Pain Management Strategies and Enhanced Bowel Recovery

Raoul Concepcion, MD: For nongastrointestinal surgery, is alvimopan still on the protocol? Or, do you have to have a bowel anastomosis?

Traci Hedrick, MD, MS, FACS, FACRS: In some protocols for gynecology, it’s there. Certainly, it’s there for gynecology oncology, and I know of some urologists that consider it. There are ongoing trials in spine surgery, but, for the most part, it’s used in people with a bowel anastomosis.

Sanjay Patel, MD: That’s correct. That’s what the literature shows, that’s what the data shows, and that’s probably how they got the indication. But certainly, it’s being studied across various types of surgeries.

Raoul Concepcion, MD: Clearly, it sounds like based upon its mechanism of action, being a mu-opioid receptor antagonist, that the key is as long as you’ve got opioids in play as part of your postoperative analgesia, that this drug should be...

Traci Hedrick, MD, MS, FACS, FACRS: It doesn't take much. There’s a set in colorectal surgery that shows a single dose of 2 mg of Dilaudid will delay GI function. So, while we’ve certainly reduced opioids, there’s very few patients that are not going to at least receive 1 oxycodone or 1 dose of opioids.

Declan Fleming, MD: Under the old management paradigm, you start with narcotics. And when that doesn’t work well enough, you just give more narcotics and more narcotics after that. Getting away from that, and switching to this embracing of multimodal non-narcotic pain management, it’s been the thing that has really changed things dramatically and extraordinarily.

Raoul Concepcion, MD: Yes. I think we learned that early on in the urology literature. Right before the patient woke up, you gave them a big slug of an intravenous nonsteroidal, and you used that through the postoperative period, really trying to limit the amount of opioids that you gave the prostatectomy patients. We were never so bold to use it in cystectomy patients, thinking that, “These patients are going to be so much worse.” What about this IV acetaminophen? How does that play a role?

Declan Fleming, MD: I’ve got to tell you, I was so skeptical about the use of IV acetaminophen. I just couldn’t understand how or why that would work better than oral acetaminophen. At the time that it was introduced to me, I was still relying on narcotics for the management of my patients’ pain. And when I actually looked at the literature around it and began to employ it, I was really frankly amazed at how well it worked. Now, the expense of a dose of IV acetaminophen is orders of magnitude greater than oral, and we’re trying to use oral medicines as much as possible in our ERAS (enhanced recovery after surgery) protocols. But for certain people, our esophagectomy patients, and total gastrectomy and Whipple patients, we really like to use the IV acetaminophen in the early postoperative period. Though frequently, we’ll give these people a dose of 1000 mg of oral acetaminophen shortly before the beginning of the operation.

Raoul Concepcion, MD: We briefly discussed site management, wound management, and those types of things. John, you had mentioned maybe the use of some of these subcutaneous catheters, where you can infuse a local anesthetic agent?

John Dalton, MD: As we discussed earlier, we’ve gotten away from epidurals, although we will still use them in limited application with local anesthetics. So, we avoid narcotics. There’s transverse abdominis plane (TAP) blocks that are useful in some settings, and I’ve done a lot of those for abdominal surgeries of all kinds. And then, even more local than that is a subcutaneous catheter, where the surgeon puts the catheter at the time of surgery and tunnels it out. Then, we keep infusions going as well. I think those are, very often and TAP blocks as well, just placed at the time of surgery. So, if that’s where you place the catheter, that’s probably the best way to do that. Then, that gives us a way to maintain a non-narcotic analgesia into the postoperative period. There are some other agents as well. There’s intravenous lidocaine, which is extremely cheap. The Brits use it a lot. They actually use it on the floors.

Traci Hedrick, MD, MS, FACS, FACRS: We use it.

Declan Fleming, MD: We use it as well.

John Dalton, MD: Intravenous magnesium is very cheap and very effective, and there’s ups and downs about all of these things. But each is like a bullet in your holster. There are a lot of multimodal analgesic agents that I think we need to optimize moving forward, and there’s a lot of work around those things.

Raoul Concepcion, MD: So, the role of intravenous magnesium is just to maintain intravascular volume?

John Dalton, MD: No. It actually is analgesic, as is esmolol, a short-acting beta-blocker. We can use that as infusion for pain. So, there are a lot of things that don’t affect the gut, and that’s where a lot of the anesthesia literature is going. I think we’ll see more and more of that, and what part they play in these protocols remains to be seen. I think we have to vary our protocols based on the patients’ specific history. To your question earlier about who’s a candidate and who is not, I think they need to stay on our protocols. It’s evidence-based best practice pathways, or guidelines, or whatever we want to call it, but we vary them by the individuals’ basic needs or on their specific history.

Transcript edited for clarity.