Best Practices
Esophagectomy
All best practices are subject to change and may require modifications depending on a patient’s history and status. Healthcare practitioners should always defer to their clinical judgement and, whenever appropriate, consult with additional resources for further guidance.
| Preoperative | Intraoperative | Postoperative (Inpatient) | Discharge Strategies |
|---|---|---|---|
| •Acetaminophen •NSAIDs (consider selective COX-2 inhibitors for fewer side effects) •Low-dose gabapentinoids •Regional anesthesia ...oThoracic epidural ...oParavertebral block with catheter ...oErector spinae block ...oSerratus anterior block | •Dexamethasone 0.1 mg/kg •IV NSAIDs if not given preop •Consider IV ketamine •Run regional catheters if hemodynamicaly tolerated | •Opioid PCA for non-regional anesthesia patients and transition to oral pain medicine as soon as possible; consider tramadol^ as first line oral opioid •Continue regional anesthesia catheter techniques until ready for discharge assessment •Continue acetaminophen, NSAIDs and low-dose gabapentinoids ^The recommendation for tramadol is opinion from the Thompson et al. paper referenced below and is controversial as tramadol is a pro-drug and can have variable metabolism. Judicious use of any opioid to clinical effect is recommended in the postoperative pain setting. | MANAGEMENT OF PAIN W/O MEDICATION: Suggestions? CO-ANALGESICS: •Acetaminophen (regular dosing, defined duration) •NSAIDs (regular dosing, defined duration) •Consider gabapentinoids for presumed neuropathic pain (regular dosing, defined duration) OPIOID PRESCRIPTION*: 0-20 tabs |
^Gabapentinoids are often recommended for acute pain management in certain surgeries based on small studies. However, based on recent systematic reviews and meta-analysis there is limited evidence to support universal use. A provider’s clinical judgement is recommended on an individual case basis.
*All tabs for discharge are oxycodone, 5mg. To convert this dosage, please visit this page. For conversions involving oxycodone, please note that it is 50% more potent than morphine. If prior to discharge the patient tolerates tramadol 50mg, utilize this modality. We encourage prescribers to consider discharge prescriptions of short-acting opioids at the lowest effective dose, with the lowest potency, for the shortest duration.
Before surgery, and at the surgical safety checklist time, the surgical and anesthesia team should work together to develop a multimodal pain management plan with active strategies to optimize perioperative pain management.
Healthcare practitioners are also encouraged to help patients set realistic expectations around pain management, including the use of prescription medications. Additional useful information to enhance recovery after surgery can be found at Enhanced Recovery Canada.
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References
Chin KJ, Versyck B, Pawa A. Ultrasound-Guided Fascial Plane Blocks of the Chest Wall: A State-Of-The-Art Review. Anaesthesia. 2021 Jan;76 Suppl 1:110-26.
Felix MMDS, Ferreira MBG, da Cruz LF, Barbosa MH. Relaxation Therapy with Guided Imagery for Postoperative Pain Management: An Integrative Review. Pain Manag Nurs. 2019 02;20(1):3-9.
Low DE, Allum W, De Manzoni G, Ferri L, Immanuel A, Kuppusamy M, et al. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg. 2019 Feb;43(2):299-330.
Mehran RJ, Martin LW, Baker CM, Mena GE, Rice DC. Pain Management in an Enhanced Recovery Pathway After Thoracic Surgical Procedures. Ann Thorac Surg. 2016 Dec;102(6):e595-e596.
Overton HN, Hanna MN, Bruhn WE, Hutfless S, Bicket MC, Makary MA, et al. Opioid-Prescribing Guidelines for Common Surgical Procedures: An Expert Panel Consensus. J Am Coll Surg. 2018 10;227(4):411-8.
Shanthanna H, Moisuik P, O'Hare T, Srinathan S, Finley C, Paul J, et al. Survey of Postoperative Regional Analgesia for Thoracoscopic Surgeries in Canada. J Cardiothorac Vasc Anesth. 2018 08;32(4):1750-5.
Song C, Lu Q. Effect of Dexmedetomidine Supplementation for Thoracoscopic Surgery: A Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Surg. 2022 Apr 6;17(1):70.
Thompson C, French DG, Costache I. Pain Management Within an Enhanced Recovery Program After Thoracic Surgery. J Thorac Dis. 2018 Nov;10(Suppl 32):S3773-S3780.
Verret M, Lauzier F, Zarychanski R, Perron C, Savard X, Pinard AM, et al. Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis. Anesthesiology. 2020 08;133(2):265-79.
Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHaffie JG, et al. Mindfulness Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced Analgesia. J Neurosci. 2015 Nov 18;35(46):15307-25.
Zeidan F, Martucci KT, Kraft RA, Gordon NS, McHaffie JG, Coghill RC. Brain Mechanisms Supporting the Modulation of Pain by Mindfulness Meditation. J Neurosci. 2011 Apr 6;31(14):5540-8.
Treatment Altering Factors
Below are a few of the more common and/or impactful health factors that may result in deviation from the above best practices. Please note that the following list is not exhaustive and that the remarks for each factor are not surgery-specific. Healthcare practitioners should always defer to their clinical judgement and, if appropriate, consult with additional resources for further guidance. See our full disclaimer here.
Organ Dysfunction
Hepatic dysfunction/Excessive alcohol intake
| •In general: Limit or avoid acetaminophen altogether, depending on degree of hepatic dysfunction •Preoperative: Avoid or reduce dose of acetaminophen •Intraoperative: Decrease dose of opioids, benzodiazepines, meperdine •Postoperative: Reduce dose of acetaminophen •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Renal dysfunction
| •In general: Limit or avoid NSAIDs altogether, depending on degree of renal dysfunction •Preoperative: Avoid NSAIDs and use gabapentinoids cautiously •Intraoperative: Avoid morphine and meperidine •Postoperative: Avoid NSAIDs and use lower dose of gabapentin •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Patient Specific Factors
Advanced age
| •Preoperative: Due to the frequency of multiple comorbidities in advanced age, anesthesia preoperative consult as needed to preoptimize. Also, manage anticoagulants where indicated; avoid long delays in hip fracture patients and practice preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated •Postoperative: Regular dose acetaminophen; oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities |
Chronic pain and/or long-term opiate use
| •In general: May attempt to wean chronic opioids if surgery is to treat issues contributing to the chronic pain but otherwise continue chronic pain medication perioperatively if patient uses it •Preoperative: Anesthesia consult where indicated; continue preop opioids on day of surgery and give preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated; use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance •Postoperative: Use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance; regular dose acetaminophen and oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities and avoid opioid dose escalation from preop, if possible |
History of difficulty with postop pain management
| •Consider regional anesthetic techniques, if feasible for specific surgical procedure |
Uncontrolled anxiety/depressive symptoms
| •Preoperative: Consider anxiolytics prior to administration of anesthetic •Discharge: While reviewing expected duration of opioid use, as well as opioid safety strategies including the appropriate storage and disposal of unused pills, should be standard practice, it is of paticular importance with patients who have uncontrolled anxiety/depressive symptoms Special note for paediatric surgeries: Given the risk of opioid misuse in youth with depressive symptoms, consider heightened opioid safety factors including reviewing with caregivers at discharge |
System Disorders
Coagulopathy
| •Avoid neuraxial techniques if any abnormal coagulation; consider following ASRA guidelines |
Obstructive sleep apnea
| •Preoperative: Use multi-modal analgesia; reduce or avoid use of gabapentinoids •Intraoperative: Reduce or avoid benzodiazepines; reduce doses of opioid medications •Postoperative: Use multi-modal analgesia; reduce use of opioids and gabapentinoids •Discharge: Reduce opioid dosing |