American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) Joint Consensus Statement on Optimal Analgesia within an Enhanced Recovery Pathway for Colorectal Surgery: Part 2—From PACU to the Transition Home

Spinal anesthesia is placed preoperatively but still needs to be considered: First, as the spinal wears off and there is a transition in analgesia required and second, if long-acting opioids have been added then vigilance regarding postoperative respiratory depression is required.

Following open colonic surgery, a continuous epidural infusion placed at an appropriate spinal level to provide coverage of the wound should be used. Ideally, the epidural infusion can be commenced before surgery and continued intraoperatively and postoperatively. The pain of laparoscopic colectomy reduces more quickly than open surgery due to the smaller abdominal incisions making the benefits for a continuous epidural less clear (Chung et al. 2007). Laparoscopic colectomy can still be as painful as open colectomy particularly in the first 24 h (Maartense et al. 2004). Patient indications include significant preexisting pulmonary impairment or chronic opioids use with tolerance. Thoracic epidural infusions employing a combination of local anesthetic and opioid provide the best analgesia in colorectal surgery but addition of opioids to an epidural solution can slow bowel motility (Jorgensen et al. 2000). Local anesthetic or opioid alone can also be infused where indicated.

In the recovery room and postoperatively, a continuous lidocaine infusion at a rate of approximately 1–1.5 mg/kg/hr IV for up to 48 h postoperatively has been shown to be beneficial (McEvoy et al. 2016; Wongyingsinn et al. 2011; Ventham et al. 2015). The optimal dosing and duration of lidocaine is still not known, and the side effects are directly related to the serum lidocaine level (Khan et al. 2016a)

Ketamine infusions can be employed as a supplemental or rescue analgesia technique in patients who have failed initial management in the postoperative period. Low dose ketamine infusions can be used on a general floor and do not require additional nursing interventions or personnel (Jouguelet-Lacoste et al. 2015). When compared with opioids alone, ketamine has been shown in meta-analysis and systematic reviews to demonstrate improved pain control and reduced PONV without increases in adverse side effects (Jouguelet-Lacoste et al. 2015; Wang et al. 2016; Ding et al. 2014). Ketamine should be considered as an adjunct for those experiencing pain not adequately controlled by other schedule non-opioid medications and is particularly useful in patients on long-term opioid medication. Low-dose ketamine (2 mcg/kg/min IV) after major abdominal surgery has been shown to reduce postoperative opioid requirements (Laskowski et al. 2011; Sami Mebazaa et al. 2008; Zakine et al. 2008).

Acetaminophen and NSAIDs have been reported as the backbone of multimodal analgesia in the postoperative period of ERPs. There is evidence that they can reduce the need for opioids by 15–50% (Elia et al. 2005; Jibril et al. 2015; O’Neal 2013; Smith 2011; Toms et al. 2008). It is reasonable, barring any contraindications, to provide scheduled oral or IV doses of acetaminophen and NSAIDs in the postoperative period.

Ileus is one of the most frequent issues increasing hospital length of stay in patients undergoing colorectal surgery with associated increase in healthcare costs. The cause of ileus is multifactorial but opioids have a significant impact (Hubner et al. 2015). Novel agents that are μ-opioid receptor antagonist of μ-opioid receptors within the gastrointestinal tract are thought to block the gastrointestinal effects of opioids without blocking the analgesic efficacy, thus reducing the likelihood of opioid-induced constipation or ileus. In a meta-analysis of three randomized controlled trials examining the efficacy if 12 mg of alvimopan (vs. placebo) in patients undergoing abdominal surgery in an accelerated recovery program found that alvimopan significantly reduced time to the hospital discharge and gastrointestinal recovery (Vaughan-Shaw et al. 2012). A meta-analysis of patients undergoing laparoscopic surgery (although not necessarily in an accelerated recovery program) found a reduction in postoperative ileus development when patients were given alvimopan compared to placebo; however, the other factors contributing to ileus were not controlled in these studies (Nguyen et al. 2015).

Few studies are available to guide the clinician with regard to the precise most optimal dosing, start and stop time for different perioperative interventions. The incidence of severe pain decreases over each day from surgery through the first 1–2 weeks after surgery. Several meta-analyses have indicated that certain medications given preoperatively are associated with a decrease in postoperative pain and opioid consumption. These medications include celecoxib, (Khan et al. 2016b), acetaminophen (De Oliveira et al. 2015; Doleman et al. 2015a), gabapentin (Doleman et al. 2015b; Seib and Paul 2006), and pregabalin (Mishriky et al. 2015). There is also evidence that continuing NSAIDs, acetaminophen, and gabapentinoids postoperatively as part of a multimodal analgesia pathway is associated with improved outcomes (McEvoy et al. 2016; Schmidt et al. 2013; Larson et al. 2014). However, given the method by which these studies were completed (quasi-experimental pre-post design involving a care bundle), it is not possible to know the exact effect and necessary duration for continuing these medications. For practical purposes, an example of the specific medications and dosages used in one successful ERP for CRS are included in Table 1 (McEvoy et al. 2016). However, it should be noted that there are a variety of successful approaches concerning the specific analgesic components for applying the principle of opioid avoidance presented in this consensus statement (Larson et al. 2014; Miller et al. 2014; Thiele et al. 2015).

Patients and families should be reassured that some discomfort, particularly with movement, is normal (Alawadi et al. 2016). Encouragement to use non-pharmacologic and non-opioid interventions as frontline management is essential to successful opioid-sparing approaches (Sugai et al. 2013). The impact of continued use of acetaminophen, NSAIDs and gabapentinoids beyond the acute hospital recovery phase is unknown, but some may benefit from several weeks of low risk, non-opioid analgesia (Schmidt et al. 2013). Assure a uniform process to inform the patient and family which provider will be responsible for managing postoperative pain and provide instructions on the planned taper of postoperative analgesics, including a timeline for return to preoperative or lower opioid dosing for those on chronic opioids (Rose et al. 2016). Adding new prescriptions of opioids, benzodiazepines, sedative-hypnotics, anxiolytics or central nervous system depressants at the time of transition out of the hospital should be avoided. If opioids are continued at discharge, patients and families should be counseled about the risks of co-administration with alcohol and other central nervous system depressants, as well as the dangers of prescription opioid diversion. Teams should instruct the patient and family on the importance of secure storage of their medications and prompt disposal of controlled substances either through a Drug Enforcement Agency (DEA) approved take-back program or Food and Drug Administration (FDA) guideline for safe disposal of medicine (Rose et al. 2016). The agreed preoperative plan to taper off opioids added for surgery as surgical healing takes place should be followed. The goal is always the shortest duration and lowest effective dose whenever using opioids. It may be appropriate to discharge patients on acetaminophen, NSAIDs, and/or gabapentinoids only, or with only a very limited supply of short-acting opioids (e.g., 2–3 days)—even if they were taking opioids preoperatively.¹

Q2: What are effective strategies for troubleshooting patients who need rescue analgesia?

Statement: Use a stepwise approach including assessment of potential causes, maximizing non-opioid approaches and if needed using a brief course of short-acting opioid.

Conventional opioid rescue treatment commonly termed “breakthrough” dosing is not the first approach that should be employed when optimal analgesia is not achieved, as it can rapidly negate effects of opioid-sparing regimens (Cooney 2016). When pain is poorly controlled, it is important to establish the etiology and consider other treatable causes. In addition to incisional pain, common causes of pain following CRS may include bowel distention from flatus, diaphragmatic irritation referred to the shoulder, or muscle wall soreness caused by stretch and cramping. Pain that does not respond to usual treatment may signal a complication or otherwise treatable cause. A structured approach for “rescue” analgesia should be in place, such as described in Fig. 2. Additionally, because pain is always an emotional experience attention to the patient experience (e.g., understanding of goals, coping strategies and fears) is important in all rescue steps.

Q3: How can analgesia be measured in a clinically-meaningful way?

Statement: Measurement of analgesia after colorectal surgery should occur through a system that accounts for patient experience and overall function.

A more detailed framework for comprehensive measurement of quality of care relevant to enhanced recovery programs (ERPs) in elective colorectal surgery is detailed elsewhere (Moonesinghe SR et al. 2016). Here, we focus on outcome measures related to the treatment of pain. Measurement of optimal analgesia is complex and dependent on the purpose (e.g., clinical point-of-care decision making, quality improvement or research). Outcome domains recommended for assessment of single-dose acute pain analgesic trials include pain intensity, pain relief, adverse effects and physical function such as the ability to ambulate without assistance, and other clinically relevant recovery measures (Cooper et al. 2016). In the clinical setting, pain intensity ratings documented at variable time periods in the patient record are often tempting as an outcome measure for enhanced recovery teams, however, may not accurately reflect the patient experience and are void of physical function. Median and range values of patient report of pain severity using a 0–10 numerical rating scale at specified time periods yielding the Sum of Pain Intensity Differences (SPID) or Total Pain Relief Score (TOTPAR) at 24 and 48 h on movement and rest are the commonly used measures in research studies, but data capture is labor intensive and not practical for most ERP teams. Also, a systematic review of movement-evoked pain (e.g., deep breathing, ambulation) versus pain at rest in postsurgical clinical trials concluded that the assessment of movement-evoked pain is poorly defined and has been neglected (Srikandarajah and Gilron 2011).

A QI dataset for optimal analgesia would ideally include a measure of DREAMS (Drinking, Eating, Analgesia, Mobilizing, Sleeping); however, to date, there is no specific validated research tool. Administration of a validated health-related quality of life questionnaire such as the EuroQoL (EQ5D) or the Medical Outcomes Short-Form Health Survey (SF-36), before surgery and at various time points postoperatively is ideal but may not be readily achievable (Brazier et al. 1993; Patt & Mauerhan 2005). Researchers and clinicians are increasingly recognizing the importance of using assessments that reflect experience in the “real world”. Two multidimensional patient-reported outcome instruments designed for use in the first day after surgery have been validated including the revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) and the International Pain Outcome (IPO) Questionnaire (Gordon et al. 2010; Rothaug et al. 2013). Both capture domains of pain and pain relief, impact of pain on emotions and physical function, treatment side effects, and perceptions of care and can be recommended for use in quality improvement studies. The IPO is of particular value because it provided comparative benchmarking data as part of the only international acute postoperative pain registry, Pain-Out (http://​pain-out.​eu).

An important aspect of the patient experience is satisfaction. Patient satisfaction is a notoriously complicated outcome measure that has long been paradoxical in nature in pain management studies. In 2008, the Centers for Medicare and Medicaid started publicly reporting the results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The HCAHPS survey is the first standardized national survey that publicly reports patients’ perceptions of their hospital care. The survey evaluates the patient’s experience of their hospital stay and their overall rating and satisfaction of the hospital. One domain of the survey is pain management. The pursuit of high HCAHPS performance has been blamed for pressure on medical providers to honor patient requests for unnecessary and in some cases potentially harmful amounts of opioids. Decoupling pain management HCAHPS scores from hospital payment scoring calculations is one of several recent Health and Human Services actions designed to reduce opioid use. Nevertheless, the HCAHPS pain composite scores for various subgroups of patients, such as those on enhanced recovery pathways, can serve as an important driving force for resources and change.

Concerning other validated measures, it appears that PROMIS instruments faithfully capture information in respondents’ natural environments and reflect the participants’ real-life symptom, but the number of components for future work should be limited in order to reduce patient burden and the analytic workload while delivering results (Stone et al. 2015; Bingener et al. 2015). In the absence of a Health-Related Quality of Life (HRQoL) instrument specifically validated for the postoperative pain setting, Taylor and colleagues used two generic questionnaires, the 12-item Short-Form health survey (SF-12) and EQ-5D in general surgery and orthopedic procedure patients to measure impact of pain on quality of life on postoperative day seven (Taylor et al. 2013). Multivariate regression analyses showed that irrespective of confounding factors (e.g., age, gender, and preoperative HRQoL) patients with severe postoperative pain experience important reductions in both physical and mental well-being domains of their HRQoL. Long-term outcomes impacted by perioperative analgesia include persistent postsurgical pain (PPP), quality of life, and cancer recurrence. An observational study in Europe on patients with general surgery and orthopedic procedures reported that a 10% increase in the percentage of time spent in severe pain in the first day after operation was associated with a 30% increase of PPP at 12 months, indicating the amount of time spent in severe pain was more significant than a single-pain intensity (Fletcher et al. 2015). Specific evaluation for colorectal surgery on the consequences of PPP for quality of life and function has not yet been validated (Kehlet and Jorgensen 2016).

In summary, the outcomes of analgesic technique are diverse in nature, and clinical consequences vary from unpleasant symptoms to mortality (Lee et al. 2015). Traditional outcome measures used in acute pain clinical trials, such as opioid consumption, worst or averaged pain intensity ratings, and length of stay appear to be less than ideal because they are either poorly defined or have little demonstrable clinical value. Rare harm outcomes are nearly absent in the literature in part because they are extraordinarily difficult to measure (Gordon et al. 2016). Teasing out the impact of analgesic strategies among a multifactorial enhanced recovery pathway on important recovery issues may be impossible but an ERP should include analgesia measures that account for patient experience, function, and quality of life.

Q4: What are the research gaps that exist in regards to perioperative analgesia in colorectal surgery?

Statement: Controversy exists surrounding the effects of analgesia management on short and long-term outcomes in colorectal surgery.

There are numerous research gaps that exist in regards to achieving optimal perioperative analgesia in CRS ERPs. Very few individual randomized controlled trials and almost no meta-analysis have examined perioperative interventions concurrently for both CRS patients and ERPs. Future studies in this domain need to investigate the optimal dosing, timing, and combinations of perioperative interventions in CRS ERPs throughout the entire perioperative period, with a focus not only on pain scores and opioid consumption but also on a structured approach to also assess the effect on functional recovery and adverse effect from analgesics. Finally, if standardized national and international data registries become available, then insight into real-world efficacy of specific analgesic components or combinations could be obtained from a regression analysis in a large cohort with excellent compliance from ERPs employing different analgesic strategies.