ERAS Protocol Options for Perioperative Pain Management of Substance Use Disorder in the Ambulatory Surgical Setting.

Even prior to the COVID-19 pandemic, rates of ambulatory surgeries and ambulatory patients presenting with substance use disorder were increasing, and the end of lockdown has further catalyzed the increasing rates of ambulatory patients presenting for surgery with substance use disorder (SUD). Certain subspecialty groups of ambulatory procedures have already established protocols to optimize early recovery after surgery (ERAS), and these groups have subsequently enjoyed improved efficiency and reduced adverse outcomes as a result. In this present investigation, we review the literature as it relates to substance use disorder patients, with a particular focus on pharmacokinetic and pharmacodynamic profiles, and their resulting impact on the acute- or chronic user ambulatory patient. The systematic literature review findings are organized and summarized. We conclude by identifying areas of opportunity for further study, specifically with the aim of developing a dedicated ERAS protocol for substance use disorder patients in the ambulatory surgery setting. - Healthcare in the USA has seen an increase in rates of both substance use disorder patients and separately in ambulatory surgery cases. - Specific perioperative protocols to optimize outcomes for patients who suffer from substance use disorder have been described in recent years. - Agents of interest like opioids, cannabis, and amphetamines are the top three most abused substances in North America. - A protocol and recommend further work should be done to integrate with concrete clinical data, in which strategies should be employed to confer benefits to patient outcomes and hospital quality metrics like those enjoyed by ERAS protocol in other settings.

Evolving Therapeutic Roles of Nasogastric Tubes: Current Concepts in Clinical Practice.

Nasogastric tubes (NGT) have been in use for over 100 years and are still considered as essential and resuscitative tools in multiple medical specialties for acute and chronic care. They are vital for decompression of the stomach in the presence of bowel obstruction in the critically ill and useful as a conduit for the administration of medications and sometimes for short term parenteral nutrition. The placement of nasogastric tubes is relatively routine. However, they must be inserted and maintained safely and effectively to avoid serious and possibly even fatal associated complications. This review focuses on recent updates in research regarding nasogastric tubes. Cognizance of the recent advances in indications, contraindications, techniques of insertion, confirmation of correct positioning, securement, complications, management of complications, and state of the art research about the nasogastric tube is crucial for practitioners of all medical and surgical specialties.

Ambulatory Pain Management in the Pediatric Patient Population.

PURPOSE OF REVIEW: Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia. RECENT FINDINGS: A multimodal approach to pain management should be applied to the ambulatory setting to decrease postoperative pain. These include non-pharmacological techniques, multimodal pharmacologics, and neuraxial and peripheral nerve blocks. Postoperative pain management in pediatric ambulatory surgical patients remains suboptimal at most centers due to limited evidence-based approach to postoperative pain control. Pediatric ambulatory pain management requires a multipronged approach to address this inadequacy.

Analgesia for Gynecologic Oncologic Surgeries: A Narrative Review.

PURPOSE OF REVIEW: Gynecologic oncologic malignancies are amongst the most common cancers affecting women across the world. This narrative review focuses on the current state of evidence around optimal perioperative pain management of patients undergoing surgeries for gynecologic malignancies with a specific focus on cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). RECENT FINDINGS: Recent improvements in postoperative pain management following all types of gynecologic procedures, including minimally invasive, open-abdominal, or CRS + HIPEC, have been implemented through enhanced recovery after surgery (ERAS) protocols. These protocols encompass the use of preemptive analgesia, neuraxial and regional techniques, local anesthetic infiltration, and multimodal analgesia. The severity of postoperative pain varies for minimally invasive cancer surgery to open debulking procedures. Therefore, an individualized perioperative analgesic plan is critical depending on the surgical approach. For CRS + HIPEC, neuraxial techniques such as thoracic epidurals and opioid sparing multimodal analgesics have shown efficacy in the perioperative period. However, future research is needed as many of these patients develop chronic pain with very limited research done in this realm.

Enhanced Recovery After Surgery: Opioid Sparing Strategies After Discharge: A Review.

PURPOSE OF REVIEW: Many surgical subspecialties have developed enhanced recovery after surgery (ERAS) protocols that focus on multimodal analgesia to limit opioid use during a hospital stay and improve patient recovery. Unfortunately, ERAS protocols do not extend to post-discharge patient care, and opioids continue to be over prescribed. The primary reason seems to be a lack of good quality research evaluating extended use of a multimodal analgesic approach. This review was undertaken to evaluate available evidence for non-opioid analgesics in the postoperative period after discharge, utilizing Pubmed, Scopus, and Google Scholar. RECENT FINDINGS: Several studies have explored strategies to reduce the overprescribing of opioids after surgery without worsening postoperative pain scores or complications. However, these studies do not necessarily reflect on situations where an ultra-restrictive protocol may fail, leading to breakthrough pain. Ultra-restrictive opioid protocols, therefore, could risk undertreatment of acute pain and the development of persistent post-surgical pain, highlighting the need for a review of non-opioid strategies. Our findings show that little research has been conducted on the efficacy of non-opioid therapies post-discharge including acetaminophen, NSAIDs, gabapentin, duloxetine, venlafaxine, tizanidine, valium, and oral ketamine. Further studies are warranted to more precisely evaluate the utility of these agents, specifically for their side effect profile and efficacy in improving pain-control and function while limiting opioid use.

Does Choice of Steroid Matter for Treatment of Chronic Low Back Pain with Sacroiliac Joint Injections: a Retrospective Study.

PURPOSE OF REVIEW: Prevalence of chronic low back pain (cLBP) is increasing. Sacroiliac joint (SIJ) is a common source of cLBP, but data behind its diagnosis and treatment is controversial. There is moderate quality evidence for effectiveness of therapeutic SIJ injections. However, there are no studies comparing the two most common steroid preparations, methylprednisolone (MTP) and triamcinolone (TAC) in SIJ injections. RECENT FINDINGS: After institutional IRB approval, a retrospective chart review was conducted to evaluate the effectiveness of SIJ injections in terms of pain relief at 1-month follow-up and compare MTP versus TAC. All injections were performed by a single pain physician with fluoroscopic guidance. RESULTS: Sixty-five percent of patients in the MTP group and 57% patients in the TAC group had >50% pain relief at 1-month follow-up, with no statistical difference between the two groups. Patients in the TAC group had significantly greater BMI and consisted of higher proportion of smokers (72% patients in TAC group versus 39% patients in the MTP group, p-value 0.004). Other sources of pain such as facet joints were unmasked post-procedurally after SIJ injections, with this unmasking being significant for the TAC group. Opiate use decreased in the MTP group from 35% pre-procedurally to 20% post-procedurally, and this difference did not reach statistical significance. Both MTP and TAC are effective in providing pain relief for SIJ pain at 1-month follow-up, with no statistical difference between the two types of steroids. Although not statistically significant, there is a modest reduction in opiate use in the MTP group.

Acute Pain Management of Chronic Pain Patients in Ambulatory Surgery Centers.

PURPOSE OF REVIEW: With the widespread growth of ambulatory surgery centers (ASCs), the number and diversity of operations performed in the outpatient setting continue to increase. In parallel, there is an increase in the proportion of patients with a history of chronic opioid use and misuse undergoing elective surgery. Patients with such opioid tolerance present a unique challenge in the ambulatory setting, given their increased requirement for postoperative opioids. Guidelines for managing perioperative pain, anticipating postoperative opioid requirements and a discharge plan to wean off of opioids, are therefore needed. RECENT FINDINGS: Expert guidelines suggest using multimodal analgesia including non-opioid analgesics and regional/neuraxial anesthesia whenever possible. However, there exists variability in care, resulting in challenges in perioperative pain management. In a recent study of same-day admission patients, anesthesiologists correctly identified most opioid-tolerant patients, but used non-opioid analgesics only half the time. The concept of a focused ambulatory pain specialist on site at each ASC has been suggested, who in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized. This review focuses on perioperative pain management in three subsets of patients who exhibit opioid tolerance: those on large doses of opioids (including abuse-deterrent formulations) for chronic non-malignant or malignant pain; those who have ongoing opioid misuse; and those who were prior addicts and are now on methadone/suboxone maintenance. We also discuss perioperative pain management for patients who have implanted devices such as spinal cord stimulators and intrathecal pain pumps.

Ultrasound-Guided Neuraxial Anesthesia.

PURPOSE OF REVIEW: There has been a recent surge of interest in clinical applications of ultrasound, which has revolutionized acute pain management. This review is to summarize the current status of ultrasound utilization in neuraxial anesthesia, the most common type of regional anesthesia. RECENT FINDINGS: Ultrasound-assisted and ultrasound-guided neuraxial anesthesia has improved clinical accuracy and patient safety through landmark identification including proper vertebral level and midline, as well as via measurements on neuraxial space. Direct needle or catheter visualization during the entire procedure has not yet been achieved consistently. The recent introduction of ultrasound into neural anesthesia has clinical performance benefits and patient safety implications, with documented improvement on overall efficacy with higher first attempt success rate as well as less needle pass. More controlled studies are needed for the overall impact of ultrasonography in neuraxial anesthesia in obstetric and non-obstetric patients.

Endometriosis Pain Management: a Review.

PURPOSE OF REVIEW: The purpose of this review is to summarize the up-to-date pain management options and recommendations for the challenging disease, endometriosis. RECENT FINDINGS: The mainstays of endometriosis advances of both surgical and medical management continue to evolve. Experimental pharmaceuticals include Gestirone, and aromatase inhibitors have shown promise but are still under scrutiny. Surgical techniques include laparoscopic uterosacral nerve ablation/resection and presacral neurectomy. No studies have directly compared medical versus surgical management, and as such, no one treatment modality can be recommend as superior to the other. Patients may initially be given a medical diagnosis and treated with nonsteroidal anti-inflammatory drugs, neurolepitcs, OCP, GNRH agonists/antagonists, and Danazol. Assessing the success of these regimens has proved difficult. Surgical management relies on various methods including excision/ablation of the lesions, nerve ablation, neurectomy, hysterectomy, and oophorectomy.

Ultrasound for peripheral and arterial access.

Peripheral venous access is perhaps the most commonly performed procedure in hospitals, urgent care, or surgical centers across the country. The ability to obtain peripheral intravenous (IV) access, and in a timely manner, is arguably one of the most important skill sets to be mastered by health care professionals. While skill and experience play a role in successful and timely vascular access, numerous patient factors such as obesity, diabetes, IV drug use, and chronic kidney disease may pose unique challenges to even the most skilled health care professional. In patients with difficult access, there are often multiple attempts, which can be both time consuming for the provider and painful for the patients. Direct visualization of blood vessels using ultrasonography has an advantage over the standard landmark technique and can improve the success rate of peripheral IV or arterial line placement in this patient population. Given the success of ultrasound guidance with access placement, it is imperative that all health care profesionals become proficient with this technique. The aim of this review article is to provide concise and practical information on the basics of ultrasound and its application to obtain peripheral venous and arterial access.

Novel Regional Anesthesia for Outpatient Surgery.

PURPOSE OF REVIEW: Peripheral nerve blocks are effective and safe modalities for perioperative analgesia. But it remains unclear what blocks are adequate for ambulatory surgeries, as well as the proper patient management before and after discharge. RECENT FINDINGS: Emerging nerve blocks have sparked interests due to ease to perform under ultrasound guidance and lower risks of adverse events. Some of these novel blocks are particularly suitable for ambulatory procedures, including but not limited to motor-sparing lower extremity nerve blocks and phrenic-sparing nerve blocks for shoulder surgeries. The adoption of peripheral nerve block into outpatient surgery is a multidisciplinary effort that encompasses appropriate patient choice, careful selection of nerve blocks that minimize potential adverse events after discharge, and proper patient follow-up until block effects resolve.

Challenges of Robotic Gynecologic Surgery in Morbidly Obese Patients and How to Optimize Success.

PURPOSE OF REVIEW: Robotic surgery has been shown to have a significant benefit in obese gynecologic patients over open surgery. However, robotic surgery in these patients requires a thorough understanding of the physiologic adaptations caused by obesity, adequate preoperative optimization, specialized equipment and techniques, and careful attention to intra- and postoperative management in order to minimize complications. This article reviews the benefits of a minimally invasive approach in obese patients and provides a thorough guide to perioperative management of obese patients undergoing robotic gynecologic surgery. A useful set of tips and tricks to overcome many of the technical challenges in performing robotic surgery in the obese patients is included. RECENT FINDINGS: In the USA, obesity has risen to affect 39.8% of the population, which leads to increased incidence of mortality, hypertension, diabetes, heart disease, and stroke. Moreover, obese patients are at greater risk of perioperative complications during gynecologic surgery. With the use of laparoscopy, many of the perioperative risks of surgery in obese patients can be ameliorated. However, minimally invasive surgery in obese patients is technically challenging. Robotic-assisted laparoscopy addresses several of these challenges, allowing surgeons to offer minimally invasive approaches to patients with extreme BMIs while reducing perioperative risk. Obese patients undergoing gynecologic surgery receive a greater benefit than their non-obese counterparts from a laparoscopic approach, and current data support the safety and feasibility of robotic surgery in the obese population. Therefore, every effort to offer a minimally invasive surgery to obese patients should be made.

Perioperative Pain Management in the Critically Ill Patient.

PURPOSE OF REVIEW: The assessment and management of perioperative pain in an intensive care setting is complex and challenging, requiring several patient-specific considerations. Administering analgesia is difficult due to interacting effects of pre-existing conditions, interventions, and deviation from standard levels of expressiveness of pain. A significant part of this complexity also arises from the reduced capacity of critically ill patients to fully communicate the severity and nature of their pain. We provide an overview of pharmacological approaches and regional techniques, which can be employed alongside the management of anxiety and sleep, to alleviate pain in the critically ill patients in the perioperative period. These interventions require additional assessments unique to critical care, yet achieving pain relief for improving clinical outcomes and patient satisfaction remains a constant. RECENT FINDINGS: The latest research has found that the development of standardized mechanisms and protocols to optimize the diagnosis, assessment, and management of pain in the critically ill can provide the best outcomes. The numerical rating scale, critical care pain observation criteria, and behavior pain scale has shown higher reliability to accurately assess pain in the critically ill. Most importantly, preemptive analgesia and the emphasis on early pain control-in the perioperative setting, ICU, and post-discharge-are crucial in minimizing chronic post-discharge pain. Finally, the multimodal approach is still found to be the most effective. This includes pharmacological treatments, regional nerve block, and epidural techniques, as well as alternative methods that are cheap, safe, and easily available. All these together have shown to help control pain, provide psychological support, and prevent long-term co-morbidities in the critically ill. Largely, pain in the critically ill patient is still a very complex issue that requires appropriate diagnosis, assessment, and management of the pain itself and treating all the underlying co-morbidities as well. Many different factors makes it challenging, especially the difficulty in communicating with an ICU patient. However, by looking at the patient as a whole, treating pain early with the multimodal approach, there seems to be some promising results in improving outcomes. It has shown that the improved outcomes in critically ill patients in the perioperative period seen with optimized pain management and ICU can shorten hospital stays, decreased inpatient costs, and limit the use of limited resources.

Analysis of Multiple Routes of Analgesic Administration in the Immediate Postoperative Period: a 10-Year Experience.

PURPOSE OF REVIEW: An increasing amount of literature supports a multimodal approach to analgesic administration in the management of postoperative pain. The purpose of this study and review was to further evaluate the differences in efficacy in controlling immediate postoperative pain among the various routes of analgesia administration. RECENT FINDINGS: This study consisted of an analysis of the various routes of analgesic administration (parental, neuraxial, and oral/rectal) in 107,671 consecutive surgical cases performed over a 10-year period at Yale New Haven Hospital. This study included variables of postoperative pain score at initial request for analgesic, pain score at discharge, nausea and vomiting in the post-anesthesia care unit, and gender. The most common route of administration of analgesia in our study was via the parenteral route (29,962), and the least common route was the neuraxial route (1319). There was a significant decrease in pain scores at the time of discharge in all three groups relative to the pain score at first request for analgesia. Multimodal analgesia via various routes of administration targets numerous proponents of the nervous system with the intent to reduce the adverse side effects of the individual analgesics if given alone or as an additive to produce synergistic analgesia. Our study suggests that although all the routes investigated (parenteral, neuraxial (intrathecal/epidural), and per os or per rectum (PO/PR)) promote significant pain relief on discharge from the PACU, the group that received neuraxial analgesia reported the lowest incidence of nausea and vomiting.

Perioperative Considerations in the Management of Anticoagulation Therapy for Patients Undergoing Surgery.

PURPOSE OF REVIEW: As ambulatory surgery has become increasingly more common, the appropriate management of anticoagulation therapy in patients undergoing invasive procedures has become progressively more relevant to healthcare professionals. The purpose of this literature review is to provide an overview of current common anaticoagulants and their pharmacological properties and to evaluate recent relevant literature and bridging therapy and provide recommendations on risk-guided therapy. RECENT FINDINGS: With the development of new drugs and the advancing study and practice of anticoagulation use, clinicians must keep up-to-date on the optimal management of patients requiring anticoagulation. NOACs and warfarin continue to be the mainstays of treatment, with varying timelines regarding when to hold administration of the different agents within the perioperative period. There are numerous factors that are considered in patients with multiple comorbidities including the risk for stroke on long-term anticoagulation and risk for thromboembolism, particularly in the perioperative setting when certain medication regimens may be altered and/or briefly held. There is ongoing investigation whether certain NOACs have more efficacy or greater safety profiles, depending on the degree of surgical intervention.

New opioid receptor modulators and agonists.

There has been significant research to develop an ideal synthetic opioid. Opioids with variable properties possessing efficacy and with reduced side effects have been synthesized when compared to previously used agents. An opioid modulator is a drug that can produce both agonistic and antagonistic effects by binding to different opioid receptors and therefore cannot be classified as one or the other alone. These compounds can differ in their structures while still possessing opioid-mediated actions. This review will discuss TRV130 receptor modulators and other novel opioid receptor modulators, including Mitragyna "Kratom," Ignavine, Salvinorin-A, DPI-289, UFP-505, LP1, SKF-10,047, Cebranopadol, Naltrexone-14-O-sulfate, and Naloxegol. In summary, the structural elucidation of opioid receptors, allosteric modulation of opioid receptors, new opioid modulators and agonists, the employment of optogenetics, optopharmacology, and next-generation sequencing of opioid receptor genes and related functionality should create exciting new avenues for research and therapeutic development to treat conditions including pain, opioid abuse, and addiction.

Perioperative Management of Patients with Addiction to Opioid and Non-opioid Medications.

PURPOSE OF REVIEW: With the rise of the opioid epidemic, anesthesiologists will find themselves faced with opioid-addicted patients more frequently. Addiction to opioids may also occur concurrently with abuse of other non-opioid medications. Our review article seeks to outline an armamentarium of pain management strategies in the perioperative period for these patients with addiction to opioid and non-opioid medications. RECENT FINDINGS: Statistics from the CDC demonstrate a shocking increase in opioid prescription rates and opioid-related deaths. Furthermore, opioid-addicted patients have notoriously undertreated pain in the perioperative period. A multitude of strategies are available in the perioperative period to treat pain in these patients. Formulating treatment plans for opioid and non-opioid-addicted patients undergoing surgery should include considerations in the pre-, intra-, and post-operative period. Our review article outlines several non-opioid modalities which may be employed to treat pain in these patients; however, particularly in the opioid-addicted population, the practitioner must be aware that non-opioids alone may not suffice to treat post-surgical pain. Consultation with pain management may be warranted to optimize opioid and non-opioid treatment for these patients.

Functional Connectivity Alterations: Novel Therapy and Future Implications in Chronic Pain Management.

BACKGROUND: Chronic pain is a major public health problem resulting in physical and emotional pain for individuals and families, loss of productivity, and an annual cost of billions of dollars. The lack of objective measures available to aid in diagnosis and evaluation of therapies for chronic pain continues to be a challenge for the clinician. OBJECTIVES: Functional magnetic resonance imaging (fMRI) is an imaging technique that can establish regional areas of interest and examine synchronous neuronal activity in functionally related but anatomically distinct regions of the brain, known as functional connectivity. STUDY DESIGN: The present investigation examines changes in functional connectivity in 4 common pain syndromes: chronic back pain (CBP), fibromyalgia, diabetic neuropathy, and complex regional pain syndrome (CRPS). SETTING: This is a review of the current understanding of functional connectivity. METHODS: Utilizing functional imaging, patients with these conditions have been shown to have significant structural and functional differences when compared to healthy controls. RESULTS: Functional connectivity, therefore, has the potential to assist in diagnostic classification of different pain conditions, predict individual responses to specific therapeutic interventions, and serve as a gateway for personalized medicine. Indirect activation of brain activity can be seen by the blood flow to the brain at specific sites, with chronic pain patients having increased brain activity. LIMITATIONS: The present investigation is limited in that few studies have examined this relatively new modality. CONCLUSIONS: Knowing and observing the brain's activity as related to pain gives pain patients an opportunity to decrease pain-related brain activity and decrease severe chronic pain. This modality can be used along with interventional pain management techniques in order to provide optimum pain relief. KEY WORDS: Functional connectivity, fMRI, chronic pain, chronic back pain, fibromyalgia, diabetic neuropathy, chronic regional pain syndrome.

Post-operative Weaning of Opioids After Ambulatory Surgery: the Importance of Physician Stewardship.

PURPOSE OF REVIEW: We performed a systematic review to elucidate the current guidelines on weaning patients from opioids in the post-operative ambulatory surgery setting, and how pain management intraoperatively can impact this process. DESIGN: The review highlights the most up-to-date research from clinical trials, patient reports, and retrospective studies regarding both the current guidelines and weaning of opioid analgesia in ambulatory surgery setting. RECENT FINDINGS: A striking paucity of convincing evidence exists on ambulatory postoperative pain management discontinuation or weaning of pain medications. However, retrospective and patient-reported studies suggest our approach should be similar to acute pain management strategies. The first steps include identifying high-risk patients and devising an appropriate pain plan. This may be accomplished by implementing multimodal analgesia, anticipating opioid needs, and the proper use of regional anesthesia. The increasing roles for Transitional Pain Service (TPS), Perioperative Surgical Home (PSH), and Enhanced Recovery After Surgery (ERAS) may also guide us in this process. Patients discharged from same-day surgery may lack the additional infrastructure of a hospital or medical establishment to monitor postoperative recovery. As such, weaning of pain medications in ambulatory surgery settings requires teams that are adept at treating varied patient populations through a tailored, novel means that invoke multimodal analgesia. Given the growth of surgeries moving toward the ambulatory sector, more data and practice guidelines are needed to direct postoperative pain regimen titration for the patients.