Multimodal analgesia (MMA) as the cornerstone of the enhanced recovery after surgery (ERAS) protocol


From the patient’s point of view, one of the most difficult aspects of surgery is the recovery.

After colorectal surgery, for example, the typical recovery involves prolonged rehabilitation with significant effects on metabolic, neural and pulmonary function1, compounded by often-significant postsurgical pain.

However, over the past 20 years a multidisciplinary group of doctors and nurses in Europe has been studying, practicing and advocating for a different approach that is designed to achieve a quicker recovery after major surgery.2 Known as Enhanced Recovery after Surgery, the protocol has been in use in Europe for nearly two decades and is now gaining ground in U.S. hospitals.3 A key component of ERAS is the maximal use of multimodal analgesia, known as MMA, an acute-pain reduction protocol that reduces reliance on opioids and harnesses the benefits of multiple pain medications, including intravenous and oral acetaminophen, to target more than one pain pathway.4

Overview of ERAS

ERAS is a multimodal, interdisciplinary and evidence-based system of perioperative care that is designed to achieve early recovery after major surgery. Also referred to as “fast-track surgery”5 and, in the United States, as Perioperative Surgical Home6, the system is comprehensive, touching all of the steps in the surgical process, and requires close coordination among all providers on the perioperative care team.

The idea underpinning ERAS is to attenuate the body’s profound stress response to surgery.1,7 Thus, ERAS methods involve disruption of the key medical stressors that keep patients in the hospital after surgery. These stressors include: need for parenteral analgesia, need for intravenous fluids secondary to gut dysfunction and bed rest caused by lack of mobility. Addressing these stressors, the over-arching elements of ERAS protocols are7:

· preoperative counseling
· optimization of nutrition
· standardized analgesic and anesthetic regimens
· early mobilization

Of note, three of the four over-arching components are non-drug measures. The ERAS Society delineates several important non-drug measures that can reduce total care time and postoperative complications. (Table 1)

Table1 (1)

Many of the components of ERAS are counter to traditional practice. For example, instead of requiring nothing by mouth preoperatively, ERAS protocols do not require prolonged fasting, and may even recommend food and fluid prior to surgery. Indeed, preoperative carbohydrate and fluid loading were associated with reduced hospital length of stay in an international registry of ERAS implementation sites.10 Another example pertains to the long-held practice of requiring empty bowels—ERAS protocols often specify no or only selective bowel preparation. Most importantly, a cornerstone of ERAS is the use of non-opioid analgesics as part of a multimodal analgesic regimen, to target various pain pathways. Table 2 provides examples of medications utilized in successful MMA protocols.

Table2 (1)

Cornerstone of ERAS: Multimodal Analgesia

Inadequate pain control can delay recovery14 and increase the risk for complications.13 Thus, optimal pain management post-surgically is, by necessity, an important component of ERAS.

A cornerstone of ERAS, therefore, is a particular acute-pain-management protocol called multimodal analgesia.4 MMA aims to reduce the reliance on the large doses of opioids as first-line monotherapy that have become commonplace at hospitals across the United States4, as complications resulting from large doses of opioids are associated with increased length of stay and risk of readmission.15,16

MMA uses two or more analgesic agents or techniques simultaneously. The idea is that opioids and other analgesics act on different pain pathways additively or synergistically to achieve better pain relief.17,18 The drugs that are used in conjunction with lower doses of opioids to manage moderate to severe acute pain include: intravenous or oral acetaminophen, intravenous or oral nonsteroidal anti-inflammatory drugs, local anesthetics, anticonvulsants and nonpharmacologic agents.11,19,20,21

At the University of Virginia, implementation of an ERAS protocol was successful in reducing the amount of opioids administered for pain during the intraoperative and postoperative period by close to 80 percent.12 Other studies show MMA can reduce opioid-related adverse events22,23 improve23 functional outcomes and hasten functionality21,24,25,28 and reduce hospital length of stay.27 And, like ERAS as a whole, MMA has been shown to reduce the cost of care.20,28

While ERAS gradually works its way into U.S. hospitals, the MMA component is one piece of ERAS—indeed, its cornerstone—that the bedside practitioner could potentially influence and participate in even before the initiation of a comprehensive ERAS protocol.

Benefits of ERAS

The advantages of ERAS have been well understood in Europe for many years, and are starting to be adopted in the United States.29 Compared with traditional recovery protocols, the use of the ERAS pathway has been shown to reduce postoperative complications by up to 50%1, reduce hospital length of stay1, 12, reduce complication rates1, 12 and increase patient satisfaction.12 In addition, the cost-effectiveness of ERAS has been demonstrated in numerous studies around the world, including in the United States12 ,29 , New Zealand30, England31 and The Netherlands32, as well as in an international review.33

One analysis, conducted at The Johns Hopkins Hospital in Baltimore, found that the considerable cost of implementing an ERAS program for colorectal surgery—nearly $553,000— was offset by a savings of more than $948,000 in the first year alone.29 Another U.S. prospective study, at the University of Virginia Health System, followed 199 consecutive, well-matched colorectal surgery patients, about half of whom underwent ERAS and half the traditional recovery protocol.12 The study found a savings of more than $7,000 per patient who participated in the ERAS program.

Evolution of ERAS

ERAS took hold in Europe many years before U.S. doctors and hospitals began to embrace it.29 It was pioneered by the Danish professor, Henrik Kehlet, M.D., Ph.D., in 1993. After Dr. Kehlet showed significantly reduced length of stay and hospital costs, five centers in northern Europe collaborated to develop ERAS standards.3 This group, the ERAS Study Group, developed and published an evidence-based consensus protocol in 2005 and updated and expanded it in 2009. 34

The ERAS Society was founded in 2010 in Sweden.2 Initially used in open colorectal surgery, ERAS has since been implemented in vascular surgery, thoracic surgery, orthopedics, gynecology and urology.3,7

As the wide-ranging benefits of ERAS protocols become more well known and the evidentiary basis of the practice becomes more well accepted, healthcare practitioners should expect to see ERAS—and especially its cornerstone, multimodal analgesia—become more prevalent in the United States.


The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.


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