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Table 1 An example of components of an ERP for colorectal surgery patients utilizing maximodal non-opioid analgesiaa

From: American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) Joint Consensus Statement on Optimal Analgesia within an Enhanced Recovery Pathway for Colorectal Surgery: Part 2—From PACU to the Transition Home

Perioperative period Components Adjustments/Notes
Preoperative Gabapentin: 300–600 mg PO >1 hour before OR time - Reduce to 300 mg PO in patients >65y
- Consider not giving or reducing to 100 mg PO in patients >75y
- Consider dose reduction in patients with OSA
Acetaminophen: 1000 mg PO >1 hour before OR time - Reduce to 650 mg PO if <70kg
- Don’t use if h/o significant liver disease
Bilateral TAP Blocks ± rectus sheath blocks OR thoracic epidural catheter - TAP - ropiv 0.25% + dex 4mg (25–30mL/side)
- Rectus sheath - ropiv 0.25% + dex 2 mg (10–12mL/side) [add rectus sheath blocks for if any portion of incision [e.g. periumbilical handport] or large ports above umbilicus]
- Thoracic epidural used for midline incision extending from above T8 to below umbilicus [use during intraoperative period]
Intraoperative No induction opioids; minimize opioid use during anesthetic - Volatile agent or propofol anesthetic in addition to ketamine
- Esmolol for heart rate control
Ketamine: 0.5 mg/kg with induction bolus plus 5mcg/kg/min until fascia closure. - Consider reducing bolus (0.25mg/kg) or not using bolus in elderly patients >65 years of age.
Lidocaine: 1.5 mg/kg bolus with induction then 2mg/min drip from induction to case end - Contraindications: Unstable heart disease, recent MI, heart block, heart Failure, electrolyte disturbances, liver disease, seizure disorder, current anti-arrhythmic therapy [e.g. amiodarone, sotalol]
Ketorolac: 30 mg IV at fascia closure - Reduce to 15 mg IV if >65y, CrCl < 30, or patient weight <50kg.
- Consider avoiding for h/o renal dysfunction or GI bleed
Methadone: Consider methadone 10–20 mg IV with induction for patients with chronic opiate use; may consider higher doses based on home opioid regimen. - If opioids required, consider methadone on emergence or in PACU (5 mg IV boluses) q5–10 min prior to using other opioids.
Postoperative Gabapentin: 300-600 mg PO TID starting DOS until discharge - Use lower dose for >65y or if patient having sedation/dizziness
- Post-discharge: final inpatient dose PO TID × 7 days, then half dose PO TID × 7 days [2 week post-op course total]
Acetaminophen: 1000 mg PO Q8hr starting DOS until discharge - Reduce to 650 mg PO Q6h if <70kg
- Post-discharge: 500–1000mg PO Q8h × 3 days and then PRN
Lidocaine Continued from PACU or after thoracic epidural catheter removed
Order for PACU to continue 24h: 1 mg/min IV if <70 kg; 1.5 mg/min IV if 70–100 kg; 2 mg/min IV >100 kg.
Contraindications as above
Ketorolac: 30mg IV q6h × 3 days - Reduce to 15 mg IV Q6h in patients >65y, CrCl < 30, or weight <50kg
- Hold if evidence of acute kidney injury
Opioids: as needed (PRN) Example: Oxycodone 5mg PO Q4 PRN pain >4/10; consider opioid PCA or PRN bolus for breakthrough pain, but not a standard order.
- Post-discharge: short course of short-acting opioid (e.g. oxycodone 5mg q6h PRN × 3days) unless chronic pain/opioid use concerns to address.
Thoracic Epidural If used, continue with local anesthetic (e.g. bupivacaine 0.1%) +/- opioid if needed for denser quality block (e.g. hydromorphone 10mcg/mL)
  1. aIt should be noted that this is one example of a successful ERP for CRS, but there are many approaches concerning the specifics of medications and doses. Ropiv ropivicaine, dex dexamethasone, mL milliliter, mg milligram, TAP transversus abdominis plane, PACU post anesthesia care unit, PCA patient-controlled analgesia