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Review of Eras Pain Management Protocols 115

shows that prophylactic administration of dexamethasone and ondansetron on anes-

thesia induction and haloperidol administration at the end of surgery reduces post-

operative pain intensity and opioid use in Laparoscopic sleeve gastrectomies [52,

53]. Anger et al. conducted a systematic review study with the intention of devel-

oping guidelines for the management of postoperative pain after primary elective

total hip arthroplasty. This group found a signiﬁcant value for the incorporation of

dexamethasone in perioperative multimodal analgesia- causing reduced pain, earlier

patient ambulation, reduced morphine consumption, and reduced PONV. 10 mg of

perioperative dexamethasone had a signiﬁcant effect on reducing postoperative pain,

opioid consumption in the ﬁrst 24 h, and correlates with early ambulation and a

shorter length of hospital stay. Furthermore, 10 mg dexamethasone administration

24 h postoperatively reduced morphine consumption on day two and was associated

with a shorter length of stay when compared with a single dose [54]. In addition,

a systematic review by Singh et al. showed that both intravenous and perineural

administration of dexamethasone decrease the occurrence of rebound pain following

a peripheral nerve block administered for postoperative pain management [ 55].

12 NMDA Receptor Antagonists and Ketamine

Ketamine is an NMDA receptor antagonist commonly administered as a general

anesthetic induction agent and multimodal perioperative pain management adjunct.

Typically used in conjunction with opioids, ketamine enhances opioid effects and

contributes to the alleviation of chronic pain [56]. In higher dosages, the use of

ketamine is suboptimal owing to undesirable effects, including hallucinations, night-

mares, nausea, dizziness, and blurred vision. Additionally, evidence regarding the

efﬁcacy of lower doses in managing acute postoperative pain has been inconclusive

[57]. Current literature does not provide sufﬁcient evidence to support the routine use

of ketamine perioperatively to reduce postoperative pain. Furthermore, the dosing of

ketamine across different studies varied greatly with studies providing an induction

bolus ranging from 0.1 mg/kg to 1 mg/g and continuous IV infusions postopera-

tively for 24 h ranging from 2 mcg/kg/hr to 250 mcg/kg/hr [58–60]. Meyer-Friebem

et al. conducted a systematic review and meta-analysis to evaluate the effects of peri-

operative ketamine on postoperative pain management and found, with low conﬁ-

dence, that ketamine had mild and insigniﬁcant pain reducing effects. However, they

found, with moderate conﬁdence, a signiﬁcant effecton reducing morphine consump-

tion post-operatively. They did not include a meta-analysis of the ketamine-related

adverse effects due to the low quality of evidence. Their study mainly included

randomized controlled trials in spine surgery and lower limb orthopedic surgery

settings [58]. A meta-analysis by Wang et al. looking at the effects of ketamine

on pain management in Cesarean sections showed that Ketamine administration

reduces pain and reduces opioid consumption postoperatively. This study also did

not include an analysis of ketamine-related side effects due to the low amount of

evidence [59]. A randomized, prospective, double-blinded, and placebo-controlled

https://t.me/med1917

116 G. Yacoub et al.

study by Loftus et al. indicates that administering intraoperative ketamine can result

in decreased opiate usage during the 48 h following surgery in patients with chronic

pain and opiate dependency. Furthermore, ketamine may contribute to lower opioid

consumption and reduced pain intensity throughout the entire postoperative period

[61]. A meta-analysis by Mariscal et al. showed that ketamine administration had no

signiﬁcant effect on postoperative pain but signiﬁcantly reduced postoperative opioid

administration in adolescent idiopathic scoliosis patients undergoing spinal fusion

[60]. Overall, the literature studying the beneﬁts of including ketamine in multimodal

analgesia is inconsistent and inconclusive. Furthermore, there is a lack of sufﬁcient

data analyzing the signiﬁcance and prevalence of ketamine-related adverse effects

including hallucinations, confusion, and prolonged intubation.

13 Central α-2 Agonists

Central α-2 agonists inhibit norepinephrine release from presynaptic neurons and

centrally induce analgesia via the locus coeruleus [62]. These effects block with-

drawal symptoms in opioid users but also reduce a patient’s need for additional

anesthetics or sedatives [63]. Despite being shown to reduce postoperative pain and

opioid consumption, alpha-2 agonists, like dexmedetomidine and clonidine, are asso-

ciated with adverse events including bradycardia, hypotension, and sedation. A meta-

analysis was conducted by Yu et al. evaluating randomized control trials in a variety of

operative settings including thoracic, breast, gynecological, urological, and abdom-

inal surgeries to evaluate the effect of dexmedetomidine on postoperative pain and

opioid consumption. These studies evaluated in this analysis used dexmedetomidine

for inducing or maintaining anesthesia, or both. The studies all used a narrow dosing

range of 0.1–1 mcg/kg for bolus administrations and 0.1-1mcg/kg/hr for anesthesia

maintenance. This study shows that the use of dexmedetomidine signiﬁcantly reduces

postoperativepain at the 2 and 4 h mark and signiﬁcantly reduces the need for postop-

erative rescue analgesia. Furthermore, the use of dexmedetomidine reduces PONV

occurrence and opioid consumption. However, side effects reported include signiﬁ-

cant increase in risk of bradycardia and signiﬁcantly prolonged time until extubation

for patients in the dexmedetomidine group [64]. Heybati et al. performed a similar

analysis with the goal of determining the effects of different analgesics speciﬁcally in

the adult cardiac surgery setting. Their analysis shows, with moderate to high conﬁ-

dence, that use of clonidine or dexmedetomidine signiﬁcantly reduces postoperative

pain at the 24-h mark [40]. Ding et al.’s meta-analysis study on laparoscopic gyneco-

logic surgeries shows, with high conﬁdence, that dexmedetomidine administration

reduces postoperative pain and opioid consumption at 24 h [24]. A meta-analysis

by Wang et al. analyzing the effects of perioperative dexmedetomidine (0.5-2mcg/

kg) on postoperative pain in the primary total hip or knee arthroplasty setting shows

that dexmedetomidine signiﬁcantly reduced pain at 24 h and risk of PONV but was

associated with signiﬁcantly increased risk of bradycardia [65].

https://t.me/med1917

Review of Eras Pain Management Protocols 117

14 Conclusion

ERAS protocols are an imperative component of contemporary perioperative anes-

thetic and analgesic care. Effective implementation of these protocols promises an

opportunity to optimize patient outcomes and speed recovery. A key component of

ERAS pathways includes multimodal analgesia, a strategy that combines various

analgesic techniques to effectively manage pain while minimizing the reliance on

opioids. This approach reduces postoperative pain and opioid-related side effects.

Integrating multimodal analgesia into ERAS protocols has improved patient comfort,

facilitated early mobilization, and contributed to a faster overall recovery. The

combined impact of ERAS and multimodal analgesia emphasizes a comprehensive

and patient-focused strategy in surgical care, promoting improved results and a more

streamlined healthcare experience.

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8538

https://t.me/med1917

Preoperative Preparation for Regional

Anesthesia

Melanie Donnelly and Peter W. Coleman

Abstract Patients present for surgery with a myriad of concerns that may impact

perioperative pain management and functional recovery. In addition, these patients

may present with complicated analgesic regimens, be exposed to unprescribed anal-

gesics, or have a history of abuse and discussions with patients regarding these

factors can simultaneously build rapport and improve adherence with collaboratively

constructed analgesic plans. Regional anesthesia is a unique analgesic component

which may either be the sole anesthetic for a surgery, or a critical part of postop-

erative pain management. It may also be an additional source of stress and anxiety

for patients and their friends and family on the day of surgery. As a component of

a comprehensive perioperative analgesic discussion, adequate preoperative prepara-

tion for regional anesthesia may not only improve patient satisfaction and reduce

anxiety, but also improve patient outcomes.

Keywords Regional Anesthesia

· Preoperative education · Postoperative pain ·

Patient centered · Decision aids

1 Introduction

Preoperativepatient education improvesmultiple endpoints of patient care. The anes-

thesiologist often faces barriers to timely involvement in preoperative preparation.

Regional anesthesia is a unique and beneﬁcial modality which, while an important

part of many perioperative plans, is often poorly introduced to patients prior to the

day of surgery. Several approaches to preoperative preparation, including web based

M. Donnelly (

) · P. W. Coleman

Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA

e-mail: mdonnelly@mcw.edu

P. W. Coleman

e-mail: peter.coleman@cuanschutz.edu

P. W. Coleman

Anesthesiology, University of Colorado, Aurora, USA

A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,

https://doi.org/10.1007/978-3-031-67648-2_9

123

https://t.me/med1917

124 M. Donnelly and P. W. Coleman

and written modalities, have demonstrated not only improved patient satisfaction and

decreased patient anxiety but also improved patient outcomes. These may be applied

to preoperative preparation for regional anesthesia.

2 Discussion

In 2001, the Institute of Medicine established a framework for the assessment of

health care quality. A component of this framework included the domain of “patient-

centered” care which is “Providing care that is respectful of and responsive to indi-

vidual patient preference, needs and values and ensuring that patient values guide

all clinical decisions” [1]. Supporting this principle, the American Pain Society

published guidelines in 2016 which recommend “…patient and family centered indi-

vidually tailored education to the patient, including information on treatment options

for the management of postoperative pain….” The guidelines also promote the use

of a shared decision-making process to create an individually tailed pain manage-

ment plan. It has been shown that patient engagement and collaborative decision-

making processes between providers and patients in healthcare, result in improved

health outcomes [2, 3]. The demonstrated beneﬁts of preoperative education include

decreased length of stay, increased patient and family satisfaction, reduced opioid

use, and reduced patient anxiety [4, 5].

In the course of providing anesthesia care and perioperative pain management,

unique challenges to providing patient centered care and comprehensive preopera-

tive education may emerge [6]. One of the major barriers is related to the typical

timing of a preoperative visit between a patient and their anesthesiologist. In many

medical centers, anesthesiologists only become involved with patient care on the

day of surgery in the preoperative holding area. By this time, patients have made the

decision to proceed with surgery and it is more likely that this preoperative conversa-

tion focuses on medical history and planned anesthetic pathways rather than on the

patients’ overall goals of health and values exploration. As Clapp so aptly pointed

out, when the anesthesiologist meets patients on the day of surgery, the anesthesia

and consent process may be seen by the patient as part of a “package of care that has

already been decided upon in the surgeon’s ofﬁce” [7]. Clapp also points out that the

anesthesia concerns in this setting may be subordinate to concerns speciﬁcally related

to the surgical plan. Additionally, there is frequently intense time pressure in the

preoperative day of surgery environment, with anesthesiologists often being allotted

only 5–10 min with a patient prior to surgery. In this short time period, it would be

challenging to have the necessary conversations to accomplish collaborative decision

making about patient care. Further, patients may be anxious or overwhelmed by the

unfamiliarity of the environment, the prospect of post-operative pain, the idea of total

loss of control when “going under” or any number of other legitimate psychological

stressors.

There are a number of reasons to implement pre-operative education programs

or pathways that focus on anesthesia and surgery prior to the day of surgery. The

https://t.me/med1917

Preoperative Preparation for Regional Anesthesia 125

most common stressors for patients having surgery are “lack of knowledge and fear

of the unknown” which can lead to anxiety about and around the experience [8].

Both of these can be, at least partially, alleviated with preoperative contact and effec-

tive preoperative education [8]. Given the constraints around time and contact with

patients on the day of surgery, there may be some beneﬁt to creating workﬂows

and materials that would provide preoperative education to patients regarding anes-

thesia. These could incorporate decision aids to further prepare patients to have more

informed conversations with their anesthesiologists on the day of surgery.

Perioperative surgical home literature has demonstrated that early patient engage-

ment can be beneﬁcial to both the patient and healthcare system by supporting patients

in their decision making, establishing expectations around surgery and anesthesia,

and opening the lines of communication [3]. In joint arthroplasty patients and those

having colonic surgery, it has been demonstrated that preoperative education and

counseling can be part of a care pathway which may lead to lessened complication

rates and lower readmission rates [3, 9, 10].

3 Patient Outcomes

In order to optimize postoperative recovery, patients must understand what support

they will beneﬁt from and what to expect during the recovery process. Barriers to

patients’ experiencing optimal recovery include preoperative anxiety, which has been

shown to be a predictor of higher pain scores for a wide range of surgeries [11]. Even

in what might be considered minor surgery, preoperative mental state can have a

large impact on postoperative recovery [11].

Fear and anxiety surrounding anesthesia and surgery may be the result of fear of

the unknown and knowledge deﬁcits about the process. Patients indicate that some

concerns about anesthesia include fear of dying during anesthesia (8–55%), being

awake during anesthesia (5–54%), postoperative pain (5–65%) and post-operative

nausea (5–48%) [12] Though many studies have discovered the positive impact on

anxiety related to preoperative education[14–17], there are some that demonstrate

no improvement in anxiety [12, 18].

Preoperative education for patients regarding anesthesia has been predominantly

shown to reduce anxiety surrounding the surgical experience and improve satisfac-

tion. One group examined the impact of preoperative education on anxiety levels

before surgery in patients s cheduled for total joint arthroplasty [13]. The preopera-

tive education provided included pamphlets and a video prepared by the American

Society of Regional Anesthesia and Pain Medicine (now ASRA Pain Medicine). In

this study, sharing preoperative education materials was shown to signiﬁcantly mini-

mize the increase in anxiety on the day of surgery. Interestingly, despite this positive

ﬁnding, about 70% of both the intervention group and control group reported that

anesthesia options for surgery had not been discussed prior to meeting with their

anesthesia professionals on the day of surgery. These ﬁndings did indicate that those

patients in the intervention group were more likely to prefer regional anesthesia and

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