What is the optimal pain management regimen post-operative colon surgery?

From the Guidelines

The optimal pain management regimen post-operative colon surgery involves a multimodal approach, including mid-thoracic epidural analgesia, multimodal analgesia with paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetic techniques such as transversus abdominis plane (TAP) blocks or wound infiltration with bupivacaine, as recommended by the Enhanced Recovery After Surgery (ERAS) society guidelines 1.

Key Components of Pain Management

• Mid-thoracic epidural analgesia should be utilized in colonic surgery if possible, as it provides superior analgesia to systemic opioids 1.
• Multimodal analgesia with paracetamol and NSAIDs can spare opioid use and side effects by 30% 1.
• Local anesthetic techniques such as TAP blocks or wound infiltration with bupivacaine can further reduce opioid requirements 1.
• Early mobilization, proper positioning, and use of abdominal binders can provide additional pain relief.

Opioid Use and Management

• Long-acting opioids should not be used routinely for acute postoperative pain, and patient-centred approaches should be used to limit the number of tablets and duration of usual discharge opioid prescriptions 1.
• Automated post-discharge repeat prescriptions for opioids should be avoided, and patients should be advised on safe storage and disposal of unused opioids 1.

Considerations for Specific Patient Populations

• Patients undergoing open rectal surgery may benefit from thoracic epidural anaesthesia (TEA) for 48-72 hours, while those undergoing laparoscopic surgery may benefit from epidural or intravenous lidocaine 1.
• Patients with preoperative pain partially induced by neoadjuvant radiotherapy may require a multi-pharmacological approach to manage neuropathic pain components 1.

Overall Approach

• A multimodal approach to pain management, incorporating multiple modalities and techniques, is essential for effective pain control and minimizing side effects after colon surgery 1.

From the FDA Drug Label

The overall quality of pain relief, as judged by the patients, in the ropivacaine groups was rated as good or excellent (73% to 100%). Continuous epidural infusion of Ropivacaine Hydrochloride 2 mg/mL (0. 2%) during up to 72 hours for postoperative pain management after major abdominal surgery was studied in 2 multicenter, double-blind studies. Clinical studies with 2 mg/mL (0. 2%) Ropivacaine Hydrochloride have demonstrated that infusion rates of 6 to 14 mL (12 to 28 mg) per hour provide adequate analgesia with nonprogressive motor block in cases of moderate to severe postoperative pain.

The optimal pain management regimen post-operative colon surgery is epidural infusion of Ropivacaine Hydrochloride 2 mg/mL (0.2%) at 6 to 14 mL/h (12 to 28 mg), which has been shown to provide adequate analgesia with nonprogressive motor block in cases of moderate to severe postoperative pain 2.

• Key points:
  • Infusion rates: 6 to 14 mL/h (12 to 28 mg)
  • Duration: up to 72 hours
  • Pain relief: good or excellent (73% to 100%)

From the Research

Optimal Pain Management Regimen

The optimal pain management regimen post-operative colon surgery involves a multimodal approach, combining different analgesic agents and techniques to minimize pain and reduce opioid use.

• The use of paracetamol, epidural analgesia, and non-steroidal anti-inflammatory drugs (NSAIDs) has been recommended for optimal pain management after open colectomy 3.
• Intra-operative and postoperative Cyclo-oxygenase (COX)-2 specific-inhibitors or NSAIDs are recommended for colonic surgery, with the analgesic regimen including intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, epidural and continued postoperatively with opioids used as rescue analgesics 3.
• If epidural is not feasible, bilateral TAP block or IV lidocaine are recommended, with safety issues highlighted, including the risk of toxicity with local anaesthetics 3.

Multimodal Analgesic Approaches

Multimodal analgesic approaches are an important part of Enhanced Recovery After Surgery (ERAS) protocols for colorectal surgery.

• A comparison of ERAS protocols from 15 institutions found that all but three protocols used preoperative multimodal analgesics, with acetaminophen, celecoxib, and gabapentin being the most common 4.
• Intraoperative recommendations included the use of ketamine, lidocaine, magnesium, and ketorolac, with some protocols advocating for the use of opiates, while others aimed to minimize total opioid dose 4.
• The use of multimodal pain management, including liposomal bupivacaine, has been shown to improve postoperative outcomes, decrease lengths of stay, and increase bed availability 5.

Oral vs Intravenous Acetaminophen

The use of oral vs intravenous acetaminophen within an ERAS protocol in colorectal surgery has been evaluated.

• A retrospective observational study found that the use of intravenous acetaminophen was associated with decreased opioid use and reduced postoperative nausea and vomiting, compared to oral acetaminophen 6.
• The study suggested that intravenous acetaminophen may be superior to oral acetaminophen in the early postoperative setting, although significant limitations included the retrospective nature and single-institution setting of the study 6.

Postoperative Pain Management

The appropriate management of postoperative pain is contingent on a cooperative effort from healthcare professionals and depends on the patient, underlying medical conditions, and the type of surgery.

• Regional anesthetic techniques, such as caudal epidural blocks and ilioinguinal/iliohypogastric nerve blocks, can provide excellent postoperative analgesia and reduce the amount of general anesthesia required 7.
• Traditional medications, such as oral and parenteral narcotics, non-steroidal anti-inflammatory drugs, and acetaminophen, are commonly used to treat postoperative pain, with the goal of providing the least painful perioperative experience possible 7.