How a multimodal pain regimen can enhance ERAS protocols

In a webinar, hosted by Becker's Healthcare and Mallinckrodt Pharmaceuticals, anesthesiologist Ray Soto, MD, discussed the use of multimodal anesthesia in surgery, particularly how multimodal pain care can enhance the move to value-based care. Dr. Soto is the director of education and the anesthesiology residency program for Royal Oak, Mich.-based Beaumont Health System as well as a professor of anesthesiology at the Oakland University William Beaumont School of Medicine in Rochester, Mich.

"We spend a lot of money on healthcare," he says. "The big focus for last five years has been to move toward value-based care. We need to make tough decisions and figure out ways to use resources efficiently."

Healthcare providers aim to streamline care and reduce variation by standardizing protocols to achieve reproducible outcomes. The Enhanced Recovery After Surgery multimodal perioperative care pathway model focuses on optimizing the patient's pain management and postoperative period to achieve early recovery from major operations.

"The idea is, if you have identical twins with the same medical history and undergoing the same procedure in different states, their outcomes should be the same," says Dr. Soto. "But that is not the case in the U.S. right now. Variability is rampant."

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ERSA protocols focus on embedding evidence-based practices into the pre-, intra- and postoperative periods. Preoperative patient education is one of the most overlooked areas, but is crucial to improving outcomes.

"The expectation of patients in U.S. is that there will be no pain after surgery," says Dr. Soto. "We need to provide expectation management before surgery, so patients know that they will be in some amount of pain. Those who attend a surgery optimization class and are prepared to deal with the pain are more satisfied."

A study published in Anesthesia & Analgesia in 2003 shows that only 63 percent of patients receive education on pain management prior to surgery. But pain is the No. 1 side effect that worries patients, notes Dr. Soto.

"We need to address this," he says. "We do a poor job of telling our patients what to expect. There is a hesitancy to give patients a true understanding of what to expect. It's important to get patients and their caregivers into a preoperative class so expectations are clear."

Allowing patients to consume liquid until two hours before surgery and early mobilization post-surgery are two evidence-based practices that could help standardize care. These practices are not typically followed in healthcare facilities despite studies showing the practices are safe and effective in enabling a speedy recovery.

The Perioperative Surgical Home model, a branded model developed by the American Society of Anesthesiologists and American College of Surgeons, also streamlines care while putting patient experience front and center. The model, similar to ERAS protocols, is designed to reduce costs and improve patient satisfaction by lowering length of stay and complication rates.

How multimodal anesthesia can enhance pain care   
The ERAS and PSH protocols emphasize multimodal analgesia use in the intraoperative period to speed recovery without over dependence on opioids.

Opioids have historically been the primary form of pain management in the United States. However, the use of opioids has been linked to a higher degree of side-effects, including vomiting, nausea, constipation and dizziness.

A 2004 study published in British Journal of Anaesthesia found that patients would rather deal with some degree of pain than opioids' side effects. The patients were asked if they prefer significantly reduced pain with some side effects or some amount of pain with fewer side effects. Overwhelmingly, patients chose the latter.   

Multimodal analgesia involves administering two or more analgesic agents or techniques that use different mechanisms to provide analgesia and target different parts of the body, including local analgesia, peripheral analgesia and agents that affect the brain and spinal cord.

"It is not a question of which one to use, but rather in what combination," says Dr. Soto.

Opioid monotherapy involves prescribing opioids no matter the type and severity of pain. A multimodal regimen involves stacking medications on top of each other for different kinds of pain.

According to Dr. Soto, the following are the most common non-opioids used in multimodal pain plans:

•    Acetaminophen (acetaminophen)
•    Alpha-2 agonists (clonidine, dexmedetomidine)
•    Gabapentinoids (gabapentin, pregabalin)
•    Local anesthetics (bupivacaine, lidocaine, liposomal bupivacaine)
•    NMDA receptor antagonists (ketamine)
•    Nonsteroidal anti-inflammatory drugs (celecoxib, ibuprofen, ketorolac, diclofenac)

However, providers must take into account certain treatment considerations before implementing a multimodal pain regimen. Anesthesiologists and surgeons determine the drug regime based on the type of surgery and discuss the expected pain and medication side effects. Clinician champions for multimodal pain control will drive protocol implementation, which requires providers to gather clinical data and monitor the protocol's effectiveness. Organizations that effectively employ implementation strategies will standardize care and improve pain management.

Watch the webinar here.

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