Perioperative management: Pain and other considerations for enhanced recovery after surgery (ERAS)





Advances in laparoscopic, and later robotic urologic, surgery, came about in quantum leaps, ignited by the first laparoscopic radical nephrectomy in 1990. These advances resulted in a sudden rush to challenge all procedures previously performed in an open fashion, leading to techniques and technologies that have replaced almost every urological open procedure, delivering less morbidity, shorter recovery, and improved cosmesis, while matching or exceeding outcomes from years of open surgery. The enthusiasm for these minimally invasive procedures brought great satisfaction to both patients and surgeons. It wasn’t until the opioid pandemic began to ravage and shorten patients’ lives that we realized that just performing minimally invasive surgical techniques was not enough. These new techniques also led to less pain and suffering and a reduced need for large quantities of narcotics; nevertheless, we prescribed, in most cases, the same large quantities of tablets despite the diminishing need for their use.


Only recently have surgeons been pushed to explore aspects of surgical recovery and look beyond gloating over what can be accomplished through 1 cm or smaller incisions. Quantum leaps in postperioperative, intraoperative, and postoperative recovery are now needed to truly help our patients benefit from all aspects of modern surgery. The objective of this chapter is to increase awareness of some of the most recent and important evidence-based guidelines in this realm. We are hoping that the facts will integrate their way into daily practice by displacing or replacing old dogma and unmeasured and unproven habits, in much the same way the evidence behind overprescribing opioids has struggled and is now succeeding in changing practice patterns and building new habits.


The recommendations taken from the literature represent the next step in modern surgical treatments. Use of enhanced recovery after surgery (ERAS) protocols (EP) is a multimodal, multidisciplinary approach to pre-, intra-, and postoperative patient care that has been shown to reduce mortality and morbidity in surgery patients. Though originally developed in the realm of colorectal surgery, ERAS has been widely adopted by all surgical fields and has been most extensively researched for urology in the context of radical cystectomy. Even in a urologic setting these protocols have been shown to reduce morbidity and hospital length of stay (LOS) and improve patient care.


Preoperative


Preoperative anesthetics





  • 100–300 mg gabapentin, 975 mg acetaminophen, and 400 mg celecoxib 2 hours before surgery



Preoperative pain protocols are commonly employed when patients present for surgery because of their effectiveness at reducing postoperative pain and intra-/postoperative opioid consumption. The use of gabapentin has been controversial, but many reports support its use in the perioperative period. Lower doses of gabapentin should be given to older patients, as high doses can result in prolonged sleepiness and decreased responsiveness in the immediate postoperative period.


A 2006 meta-analysis consisting of eight randomized placebo-controlled studies that analyzed the effect of gabapentin found that those who received gabapentinoids before surgery had significantly lower pain scores (−11.9 at rest and −11.0 with movement on a 100-point visual analogue scale) and a reduction of 14.7 mg of morphine 24 hours postoperatively.


A 2010 randomized controlled trial of patients undergoing robotic-assisted laparoscopic radical prostatectomy found that a preoperative dose of pregabalin 150 mg, acetaminophen 975 mg, and celecoxib 400 mg orally 2 hours before the start of the procedure and continued postoperatively reduced total opioid consumption by 26.2 mg when compared with just a postoperative regimen of intravenous ketorolac 15 mg every 6 hours with oxycodone 5 mg and acetaminophen 325 mg, 1 to 2 tablets, every 4 hours as needed for pain.


A 2016 meta-analysis comparing the effect of preoperative administration of various pharmacological substances on postoperative pain found that nonsteroidal antiinflammatory drugs (NSAIDs) (in particular COX-2 inhibitors) and gabapentinoids have a significant reduction on postoperative narcotic consumption (−0.46 mg with NSAIDs, −0.68 mg with COX-2 inhibitors and −0.99 mg gabapentinoids). Opioids and other pharmacological classes did not have a significant reduction in reducing postoperative opioid consumption.


Medical optimization


Current research indicates a potential benefit to decreasing or eliminating smoking and alcohol consumption 4 weeks preoperatively and that there is a significant benefit to optimizing nutrition to avoid a nutritionally deficient state perioperatively (“Patients with preoperative albumin less than 3.5 gm/dL, body mass index less than 18.5 kg/m 2 or preoperative weight loss greater than 5% of body weight were considered to have nutritional deficiency.”).


While evidence for the benefits from reduction in smoking and alcohol consumption has mainly come from retrospective cohort analysis, the most recent research from colorectal surgery cohorts shows that reduction in smoking and alcohol consumption reduce morbidity and mortality postoperatively.


Additional research on nutrition optimization indicates that patients who are nutritionally deficient have increased mortality following invasive surgery. One study found an 11.4% difference in 90-day mortality between patients who were nutritionally deficient and nutritionally normal.


Fluid loading





  • 10–30 mL/kg crystalloid or colloid fluid given preoperatively and a goal of 1.75–2.75 L/day of maintenance fluid given to a patient



A recent Cochrane review found that perioperative fluid loading with the above dosing regimen reduces postoperative nausea and vomiting (PONV) and the need for pharmacologic intervention to prevent PONV. The goal of this suggestion is not that every patient be blindly administered the above amount of fluid but rather that patients are euvolemic as they enter the operating room and stay that way up through the postoperative period. Both hyper- and hypovolemia have deleterious effects and should be avoided. Preoperatively, the goal of euvolemia can be achieved by restricting patient fluid consumption only 2 hours before surgery and then by appropriately maintaining fluid during the operation.


There are several different strategies for intraoperative fluid management, such as goal-directed fluid therapy (GDFT) and zero-balance intraoperative fluid management. GDFT is often associated with transesophageal Doppler to measure stroke volume and to let the stroke volume guide the volume resuscitation. GDFT in conjunction with ERAS has shown no reduction in LOS, morbidity, or mortality; however, GDFT as a standalone intervention resulted in a 24% reduction in morbidity and decreased LOS by 1.55 days.


Zero-balance intraoperative fluid management, a somewhat simpler method, consists of only replacing fluid lost, not accounting for third spacing and controlling nonvolume-related hypotension with vasopressors. In a randomized, double-blinded, multicenter trial comparing zero-balance intraoperative fluid management and GDFT, researchers found no significant difference between the two in LOS, rate of complications, or the need for vasopressors.


Diet restriction and timing





  • Patients should be allowed to consume solid food up to 6 hours prior to surgery and fluids up to 2 hours prior to surgery



Traditionally, surgery patients have been instructed to begin fasting at midnight before an operation to reduce the risk of aspiration and associated morbidity. A 2003 Cochrane review found that a shortened fluid fast (allowing patients to consume fluids up until 2 hours before operation) resulted in no difference in risk of aspiration, regurgitation, or related morbidity in patients when compared with the traditional “nothing by mouth after midnight” fast. A 2017 meta-analysis of patients undergoing laparoscopic cholecystectomy found that shortened fasting times increased patient comfort, improved insulin resistance, and reduced the patient’s stress response.


Carbohydrate loading





  • Greater than or equal to 45g oral carbohydrates 2–4 hours preanesthesia



A 2014 Cochrane review found that oral preoperative carbohydrate loading in patients undergoing elective abdominal surgery resulted in a 0.3-day decrease in LOS and did not increase or decrease the rate of complications when compared with the placebo group.


Bowel preparation





  • Advisement against routine mechanical bowel prep before surgery



Previously a staple procedure among gastrointestinal (GI) surgeons, recent data show that mechanical bowel preparation before surgery can result in dehydration and unneeded stress on a patient before surgery. A 2018 meta-analysis found that mechanical bowel prep before elective colorectal surgery provided no significant improvement to mortality, LOS, reoperation, or surgical site infection compared with no mechanical bowel prep. The authors concluded that, given the risk of dehydration and other potential complications from mechanical bowel prep, there was no evidence to suggest that mechanical bowel preparation reduces postoperative complications, and it should not be administered routinely before operations.


Prophylactic antibiotics


General guidelines


The use of prophylactic antibiotics is still an area of active research, with new data emerging regularly. The following section is based upon the recommendations of the American Urological Association (AUA). These values are provided more as a guideline of what antibiotics can be used in different situations. The final evaluation and use of antibiotics should be based upon local data on common infectious organisms and the various drug resistances that are commonly encountered. We focus on prophylaxis for laparoscopic and robotic surgeries (although more broad recommendations are provided by the AUA).


The initial determination of the wound classification is an important indication for differing recommendations and therefore should be determined before and following any procedure.


The wound classification system is based on where the surgery is performed and if any neighboring systems are entered. As a reminder, class I (clean) is an uninfected wound without entry into the GI, genitourinary, or pulmonary systems. Class II (clean-contaminated) is entry into the previously mentioned systems in a controlled environment with no other contamination. Class III (contaminated) is any infected stone procedure or use of any bowel segment. Class IV (dirty) is any open trauma or abscess. Antibiotic prophylaxis is heavily based upon the wound classification. For the majority of laparoscopic/robotic procedures, the wound classification is going to be II, III, or IV. Therefore, the following guidance focuses on those classifications.


For the majority of open, laparoscopic, or robotic surgeries, a single dose of cefazolin 60 minutes before incision as prophylaxis is currently recommended as sufficient (2 g for patients <120 kg or 3 g for patients ≥120 kg). Dosing may be repeated if surgery is longer than 4 hours or if significant blood loss has occurred.


The exceptions to that general rule are the following types of procedures with their recommended antimicrobial prophylaxis:


Controlled entry into the urinary tract: cefazolin or trimethoprim-sulfamethoxazole (TMP-SMX)


Procedures involving the large bowel: cefazolin + metronidazole, second- or third-generation cephalosporin + metronidazole, or ertapenem. Of note, mechanical bowel prep and an oral antimicrobial is suggested by the AUA in these cases.


Implanted device surgeries: aminoglycoside + first-/second-generation cephalosporin or vancomycin


Urologic surgery involving the vagina: For superior anaerobic coverage, consider using a second-generation cephalosporin in place of cefazolin ( Table 8.1 ).



TABLE 8.1

American Urological Association Guidance on Preoperative Antibiotics





































































Procedure Likely Organisms Prophylaxis Indicated Antimicrobial(s) of Choice Alternative Antimicrobial(s), if required Duration of Therapy
Open, laparoscopic, or robotic surgery
Without entering urinary tract, e.g., adrenalectomy, lymphadenectomy, retroperitoneal or pelvic; clean Staphylococcus aureus, skin Consider in all cases; may not be required Cefazolin Clindamycin Single dose
Penile surgery, e.g., circumcision and penile biopsy; clean-contaminated S. aureus Likely not required
Urethroplasty; reconstruction anterior urethra, stricture repair, including urethrectomy; clean; contaminated; controlled entry into the urinary tract GNR, rarely enterococci, S. aureus Likely required Cefazolin Cefoxitin, cefotetan, ampicillin/sulbactam Single dose
Involving controlled entry into urinary tract, e.g., renal surgery, nephrectomy, partial or otherwise, ureterectomy pyeloplasty, radical prostatectomy; partial cystectomy, etc., clean-contaminated GNR (Escherichia coli) , rarely enterococci All cases Cefazolin, TMP-SMX Ampicillin/sulbactam, aminoglycoside (aztreonam) + metronidazole, or clindamycin Single dose
Involving small bowel (i.e., urinary diversions), cystectomy with small bowel conduit, other genitourinary procedures; uretero-pelvic junction repair, and partial cystectomy; clean-contaminated Skin, S. aureus , GNR, rarely enterococci All cases Cefazolin Clindamycin and aminoglycoside, cefuroxime (second-generation cephalosporin), aminopenicillin combined with a β- lactamase inhibitor + metronidazole Single dose
Involving large bowel and colon conduits; clean-contaminated GNR, anaerobes All cases


  • Cefazolin + metronidazole, cefoxitin, cefotetan, or ceftriaxone + metronidazole, and ertapenem



  • these IV agents are used along with mechanical bowel preparation and oral antimicrobial (neomycin sulfate + erythromycin base or neomycin sulfate + metronidazole)




  • Ampicillin/sulbactam



  • Ticarcillin/clavulanate



  • Piperacillin/tazobactam

Single parenteral dose
Implanted prosthetic devices: AUS, IPP, sacral neuromodulators; clean GNR, S. aureus, with increasing reports of anaerobic, and fungal organisms All cases Aminoglycoside (aztreonam) + first-/second-generation cephalosporin or vancomycin Aminopenicillin β-lactamase inhibitor, including ampicillin/sulbactam ticarcillin, or tazobactam ≤24 hours
Inguinal and scrotal cases; e.g., radical orchiectomy, vasectomy, reversals, varicocelectomy, and hydrocelectomy; clean GNR, S. aureus Of increased risk; all cases Cefazolin Ampicillin/sulbactam Single dose

Procedure-specific table; AUS: artificial urinary sphincter; GNR: Gram-negative rod; IPP: inflatable penis prosthesis; TMP-SMZ: trimethoprim-sulfamethoxazole

ERAS suggestions consolidated


Intraoperative


Intraoperative local anesthetic





  • Infiltrate port sites and incision sites with long-acting local anesthetic (such as 0.5% bupivacaine) prior to making the incision for trocar placement



In a 2004 double-blind, placebo-controlled study, Khaira and Wolf demonstrated that infiltrating incision sites with long-acting local anesthetics during laparoscopy reduced the number of morphine equivalents consumed by patients by 15.7 mg per 24 hours.




  • Consider using a laparoscopic-guided transversus abdominis plane block (L-TAP)



Intraoperative deposition of analgesia can be performed in a variety of techniques such as L-TAP, ultrasound-guided transversus abdominis plane block (US-TAP), and local infiltration of analgesia (LIA). A 2020 meta-analysis comparing these methods found that L-TAP was as effective as US-TAP in controlling pain at rest and with movement in the first 24 hours postoperatively with no reduction in opioid consumption between the two techniques. When L-TAP was compared with LIA, they found it reduced opioid consumption by 3.23 mg morphine, reduced hospital stay (50.4 hours vs. 69.6 hours) and resulted in better satisfaction rates for patients. When compared with the inactive control (i.e., placebo or “no treatment”), L-TAP reduced opioid consumption by 1.50 mg morphine.


Postoperative management


Early removal of nasogastric tube and catheters


A 2007 Cochrane review found that routine use of a nasogastric (NG) tube did not decrease time to return to bowel function, decrease the risk of aspiration of gastric contents, increase patient comfort, or shorten LOS. They recommended using it only when needed to relieve gastric symptoms.


Catheters


Much of the research into early removal of urinary catheters has been based on radical prostatectomy with either in dwelling or urethral catheter placement. There are no specific recommendations or strong research to support or refute the early removal of catheters following surgery. The clearest correlation that has been consistently demonstrated is that earlier removal of urinary catheters decreases the risk of urinary tract infection but may increase the prevalence of acute urinary retention and incontinence. One study found that administering tamsulosin (0.4 mg from 1 day before to 14 days after surgery) can decrease the prevalence of acute urinary retention by 10.1% without increasing incidence of urinary incontinence.


Pain


Opioids, prescribed in large quantities, were previously the staple of postoperative pain control; however, the morbidity and mortality associated with their use and the potential for diversion from the patient have led providers to seek out other adjuncts and guidance on their appropriate use. Below are some nonopioid alternatives and procedure-specific opioid prescription suggestions to guide postoperative pain management.



  • 1.

    Medications



    • a.

      NSAIDs: 200 mg ibuprofen + 500 mg acetaminophen




      • NSAIDs, in particular the combination of ibuprofen 200 mg plus acetaminophen 500 mg, have been shown to be one of the most effective analgesic combinations, often surpassing opioids in pain reduction with fewer associated combinations. A 2017 systematic review of randomized trials of nonopioid analgesics in adults after major surgery patients found that the greatest reduction in opioid consumption via patient-controlled analgesia (PCA) came from acetaminophen + nefopam, acetaminophen + NSAIDs, and tramadol + methimazole with a 23.9, 22.8, and 19.8 mg per 24 hours reduction in consumption, respectively. To reduce the number of opioids consumed via PCA, the most efficacious medications for monotherapy are NSAIDs, COX-2 inhibitors, and alpha-2 agonists.



    • b.

      Magnesium




      • 30–50 mg/kg intraoperatively




        • A 2020 meta-analysis of a trial with sequential analysis of noncardiac surgery patients that analyzed the effect of magnesium when added to a traditional postoperative analgesia regimen found that perioperative magnesium reduced postoperative morphine consumption by 5.6 mg per 24 hours, reduced the incidence of shivering, and extended the time to first analgesia request. They found no significant difference in the postoperative pain scores, incidence of bradycardia, or PONV.




      • 50 mg/kg loading dose for 15 minutes, then 15 mg/kg/hour




        • A 2020 randomized controlled study found that intraoperative magnesium decreases bladder discomfort after transurethral resection of bladder tumors and increases patient satisfaction with no increase in magnesium-related adverse effects.




    • c.

      Dexamethasone




      • In a 2017 systematic review by Martinez et al., researchers found that dexamethasone was significantly effective at reducing postoperative nausea; however, it did not significantly reduce reported pain and consumption of opioids. They concluded that, at the current recommended doses administered following operations, dexamethasone should be considered an antiemetic rather than an analgesic.



    • d.

      Gabapentinoids




      • Based on a 2020 meta-analysis of 24,682 patients, postoperative pain outcomes do not appear to improve with the postoperative use of gabapentin and pregabalin. There does seem to be an opioid-sparing effect; however, additional adverse outcomes are not sufficient to promote the use of gabapentinoids. Therefore, currently, the use of gabapentin is not contraindicated for postoperative pain, but there are limited data to demonstrate its effectiveness.



    • e.

      Ketamine




      • ≤0.5 mg/kg for IV bolus or ≤5 μg/kg/min for IV perfusion




        • Two separate meta-analyses found that there is a significant opioid-sparing effect when using a low-dose ketamine infusion preoperatively. , The effectiveness of ketamine appears to be based on reducing the hyperalgesia induced by opioid use by affecting the NMDA receptor. With the use of remifentanil and ketamine compared with traditional remifentanil anesthesia, there was a decrease in morphine use in minor surgery by 8.3 mg and in major surgery by 4.06 mg and a similar pain score with limited side effects. In addition, there is evidence that postoperative ketamine given via slow infusion can decrease opioid use without a significant change in postoperative pain. One limitation of this study is its basis in thoracotomy rather than laparoscopic urological procedures. A larger dose is associated with more psychomimetic properties and therefore not recommended.




    • f.

      Opioids


Aug 8, 2022 | Posted by in UROLOGY | Comments Off on Perioperative management: Pain and other considerations for enhanced recovery after surgery (ERAS)
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