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Multimodal analgesia: Optimal pain management while avoiding opioids is a key enabler of patient recovery. Furthermore, poor acute pain management is a strong risk factor for the development of chronic pain. A multimodal approach is recommended, using multiple strategies before, during and after surgery.
Intraoperatively: For open surgery, neuraxial blockade via thoracic epidural combining local anesthetics and adjuvants reduces the surgical stress response and complications, and provides excellent analgesia (1). However, epidural delays recovery in laparoscopic colon surgery in an ERP and other techniques such as spinal anesthesia and PCA are better choices (5,6). Bilateral transversus abdominis plane (TAP) block injecting at least 15ml of long acting local anesthetic can be done either under ultrasound guidance preoperatively or by the surgeon intraoperatively (2,3). Trocar site infiltration with long acting local anesthetic is used prior to incisions. As an adjuvant to systemic opioids, Intravenous lidocaine infusion given in the operating room and continued in the recovery room has analgesic and anti-inflammatory properties, reduces postoperative opioid consumption and accelerates GI function after laparoscopic colectomy (4).
For more information, see Chapter 6: The Role of the Anesthesiologist in Reducing Surgical Stress and Improving Recovery in The SAGES / ERAS® Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery
References
1. Tan M, Law LS, Gan TJ. Optimizing pain management to facilitate Enhanced Recovery After Surgery pathways. Can J Anaesth. 2015 Feb;62(2):203-18
2. Favuzza J, Delaney CP. Outcomes of discharge after elective laparoscopic colorectal surgery with transversus abdominis plane blocks and enhanced recovery pathway. J Am Coll Surg 2013;217(3):503-506
3. Johns N, O’Neill S, Ventham NT, et al. Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a systematic review and meta-analysis. Colorectal Dis 2012;14(10):e635-642.)
4. Vigneault L1, Turgeon AF, Côté D, Lauzier F, Zarychanski R, Moore L, McIntyre LA, Nicole PC, Fergusson DA. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth. 2011 Jan;58(1):22-37.
5. Hübner M1, Blanc C, Roulin D, Winiker M, Gander S, Demartines N. Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Ann Surg. 2015 Apr;261(4):648-53.
6. Levy BF, Scott MJ, Fawcett W, Fry C, Rockall TA. Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. Br J Surg. 2011 Aug;98(8):1068-78
