to become LTU by 16%
Risk Factors
Increasing age
Rural areas

6. Opioid epidemic continued
How do we stop more people from becoming LTUs?
More selective opioid use—short acting agents
Lower doses
Fewer days supply, No refills
Cumulative dose < 120 Morphine mg equivalents
CDC recommends 3-7 day supply
What happens to the left over opioids?
80% of people start their opioid use with unused opioids from family or friends
How do we reduce the risk of patients becoming LTUs for acute pain from trauma or surgery?

7. Enhanced Recovery After Surgery (ERAS)
Perioperative Pathway
Preoperative--days prior to surgery up to patient arrival in OR
Intraoperative
Postoperative—recovery room to discharge from hospital and beyond
Developed by anesthesiologists and surgeons
Evidence based interventions

8. Introduction to ERAS Multidisciplinary Multifocal
Primary care physician
Surgeon
Anesthesiologist
Acute pain service
Physical & occupational therapy
Nutritionist
Pharmacist
Nursing staff
Preoperative medication
Preoperative nutrition & conditioning
Preoperative NPO status/volume status
Intraoperative anesthesia management
Postoperative pain control
Other postoperative management

9. Anesthesia Components of ERAS
Preoperative
Intraoperative
Postoperative
Preoperative phone call & visit
NPO status
Normothermia
Multimodal analgesia
Opioids
+/- Thoracic epidural
+/- preoperative block or peripheral nerve catheter
Normothermia
Euvolemia
Medications
Ketamine
Lidocaine
+/- Iv acetaminophen
Toradol
Dexamethasone
Dexmedetomidine
Esmolol
Type of anesthesia
Blocks or catheters post- induction or in OR prior to emergence
Normothermia
Postoperative blocks or catheters
Consider same medications as preop plus
Diazepam (Valium)
Ketamine infusion
Lidocaine patch

10. Preoperative Components of ERAS
Preoperative phone call & visit, nutrition, conditioning
NPO status
Minimize NPO status,
Generally: 2 hours clear liquids, 8 hours solids
Normothermia
Pre-warm in preoperative area
Hypothermia contributes to:
Surgical site infections
Myocardial ischemia
Increased intraoperative blood loss/bleeding diatheses
Prolonged drug effects
Shivering
Skin integrity, pressure ulcer formation

11. Preoperative Components of ERAS (continued)
Multimodal analgesia
Acetaminophen
usually given po, much less expensive than iv
Contraindications: cirrhosis
Gabapentin
NMDA receptor antagonist
Dose for CrCl > 60 = 900mg
Dose for CrCl <60 or age >65 = 600mg
NSAID
ibuprofen, meloxicam (Mobic), celecoxib (Celebrex)
Contraindications: CrCl < 30, Gi bleed, PUD, h/o CABG
+/- Scopolamine patch
Contraindications: Age > 65, narrow angle glaucoma

12. Opioids preoperatively
Short acting opioids
Study by Geller et al., Journal of Arthroplasty 2019:
Retrospective cohort of 500+ patients undergoing total joint arthroplasty
Looked at oxycodone given preop versus no opioid
Oxycodone patients had higher pain scores on postop day 1, walked short distances, and consumed greater morphine mg equivalents
One of many examples indicated that short acting opioids may be contributing to post-operative hyperalgesia
Methadone
Potent mu opioid receptor agonist with rapid onset and long duration of action
N-methyl-D-aspartate (NMDA) receptor antagonist

13. ERAS for Thyroid/Parathyroid Surgery
Phase of Care
Intervention
Dose
Contraindications
Preoperative
Ibuprofen
Ibuprofen 800 mg PO
CrCl <30 mL/minute
Peptic ulcer disease or GI bleeding
History of CABG
Allergic type reactions to aspirin or other NSAIDS
Gabapentin
CrCl > 60: Gabapentin 900 mg PO
CrCl or age > 65: Gabapentin 600 mg PO
CrCl <30 ml/minute
Tylenol
Tylenol 975 mg PO
Cirrhosis with active alcohol use
Scopolamine
1.5 mg transdermally
Indicated for Apfel score > or = 3
Age > 65
Narrow angle glaucoma
Bilateral Superficial Cervical Plexus Block
Bupivacaine 0.25% 10 ml bilaterally
Hypersensitivity to amide local anesthetics
Patient refusal

14. Intraoperative Components of ERAS
Normothermia
Euvolemia
Medications
Ketamine
Lidocaine
+/- Iv acetaminophen
Toradol
Dexamethasone
Dexmedetomidine
Esmolol
Type of anesthesia: spinal versus general anesthesia
Blocks or catheters post-induction or in OR prior to emergence

15. Intraoperative Components of ERAS (continued)
Euvolemia—Fluid management
Open incisions
Colorectal/abdominal surgery
Thoracic surgery
Laparoscopic
More liberal (although use caution in case of converting to open)

16. Intraoperative Components of ERAS (continued)
Medications : Ketamine
Pcp analog/dissociative anesthetic
Also has analgesic properties
Works mu opioid receptors and NMDA receptors
Intraoperatively: iv infusion or iv bolus
Postoperative: low dose iv infusion
Indications:
Severe postoperative pain expected (thoracic/abdominal/spine)
Opioid tolerant/dependent patients
Obstructive sleep apnea patients
Treats acute & chronic pain, decreases postoperative nausea & vomiting perioperatively

17. Intraoperative Components of ERAS (continued)
Lidocaine
Amide local anesthetic
potent anti-inflammatory, anti-hyperalgesic, and gastrointestinal pro- peristaltic drug.
Iv infusion or iv boluses
Level 1 evidence from gastrointestinal surgery demonstrates decreased pain scores, opioid analgesic consumption, and side-effects
Used as component of ERAS for many surgeries, most notably spines
Good for treating hyperalgesia or when opioids are not effective in treating acute pain

18. Intraoperative Components of ERAS (continued)
+/- IV acetaminophen
Toradol
NSAID given iv
Great for postoperative if given at end of surgery
Mixed evidence on postoperative bleeding
Concern but little evidence on delayed bone healing (spine)
Dexamethasone
Iv steroid
Treats postoperative nausea and vomiting
Treats pain
Prolongs regional blocks

19. Intraoperative Components of ERAS (continued)
Dexmedetomidine
alpha-2 adrenergic receptor agonist sedative, analgesic, and anti- sympathetic effects
adjuvant analgesic at all perioperative stages
potential adverse effects: sedation, hypotension and bradycardia
Esmolol
Given instead of opioids or to supplement opioids/reduce use
Shown to decrease postoperative pain intensity, opioid consumption, and postoperative nausea and vomiting

20. Postoperative Components of ERAS
Normothermia
Postoperative blocks or catheters
Consider same medications as preoperative
Muscle relaxants for muscle spasm (and anxiety)
PACU: iv diazepam (Valium)
Ketamine infusion
At UAMS can infuse on med/surg, followed by acute pain service
Lidocaine patch
Don’t discount effectiveness

21. Thoracic & Abdominal Epidurals for postoperative pain
Advantages
Great coverage for large incisions
Block sympathetic response to surgery
Facilitates earlier mobilization postoperatively & recovery of gut function
Reduces pulmonary, cardiovascular, thromboembolic, and gastrointestinal complications occurring after surgery
Disadvantages
Can be difficult to place in some patients
Requires close follow up & quick availability of anesthesia staff
Requires collaboration of multiple hospital services & Teams
Must monitor for and limit postoperative anticoagulation

22. Peripheral Nerve Blocks/Catheters Ultrasound Guided
Benefits
Done preoperatively:
Improved hemodynamics
Decreased postoperative nausea and vomiting
Decreases postoperative opioid consumption
Risks
Small but present
Injury to nerve or surrounding structure
Infection
Bleeding
Reaction to local anesthetic
Allergy
Local anesthetic systemic toxicity

23. Peripheral Nerve Blocks/Catheters
Single shot nerve block
Peri-neural catheter
Advantages
Fast, easy for most anesthesiologists to perform
Low maintenance
Little to no follow up
Disadvantages
Limited duration of block
Possibility of rebound pain
Advantages
Greater control over duration of block
Can bolus or add adjuncts
Can turn on/off pump for neural checks, physical therapy, etc.
Disadvantages
More training
More thought
More follow up
Slightly more risk

24. Exparel: liposomal bupivacaine
Lipids separating aqueous honey-comb shaped compartments, each containing bupivacaine
Slow release of bupivacaine
Slower onset of active than plain bupivacaine
Can be given with plain bupivacaine at time of injection
No additional local anesthetics should be given for 96 hours
Evidence for efficacy in literature depending on type of block and surgery
No evidence for improvement of pain peri-articular injections
Expensive

25. Peripheral Nerve Blocks/Catheters
Upper extremity
Lower extremity
Chest wall & abdominal wall
Brachial plexus blocks
Block nerves individually
Femoral Nerve
Sciatic Nerve
Ankle
Chest Wall
Intercostal
Erector spinae
Paravertebral
Abdominal Wall
Transverse abdominal plane
Quadratus lumborum

26. Upper extremity blocks Brachial plexus anatomy
Nerve Roots
Interscalene
Trunks/Divisions
Supraclavicular
Cords
Infraclavicular
Branches
Axillary

27. Interscalene block

28. Interscalene block

29. Lower extremity blocks Two main nerve component
Femoral Nerve & Branches
Sciatic Nerve & Branches
Femoral nerve block
Block at level of groin
Hip fractures, hip replacements
Some knee surgeries
Femur involvement
Adductor canal
Mid-thigh
Saphenous nerve block
Minimal muscular component
Knee replacements, lower extremity
Subgluteal nerve block
Blocks entire sciatic nerve and branches
Knee replacements, amputations
Popliteal nerve block
Tibial nerve
Common peroneal nerve
Below knee & ankle surgeries

30. Chest wall blocks Intercostal blocks Paravertebral
Usually performed by surgeons at end of surgery
May use Exparel (disadvantage—burns the bridge for other blocks)
Paravertebral
Similar to epidural block, have same constraints with anticoagulation
Erector spinae blocks
Deposit local anesthetic in plane deep to the erector spinae muscles and superficial to the transverse processes
Achieve a craniocaudal distribution along several vertebral levels.
Consider superficial block, less constraints with anticoagulation
Great for rib fractures, thoracotomies, back surgeries and some abdominal surgeries
May have local anesthetic spread to paravertebral & epidural spaces

31. Abdominal wall blocks Transverse abdominal plane Quadratus lumborum
Inject local anesthetic at the fascial plane between internal oblique muscle & transverse abdominis muscle
Limited to somatic anesthesia of the abdominal wall and highly dependent on interfascial spread
Will not help with visceral pain
Used for big abdominal incisions (with catheters) when epidural analgesia is not used
Quadratus lumborum
Somatic as well as visceral analgesia of both the abdominal wall and the lower segments of the thoracic wall
Provide visceral analgesia due to their paravertebral and possibly epidural spread

32. Summary of ERAS—putting it all together Multiple approaches to controlling pain at all stages of surgery
Brain/Spine
Peripheral Nerve
Surgical site
Acetaminophen
NMDA antagonists
Methadone
Gabapentin
Ketamine
Alpha-2 agonists
Dexmedetomidine
Local anesthetics
For neuroaxial analgesia
Opioids work here but we want to minimize these
Local anesthetics
Peripheral nerve blocks/catheters
Steroids
Dexamethasone
Alpha-2 agonists
Local anesthetics
NSAIDS
Muscle relaxants

33. References
Deyo MD MPH, et al. Association Between Initial Opioid Prescribing Patterns and Subsequent Long-term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study. J of Gen Intern Med. 2016: 32(1):21-7.
Cooper MD, et al. Preemptive Analgesia With Oxycodone Is Associated With More Pain Following Total Joint Arthroplasty. Journal of Arthroplasty. 2018: xxx 1-6.
Schwenk MD, et al. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018; 43:
N Eipe MBBS MD1, S Gupta MD, and J Penning MD. Intravenous lidocaine for acute pain: an evidence-based clinical update. BJA Education. 2016, 16 (9): 292–298.
Watts, et al. The effect of perioperative esmolol on early postoperative pain: A systematic review and meta-analysis. J Anaesthesiol Clin Pharmacol Jan-Mar; 33(1): 28–39.
Chaoliang Tang and Zhongyuan Xia. Dexmedetomidine in perioperative acute pain management: a non-opioid adjuvant analgesic. J Pain Res. 2017; 10: 1899–1904.
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