Postoperative Pain Management: Is the Surgical Team Approach Finally Getting It Right?
Michael A.E. Ramsay M.D.
Ramsay, M. A. (2019). “Postoperative Pain Management: Is the Surgical Team Approach Finally Getting It Right?” Ann Surg 270(2): 209-210.
The concerns that many physicians have with the management of epidural anesthesia for open liver surgery include the increased risk of a neuraxial hematoma resulting from a postoperative coagulopathy. In some centers this has resulted in the reluctance to using the modality and in others to withholding of venous thromboembolism (VTE) prophylaxis until the prothrombin time-derived international normalized ratio (PT-INR) has returned to less than 1.5. This, in some centers leads to the administration of fresh frozen plasma to correct the PT-INR. A review of the National Surgical Quality Improvement Program data for extended hepatic resections, the VTE rate has been reported as high as 5.8%. This exceeds the rate for most major abdominal surgeries including colectomy. It has now been well established that many of these patients with an increased PT-INR have normal or increased coagulable states and do need VTE protection. The success of epidural anesthesia to provide optimal pain management for open liver surgery requires the formation of a surgical team. An experienced team approach leads to greater success, including the reduction of complications, early mobilization and discharge home, and thereby increased patient safety. Postoperative analgesia still continues to be inadequately managed in many centers. However, Kehlet and Wilmore, have developed enhanced recovery pathways (ERPs) after surgery that have resulted in early mobility and discharge, good pain management with multimodal analgesia and reduced or opioid-free therapy, and reduced morbidity and mortality. Protocols that promote ERPs have become more frequently used and the evidence to support these protocols is getting stronger. Randomized clinical trials have shown that ERPs are effective as long as each member of the perioperative team is well versed in the protocols, carries them out effectively, and the data are collected and monitored. These protocols are not just reliant on 1 anesthetic technique but rather rely on the experience of all team participants to be expert in the techniques used. The team must consist of the surgeon, anesthesiologist, perioperative nurses, pharmacy staff, physical and respiratory therapists, and the patient, together with a coordinator who collects the data and helps to demonstrate what is or is not working. This will enable the team and the hospital to track progress, provide education, and more importantly to learn where they are having success and what areas need improvement. The surgical team should have regular meetings to discuss patient management. (Excerpt from text, p. 209; no abstract available.)