Tag: Lidocaine

Multimodal Analgesia Pain Management

Methadone: perioperative use; acute and chronic pain

Buprenorphine

Orthopedic Surgery

Updates on Multimodal Analgesia for Orthopedic Surgery. Anesthesiol Clin. 2018 Sep;36(3):361-373.

Enhanced Recovery After Surgery (ERAS)

ERAS for general surgery

Cardiac ERAS

Non-Opioid Analgesics

Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg. 2017 Jul 1;152(7):691-697.

Preemptive Analgesia Decreases Pain Following Anorectal Surgery: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial. Dis Colon Rectum. 2018 Jul;61(7):824-829.

Gabapentinoids

Ketamine

Lidocaine

Regional Anesthesia

TAP block

Regional for Cardiothoracic Anesthesia

PECS and serratus blocks

Thoracic blocks: ESP, PVB, TEA block

Paravertebral catheters

Regional Anesthesia catheters

Adjuncts to prolong regional anesthesia

ERAS for Cardiac Surgery

ERAS for cardiac surgery. #eras #pain #multimodal #opioids #surgery #cardiac #perfusion #perfusionist

I have been utilizing ERAS in general surgery, OB, and ortho cases. Diving into one of my more tricky populations, I opted to see what ERAS practices are out there for cardiac surgery. Careful what you look for my friends. There’s actually a good amount of information out there!

Updated: Dec 2021

Up-To-Date: Anesthetic management for enhanced recovery after cardiac surgery (ERACS). Nov 2021.

Guidelines for Perioperative Care in Cardiac SurgeryEnhanced Recovery After Surgery Society Recommendations.  JAMA Surg. 2019;154(8):755-766. doi:10.1001/jamasurg.2019.1153

ERAS CS: Opioid Reduction Strategies in Cardiac Surgery – STS 8 in 8 Series. Sept 2020.

ERAS CS: Standardizing Evidence Based Best Practice in Periopertive Cardiac Surgical Care. Nov 2020.

CTSNet: “Cardiac Surgery Re-start and Beyond – Optimizing ICU Resource Utilization and Patient Safety”. Sept 2020.

CTSNet: “Enhanced Recovery After Cardiac Surgery Part II: Intraoperative and Postoperative.” June 2019.

CTSNet: ERAS Guidelines for Perioperative Care in Cardiac Surgery. July 2019.

ACCRAC podcast: ERAS for Cardiac Surgery

ERAS Cardiac Consensus Abstract – April 2018

Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: a randomized clinical trial. European Journal of Cardio-Thoracic Surgery, Volume 54, Issue 3, 1 September 2018, Pages 491–497, https://doi.org/10.1093/ejcts/ezy100

** Audio PPT ** American Association for Thoracic Surgery: Enhanced Recovery After Cardiac Surgery. April 2018

The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. The Journal of Thoracic and Cardiovascular Surgery. April 2018Volume 155, Issue 4, Pages 1843–1852.

Enhanced Recovery for Cardiac Surgery. J Cardiothorac Vasc Anesth. 2018 Jan 31. pii: S1053-0770(18)30049-1. DOI: https://doi.org/10.1053/j.jvca.2018.01.045

ERAS
From Journal of Anesthesiology
 
Aggregation of Marginal Gains in Cardiac Surgery: Feasibility of a Perioperative Care Bundle for Enhanced Recovery in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth. 2016 Jun;30(3):665-70. doi: 10.1053/j.jvca.2016.01.017. Epub 2016 Jan 16.
 

A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg. 2017 Jan;153(1):118-125.e1. doi: 10.1016/j.jtcvs.2016.09.016. Epub 2016 Sep 19.

Clinical Trial: The Safety and Efficacy of the Enhanced Recovery After Surgery(ERAS) Applied on Cardiac Surgery With Cardiopulmonary Bypass: a Single Center, Randomized, Controlled Clinical Study. May 2017.

A Multidisciplinary Protocol-Driven Approach to Improve Extubation Times After Cardiac Surgery. Ann Thorac Surg 2018;105:1684–90.

Enhanced Recovery After Cardiac Surgery Society

**Enhanced Recovery After Cardiac Surgery Society Expert Recommendations**

My blog posts:

Key Points

  • Level 1 (Class of recommendation=Strong Benefit):
    • Tranexamic acid or epsilon aminocaproic acid should be administered for on-pump cardiac surgical procedures to reduce blood loss.
    • Perioperative glycemic control is recommended (BS 70-180; [110-150]).
    • A care bundle of best practices should be performed to reduce surgical site infection.
    • Goal-directed therapy should be performed to reduce postoperative complications.
    • A multimodal, opioid-sparing, pain management plan is recommended postoperatively
    • Persistent hypothermia (T<35o C) after CPB should be avoided in the early postoperative period. Additionally, hyperthermia (T>38oC) should be avoided in the early postoperative period.
    • Active maintenance of chest tube patency is effective at preventing retained blood syndrome.
    • Post-operative systematic delirium screening is recommended at least once per nursing shift.
    • An ICU liberation bundle should be implemented including delirium screening, appropriate sedation and early mobilization.
    • Screening and treatment for excessive alcohol and cigarette smoking should be performed preoperatively when feasible.
  • Level IIa (Class of recommendation=Moderate Benefit)
    • Biomarkers can be beneficial in identifying patients at risk for acute kidney injury.
    • Rigid sternal fixation can be useful to reduce mediastinal wound complications.
    • Prehabilitation is beneficial for patients undergoing elective cardiac surgery with multiple comorbidities or significant deconditioning.
    • Insulin infusion is reasonable to be performed to treat hyperglycemia in all patients in the perioperative period.
    • Early extubation strategies after surgery are reasonable to be employed.
    • Patient engagement through online or application-based systems to promote education, compliance, and patient reported outcomes can be useful.
    • Chemical thromboprophylaxis can be beneficial following cardiac surgery.
    • Preoperative assessment of hemoglobin A1c and albumin is reasonable to be performed.
    • Correction of nutritional deficiency, when feasible, can be beneficial.
  • Level IIb (Class of recommendation=Weak Benefit)
    • A clear liquid diet may be considered to be continued up until 4 hours before general anesthesia.
    • Carbohydrate loading may be considered before surgery.

ERAS for cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia

Volume 32, Issue 6, December 2018, Pages 2760-2770.

grant.eracs_.jtcvs-002.pdf

multimodal-analgesia-protocol-pocket-card.pdf

Cardiac ERAS. JCVA 2020. PDF.

**Guidelines for Perioperative Care in Cardiac SurgeryEnhanced Recovery After Surgery Society Recommendations. JAMA, May 2019.**

Enhanced Recovery After Surgery (ERAS)

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Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011 Oct; 5(5): 342–348.

Dario Bugada, Valentina Bellini, Andrea Fanelli, et al., “Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach,” Surgery Research and Practice, vol. 2016, Article ID 3561249, 6 pages, 2016. doi:10.1155/2016/3561249

Enhanced Recovery After Surgery: If You Are Not Implementing it, Why Not? PRACTICAL GASTROENTEROLOGY • APRIL 2016.

A Systematic Review of Enhanced Recovery After Surgery Pathways: How Are We Measuring ‘Recovery?’ Session: Poster Presentation. Program Number: P613

46210

Sturm L and Cameron AL. Fast-track surgery and enhanced recovery after surgery (ERAS) programs. ASERNIP-S Report No. 74. Adelaide, South Australia: ASERNIP-S, March 2009.

Summary of Enhanced Recovery after Surgery Guideline Recommendations. Canada.

Patients Benefit From Enhanced Recovery Programs: Are Better Prepared for Surgery, Have Less Pain, Studies Show. Oct 2016. American Society of Anesthesiologists.

Enhanced Recovery after Surgery Guideline: Perioperative Pain Management in Patients Having Elective Colorectal Surgery: A Quality Initiative of the Best Practice in General Surgery Part of CAHO’s ARTIC program. April 2013.

Preserved Analgesia With Reduction in Opioids Through the Use of an Acute Pain Protocol in Enhanced Recovery After Surgery for Open Hepatectomy. Regional Anesthesia & Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 451–457.

Regional Anesthesia for surgery and other comparative studies. Sweden.

ERAS: Role of Anesthesiologist. UTSW.

Stanford Anesthesia ERAS pathway website

13012_2017_597_fig6_html

Enhanced Recovery after Surgery Versus Perioperative Surgical Home: Is It All in the Name? Anesthesia & Analgesia: May 2014 – Volume 118 – Issue 5 – p 901–902

The Role of Regional Anesthesia in ERAS pathways. Sept 2015. UCSF.

ERAS Pathway Improves Analgesia, Opioid Use and PONV Following Total Mastectomy. Anesthesiology News. May 2016.

Anesthesia Practice and ERAS. Cooper University Hospital. 2017.

ERAS: Anesthesia Tutorial of the Week. Number 204. Nov 2010.

ERAS and Anesthesia. Anesthesia Business Consultants. May 2015.

All about ERAS: Why anesthesiologists need to understand this concept. Becker’s ASC Review. June 2015.

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I’d love to incorporate my findings and use of lidocaine infusions and ketamine infusions on intraoperative and postoperative pain as a multimodal pain management pathway.

What we’re using:

  • July 2020
    • Acetaminophen 1g PO (cardiac, gen surg)
    • Celebrex 400mg PO (gen surg)
    • Gabapentin 600mg PO (gen surg)
    • Lyrica 75mg PO (cardiac)
    • Entereg mg PO (gen surg)

Enhanced Recovery After Surgery (ERAS)

Enhanced recovery after surgery #ERAS #anesthesia #pain #recovery

srv160008f1

Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011 Oct; 5(5): 342–348.

Dario Bugada, Valentina Bellini, Andrea Fanelli, et al., “Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach,” Surgery Research and Practice, vol. 2016, Article ID 3561249, 6 pages, 2016. doi:10.1155/2016/3561249

Enhanced Recovery After Surgery: If You Are Not Implementing it, Why Not? PRACTICAL GASTROENTEROLOGY • APRIL 2016.

A Systematic Review of Enhanced Recovery After Surgery Pathways: How Are We Measuring ‘Recovery?’  Session: Poster Presentation. Program Number: P613

46210

Sturm L and Cameron AL. Fast-track surgery and enhanced recovery after surgery (ERAS) programs. ASERNIP-S Report No. 74. Adelaide, South Australia: ASERNIP-S, March 2009.

Summary of Enhanced Recovery after Surgery Guideline Recommendations. Canada.

Patients Benefit From Enhanced Recovery Programs: Are Better Prepared for Surgery, Have Less Pain, Studies Show. Oct 2016. American Society of Anesthesiologists.

Enhanced Recovery after Surgery Guideline: Perioperative Pain Management in Patients Having Elective Colorectal Surgery: A Quality Initiative of the Best Practice in General Surgery Part of CAHO’s ARTIC program. April 2013.

Preserved Analgesia With Reduction in Opioids Through the Use of an Acute Pain Protocol in Enhanced Recovery After Surgery for Open Hepatectomy. Regional Anesthesia & Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 451–457.

Regional Anesthesia for surgery and other comparative studies. Sweden.

ERAS: Role of Anesthesiologist. UTSW.

Stanford Anesthesia ERAS pathway website

13012_2017_597_fig6_html

Enhanced Recovery after Surgery Versus Perioperative Surgical Home: Is It All in the Name? Anesthesia & Analgesia: May 2014 – Volume 118 – Issue 5 – p 901–902

The Role of Regional Anesthesia in ERAS pathways. Sept 2015. UCSF.

ERAS Pathway Improves Analgesia, Opioid Use and PONV Following Total Mastectomy. Anesthesiology News. May 2016.

Anesthesia Practice and ERAS. Cooper University Hospital. 2017.

ERAS: Anesthesia Tutorial of the Week. Number 204. Nov 2010.

ERAS and Anesthesia. Anesthesia Business Consultants. May 2015.

All about ERAS: Why anesthesiologists need to understand this concept. Becker’s ASC Review. June 2015.

hqdefault

 

I’d love to incorporate my findings and use of lidocaine infusions and ketamine infusions on intraoperative and postoperative pain as a multimodal pain management pathway.

Lidocaine infusions for pain

From Anesthesiology 2017

BJA Educ, April 2016. Intravenous lidocaine for acute pain: an evidence-based clinical update

Lidocaine Infusion for Perioperative Pain Management – Vanderbilt

Cocharane Library, July 2015. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery.

Perioperative Use of Intravenous Lidocaine. Anesthesiology 4 2017, Vol.126, 729-737.

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Open Access Journals, Jan 2017. Lidocaine Infusion: A Promising Therapeutic Approach for Chronic Pain.

Anesthesiology, April 2017. Perioperative use of IV lidocaine.

From Jama Surgery 2017

Here’s what I’m currently using:

  • October 2017
  • Lidocaine bolus: 1.5mg/kg on induction
  • Infusion: 2-3mg/kg/hr after induction to end surgery
  • If cardiac on CPB: bolus 1.5mg/kg on induction; Infusion: 4 mg/min x 48 hrs or discharge from ICU; On CPB bolus 4 mg/kg.
  • July 2020
  • I moved away from lidocaine infusions for pain bc they didn’t seem to help with postoperative cognitive decline.
  • Excel spreadsheet for dosing

I’m also currently working on ERAS protocols for my practice as well as the use of ketamine infusions for intraoperative and postoperative pain and recovery.

Lidocaine infusions for pain

From Anesthesiology 2017

BJA Educ, April 2016. Intravenous lidocaine for acute pain: an evidence-based clinical update

Lidocaine Infusion for Perioperative Pain Management – Vanderbilt

Cocharane Library, July 2015. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery.

Perioperative Use of Intravenous Lidocaine. Anesthesiology 4 2017, Vol.126, 729-737.

30tt01

Open Access Journals, Jan 2017. Lidocaine Infusion: A Promising Therapeutic Approach for Chronic Pain.

Anesthesiology, April 2017. Perioperative use of IV lidocaine.

From Jama Surgery 2017

 

Here’s what I’m currently using:

  • October 2017
    • Lidocaine bolus: 1.5mg/kg on induction
    • Infusion: 2-3mg/kg/hr after induction to end surgery
    • If cardiac on CPB: bolus 1.5mg/kg on induction; Infusion: 4 mg/min x 48 hrs or discharge from ICU; On CPB bolus 4 mg/kg.

I’m also currently working on ERAS protocols for my practice as well as the use of ketamine infusions for intraoperative and postoperative pain and recovery.

Blunting hemodynamic response to tracheal intubation #anesthesia

2% Lidocaine HCl preparation, pre-filled AbboJ...
Image via Wikipedia

https://secure.muhealth.org/~ed/students/articles/AnesthAnalg_72_p0482.pdf

This is an older study done that looked at placebo, lidocaine, fentanyl, and esmolol to blunt the effects of tracheal intubation/DL that typically occurs with it.  They looked at MAP/SBP and HR.  From their data, it appears that esmolol is the winner.  However, the doses of medication were not titrated to body weight.  It seems that everyone got the same dose.  Also, looks like everyone received pancuronium, a nice cardioaccelerator.  But, for what it’s worth, I can see using esmolol on pt’s who need perfect HR/BP control and no CHF.

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