Lancaster Physician Summer 2019 - 16

L A N C A S T E R M E D I C A L S O C I E T Y.O R G

Best Practices

Surgical patients are at risk of becoming
chronic opioid users with up to 7 percent
of previously opioid naive patients continuing to take opioids years later.2 Prescription
opioids given to the patient at discharge is
an independent risk factor for chronic opioid
use, according to the American Society of
Anesthesiologists.3 Unused pills are diverted
and sold to addicted Individuals, according
to the American College of Surgeons.
With Enhanced Recovery After Surgery
guidelines, some patients may be spared from
opioid therapy and the potential cycle of
addiction that stems from it. In the 1990s, the
concept of "fast-track surgery" was introduced
to the care of the surgical patient with a focus
on decreasing the length of stay in the hospital.
In the early 2000s, European physicians collaborated to establish guidelines for Enhanced
Recovery After Surgery (ERAS), an evidence
based, multidisciplinary team approach to caring for surgical patients. Since then, there have
been guidelines introduced across all surgical
specialties including colorectal; ear, nose and
throat; cardiothoracic; vascular; orthopedics;
gynecology/oncology; and plastics.

What does this
new approach
look like in
the surgical
patient? It starts
from the first
visit with the
surgeon.

The surgeon sets the expectation that the
patient is a candidate for ERAS and will have
a multidisciplinary team-consisting of the
surgeon, anesthesiologist, nurses, social worker,
physical therapist, and respiratory therapist-
working with them to decrease opioid use,
decrease post-operative nausea and vomiting,
ambulate early, and ultimately decrease time
spent in the hospital.

After the surgeon sets the expectation, the
patient is referred to appropriate specialists
that will optimize the patient's comorbidities
including asthma, COPD, diabetes, and
weight management. The patient is then given
a carbohydrate drink with instructions to drink
the morning of surgery, up to two hours prior
to surgical start time. Relaxed fasting guidelines have been shown to reduce the overall
physiological stress of surgery on the body. A
carbohydrate drink decreases insulin resistance
and the clear liquid helps maintain a normal
fluid balance throughout the surgical process.
The patient also receives a chlorhexidine scrub
to bathe with the night before surgery, thus
decreasing skin bacteria and risk of infection.
On the day of surgery, the patient will receive
alternative multimodal pain management.
Alternative pain management is one of the
cornerstones of ERAS. Patients who receive
acetaminophen and gabapentin, a non-opiate
medication that acts on the nerves, need less
pain medication during and after surgery. The
goal of ERAS is to prevent pain, rather than
treat it after it's out of control. In addition,
regional anesthesia including spinal, epidural,
and nerve blocks are utilized to decrease pain
by numbing the nerves involved with the
surgical site. Most patients can manage pain
with acetaminophen and NSAIDs alone with
the occasional tramadol as needed for breakthrough pain. This means fewer patients are
exposed to intravenous opiates during surgery
and are sent home with a dramatic decrease in
the number of opioid-containing pills. Fewer
pills at home means they are less likely to be
misused or diverted.

decreases the incidence of PONV. In a single
center study of 1,000 patients using multimodal pain management techniques to avoid
opioids, only 11 percent of patients experienced nausea compared to a 50-80 percent
of patients that usually experience nausea for
the same surgery.4
In addition to multimodal pain management, PONV prevention, relaxed fasting
guidelines, and chlorhexidine scrub, surgeons
are choosing minimally invasive techniques.
This means more patients are planning to have
laparoscopic surgery instead of laparotomy
and robotic-assisted instead of open abdomen
hysterectomy with a low transverse incision.
What does this mean for the patient? Ultimately, it means less pain and faster recovery. The
patient doesn't have recover from an incision
through muscle tissue in addition to their
hysterectomy; they only have to recover from
four small port incisions. With less invasive
techniques the patient can avoid taking as
much pain medication and can recover with
NSAIDs and acetaminophen with only the
occasional opioid pill.
Now, with all of this well-intentioned and
evidence-based protocols, I want to draw
attention to the idea of a "decrease" in opioid
therapy. Opiates are an effective medication to
treat pain, especially acute pain like that caused
by surgery. This is not to say we are trying to
avoid pain medications altogether at the cost
of the patient's comfort. We are treating pain
from multiple and diverse angles to decrease the
patient's perception of pain, not to withhold
necessary treatment.

Another aspect of ERAS is the aggressive
prevention and treatment of post-operative
nausea and vomiting (PONV). PONV is what
happens to some patients after general anesthesia.
Susceptible individuals are usually young, healthy
female adults with a history of motion sickness.
Additional medications for at-risk individuals and
individuals with previous episodes of PONV are
warranted under the ERAS guidelines.

Enhanced Recovery After Surgery is an evidence based, multidisciplinary initiative to treat
patients effectively and efficiently throughout
the surgical process. Its aim is to decrease opioid
use and avoid surgical complications while
increasing patient satisfaction. We want to give
our patients the best care we are able to provide.
Together, we can overcome the opioid epidemic
and empower our patients to be well.

As an additional preventative measure for
PONV is the avoidance of opioid therapy.
Opioids, as it turns out, are an independent
risk factor for PONV. According to the ASA,
opioid-free general anesthesia dramatically

ENDNOTES

LANCASTER

PHYSICIAN

1 www.drugabuse.gov
2 www.facs.org/education/opioids
3 ASAHQ.org
4 Ibid

http://www.drugabuse.gov http://www.facs.org/education/opioids http://www.ASAHQ.org

Lancaster Physician Summer 2019

Table of Contents for the Digital Edition of Lancaster Physician Summer 2019