A. Merchea1, J. Lovely4, A. Jacob3, D. Colibaseanu1, S. Kelley2, K. Mathis2, G. Spears5, M. Huebner6, D. Larson2 1Mayo Clinic – Florida,Colon & Rectal Surgery,Jacksonville, FL, USA 2Mayo Clinic,Colon & Rectal Surgery,Rochester, MN, USA 3Mayo Clinic,Anesthesiology,Rochester, MN, USA 4Mayo Clinic,Hospital Pharmacy Services,Rochester, MN, USA 5Mayo Clinic,Biostatistics,Rochester, MN, USA 6Michigan State University,Statistics,Lansing, MI, USA
Introduction: Multimodal analgesia is an essential component of an enhanced recovery pathway (ERP). An ERP that includes the use of single injection intrathecal analgesia (IA) has been shown to decrease morbidity, decrease cost, and shorten length of stay (LOS). Limited data exist on safety, feasibility, and the optimal intrathecal medication regimen in the setting of an ERP for patients undergoing colorectal surgery. Our objective was to characterize efficacy, safety, and feasibility of IA within an ERP program in a large cohort of colorectal surgical patients.
Methods: A retrospective review was conducted to identify all consecutive patients age ≥ 18 years that underwent open or minimally-invasive colorectal surgery from October 2012 to December 2013. All patients were enrolled in an institutionally derived ERP that included the use of single-injection IA – consisting of opioid-only intrathecal (IA-O) or opioid with a local anesthetic (IA-L). Patient records were reviewed for demographic data, anesthetic management, analgesic efficacy (pain scores, opiate consumption), post-operative ileus (POI), adverse effects, and LOS.
Results: 601 patients were identified. The majority received opioid-only IA (91%, n=547) rather than a multimodal IA regimen. Median (IQR) LOS was 3 (2-5) days. Median (IQR) total oral morphine equivalents (OME) used was 24 (0-83). A greater proportion of patients receiving IA-O utilized zero OMEs compared to IA-L (30% vs. 15%, p=0.03). Overall, 28% of patients required no additional narcotic other than that included with the intrathecal. There was no difference in LOS or POI based on intrathecal medication received or dose of intrathecal opioid. Pain scores were similar at all time intervals, however the median 48 hour maximum reported pain score was greater in those patients receiving IA-L (7 vs. 6, p=0.045). Overall, development of respiratory depression or pruritus was rare (0.2% and 1.2%, respectively). One patient required blood patch for post-dural headache.
Conclusion: Intrathecal analgesia is safe, feasible, and efficacious in the setting of ERP for colorectal surgery. All regimens and doses achieved a short LOS, low pain scores, and a low incidence of POI.
