Table 4 Multimodal analgesic protocol for major intra-abdominal surgery ERAS care pathways included in the IMPAKT ERAS trial at Vanderbilt University Medical Center
Preoperative multimodal analgesic regimen: |
Acetaminophen: 1000 mg PO 1 h before OR time |
• Reduce to 650 mg PO if < 70 kg |
• avoid if Child score Class C liver disease |
Gabapentin: 100–300 mg PO 1 h before OR time |
• Reduce to 100 mg PO in patients > 65y |
• Consider not giving or reducing to 100 mg PO in patients > 75y |
• For those on home gabapentin, ensure that 100–150% of home dose was taken on AM of surgery (either at home or in preop holding area) |
Regional Analgesia: |
Mini-laparotomy or hand-assisted laparoscopy: |
• Truncal nerve blocks – bilateral transversus abdominis plane (TAP) and rectus sheath blocks |
◦ Ropivacaine 0.25% + dexamethasone 4 mg (30-45 mL/side total) |
Ostomy takedown/creation with unilateral incision |
• Bilateral TAP blocks (if ostomy above umbilicus, consider adding rectus sheath) |
◦ Ropivacaine 0.25% + dexamethasone 4 mg (30-45 mL/side total) |
Laparotomy: |
• Thoracic epidural catheter (TEC) with infusion starting at 8 mL/hr with 3 mL/15 min patient controlled epidural analgesia (PCEA) |
• 0.1% ropivacaine + 10 mcg/mL hydromorphone |
◦ Adjustment to rate and concentration determined by clinical outcomes in pain coverage and hemodynamics |
Intraoperative multimodal analgesic regimen: |
Opioids: No induction opioids, and minimize opioid use during anesthetic |
• If necessary, use esmolol for heart rate control and an anti-hypertensive of choice for BP control |
• Assess need for opioid upon emergence |
◦ Utilize methadone 5 mg IV bolus q5-10 min as first-line prior to other opioids |
Thoracic epidural: utilize if present, consider bolus with 0.125- 0.25% bupivacaine prior to incision |
Lidocaine infusion: 1.5 mg/kg bolus with induction, then 2 mg/min drip from induction to case end |
Ketamine infusion: 0.5 mg/kg IV bolus with induction, infusion of 5mcg/kg/min IV after induction until fascia closure (up to 100 kg) |
Ketorolac: 30 mg IV at fascia closure |
◦ reduce to 15 mg IV if > 65y, CrCl < 30, or patient weight < 50 kg |
◦ consider avoiding for h/o renal dysfunction or GI bleed |
Postoperative multimodal analgesic regimen: |
Lidocaine infusion for 24 h (continued from PACU or after TEC removed) |
• 1 mg/min IV if < 70 kg |
• 1.5 mg/min IV if 70–100 kg |
• 2 mg/min IV > 100 kg |
Ketamine Infusion for 48 h (continued from PACU) |
• 2.5 mcg/kg/min infusion (use patient’s body weight, up to a max of 100 kg) |
• Consider prolonging infusion for continued Nil Per OS or uncontrolled pain |
• Contraindications: increased intracranial pressure, increased intraocular pressure |
Acetaminophen 1000 mg PO Q8hr starting POD 0 until discharge |
• Reduce to 650 mg PO Q6h if < 70 kg |
• Reduce to 500 mg Q8h for liver disease |
• Don’t use if Child Class C liver disease |
Gabapentin 300–600 mg PO q8h starting POD 0 until discharge. |
Use lower dose for > 65y or if patient having significant sedation/dizziness |
Dose/frequency should be adjusted based on renal function: |
• CrCl > 60 ml/min: 300-1200 mg TID |
• CrCl > 30–59 ml/min: 200-700 mg BID |
• CrCl > 15-29 ml/min 200-700 mg once daily |
• CrCl < 15- reduce dose in proportion to CrCl ~ 100–300 mg once daily |
• ESRD requiring hemodialysis- dose based on CrCl, plus single supplemental dose of 125-250 mg after dialysis |
Ketorolac: 30 mg IV Q6h × 3 days |
• Reduce to 15 mg IV Q6h in patients > 65y, CrCl < 30, or weight < 50 kg |
Opioid PRN |
• Consider lowest possible dose and frequency for pain control |
• For opioid naïve patients: |
◦ First line: tramadol 50 mg q 4–6 H PRN (max 400 mg/24 h), for pain > 4/10 |
◦ Second line: oxycodone 5 mg PO Q4 PRN pain > 4/10 |
◦ Breakthrough pain: consider hydromorphone IV PRN bolus |
• For patients on chronic opioid therapy: ensure meeting 100–125% of home oral dose, with goal of avoiding significant opioid escalation |
Regional Analgesia: |
• Truncal nerve blocks can be repeated on POD 1 if uncontrolled pain is determined to be incisional |
• TEC, if present: continue with infusion at 8 mL/hr of 0.1% ropivacaine + 10 mcg/mL hydromorphone with 3 mL/15 min PCEA |
◦ Adjustment to rate and concentration determined by clinical outcomes in pain coverage and hemodynamics |
◦ Re-evaluate each day for the necessity of the epidural up to 5 days. It is typically removed on the day prior to anticipated discharge to ensure adequate pain control on an oral regimen |