The goal of ERAS is to reduce perioperative complications and to achieve functional recovery as fast as possible – but not at the cost of additional complications. “We want to get the patients out of the hospital in better shape than they would be after a traditional approach but that does not necessarily mean we need to get them out of the hospital faster than usual”, says Dr Tzabazis.

He explains: “you really need to tailor your approach to your individual patient and to the type of surgery that this patient is having”, he explains. For example, if a patient is undergoing major abdominal surgery with a big mid-line incision, the traditional approach [of] placing in a pre-operative epidural catheter is still valid. “However, we are now increasingly using a multimodal pain approach where we add IV or oral analgesic drugs as well and that is not only opioids but also increasingly non-opioids.  Some people have called this a ‘maxi-modal’ approach where we kind of try to … mix together all the different analgesics that we have available ….. to reduce side effects [compared with] one single medication.”

In view of the opioid crisis, it is important to try to reduce opioid requirements in the immediate post-operative period and also in the long-term post-operative period. A review article by Blumenthal in 2019 described a study comparing a historical pre-ERAS cohort with a post-ERAS cohort for four different types of surgery, including colorectal and obstetric/gynaecologic surgery. It showed that “you could actually reduce postoperative morphine equivalent requirements dramatically – by as much as 80 percent; …… that’s huge – in the post-operative period without compromising patients’ well-being or complications”, says Dr Tzabazis

Both paracetamol and non-steroidal anti-inflammatory drugs are well absorbed when given orally but intravenous administration offers advantages in the peri-operative period. “If you want to time the onset of action of your non-opioid IV analgesics you need to give them intravenously – that’s common sense”, he adds.

Multimodal analgesia is now the standard of care for post-operative pain relief and it can readily be explained to patients.  Dr Tzabazis uses a food analogy. He says, “If you’re hungry you can fill yourself up with potatoes or rice only, but if you ….. add a little ingredient here and there you can be filled up too, but it tastes a lot better, and that’s something patients usually understand really well”.

In practice, he uses the ‘WHO top-down’ [pain ladder] approach. This involves the use of “strong opioids in the immediate post-operative period but usually at a slightly lower dose than I would have used in the past and then I add ….  non-opioids because of the opioid-sparing effect that has been well established…..  From there on I’m trying to taper it down – the opioids first”, he explains.

The availability of intravenous formulations of non-opioid analgesics – paracetamol and ibuprofen – has made it much easier for anaesthetists to administer them in the post-operative period “with a guaranteed onset of action at the chosen time point”, says Dr Tzabazis. “I think if you if you’re still using an opioid-only-based post-operative pain management approach you’re a dinosaur”, he adds.

The combination of analgesic approaches used depends on the type of surgery and the individual patient. “Pain is very individual so you need to always have an individual approach but whenever you can use a regional approach or when whenever you can block a nerve that that …… innervates the area of interest you should probably go for that.  Personally, I use the ‘WHO top-down’ [pain ladder] approach where I … add strong opioids in the immediate post-operative period but usually at a slightly lower dose than I would have used in the past and then I add ….  non-opioids because of the opioid-sparing effect that has been well established…..  From there on I’m trying to taper it down – the opioids first. Hopefully I can have my patients well-controlled with the pain with just a regional approach – if there’s a catheter in place – plus non-opioids.  Then, eventually, the regional approach or the catheter needs to come out and hopefully at that time patients can be managed without any opioids and only non-opioids are being given”, explains Dr Tzabazis.

Transdermal fentanyl has been used in some centres as part of the post-operative pain relief protocol. Dr Tzabazis says there are several reasons why this is not desirable. He says, “It would not be my first choice really because the [absorption] kinetics [are] just so slow, I mean, you put it on and you know after so many hours you might have an effect or not. There’s the additional disadvantage [that] the drug uptake depends upon skin perfusion. You know, it’s not uncommon for patients to get a little hypothermic during surgery but at the same time we sometimes apply forced air warming which …. might cause hyperaemia and hyperperfusion of that particular area so the uptake might be higher than you would expect. So, this is not this is not a great choice for post-operative pain.” Furthermore, there can be pain ‘peaks’ when the patient starts moving around and it would be difficult to manage this type of pain with a transdermal approach. Transdermal fentanyl is probably better suited to the management of a chronic pain. “For post-operative pain I would say that’s a no-go”, he concludes.

Multimodal analgesia is now the standard of care for post-operative pain relief. The availability of intravenous formulations of non-opioid analgesics has made it much easier for anaesthetists to administer in the post-operative period “with a guaranteed onset of action at the chosen time point”, says Dr Tzabazis. “I think if you if you’re still using an opioid-only-based post-operative pain management approach you’re a dinosaur”, he adds.

When explaining multimodal analgesia to patients Dr Tzabazis uses a food analogy. He says, “If you’re hungry you can fill yourself up with potatoes or rice only, but if you ….. add a little ingredient here and there you can be filled up too, but it tastes a lot better, and that’s something patients usually understand really well”. This is consistent with the evidence-based approach aiming for the common goal of well-controlled pain management, he adds.

Read and watch the full series on our website or on YouTube.

A review article by Blumenthal in 2019 described a study comparing a historical pre-ERAS cohort with a post-ERAS cohort for four different types of surgery, including colorectal and obstetric/gynaecologic surgery. It showed that “you could actually reduce postoperative morphine equivalent requirements dramatically – by as much as 80 percent; …… that’s huge – in the post-operative period without compromising patients’ well-being or complications”, says Dr Tzabazis

Both paracetamol and non-steroidal anti-inflammatory drugs are well absorbed when given orally but intravenous administration offers advantages in the peri-operative period. “They are well absorbed however you have to remember that that most of the pharmacokinetic studies that that we’re looking at are in healthy volunteers….. so, they didn’t have any surgery and they didn’t get any opioids that might slow down GI (gastro-intestinal) motility. So, we don’t really know how much of these drugs are being absorbed [in post-operative patients]”, explains Dr Tzabazis. The key issue here is timing of onset of action. “If you want to time the onset of action of your non-opioid IV analgesics you need to give them intravenously – that’s common sense”, he adds.

Research has shown that pain control is marginally better when IV non-opioid analgesics are added. This “did not reach significance in in most studies, however, we get [that] slightly better pain control with a significantly reduced opioid requirement and that is usually or very often accompanied by reduction in side-effects that are typically caused by opioids, such as nausea and vomiting, says Dr Tzabazis.

Read and watch the full series on our website or on YouTube.

Enhanced recovery after surgery (ERAS) is a really hot topic right now and there are protocols for almost any kind of surgery that you can imagine, according to Dr Tzabazis.  The overall goal for ERAS is to reduce perioperative complications and to achieve functional recovery as fast as possible – but not at the cost of additional complications. He describes this as a “better first, then fast” approach.

“We want to get the patients out of the hospital in better shape than they would be after a traditional approach but that does not necessarily mean we need to get them out of the hospital faster than usual so if they have to stay as long as they used to with the traditional approach that’s fine but the overall and very first objective is to get them out of the hospital better in better shape [than] they were with a traditional approach”, says Dr Tzabazis.

A multitude of approaches can be used to manage peri-operative pain. Regional anaesthesia has an important place. This could be by means of epidural administration, a nerve block or continuous peripheral nerve block. The other important approach is systemic administration of opioid and non-opioid analgesics, either at regular intervals or continuously using a syringe pump. Local anaesthetics might also be given, such as IV lidocaine (lignocaine).  There is now a big group of non-opioid analgesics – “that being ibuprofen, acetaminophen or paracetamol but then there’s also new additions such as the gabapentinoids. We also have ketamine- that’s a drug that is increasingly being used in perioperative pain management – and then we also have the alpha-agonists such as clonidine or dexmedetomidine. So we have really a huge armamentarium to treat perioperative pain from all kinds of different angles – and we should really use the best approach for individual patients”, says Dr Tzabazis

In practice, “you really need to tailor your approach to your individual patient and to the type of surgery that this patient is having”, he explains. For example, if a patient is undergoing major abdominal surgery with a big mid-line incision, the traditional approach [of] placing in a pre-operative epidural catheter is still valid. “However, we are now increasingly using a multimodal pain approach where we add IV or oral analgesic drugs as well and that is not only opioids but also increasingly non-opioids.  Some people have called this a ‘maxi-modal’ approach where we kind of try to … mix together all the different analgesics that we have available ….. to reduce side effects [compared with] one single medication.” In view of the opioid crisis, it is important to try to reduce opioid requirements in the immediate post-operative period and also in the long-term post-operative period, he comments.

Read and watch the full series on our website or on YouTube.