Perioperative care for acute pain management
Patients with chronic pain who are hospitalized have a higher risk of morbidity and mortality, longer lengths of stay, and more frequent readmissions than patients without chronic pain.
ORLANDO — Perioperative surgical homes and Enhanced Recovery After Surgery (ERAS) protocols can improve postoperative outcomes in patients with chronic opioid use. David Edwards, MD, PhD, from Vanderbilt University, discussed the role of perioperative surgical homes and ERAS protocols in acute pain management at the American Academy of Pain Medicine 33rd Annual Meeting in Orlando, Florida.1
Patients with chronic pain who are hospitalized have a higher risk of morbidity and mortality, longer lengths of stay, and more frequent readmissions than patients without chronic pain.2,3 Among patients who are hospitalized, pre-admission opioid use is common; in one study, 13% of inpatients at Massachusetts General Hospital reported taking opioids prior to admission.2
Preoperative chronic opioid use is associated with an increased risk for adverse events and poor outcomes. Opioid-tolerant patients have 20% longer lengths of stay and up to 3 times the rate of readmissions compared with patients without opioid tolerance.2 Preoperative opioid use is linked to greater disability, lower quality of life, and higher mortality in the postoperative period.1
“There are many goals of care for surgical patients that can only be met by 1) working as a team with our colleagues, and 2) implementing evidence-based practice along the entire care continuum,” Dr Edwards said in an interview with Clinical Pain Advisor. “This is what the perioperative surgical home and ERAS pathways of care help us do.”
A key element of the perioperative surgical home model includes reducing risk factors for poor outcomes by implementing behavioral changes during the preoperative period. For patients who are chronic opioid users, preoperative measures may include addressing anxiety or reducing opioid dose, which may lead to better postoperative outcomes. Comprehensive team-based and coordinated care may be achieved by engaging providers, from nurses to surgeons to the anesthesiologists, in the preoperative stage through the time of discharge.1
ERAS protocols embody the concepts of the perioperative surgical home and promote early postsurgical recovery by implementing evidence-based best practices. Essential components of ERAS protocols include optimizing preoperative care, using non-opioid analgesics to treat pain, and — if opioids are needed — controlling escalation of opioids to minimize risk. ERAS protocols have been shown to decrease lengths of stay and postsurgical complication rates by up to 30%.1
“An important outcome for patients is to limit the risks associated with opioids,” Dr Edwards said. “Perioperative surgical homes and ERAS protocols drastically reduce the need for opioids.”
- Edwards DA. Perioperative surgical home, engaging patients and providers to optimize acute pain management. Presented at: the American Academy of Pain Medicine 33rd Annual Meeting; March 16-19, 2017; Orlando, Florida.
- Gulur P, Williams L, Chaudhary S, Koury K, Jaff M. Opioid tolerance--a predictor of increased length of stay and higher readmission rates. Pain Physician. 2014;17(4):E503-E507.
- Herzig SJ, Rothberg MB, Cheung M, Ngo LH, Marcantonio ER. Opioid utilization and opioid-related adverse events in nonsurgical patients in US hospitals. J Hosp Med. 2014;9(2):73-81. doi: 10.1002/jhm.2102