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Better Pain Management Speeds Recovery after Colorectal Surgery

June 13th, 2016

Better Pain Management Speeds Recovery after Colorectal Surgery
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Dr. Anne Lin and Dr. Maxime Cannesson

Patients at UCLA Health will likely recover more quickly after colorectal surgery and return home sooner, thanks to better pain management techniques and other care improvements, as part of a program that will begin full implementation on June 15.

The new enhanced recovery program has developed best-practice protocols for the care of patients before, during, and after colorectal surgery, designed to improve comfort and speed recovery. The program is a collaborative effort on the part of the Department of Anesthesiology & Perioperative Medicine and the Department of Surgery's Section on Colon and Rectal Surgery, with the cooperation and support of nursing and pharmacy services.

One of the major initiatives involves pain management. Anne Lin, MD, Assistant Professor of Colon and Rectal Surgery, realized that some of her patients were staying in the hospital longer than average after surgery on the colon, small intestine, or rectum, because they were slow to recover bowel function after surgery. If they couldn't eat or drink sufficiently, they couldn't go home.

The chief culprit? Narcotic pain medications, such as morphine and hydromorphone (Dilaudid), that are often used to manage postoperative pain but may result in opioid-induced constipation (OIC). This problem is so common and may be so distressing that it was even the subject of a 2016 Super Bowl TV advertisement.

Anesthesiologist Maxime Cannesson, MD, PhD, Vice Chair for Perioperative Medicine, knew that his department could help. He enlisted the aid of Siamak Rahman, MD, who specializes in pain medicine. Dr. Rahman and other anesthesiologists on the Acute Pain Service are experts in regional anesthesia techniques, including a special type of ultrasound-guided nerve block for abdominal incisions called a "transverse abdominis plane" or "TAP" block.

Working with Dr. Lin, Dr. Rahman developed a plan to use a new long-acting local anesthetic (liposomal bupivacaine) in TAP blocks, and to give IV acetaminophen around the clock, to reduce the amount of Dilaudid and other opioid pain medications that colorectal surgery patients needed after surgery. The patients in their pilot study of this pain regimen recovered bowel function up to two days earlier than patients who received the usual medications.

Now the new enhanced recovery program is expanding beyond the pilot phase, and the scope now extends to other important issues in the care and recovery of colorectal surgery patients. UCLA is fortunate to have faculty physicians who specialize all of these different areas.

  • Dr. Cannesson is one of the founding members of the Anesthesia Society for Enhanced Recovery (ASER), and has performed extensive research on finding the "sweet spot" for the amount of IV fluid administered to patients during abdominal surgery-not too much, which can slow the return of bowel function, and not too little, which can adversely affect the kidneys.
  • Dr. Lin and her colleagues, Kevork Kazanjian, MD, the chief of the Section of Colon and Rectal Surgery, and Jonathan Sack, MD, are experts in minimally invasive surgical techniques, using special cameras and instruments to avoid large surgical incisions whenever possible.
  • Eilon Gabel, MD, MS, and Ira Hofer, MD, the anesthesiology department's Director of Clinical Informatics, are working on using information technology to capture data and provide real-time feedback to clinicians on using best practice protocols.
  • Nir Hoftman, MD, the Director of Thoracic Surgery Anesthesiology, and Karen Sibert, MD, are advising on the best techniques for ventilator management during surgery.
  • Nirav Kamdar, MD, MPP, and John Shin, MD, developed the protocol for optimal management of glucose control for diabetic patients, who are at higher risk for postoperative infections.
  • Anahat Dhillon, MD, Joe Hong, MD, John Shin, MD, and Keren Ziv, MD, collaborated on a protocol for the prevention of postoperative nausea and vomiting.

 

The enhanced recovery program's executive sponsors are Joe Hines, MD, Chief of the Division of General Surgery, and Aman Mahajan, MD, PhD, Chair of the Department of Anesthesiology & Perioperative Medicine. The project is supported by two experienced nurses with extensive background in quality improvement and patient safety: Hallie Chung, who is an expert in the National Surgical Quality Improvement Project and its standards of care, and Carol Lee, a surgical and anesthesia quality specialist.



Karen Sibert, MD

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