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Allen KamravaMD · MBA · FACS · FASCRS

Lifestyle

Pain Management Protocols

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Back to work
N/A
Success rate
Greater than 90% (in reducing opioid use)
Recurrence
N/A

What it is

What are Pain Management Protocols?

Postoperative pain management protocols are a structured, multimodal approach to controlling pain after surgery, with a focus on minimizing the use of opioids. These protocols are a key component of Enhanced Recovery After Surgery (ERAS) pathways. The strategy involves combining different types of pain medications that work on different pain receptors and pathways. This allows for a synergistic effect, providing superior pain control while reducing the side effects associated with high doses of a single medication, particularly opioids. The protocol begins before surgery and continues through the intraoperative and postoperative periods.

Key Components:

  • Preoperative: Patients may receive non-opioid analgesics like acetaminophen and gabapentinoids before surgery.
  • Intraoperative: Anesthesiologists use regional blocks (e.g., epidurals, TAP blocks), intravenous lidocaine, ketamine, and non-steroidal anti-inflammatory drugs (NSAIDs) to minimize the need for intraoperative opioids.
  • Postoperative: A scheduled regimen of oral medications, including acetaminophen and NSAIDs, forms the foundation of postoperative pain control. Opioids are reserved for 'breakthrough' pain that is not controlled by the scheduled non-opioid medications.

Am I a candidate?

Who are Good Candidates for these Protocols?

Pain management protocols are ideal for all patients undergoing major colorectal surgery, both open and minimally invasive. They are particularly beneficial for patients who are at higher risk for opioid-related side effects, such as the elderly, patients with obstructive sleep apnea, or those with a history of opioid dependence. The goal is to facilitate early mobilization, quicker return of bowel function, and a faster overall recovery for every surgical patient.

Recovery

What is the Recovery Process Like?

Patients on a multimodal pain management protocol can expect a more comfortable recovery with less nausea, sedation, and constipation compared to traditional pain management. This allows for earlier participation in physical therapy, quicker tolerance of a regular diet, and a faster return to normal activities. Patients are educated about the goals of the protocol and are active participants in their pain management. They are encouraged to take their scheduled non-opioid medications and to use opioids only as needed for severe pain. The result is a smoother, faster recovery and a shorter hospital stay.

Risks & considerations

What are the Risks?

A multimodal pain regimen is very safe and is designed to reduce the risks associated with traditional, opioid-heavy pain management. Potential risks are related to the specific medications used:

  • NSAIDs (e.g., Ketorolac, Ibuprofen): Can increase the risk of kidney injury, particularly in patients with pre-existing renal disease or dehydration. There is also a small risk of gastrointestinal bleeding or ulcers.
  • Acetaminophen: Is very safe at recommended doses but can cause severe liver damage if taken in excess of 4 grams per day.
  • Gabapentinoids (e.g., Gabapentin, Lyrica): Can cause drowsiness and dizziness.
  • Regional Anesthesia (e.g., Epidurals, TAP blocks): Carry small risks of bleeding, infection, or nerve injury at the injection site.

By using lower doses of multiple agents, the risk of side effects from any single medication is significantly reduced.

Sources

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