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A Standardized Multimodal Analgesia Protocol Reduces Perioperative Opioid Use in Minimally Invasive Colorectal Surgery

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Multimodal analgesia protocols are becoming a common part of enhanced recovery pathways after colorectal surgery. However, few protocols include a robust intraoperative component in addition to pre-operative and post-operative analgesics.

Method

A prospective cohort study was performed in an urban teaching hospital in patients undergoing minimally invasive colorectal surgery before and after implementation of a multimodal analgesia protocol consisting of pre-operative (gabapentin, acetaminophen, celecoxib), intraoperative (lidocaine and magnesium infusions, ketorolac, transversus abdominis plane block), and post-operative (gabapentin, acetaminophen, celecoxib) opioid-sparing elements. The main outcome measure was use of morphine equivalents in the first 24-h post-operative period.

Results

The study cohort (n = 71) included 41 patients before and 30 patients after implementation of a multimodal analgesia protocol. Mean age of the entire study cohort was 47 ± 19.7 years and 46% were male. Patients undergoing surgery post-multimodal analgesia vs. pre-multimodal analgesia had significantly lower use of IV morphine equivalents in first 24-h post-operative period (5.8 ± 6.4 mg vs. 22.8 ± 21.3 mg; p = 0.005) and first 48-h post-operative period (7.6 ± 9.4 mg vs. 42 ± 52.9 mg; p = 0.0008). This reduction in IV morphine equivalent use post-multimodal analgesia was coupled with improved pain scores in the post-operative period. Post-operative hospital length of stay, post-operative ileus, and overall complications were not significantly different between groups.

Conclusions

Multimodal analgesia incorporating pre-operative, intraoperative, and post-operative opioid-sparing agents is an effective method for reducing perioperative opioid utilization and pain after minimally invasive colorectal surgery.

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Author information

Authors and Affiliations

  1. Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA, 90048, USA

    Angela Mujukian, Adam Truong, Phillip Fleshner & Karen Zaghiyan

  2. Department of Pharmacy, Cedars Sinai Medical Center, Los Angeles, CA, USA

    Hai Tran & Rita Shane

Authors
  1. Angela Mujukian
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Contributions

(per the International Committee of Medical Journal Editors (ICMJE) guidelines)

Angela Mujukian

• Substantial contributions to acquisition, analysis, or interpretation of data

• Original drafting; revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Adam Truong

• Substantial contributions to acquisition, analysis, or interpretation of data

• Revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Hai Tran

• Substantial contributions to conception and design of the work

• Revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Rita Shane

• Substantial contributions to conception and design of the work

• Revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Phillip Fleshner

• Substantial contributions to conception and design of the work

• Revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Karen Zaghiyan

• Substantial contributions to conception and design of the work; acquisition, analysis or interpretation of data

• Drafting and revision for critically important intellectual content

• Final approval of the version to be published

• Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

Corresponding author

Correspondence to Karen Zaghiyan.

Ethics declarations

The study was conducted in accordance with the ethical principles stated in the Declaration of Helsinki20 and local regulations. All research-related activities were approved by the Cedars-Sinai Medical Center Institutional Review Board (nos. 46571 and 54607). Written informed consent was obtained from all participants.

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The authors declare that they have no conflict of interest.

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Mujukian, A., Truong, A., Tran, H. et al. A Standardized Multimodal Analgesia Protocol Reduces Perioperative Opioid Use in Minimally Invasive Colorectal Surgery. J Gastrointest Surg 24, 2286–2294 (2020). https://doi.org/10.1007/s11605-019-04385-9

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