Efficacy and Outcomes of Intrathecal Analgesia as Part of an Enhanced Recovery Pathway in Colon and Rectal Surgical Patients

Amit Merchea, Jenna K Lovely, Adam K Jacob, Dorin T Colibaseanu, Scott R Kelley, Kellie L Mathis, Grant M Spears, Marianne Huebner, David W Larson, Amit Merchea, Jenna K Lovely, Adam K Jacob, Dorin T Colibaseanu, Scott R Kelley, Kellie L Mathis, Grant M Spears, Marianne Huebner, David W Larson

Abstract

Purpose: Multimodal analgesia is an essential component of an enhanced recovery pathway (ERP). An ERP that includes the use of single-injection intrathecal analgesia (IA) has been shown to decrease morbidity and cost and shorten length of stay (LOS). Limited data exist on safety, feasibility, and the optimal IA regimen. Our objective was to characterize the efficacy, safety, and feasibility of IA within an ERP in a cohort of colorectal surgical patients.

Methods: We performed a retrospective review of all consecutive patients aged ≥ 18 years who underwent open or minimally invasive colorectal surgery from October 2012 to December 2013. All patients were enrolled in an institutional ERP that included the use of single-injection IA. Demographics, anesthetic management, efficacy (pain scores and opiate consumption), postoperative ileus (POI), adverse effects, and LOS are reported.

Results: 601 patients were identified. The majority received opioid-only IA (91%) rather than a multimodal regimen. Median LOS was 3 days. Overall rate of ileus was 16%. Median pain scores at 4, 8, 16, 24, and 48 hours were 3, 2, 3, 4, and 3, respectively. There was no difference in postoperative pain scores, LOS, or POI based on intrathecal medication or dose received. Overall, development of respiratory depression (0.2%) or pruritus (1.2%) was rare. One patient required blood patch for postdural headache.

Conclusion: Intrathecal analgesia is safe, feasible, and efficacious in the setting of ERP for colorectal surgery. All regimens and doses achieved a short LOS, low pain scores, and a low incidence of POI. This trial is registered with Clinicaltrails.gov NCT03411109.

References

    1. Hubner M., Lovely J. K., Huebner M., Slettedahl S. W., Jacob A. K., Larson D. W. Intrathecal analgesia and restrictive perioperative fluid management within enhanced recovery pathway: hemodynamic implications. Journal of the American College of Surgeons. 2013;216(6):1124–1134. doi: 10.1016/j.jamcollsurg.2013.02.011.
    1. Adamina M., Kehlet H., Tomlinson G. A., Senagore A. J., Delaney C. P. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery. 2011;149(6):830–840. doi: 10.1016/j.surg.2010.11.003.
    1. Muller S., Zalunardo M. P., Hubner M., Clavien P. A., Demartines N., Zurich Fast Track Study Group A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology. 2009;136(3):842–847. doi: 10.1053/j.gastro.2008.10.030.
    1. Varadhan K. K., Neal K. R., Dejong C. H., Fearon K. C., Ljungqvist O., Lobo D. N. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clinical Nutrition. 2010;29(4):434–440. doi: 10.1016/j.clnu.2010.06.005.
    1. Wind J., Polle S. W., Fung Kon Jin P. H., et al. Systematic review of enhanced recovery programmes in colonic surgery. British Journal of Surgery. 2006;93(7):800–809. doi: 10.1002/bjs.5384.
    1. Lovely J. K., Maxson P. M., Jacob A. K., et al. Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. British Journal of Surgery. 2012;99(1):120–126. doi: 10.1002/bjs.7692.
    1. Kehlet H., Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. British Journal of Surgery. 1999;86(2):227–230. doi: 10.1046/j.1365-2168.1999.01023.x.
    1. Delaney C. P., Zutshi M., Senagore A. J., Remzi F. H., Hammel J., Fazio V. W. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Diseases of the Colon and Rectum. 2003;46(7):851–859. doi: 10.1007/s10350-004-6672-4.
    1. Anderson A. D., McNaught C. E., MacFie J., Tring I., Barker P., Mitchell C. J. Randomized clinical trial of multimodal optimization and standard perioperative surgical care. British Journal of Surgery. 2003;90(12):1497–1504. doi: 10.1002/bjs.4371.
    1. Khoo C. K., Vickery C. J., Forsyth N., Vinall N. S., Eyre-Brook I. A. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Annals of Surgery. 2007;245(6):867–872. doi: 10.1097/01.sla.0000259219.08209.36.
    1. Tsikitis V. L., Holubar S. D., Dozois E. J., Cima R. R., Pemberton J. H., Larson D. W. Advantages of fast-track recovery after laparoscopic right hemicolectomy for colon cancer. Surgical Endoscopy. 2010;24(8):1911–1916. doi: 10.1007/s00464-009-0871-y.
    1. Larson D. W., Batdorf N. J., Touzios J. G., et al. A fast-track recovery protocol improves outcomes in elective laparoscopic colectomy for diverticulitis. Journal of the American College of Surgeons. 2010;211(4):485–489. doi: 10.1016/j.jamcollsurg.2010.05.007.
    1. Levy B. F., Tilney H. S., Dowson H. M., Rockall T. A. A systematic review of postoperative analgesia following laparoscopic colorectal surgery. Colorectal Disease: The Official Journal of the Association of Coloproctology of Great Britain and Ireland. 2010;12(1):5–15. doi: 10.1111/j.1463-1318.2009.01799.x.
    1. Marret E., Remy C., Bonnet F., Postoperative Pain Forum Group Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. British Journal of Surgery. 2007;94(6):665–673. doi: 10.1002/bjs.5825.
    1. Gwirtz K. H., Young J. V., Byers R. S., et al. The safety and efficacy of intrathecal opioid analgesia for acute postoperative pain: seven years’ experience with 5969 surgical patients at Indiana University Hospital. Anesthesia and Analgesia. 1999;88(3):599–604. doi: 10.1097/00000539-199903000-00026.
    1. Levy B. F., Scott M. J., Fawcett W., Fry C., Rockall T. A. Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. British Journal of Surgery. 2011;98(8):1068–1078. doi: 10.1002/bjs.7545.
    1. Virlos I., Clements D., Beynon J., Ratnalikar V., Khot U. Short-term outcomes with intrathecal versus epidural analgesia in laparoscopic colorectal surgery. British Journal of Surgery. 2010;97(9):1401–1406. doi: 10.1002/bjs.7127.
    1. Wongyingsinn M., Baldini G., Stein B., Charlebois P., Liberman S., Carli F. Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial. British Journal of Anaesthesia. 2012;108(5):850–856. doi: 10.1093/bja/aes028.
    1. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration: an updated report by the American Society of Anesthesiologists task force on neuraxial opioids and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2016;124(3):535–552. doi: 10.1097/ALN.0000000000000975.
    1. Ahlers O., Nachtigall I., Lenze J., et al. Intraoperative thoracic epidural anaesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery. British Journal of Anaesthesia. 2008;101(6):781–787. doi: 10.1093/bja/aen287.
    1. Ali M., Winter D. C., Hanly A. M., O’Hagan C., Keaveny J., Broe P. Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life. British Journal of Anaesthesia. 2010;104(3):292–297. doi: 10.1093/bja/aeq006.
    1. Carli F., Mayo N., Klubien K., Schricker T., Trudel J., Belliveau P. Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology. 2002;97(3):540–549. doi: 10.1097/00000542-200209000-00005.
    1. Guay J. The benefits of adding epidural analgesia to general anesthesia: a metaanalysis. Journal of Anesthesia. 2006;20(4):335–340. doi: 10.1007/s00540-006-0423-8.
    1. Kehlet H. Epidural analgesia and postoperative outcome. The Lancet. 2008;372(9656):p. 2109. doi: 10.1016/s0140-6736(08)61915-7.
    1. Orlov D., Ankichetty S., Chung F., Brull R. Cardiorespiratory complications of neuraxial opioids in patients with obstructive sleep apnea: a systematic review. Journal of Clinical Anesthesia. 2013;25(7):591–599. doi: 10.1016/j.jclinane.2013.02.015.
    1. Horlocker T. T., McGregor D. G., Matsushige D. K., Schroeder D. R., Besse J. A. A retrospective review of 4767 consecutive spinal anesthetics: central nervous system complications. Perioperative Outcomes Group. Anesthesia and Analgesia. 1997;84(3):578–584. doi: 10.1213/00000539-199703000-00021.
    1. Larson D. W., Lovely J. K., Cima R. R., et al. Outcomes after implementation of a multimodal standard care pathway for laparoscopic colorectal surgery. British Journal of Surgery. 2014;101(8):1023–1030. doi: 10.1002/bjs.9534.
    1. Sviggum H. P., Arendt K. W., Jacob A. K., et al. Intrathecal hydromorphone and morphine for postcesarean delivery analgesia: determination of the ED90 using a sequential allocation biased-coin method. Anesthesia and Analgesia. 2016;123(3):690–697. doi: 10.1213/ane.0000000000001229.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe