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 1-from the preoperative period to PACU

Matthew D McEvoy, Michael J Scott, Debra B Gordon, Stuart A Grant, Julie K M Thacker, Christopher L Wu, Tong J Gan, Monty G Mythen, Andrew D Shaw, Timothy E Miller, Perioperative Quality Initiative (POQI) I Workgroup, Robert H Thiele, Karthik Raghunathan, C S Brudney, Dileep N Lobo, Daniel Martin, Anthony Senagore, Stefan D Holubar, Traci Hedrick, John Kellum, Ruchir Gupta, Mark Hamilton, S Ramani Moonesinghe, Mike P W Grocott, Elliott Bennett-Guerrero, Thomas J Hopkins, Roberto Bergamaschi, Stuart McCluskey, Vijaya Gottumukkala, Matthew D McEvoy, Michael J Scott, Debra B Gordon, Stuart A Grant, Julie K M Thacker, Christopher L Wu, Tong J Gan, Monty G Mythen, Andrew D Shaw, Timothy E Miller, Perioperative Quality Initiative (POQI) I Workgroup, Robert H Thiele, Karthik Raghunathan, C S Brudney, Dileep N Lobo, Daniel Martin, Anthony Senagore, Stefan D Holubar, Traci Hedrick, John Kellum, Ruchir Gupta, Mark Hamilton, S Ramani Moonesinghe, Mike P W Grocott, Elliott Bennett-Guerrero, Thomas J Hopkins, Roberto Bergamaschi, Stuart McCluskey, Vijaya Gottumukkala

Abstract

Background: Within an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver "optimal analgesia," which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects.

Methods: With input from a multi-disciplinary, international group of clinicians, and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients.

Discussion: As a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery ERP. The goal was two-fold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus from the preoperative period to the post-anesthesia care unit. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of optimal analgesia as set forth in this document.

Keywords: Colorectal; Enhanced recovery pathway; Multimodal; Non-opioid adjuncts; Optimal analgesia; Outcomes; Pain management; Perioperative; Quality.

Figures

Fig. 1
Fig. 1
The core components of providing optimal analgesia. Pain after surgery can have profound effects on patient recovery. However, the complete elimination of pain may also have untoward effects, as listed in the figure. Optimal analgesia after surgery is an approach to pain control that facilitates a positive patient experience through optimized patient comfort that facilitates functional recovery while minimizing adverse drug events
Fig. 2
Fig. 2
Suggested components of a multimodal approach to pain management in an ERP for colorectal surgery. Of note, the plan should be comprehensive, encompassing all phases of perioperative care from preoperative to post-discharge. However, current evidence is insufficient to determine how many components should be selected in order to maximize pain control, reduce opioid burden, and avoid the side effects of all analgesics used. (ERP enhanced recovery pathway)

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