NHS FORTH VALLEY Enhanced Recovery After Surgery (ERAS) Pain Management Guidelines Colorectal

Date of First Issue 01/08/2013 Approved 27/01/2016 Current Issue Date 27/01/2016 Review Date 27/01/2017 Version 3.0 EQIA Yes 01/04/2013 Author / Contact Dr Sonia Allam, Consultant Anaesthetist Group Committee – ERAS Steering Group Final Approval This document can, on request, be made available in alternative formats

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Management of Policies Procedure control sheet (Non clinical documents only) Enhanced Recovery After Surgery (ERAS) Pain Management Guidelines Colorectal

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Consultation and Change Record – for ALL documents Contributing Authors:

Dr Sonia Allam, Dr Mark Worsley, Dr Peter Beatty Dr S Lakshminarayan

Consultation Process:

ERAS Steering, Operational and Working Groups; Dept of Anaesthesia Clinical Meetings; Theatre Senior Nurses

Distribution: Change Record

Date

Author

Change

Version

27.1.16

All

Multiple (below)

3.0

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1. Introduction An Enhanced Recovery Programme is about improving patient’s outcomes and speeding up recovery after surgery. There are benefits to both patients and staff. Enhanced Recovery After Surgery (ERAS) is a recognised integrated, multimodal approach to perioperative care, designed to minimise post operative organ dysfunction and return the patient to normality as soon as possible. 2. Policy Statement This document provides guidance for pain management for ERAS patients undergoing major surgery 3. Scope The document covers: Colorectal – Anaesthesia and Pain Management Guidance for Open and Laprascopic Colorectal Surgery

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Anaesthesia for Enhanced Recovery Open Colorectal Surgery

The aim is to minimise physiological stress and achieve rapid post-op awakening and rapid return to normal ambulatory and bowel function, with minimal pain & post-op nausea and vomiting. Pre-op Information leaflet and education given at pre-op assessment clinic. Discuss anaesthetic, analgaesic (epidural or other techniques as appropriate, following discussion with surgeon) and ambulatory plan on admission (usually day of surgery). ‘You may have some pain, but we aim to keep this under control’. Avoid sedative premedication. Maintain good pre-op hydration. Nutritional support includes administration of carbohydrate drinks (Preload) night before and up to 2 hours pre-op (allow 30 mins to drink). (Surgeons now routinely avoiding ORAL bowel prep, but if used ensure IV fluids administered over night).

Intra-op Opiate sparing analgaesic options:   

 

Epidural, low thoracic, T9-11, aimed at mid wound level, and used intra-op to minimise stress response (ideally pre-incision) for midline or upper transverse incisions Or Rectus Sheath Catheters or blocks (currently HDU post op if catheters), for midline incisions. Or Lignocaine Infusion Bolus 1.5 mg/kg (over 20 mins) Then infusion of 1mg/min (patients < 70kg), or 2mg/min (patients > 70kg) for 12 hours, if going to HDU (or stop before leaving recovery if returning to ward). [i.e. using 1% lignocaine – infusion rates 6mls/hr or 12mls/hr depending on weight]. Intrathecal opiate +/- TAP blocks eg for low transverse incisions Or appropriate combinations based on planned surgery

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Short Acting General Anaesthetic – TIVA or Desflurane / Remifentanil TIVA, avoiding N2O, gives rapid, nausea free recovery. Target Controlled Infusion (TCI) via PK Pump Propofol 1% using Marsh PK model (unless experienced in Shneider model) Remifentanil 50g/ml (2mg in 40ml) An approximate guide (will vary with age, fitness etc), titrate to individual: Propofol target (Cpt) g/ml Remi target (Cpt) ng/ml

Induction and Intubation 3- 5 4- 6

Maintenance 2.5 – 4 3–5

Induction takes a few minutes longer than by bolus. Increase initial targets more gradually in the elderly/ patients with comorbidity, allowing Ce (effect site) to equilibrate with Cp. This approach in any patient will aid haemodynamic stability. Sometimes higher targets are needed early on after KTS, or on peritoneal stimulation, then lower targets are tolerated later on. Accumulation (propofol) may occur in prolonged cases. Effective analgaesic techniques may allow lower targets.

NDNMB eg. rocuronium 50mg at induction + PRN, modestly sized ETT, normocapnic ventilation, O2/air. Invasive monitoring only if indicated by co-morbidity, intraop cardiovascular instability despite fluid optimisation (see below) or nature of surgery. Fluids: Ringers Lactate (with colloid as appropriate) as guided by Oesophageal Doppler Monitoring, aiming for stroke volume optimisation (200-250 ml fluid challenges should be administered rapidly eg pressure bag or 50 ml syringe). Head down tilt test at start may be helpful in assessing and optimising filling. Aim is to optimise circulatory filling and organ perfusion, avoiding excess fluid accumulation in tissues. Vasopressors if required to maintain MAP (consider central venous access if high requirement for vasopressors despite adequate filling). At induction consider Droperidol 0.625m and Dexamethasone 6.6mg (non-cancer surgery) Granisetron 1mg or ondansetron 4mg IV, before closing abdomen. Paracetamol 1g IV. Normothermia maintained with hot air blanket & warmed fluids, monitor temperature hourly Prophylactic antibiotics within 30 mins prior to knife to skin. Urinary Catheter. TEDS and Pneumatic compression devices. Hourly BMs in Diabetes Mellitus (start insulin if BM > 11).

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Post-op (see also pain management guideline) Ward B11 or HDU if appropriate (comorbidity +/ or surgery). Epidural PCEA with L-bupivacaine 0.1% + fentanyl 2mcg/ml. Prescribe ephedrine 30mg PRN (oral or IM, 3hrly up to 150mg/day) for epidural related hypotension and 30 mins prior to mobilisation on first post op day (see epidural hypotension guideline). Rectus Sheath Catheter Top Ups (by trained anaesthetist, HDU post op) – 20mls 0.125% L Bupivicaine via each catheter 6 hourly (eg 06.00, 12.00, 18.00, 00.00) + Opioid PCA (aim to stop PCA at 24 hours if rectus sheath catheters used) Opioid PCA should be stopped at earliest and ideally by 48 hours. Lignocine infusion to stop at 12 hours (HDU), or when leaving recovery to ward. Regular oral paracetamol. Regular ibuprofen (day after surgery if no contraindications) Antiemetics x 2 (one antiemetic regularly eg ondansetron) Step down analgaesia: Continue regular paracetamol +/- ibuprofen. Oral opioid Basal IV fluids - Ringers Lactate, but encourage early oral fluid intake (clear fluid/ protein drinks) and drip down once oral fluids established. Replacement fluid – consider “prescribing” oral fluids before IV (R/L or colloid fluid challenges if necessary). Enoxaparin 40mg sc (reduce to 20mg in renal impairment, weight less than 50kg) and TEDS. Early mobilisation on first post-op day and thereafter Other aspects of ERAS as per ward plan/diary.

References for further reading: Kehlet H. Fast track colorectal surgery. Lancet 2008; 371:791. Lassen K et al. Consesnsus View of Optimal Perioperative Care in Colorectal Surgery (ERAS Group recommendations) Arch Surg 2009;144(10): 961-969 Fearon K et al. Enhanced recovery after surgery. Clinical Nutrition 2005;24:466-477. Mythen MG et al. Perioperative Fluid Management: Consensus statement from the enhanced recovery partnership. Perioperative Medicine 2012 1:2 Varandhan, KK, Lobo DN, Ljungqvist O, Enhanced Recovery After Surgery: The Future of Improving Surgical Care. Crit Care Clin. 2010 Jul;26(3):527-47 Varandhan, KK et al. The enhanced recover after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized trials. Clin. Nutr. 2010 http://www.erassociety.org/ Version 3.0

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Pain Management Guideline for ERAS - Major Colorectal OPEN Surgery Patient Controlled Epidural Analgesia (48 hrs) L Bupivacaine 0.1% + Fentanyl 2ug/ml (6-8mls/hr) + 4-8mls bolus 20 min lockout (depending on

Or

patient weight, wound size etc)

+ 

PCA Opioid – Fentanyl or Morphine (aim stop before 48hrs) +/- Rectus Sheath Catheter Top Ups (HDU only) L Bupivicaine 0.125% 20mls each catheter 6 hrly at 06.00, 12.00, 18.00, 00.00 (reduce dose if less than 50 Kgs) OR +/- 1% Lignocaine infusion for 12 hours (HDU) or return to ward OR +/- TAP blocks (lower transverse incisions)

+  

Paracetamol 1g orally 6hrly

Paracetamol 1g orally 6hrly Ibuprofen 400mg 8hrly (day after surgery, unless contraindicated)

Rescue Analgesia Epidural top up: bag mix or levobupivacaine by pain sister (page 1100) or anaesthetist duty out of hours (page 1821, 1029 or wifi 67688)

Opioid bolus

Epidural failure: Resite epidural if possible OR Opioid PCA

Step Down Analgesia Commencing 12 hours before planned discontinuation of PCEA or PCA: Oxycodone MR 5mg or 10mg BD + Oxycodone IR 5mg PRN for breakthrough pain - aiming to step down to only PRN Oxycodone IR as soon as able Continue Paracetamol 1g orally 6hrly, Ibuprofen 400mg 8hrly (unless contraindicated)

Discharge Analgesia Patients must have adequate discharge analgesia.  Regular paracetamol, regular ibuprofen (unless contraindicated) and an opioid if Anaesthesia for Enhanced Recovery Laparoscopic Colorectal necessary (dihydrocodeine 30-60mg 4 hourly as required), oneSurgery week supply only. Version 3.0

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Anaesthesia for Enhanced Recovery Laparoscopic Colorectal Surgery The aim is to minimise physiological stress and achieve rapid post-op awakening and rapid return to normal ambulatory and bowel function, with minimal pain & post-op nausea and vomiting. Pre-op Information leaflet and education are given at pre-op assessment clinic. Discuss anaesthetic, analgesic (i.e. spinal/ other techniques as appropriate) and ambulatory plan on admission (usually day of surgery). ‘You may have some pain, but we aim to keep this under control’. Avoid sedative premedication.

Maintain good pre-op hydration. Nutritional support includes administration of carbohydrate drinks (Preload) night before and up to 2 hours pre-op (allow 30 mins to drink). (Surgeons now routinely avoiding ORAL bowel prep, but if used ensure IV fluids administered over night).

Intra-op Opiate sparing analgaesic options: :  Spinal Anaesthesia with intrathecal opiate (Diamorphine or Morphine). Eg. Diamorphine 5-10 mcg/kg (in 2.5mls of L bupivicaine 0.25 or 0.5%) Patients receiving IT morphine should be 1st on the list, to ensure any complications detected in reasonable time frame (majority apparent within 10 hours). [Incidence of complications rises with IT morphine dose of ≥ 300mcg.] Attenuate dose in elderly. 

+/- Lignocaine Infusion Bolus 1.5 mg/kg (over 20 mins) Then infusion of 1mg/min (patients < 70kg), or 2mg/min (patients > 70kg) for 12 hours, if going to HDU (or stop before leaving recovery if returning to ward). [i.e. using 1% lignocaine – infusion rates 6mls/hr or 12mls/hr depending on weight].



OR TAP Block (eg lower transverse specimen delivery incisions)



Epidural, only if strong likelihood for requirement post op. Low thoracic, T9-11, aimed at mid wound level, and used intra-op to minimise stress response (ideally pre-incision).

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Short Acting General Anaesthetic – TIVA or Desflurane / Remifentanil TIVA, avoiding N2O, gives rapid, nausea free recovery. Target Controlled Infusion (TCI) via PK Pump Propofol 1% using Marsh PK model (unless experienced in Shneider model) Remifentanil 50g/ml (2mg in 40ml) An approximate guide (will vary with age, fitness etc), titrate to individual: Propofol target (Cpt) g/ml Remi target (Cpt) ng/ml

Induction and Intubation 3- 5 4- 6

Maintenance 2.5 – 4 3–5

Induction takes a few minutes longer than by bolus. Increase initial targets more gradually in the elderly/ patients with comorbidity, allowing Ce (effect site) to equilibrate with Cp. This approach in any patient will aid haemodynamic stability. Sometimes higher targets are needed early on after KTS, or on peritoneal stimulation, then lower targets are tolerated later on. Accumulation (propofol) may occur in prolonged cases. Effective analgaesic techniques may allow lower targets.

NDNMB eg. rocuronium 50mg at induction + PRN (good muscle relaxation may allow lower inflation pressures with respect to pneumoperitoneum) Modestly sized ETT, normocapnic ventilation, O2/air. Invasive monitoring only if indicated by co-morbidity. Fluids: Ringers Lactate as guided by Oesophageal Doppler Monitoring, aiming for stroke volume optimisation (200-250 ml fluid challenges should be administered rapidly eg pressure bag or 50 ml syringe). Head down tilt test prior to pneumoperitoneum may be helpful in assessing and optimising filling and reassess filling again post pneumoperitoneum. Aim is to optimise circulatory filling and organ perfusion, avoiding excess fluid accumulation in tissues. Vasopressors if required to maintain MAP. At induction consider Droperidol 0.625mg & Dexamethasone 6.6mg (non-cancer surgery) Granisetron 1mg or ondansetron 4mg IV, before closing abdomen. Paracetamol 1g IV Normothermia maintained with hot air blanket & warmed fluids, monitor temperature hourly Prophylactic antibiotics within 30 mins prior to knife to skin. Urinary Catheter. TEDS and Pneumatic compression devices. Hourly BMs in Diabetes Mellitus (start insulin if BM > 11). If Intrathecal opiates used suggest modest dose of IV opiate towards end of case to ensure smooth transition through recovery. Version 3.0

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Post-op (see also pain management guideline) Ward B11 or HDU if appropriate (comorbidity +/ or surgery). Regular oral paracetamol. Regular ibuprofen (day after surgery if no contraindications) Antiemetics x 2 (one antiemetic regularly eg ondansetron) PCA Opioid (Fentanyl or Morphine) – Aim stop by Midday following day OR Oral MR opioid with IR opioid for breakthrough pain Aim to step down to only PRN Oral IR opioid at earliest. If intrathecal morphine used, IR oral opioids PRN ONLY before first post-op morning [If Epidural left in situ use PCEA with L-bupivacaine 0.1% + fentanyl 2mcg/ml as per open colorectal surgery pain management guideline]. Encourage early oral fluid intake (clear fluid/ protein drinks) and drip down once oral fluids established, ideally by 12pm following day. Basal IV fluids - Ringers Lactate. Replacement fluid – consider “prescribing” oral fluids before IV (R/L or colloid fluid challenges if necessary). Enoxaparin 40mg sc (reduce to 20mg in renal impairment, weight less than 50kg) and TEDS. Early mobilisation on first post-op day and thereafter. Other aspects of ERAS as per ward plan/diary.

References: Levy BF et al. Optimizing patient outcomes in laparoscopic surgery Colorectal Disease 2011 13:s7, 8-11 Kehlet H. Fast track colorectal surgery. Lancet 2008; 371:791. Lassen K et al. Consesnsus View of Optimal Perioperative Care in Colorectal Surgery (ERAS Group recommendations) Arch Surg 2009;144(10): 961-969 Fearon K et al. Enhanced recovery after surgery. Clinical Nutrition 2005;24:466-477. Mythen MG et al. Perioperative Fluid Management: Consensus statement from the enhanced recovery partnership. Perioperative Medicine 2012 1:2 http://www.erassociety.org/

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Pain Management Guideline for ERAS - Major Laparoscopic Colorectal Surgery * Intrathecal Opioid, then 

Intrathecal Opioid (diamorphine only), then

Oxycodone MR 5 or 10mg BD

Or



- Commence DOS if IT Diamorphine - Commence 1st Post-op morning if IT Morphine.



+ Oxycodone IR 5mg, 2 hourly as required for breakthrough pain

PCA morphine: 1mg bolus, 5 min lockout OR Fentanyl: 10mcg bolus, 5 min lockout

Aim Stop by Midday following Day

+  

Paracetamol 1g orally 6hrly Ibuprofen 400mg 8 hrly (if no contraindications, from day after surgery

Step Down Analgesia Oxycodone IR 5mg PRN up to 2hrly for breakthrough pain Plus continue Paracetamol 1g orally 6hrly and Ibuprofen 400mg 8 hrly (if no contraindications)

Discharge Analgesia Patients must have adequate discharge analgesia. 

Regular paracetamol, regular ibuprofen (unless contraindicated) and an opioid if necessary (dihydrocodeine 30-60mg 4 hourly as required), one week supply only.

* If Epidural left in situ see Open Colorectal Guidelines Version 3.0

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Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact 01786 434784. For other formats contact 01324 590886, text 07990 690605, fax 01324 590867 or e-mail - [email protected]

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