Enhanced restoration pathways within the administration of postoperativ

Enhanced restoration pathways within the administration of postoperativ


Postoperative ache is a typical however usually inadequately handled situation, with 80% of surgical sufferers experiencing postoperative ache however lower than 50% of those sufferers reporting ample ache management in response to a US Institute of Drugs report.1 As well as, a nationwide survey means that 39% of sufferers with postoperative ache expertise extreme to excessive ranges of ache.2 The implications of suboptimal postoperative ache management embrace elevated threat for morbidity and chronic postsurgical ache in addition to elevated size of hospital keep and healthcare prices.3 Ache administration within the postoperative setting presents a problem as the event and severity of ache after surgical procedure depends on varied affected person and procedural elements.4–6 Moreover, opioid medicines, the standard mainstay of postoperative ache remedy, are related to vital short- and long-term antagonistic results.7,8 Over the previous twenty years, structured perioperative applications generally known as enhanced restoration pathways (ERPs) have been developed with a purpose to standardize care and enhance outcomes.9 These pathways, which are sometimes constructed round procedure-specific, evidence-based tips from organizations such because the Enhanced Restoration After Surgical procedure (ERAS) Society, Process-Particular Postoperative Ache Administration (PROSPECT) group, and the American Society for Enhanced Restoration (ASER), are more and more thought of normal of look after sufferers present process quite a lot of surgical procedures.10–12 With regard to postoperative ache administration, ERPs apply a multimodal, opioid-sparing method.13 Particularly, non-opioid medicines and regional anesthesia methods are generally employed to attenuate use of opioid medicines.14 As methods for postoperative ache remedy proceed to evolve quickly within the context of an growing deal with enhanced postoperative restoration,15 we assessment the present proof in addition to data gaps and controversies pertaining to generally utilized postoperative ache administration modalities in ERPs.


This text is a story assessment of the literature on the administration of postoperative ache within the context of ERPs. The first goal of this assessment is to offer an outline of salient ache administration modalities employed by ERPs within the postoperative setting in addition to the present proof and proposals for his or her use. We recognized pertinent remedy modalities by reviewing present postoperative ache administration tips printed by the Enhanced Restoration After Surgical procedure (ERAS) Society, Process-Particular Postoperative Ache Administration (PROSPECT) group, and the American Society for Enhanced Restoration (ASER), together with its Perioperative High quality Initiative (POQI). As well as, we reviewed articles obtained by way of searches of the PubMed database and Google Scholar for the next phrases: “enhanced restoration ache administration”, “enhanced restoration analgesia”, “multimodal analgesia”, and “opioid-sparing analgesia”. We solely included remedy modalities employed within the postoperative setting and excluded preemptive analgesia and intraoperative administration methods. After figuring out generally utilized remedy modalities, we then reviewed articles pertaining to every particular person remedy modality obtained by looking the PubMed database, Cochrane Library database, and Google Scholar utilizing the time period “postoperative ache” plus the identify of the particular remedy modality (eg “acetaminophen”, “epidural”, and so forth.). We excluded research carried out solely within the pediatric inhabitants.

Opioid Drugs

Opioid medicines equivalent to fentanyl, morphine, hydromorphone, oxycodone, and hydrocodone exert their analgesic motion via the mu opioid receptor. Opioids are historically thought of integral to postoperative ache administration, however their use is related to plenty of antagonistic results together with urinary retention, ileus, nausea, vomiting, pruritus, respiratory melancholy, and central nervous system melancholy.7 These antagonistic results are related to elevated mortality, size of keep, threat for readmission, and healthcare prices in surgical sufferers.16,17 Opioid use can even result in tolerance and opioid-induced hyperalgesia, which can in flip contribute to the event of persistent postsurgical ache.18 Moreover, opioid use within the postoperative setting is related to elevated threat of power opioid use, which is especially regarding within the context of the present nationwide opioid epidemic.19 Due to this fact, ERPs typically make the most of opioid medicines sparingly, just for moderate-to-severe ache not attentive to different remedies, and at all times at the side of non-opioid analgesic interventions (Desk 1). The usage of non-opioid analgesic modalities is particularly necessary in sufferers with power ache who take opioids preoperatively as these sufferers are at elevated threat for extreme postoperative ache, poor postoperative ache management, and opioid-related antagonistic results within the postoperative setting.5,6,20,21

Desk 1 Widespread Non-Opioid Modalities for Therapy of Postoperative Ache in Enhanced Restoration Pathways

Implementation of ERPs has been proven to considerably scale back inpatient opioid consumption after a variety of surgical procedures.22–31 Zhao et al demonstrated a dose-response relationship between postoperative opioid consumption and opioid-related antagonistic results.32 Accordingly, a number of research recommend opioid-sparing methods could also be related to decrease charges of opioid-related antagonistic results, together with nausea, vomiting, sedation, urinary retention, and constipation.24,30–36 Decreased consumption of opioids doesn’t seem to negatively affect patient-reported ache or satisfaction ranges and, in some research, is related to improved patient-reported ache scores.25–31,34–38 The impact of opioid-sparing methods through the acute postoperative interval on power opioid use stays unclear, with some research demonstrating a discount of long run opioid use whereas others displaying no distinction.30,38–43 Though opioid-sparing postoperative analgesic interventions have clear benefits with respect to lowered antagonistic results and a few research even recommend that opioid medicines might present superior analgesia for acute ache in comparison with non-opioid therapies, the feasibility of opioid-free postoperative analgesia stays controversial and extra analysis on this space is required.44–46

If opioids are required through the postoperative interval, ERPs typically advocate that they be administered orally for sufferers who’re tolerating oral consumption. Quick-acting reasonably than long-acting opioids must be utilized in sufferers who aren’t taking opioids chronically as short-acting opioids are extra simply titratable and related to a decrease threat of unintentional overdose.47 In sufferers with renal failure, morphine and codeine are typically prevented as a consequence of lowered clearance of drug metabolites and different opioids must be used with warning.48 If frequent parenteral opioid administration is required, ERPs usually favor using patient-controlled analgesia as this supply methodology individualizes opioid dosing and is related to elevated affected person satisfaction and ache management.49 Previous to using conventional opioids, some ERPs might advocate using tramadol, which produces analgesia by way of weak mu opioid receptor agonism in addition to serotonin-norepinephrine reuptake inhibition.50 Tramadol is related to decrease charges of sure opioid-related antagonistic occasions together with constipation, respiratory melancholy, and abuse.51 Nevertheless, tramadol must be utilized rigorously in sufferers with a seizure historical past as seizures are a recognized uncommon facet impact. As well as, concomitant use of tramadol and different serotonergic medicines might precipitate serotonin syndrome.

Non-Opioid Drugs


Acetaminophen is a cornerstone of multimodal postoperative ache remedy in ERPs. Its analgesic impact is regarded as primarily mediated via inhibition of the cyclooxygenase pathway, although the precise mechanism of motion stays incompletely understood.52 A single dose of acetaminophen has been proven to offer 50% ache reduction for 4 hours in about half of sufferers experiencing moderate-to-severe acute postoperative ache.53,54 Use of acetaminophen at the side of nonsteroidal anti-inflammatory medicine can have an additive and even synergistic analgesic impact.55 As well as, acetaminophen use has been related to lowered opioid necessities through the postoperative interval.56–60 ERPs typically advocate that acetaminophen be given on a scheduled foundation as this results in extra constant dosing and is related to decreased opioid use.61 Whereas intravenous acetaminophen is related to extra favorable pharmacokinetics together with sooner onset and better plasma and cerebrospinal fluid ranges in comparison with oral and rectal acetaminophen, it doesn’t present a transparent profit with regard to analgesic efficacy and affected person outcomes.62,63 Due to this fact, use of oral acetaminophen is usually most well-liked in sufferers which might be capable of tolerate oral consumption whereas intravenous acetaminophen is beneficial in sufferers who’re unable to tolerate oral consumption or have impaired gastrointestinal tract perform.63 General, acetaminophen is well-tolerated with its most regarding antagonistic impact being hepatotoxicity at larger doses and in sufferers with liver insufficiency. Given its favorable security profile and the robust proof supporting its use for postoperative ache remedy, virtually all ERPs will advocate the routine use of acetaminophen in postoperative analgesia regimens.

Nonsteroidal Anti-Inflammatory Medicine

Nonsteroidal anti-inflammatory medicine (NSAIDs), equivalent to ibuprofen, ketorolac, and celecoxib, produce analgesia by inhibiting the cyclooxygenase enzyme and disrupting prostaglandin synthesis. NSAIDs are efficient remedies for postoperative ache and necessary adjuncts in a multimodal analgesia routine for the remedy of postoperative ache.64–66 When used at the side of opioids within the postoperative interval, NSAIDs are related to lowered opioid consumption and improved ache management.54,58,59,67,68 Combining NSAIDs with acetaminophen produces an additive or probably synergistic analgesic impact.55,67 As well as, NSAID use could also be related to a lowered threat of opioid-related unwanted side effects, together with nausea, vomiting, and sedation.33,35,36,59 Though NSAIDs are typically well-tolerated, they’re related to an elevated threat of gastrointestinal ulceration, bleeding, and renal impairment.59,69,70 The usage of NSAIDs that selectively inhibit the cyclooxygenase-2 (COX-2) enzyme, equivalent to celecoxib, might scale back the chance of gastrointestinal occasions and bleeding. Nevertheless, COX-2 inhibitors can enhance the chance of cardiovascular antagonistic occasions and are usually prevented after cardiac surgical procedure.71 Some research recommend that NSAIDs might end in bone nonunion after spinal fusions, though the general physique of proof stays inconclusive.72–74 As a result of lack of robust proof that quick time period use of NSAIDs within the perioperative setting impacts bone fusion, the ERAS Society continues to advocate NSAID use after spinal surgical procedure.75 Equally, there’s ongoing debate relating to the affiliation between NSAID use and elevated threat of anastomotic leaks after colorectal surgical procedure.76–80 Regardless of these potential dangers, many ERPs will advocate using NSAIDs except contraindicated given the robust proof supporting their efficacy within the remedy of postoperative ache.


Gabapentinoids, equivalent to gabapentin and pregabalin, are antiepileptic medicines that produce analgesia via inhibition of voltage-gated calcium channels. These medicines had been historically used within the administration of power neuropathic ache. Nevertheless, some research recommend that perioperative use of gabapentinoids might scale back acute postoperative ache, opioid consumption, and postoperative nausea and vomiting.75–87 As well as, perioperative gabapentinoid use may additionally scale back the chance of creating persistent postsurgical ache though the proof for this impact stays inadequate.88,89 Primarily based on these findings, gabapentinoids have been included as a part of a multimodal analgesia routine in some ERPs. Nevertheless, different research have referred to as into query the advantage of gabapentinoid use within the perioperative setting as they’re related to antagonistic results, and their analgesic and opioid-sparing results might in reality be clinically insignificant.90–93 Particularly, use of gabapentinoids has been linked to sedation, visible disturbances, and dizziness that may hinder early postoperative mobilization and delay restoration.81–87,90–92 As well as, perioperative gabapentin use has been related to threat of respiratory melancholy, particularly in older sufferers and people receiving larger doses of opioids.94 General, the standard of proof supporting the perioperative use of gabapentinoids stays low, and optimum dosing has not been clearly established. Moreover, gabapentinoids are at the moment solely accessible in oral formulations, which can restrict their use within the acute postoperative setting. Due to this fact, whereas gabapentinoids are a possible opioid-sparing adjunct for administration of postoperative ache, the dangers and advantages of their use must be rigorously thought of for every particular person affected person. Particularly, given their facet impact profile, gabapentinoids must be used with warning in aged sufferers in addition to sufferers with renal dysfunction, which frequently necessitates dose discount.

Alpha-2 Agonists

Alpha-2 agonists, equivalent to clonidine and dexmedetomidine, produce analgesia by stimulating alpha-2 receptors within the dorsal horn of the spinal wire and lowering transmission of nociceptive indicators. Whereas these medicines could be administered by way of a number of routes, for postoperative ache administration, clonidine is commonly given intravenously or orally whereas dexmedetomidine is usually administered intravenously. Clonidine and dexmedetomidine can be used as adjuvants in epidurals and peripheral nerve blocks to probably enhance and lengthen analgesia, though knowledge supporting these advantages is restricted.95–99 Some ERPs might make the most of clonidine or dexmedetomidine as an analgesic regulate for postoperative ache administration as some proof means that alpha-2 agonists have opioid-sparing properties.100,101 Particularly, current research recommend postoperative dexmedetomidine infusions might scale back opioid consumption and opioid-related antagonistic results.102,103 Whereas the advantages of intraoperative use of alpha-2 agonists, significantly dexmedetomidine, are well-studied, the proof supporting using alpha-2 agonists within the postoperative setting stays scarce and optimum dosing regimens haven’t been recognized. Widespread antagonistic results of alpha-2 agonists embrace sedation, hypotension, and bradycardia. These dangers must be thought of when together with alpha-2 agonists in a postoperative analgesia routine given the restricted proof supporting their use within the postoperative setting.


Ketamine is a dissociative anesthetic that antagonizes N-methyl-D-aspartate (NMDA) receptors within the mind and spinal wire to scale back transmission of ache indicators.104 Intravenous ketamine infusions at subanesthetic doses have been proven to scale back opioid consumption and enhance ache management with out inflicting main antagonistic results.105–110 The addition of ketamine to an opioid routine has additionally been proven to scale back the incidence of postoperative nausea and vomiting.107–109,111 Moreover, ketamine might forestall the event of opioid-induced hyperalgesia and opioid tolerance.112 Nevertheless, it stays unclear whether or not perioperative ketamine use reduces the chance of creating persistent postsurgical ache.89,113 The commonest antagonistic results related to use of subanesthetic doses of ketamine within the postoperative setting are neuropsychiatric signs, equivalent to hallucinations and nightmares.105 Poorly managed heart problems, hepatic dysfunction, elevated intracranial and intraocular strain, energetic psychosis, and being pregnant are thought of relative contraindications to ketamine use.114 As a part of an ERP, ketamine infusions can be utilized as an analgesic adjunct for these with moderate-to-severe ache who’ve failed preliminary remedy choices. As a result of ketamine at subanesthetic doses doesn’t suppress airway reflexes and preserves spontaneous respirations, it may be used to scale back opioid consumption in sufferers in danger for respiratory melancholy, equivalent to these with obstructive sleep apnea. Ketamine may additionally be a very helpful analgesic adjunct in sufferers who’re opioid tolerant.115,116

Intravenous Lidocaine

Lidocaine is an amide native anesthetic that has analgesic, anti-inflammatory, and anti-hyperalgesic properties when administered intravenously.117 Some research recommend that lidocaine infusions can scale back postoperative ache and opioid consumption, particularly after stomach surgical procedures.118–122 As well as, lidocaine infusions could also be related to decreased threat for postoperative nausea, vomiting, and ileus in addition to shorter length of hospital keep.118–122 Primarily based on these knowledge, some ERPs might make the most of lidocaine infusions as a part of a multimodal analgesia routine for moderate-to-severe ache, significantly after stomach surgical procedures. Nevertheless, a Cochrane assessment discovered inadequate proof to substantiate the advantage of lidocaine infusions for postoperative ache management and restoration.123 As well as, optimum dosing and infusion length haven’t been established. Due to this fact, some uncertainty stays relating to the routine use of lidocaine infusions for postoperative ache administration. Though lidocaine has a slim therapeutic index, toxicity seems to be very uncommon with infusions.119–122 The chance of lidocaine toxicity is immediately associated to plasma lidocaine ranges, which must be monitored throughout infusions.

Regional Anesthesia Methods

Peripheral Nerve Blocks

Peripheral nerve blocks (PNBs) goal native anesthetic medicines on to peripheral nerves to offer analgesia. Generally used PNBs embrace brachial plexus blocks for higher extremity surgical procedures, paravertebral blocks for thoracic surgical procedures, transversus abdominis aircraft (TAP) blocks for stomach surgical procedures, and femoral and sciatic nerve blocks for decrease extremity surgical procedures. Each single-shot PNBs and steady PNBs could be utilized to handle postoperative ache. Single-shot PNBs are primarily restricted by a brief length of motion that’s usually lower than twenty-four hours. The addition of adjuvants, equivalent to dexamethasone, dexmedetomidine, clonidine, and buprenorphine, might lengthen the analgesia supplied by single-shot PNBs, though additional research are warranted.97 There may be an growing variety of research analyzing using liposomal bupivacaine in PNBs and its impact on prolonging analgesia or improves outcomes in comparison with different native anesthetics.124,125 Steady PNBs enable for an extended length of analgesia in comparison with single-shot PNBs by delivering a continuing native anesthetic infusion by way of a perineural catheter. Steady PNBs are related to improved ache management, decreased opioid consumption, and better affected person satisfaction in comparison with single-shot PNBs.126 Sufferers who obtain steady PNBs might even be discharged house with ambulatory infusion pumps for continued ache management.

PNBs are related to a number of advantages within the perioperative setting together with improved postoperative ache management, lowered opioid consumption, faster postoperative restoration, decreased length of hospital keep, decrease threat of opioid-related antagonistic results, and elevated affected person satisfaction.127–131 In some situations, PNBs could also be related to decrease charge of issues, equivalent to hypotension, in comparison with epidural analgesia.132,133 PNBs may additionally scale back the chance of creating persistent postoperative ache.134 Nevertheless, PNBs don’t seem to scale back the chance of long-term opioid use after surgical procedure.41,42,135 Given their clear advantages within the perioperative setting, ERPs might advocate using PNBs as a part of a multimodal analgesia routine. Nevertheless, a possible complication of PNBs is motor blockade, which can result in delayed postoperative mobilization, elevated threat of falls, and extended hospital course.136–138 Due to this fact, using PNBs for postoperative ache management after sure decrease extremity surgical procedures is controversial. Though using PNBs in complete knee and hip arthroplasties is considerably controversial because of the threat of motor blockade,139 the Worldwide Consensus on Anesthesia-Associated Outcomes after Surgical procedure (ICAROS) group recommends using PNBs in complete knee and hip arthroplasties based mostly on their meta-analysis demonstrating that use of PNBs in these surgical procedures was related to decrease threat for quite a lot of issues together with cognitive dysfunction, cardiopulmonary issues, surgical website infections, thromboembolic occasions, and blood transfusions.140 Equally, the Company for Healthcare Analysis and High quality (AHRQ) recommends using PNBs in complete knee and hip arthroplasties given their quite a few demonstrated advantages.141 Some proof means that motor-sparing PNBs might protect decrease extremity muscle power and scale back the chance of issues related to motor blockade, though additional analysis is required to elucidate the optimum technique for his or her use.142–143 Different issues related to PNBs embrace bleeding, nerve harm, an infection, and native anesthetic systemic toxicity. Particular person PNBs may additionally be related to site-specific issues, equivalent to pneumothorax with brachial plexus blocks and intraperitoneal organ harm with TAP blocks. Ultrasound steering for PNB placement reduces the chance of issues in addition to improves block high quality and efficiency time.144,145 General, PNBs could be efficient interventions for the administration of postoperative ache in ERPs however the dangers, advantages, and suitability of particular PNBs must be thought of within the context of the person affected person and process.

Epidural Analgesia

Epidural analgesia includes injection of native anesthetics with or with out adjuvants into the epidural house and can be utilized to handle postoperative ache after quite a lot of thoracic, stomach, pelvic, and decrease extremity surgical procedures. In comparison with opioid-based remedy regimens, epidural analgesia is related to more practical postoperative ache management in addition to decreased postoperative morbidity and mortality.146–152 Particularly, epidural analgesia might result in faster return of bowel perform and scale back the chance of cardiac and respiratory issues after surgical procedure.148–151 Nevertheless, the impact of epidural analgesia on length of hospitalization stays unclear.147,149 Epidural analgesia may additionally scale back the chance of creating persistent postoperative ache.134 Given its demonstrated advantages within the postoperative interval, epidural analgesia is usually a beneficial a part of an opioid-sparing, multimodal analgesia routine. Nevertheless, using epidurals should be weighed in opposition to their potential antagonistic results. Dangers of epidural catheter placement embrace backache, inadvertent dural puncture, nerve or spinal wire harm, an infection, epidural hematoma, and native anesthetic systemic toxicity. Epidural analgesia may additionally result in hypotension, urinary retention, and motor blockade—all of which might delay return to performance and hospital discharge. As well as, the administration of epidural opioid medicines can result in systemic absorption and opioid-related antagonistic results equivalent to nausea, vomiting, pruritus, and respiratory melancholy. Consequently, suggestions for using epidural analgesia in ERPs are sometimes process particular. For instance, the ERAS Society typically recommends using epidural analgesia in open gastrointestinal surgical procedures, open radical cystectomies, and open gynecologic surgical procedures however not essentially in hip and knee alternative surgical procedures because of the threat of motor blockade impairing postoperative mobilization or open liver surgical procedures due partially to concern for postoperative coagulopathy delaying epidural catheter removing.139,153–159 As well as, the advantages of epidural analgesia in laparoscopic surgical procedure are much less clear in comparison with open surgical procedures.153,154,160 When using epidural analgesia, particular person risk-benefit analyses should be carried out. Epidural analgesia could be significantly advantageous in sufferers at excessive threat of ileus, cardiac issues, or pulmonary issues. Nevertheless, in different sufferers, the chance of hypotension and subsequent want for intravenous fluid or vasopressor assist might necessitate using different analgesic modalities equivalent to TAP or paravertebral peripheral nerve blocks.132,133

Limitations and Instructions for Future Analysis

This text is a story assessment of the literature reasonably than a scientific assessment. We focus solely on analgesic interventions generally utilized by ERPs within the perioperative setting. There are quite a few different pharmacologic and non-pharmacologic interventions not mentioned on this article at the moment being investigated for the remedy of postoperative ache that will finally be helpful in ERPs, starting from serotonin-norepinephrine reuptake inhibitors to novel peripheral nerve blocks to music remedy. These rising interventions signify necessary areas for future analysis. As well as, there are preemptive analgesic methods, equivalent to preoperative acetaminophen dosing, and intraoperative interventions, equivalent to esmolol infusions and native anesthetic wound infiltration, which have necessary implications for postoperative ache management however are past the scope of this assessment. This text demonstrates that there are a selection of evidence-based interventions routinely used for postoperative ache administration in ERPs, and an necessary course for future analysis is figuring out the perfect mixture of those varied modalities for particular procedures and affected person populations. Further analysis can also be wanted to evaluate the feasibility and outcomes related to opioid-free postoperative analgesia in addition to the optimum methods to attain this objective.


Postoperative ache is commonly suboptimally handled and stays a problem to handle. ERPs typically make the most of a multimodal, opioid-sparing method within the remedy of postoperative ache. Whereas opioids stay an necessary remedy choice for postoperative ache, ERPs make use of quite a lot of non-opioid systemic medicines and regional anesthetic methods with the objective of minimizing opioid consumption, lowering threat of opioid-related antagonistic results, and bettering postoperative outcomes. Whereas robust proof helps this multimodal, opioid-sparing technique, the info supporting particular modalities generally utilized in ERPs to handle postoperative ache continues to evolve quickly and data gaps and controversies stay. Consequently, there are quite a few alternatives for future analysis, and the dangers and advantages of particular remedy choices ought to at all times be thought of within the context of the person affected person and process.


There isn’t any funding to report.


Richard D. Urman reviews funding/charges from Heron, Merck, Medtronic/Covidien, Pfizer, AcelRx. He’s vice chairman of the ERAS USA Society. Different authors report no conflicts of curiosity.


1. Institute of Drugs (US) Committee on Advancing Ache Analysis, Care, and Training. Relieving Ache in America: A Blueprint for Reworking Prevention, Care, Training, and Analysis. Washington (DC): Nationwide Academies Press (US); 2011.

2. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative ache expertise: outcomes from a nationwide survey recommend postoperative ache continues to be undermanaged. Anesth Analg. 2003;97(2):534–540. doi:10.1213/01.ANE.0000068822.10113.9E

3. Gan TJ. Poorly managed postoperative ache: prevalence, penalties, and prevention. J Ache Res. 2017;10:2287–2298. doi:10.2147/JPR.S144066

4. Coppes OJM, Yong RJ, Kaye AD, Urman RD. Affected person and surgery-related predictors of acute postoperative ache. Curr Ache Headache Rep. 2020;24(4):12. doi:10.1007/s11916-020-0844-3

5. Kalkman JC, Visser Okay, Moen J, Bonsel JG, Grobbee ED, Moons MKG. Preoperative prediction of extreme postoperative ache. Ache. 2003;105(3):415–423. doi:10.1016/S0304-3959(03)00252-5

6. Yang MMH, Hartley RL, Leung AA, et al. Preoperative predictors of poor acute postoperative ache management: a scientific assessment and meta-analysis. BMJ Open. 2019;9(4). doi:10.1136/bmjopen-2018-025091

7. Wheeler M, Oderda GM, Ashburn MA, Lipman AG. Hostile occasions related to postoperative opioid analgesia: a scientific assessment. J Ache. 2002;3(3):159–180. doi:10.1054/jpai.2002.123652

8. Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive sufferers and affiliation with overdose and misuse: retrospective cohort examine. BMJ. 2018;360:j5790. doi:10.1136/bmj.j5790

9. Elhassan A, Ahmed A, Awad H, et al. The evolution of surgical enhanced restoration pathways: a assessment. Curr Ache Headache Rep. 2018;22(11):74. doi:10.1007/s11916-018-0727-z

10. Stenberg E, Dos Reis Falcão LF, O’Kane M, Liem R, Pournaras DJ, Salminen P, Urman RD, Wadhwa A, Gustafsson UO, Thorell A. Tips for Perioperative Care in Bariatric Surgical procedure: Enhanced Restoration After Surgical procedure (ERAS) Society Suggestions: A 2021 Replace. World J Surg. 2022 Jan 4. doi:10.1007/s00268-021-06394-9. Epub forward of print. PMID: 34984504.

11. Thiele RH, Raghunathan Okay, Brudney CS, Lobo DN, Martin D, Senagore A, Cannesson M, Gan TJ, Mythen MMG, Shaw AD, Miller TE; Perioperative High quality Initiative (POQI) I Workgroup. Correction to: American Society for Enhanced Restoration (ASER) and Perioperative High quality Initiative (POQI) joint consensus assertion on perioperative fluid administration inside an enhanced restoration pathway for colorectal surgical procedure.. Perioper Med (Lond). 2018 Apr 10;7:5. doi:10.1186/s13741-018-0085-8. Erratum for: Perioper Med (Lond). 2016 Sep 17;5:24. PMID: 29644051; PMCID: PMC5891923.

12. Robin F, Newman N, Garneau S, Roy M. PROSPECT tips for complete hip arthroplasty: a scientific assessment and procedure-specific postoperative ache administration suggestions.. Anaesthesia. 2021 Oct;76(10):1424. doi:10.1111/anae.15541. Epub 2021 Jul 12. PMID: 34251675.

13. Beverly A, Kaye AD, Ljungqvist O, Urman RD. Important Parts of Multimodal Analgesia in Enhanced Restoration After Surgical procedure (ERAS) Tips.. Anesthesiol Clin. 2017 35(2):e115–e143. doi:10.1016/j.anclin.2017.01.018. PMID: 28526156.

14. McEvoy MD, Scott MJ, Gordon DB, Grant SA, Thacker JKM, Wu CL, Gan TJ, Mythen MG, Shaw AD, Miller TE; Perioperative High quality Initiative (POQI) I Workgroup. American Society for Enhanced Restoration (ASER) and Perioperative High quality Initiative (POQI) joint consensus assertion on optimum analgesia inside an enhanced restoration pathway for colorectal surgical procedure: half 1-from the preoperative interval to PACU.. Perioper Med (Lond). 2017 Apr 13;6:8. doi:10.1186/s13741-017-0064-5. PMID: 28413629; PMCID: PMC5390366.

15. Helander EM, Webb MP, Bias M, Whang EE, Kaye AD, Urman RD. Use of Regional Anesthesia Methods: Evaluation of Institutional Enhanced Restoration After Surgical procedure Protocols for Colorectal Surgical procedure.. J Laparoendosc Adv Surg Tech A. 2017 27(9):898-902. doi:10.1089/lap.2017.0339. Epub 2017 Jul 25. PMID: 28742434.

16. Oderda GM, Gan TJ, Johnson BH, Robinson SB. Impact of opioid-related antagonistic occasions on outcomes in chosen surgical sufferers. J Ache Palliat Care Pharmacother. 2013;27(1):62–70. doi:10.3109/15360288.2012.751956

17. Shafi S, Collinsworth AW, Copeland LA, et al. Affiliation of opioid-related antagonistic drug occasions with scientific and price outcomes amongst surgical sufferers in a big built-in well being care supply system. JAMA Surg. 2018;153(8):757–763. doi:10.1001/jamasurg.2018.1039

18. Colvin LA, Bull F, Hales TG. Perioperative opioid analgesia-when is sufficient an excessive amount of? A assessment of opioid-induced tolerance and hyperalgesia. Lancet. 2019;393(10180):1558–1568. doi:10.1016/S0140-6736(19)30430-1

19. Hah JM, Bateman BT, Ratliff J, Curtin C, Solar E. Power opioid use after surgical procedure: implications for perioperative administration within the face of the opioid epidemic. Anesth Analg. 2017;125(5):1733–1740. doi:10.1213/ANE.0000000000002458

20. Carrol R, Angst MS, Clark JD. Administration of perioperative ache in sufferers chronically consuming opioids. Reg Anesth Ache Med. 2004;29(6):576–591.

21. Edwards DA, Hedrick TL, Jayaram J, et al. American Society for Enhanced Restoration and Perioperative High quality Initiative Joint Consensus assertion on perioperative administration of sufferers on preoperative opioid remedy. Anesth Analg. 2019;129(2):553–566. doi:10.1213/ANE.0000000000004018

22. Talboys R, Mak M, Modi N, Fanous N, Cutts S. Enhanced restoration programme reduces opiate consumption in hip hemiarthroplasty. Eur J Orthop Surg Traumatol. 2016;26(2):177–181. doi:10.1007/s00590-015-1722-2

23. Warren JA, Stoddard C, Hunter AL, et al. Impact of multimodal analgesia on opioid use after open ventral hernia restore. J Gastrointest Surg. 2017;21(10):1692–1699. doi:10.1007/s11605-017-3529-4

24. King AB, Spann MD, Jablonski P, Wanderer JP, Sandberg WS, McEvoy MD. An enhanced restoration program for bariatric surgical sufferers considerably reduces perioperative opioid consumption and postoperative nausea. Surg Obes Relat Dis. 2018;14(6):849–856. doi:10.1016/j.soard.2018.02.010

25. Web page AJ, Gani F, Crowley KT, et al. Affected person outcomes and supplier perceptions following implementation of a standardized perioperative care pathway for open liver resection. Br J Surg. 2016;103(5):564–571. doi:10.1002/bjs.10087

26. Offodile AC, Gu C, Boukovalas S, et al. Enhanced restoration after surgical procedure (ERAS) pathways in breast reconstruction: systematic assessment and meta-analysis of the literature. Breast Most cancers Res Deal with. 2019;173(1):65–77. doi:10.1007/s10549-018-4991-8

27. Schwartz AR, Lim S, Broadwater G, et al. Discount in opioid use and postoperative ache scores after elective laparotomy with implementation of enhanced restoration after surgical procedure protocol on a gynecologic oncology service. Int J Gynecol Most cancers. 2019;29(5):935–943. doi:10.1136/ijgc-2018-000131

28. Shinnick JK, Ruhotina M, Has P, et al. Enhanced restoration after surgical procedure for cesarean supply decreases size of hospital keep and opioid consumption: a high quality enchancment initiative. Am J Perinatol. 2021;38(S 01):e215–e223. doi:10.1055/s-0040-1709456

29. Dietz N, Sharma M, Adams S, et al. Enhanced restoration after surgical procedure (ERAS) for backbone surgical procedure: a scientific assessment. World Neurosurg. 2019;130:415–426. doi:10.1016/j.wneu.2019.06.181

30. Flanders TM, Ifrach J, Sinha S, et al. Discount of postoperative opioid use after elective backbone and peripheral nerve surgical procedure utilizing an enhanced restoration after surgical procedure program. Ache Med. 2020;21(12):3283–3291. doi:10.1093/pm/pnaa233

31. Adeyemo EA, Aoun SG, Barrie U, et al. Enhanced restoration after surgical procedure reduces postoperative opioid use and 90-day readmission charges after open thoracolumbar fusion for grownup degenerative deformity. Neurosurgery. 2021;88(2):295–300. doi:10.1093/neuros/nyaa399

32. Zhao SZ, Chung F, Hanna DB, Raymundo AL, Cheung RY, Chen C. Dose-response relationship between opioid use and antagonistic results after ambulatory surgical procedure. J Ache Symptom Handle. 2004;28(1):35–46. doi:10.1016/j.jpainsymman.2003.11.001

33. Marret E, Kurdi O, Zufferey P, Bonnet F, Warltier D. Results of nonsteroidal antiinflammatory medicine on patient-controlled analgesia morphine unwanted side effects: meta-analysis of randomized managed trials. Anesthesiology. 2005;102(6):1249–1260. doi:10.1097/00000542-200506000-00027

34. Fayaz MK, Abel RJ, Pugh SC, Corridor JE, Djaiani G, Mecklenburgh JS. Opioid-sparing results of diclofenac and paracetamol result in improved outcomes after cardiac surgical procedure. J Cardiothorac Vasc Anesth. 2004;18(6):742–747. doi:10.1053/j.jvca.2004.08.012

35. Ng A, Parker J, Toogood L, Cotton BR, Smith G. Does the opioid-sparing impact of rectal diclofenac following complete stomach hysterectomy profit the affected person? Br J Anaesth. 2002;88(5):714–716. doi:10.1093/bja/88.5.714

36. Gan TJ, Joshi GP, Zhao SZ, Hanna DB, Cheung RY, Chen C. Presurgical intravenous parecoxib sodium and follow-up oral valdecoxib for ache administration after laparoscopic cholecystectomy surgical procedure reduces opioid necessities and opioid-related antagonistic results. Acta Anaesthesiol Scand. 2004;48(9):1194–1207. doi:10.1111/j.1399-6576.2004.00495.x

37. Bloom DA, Manjunath AK, Gualtieri AP, et al. Affected person satisfaction after complete hip arthroplasty just isn’t influenced by reductions in opioid prescribing. J Arthroplasty. 2021;36(7S):S250–S257. doi:10.1016/j.arth.2021.02.009

38. Padilla JA, Gabor JA, Schwarzkopf R, Davidovitch RI. A novel opioid-sparing ache administration protocol following complete hip arthroplasty: results on opioid consumption, ache severity, and patient-reported outcomes. J Arthroplasty. 2019;34(11):2669–2675. doi:10.1016/j.arth.2019.06.038

39. Liu VX, Eaton A, Lee DC, et al. Postoperative opioid use earlier than and after enhanced restoration after surgical procedure program implementation. Ann Surg. 2019;270(6):e69–e71. doi:10.1097/SLA.0000000000003409

40. Ladha KS, Patorno E, Liu J, Bateman BT. Impression of perioperative epidural placement on postdischarge opioid use in sufferers present process stomach surgical procedure. Anesthesiology. 2016;124(2):396–403. doi:10.1097/ALN.0000000000000952

41. Solar EC, Bateman BT, Memtsoudis SG, Neuman MD, Mariano ER, Baker LC. Lack of affiliation between using nerve blockade and the chance of postoperative power opioid use amongst sufferers present process complete knee arthroplasty: proof from the marketscan database. Anesth Analg. 2017;125(3):999–1007. doi:10.1213/ANE.0000000000001943

42. Mueller KG, Memtsoudis SG, Mariano ER, Baker LC, Mackey S, Solar EC. Lack of affiliation between using nerve blockade and the chance of persistent opioid use amongst sufferers present process shoulder arthroplasty: proof from the marketscan database. Anesth Analg. 2017;125(3):1014–1020. doi:10.1213/ANE.0000000000002031

43. Echeverria-Villalobos M, Stoicea N, Todeschini AB, et al. Enhanced restoration after surgical procedure (ERAS): a perspective assessment of postoperative ache administration underneath ERAS pathways and its position on opioid disaster in the USA. Clin J Ache. 2020;36(3):219–226. doi:10.1097/AJP.0000000000000792

44. Fiore JF, Olleik G, El-Kefraoui C, et al. Stopping opioid prescription after main surgical procedure: a scoping assessment of opioid-free analgesia. Br J Anaesth. 2019;123(5):627–636. doi:10.1016/j.bja.2019.08.014

45. Pergolizzi JV, Magnusson P, LeQuang JA, et al. Can NSAIDs and acetaminophen successfully exchange opioid remedy choices for acute ache? Skilled Opin Pharmacother. 2021;22(9):1119–1126. doi:10.1080/14656566.2021.1901885

46. Shanthanna H, Ladha KS, Kehlet H, Joshi G. Perioperative opioid administration. Anesthesiology. 2021;134(4):645–659. doi:10.1097/ALN.0000000000003572

47. Miller M, Barber CW, Leatherman S, et al. Prescription opioid length of motion and the chance of unintentional overdose amongst sufferers receiving opioid remedy. JAMA Intern Med. 2015;175(4):608–615.

48. Dean M. Opioids in renal failure and dialysis sufferers. J Ache Symptom Handle. 2004;28(5):497–504. doi:10.1016/j.jpainsymman.2004.02.021

49. McNicol ED, Ferguson MC, Hudcova J. Affected person managed opioid analgesia versus non-patient managed opioid analgesia for postoperative ache. Cochrane Database Syst Rev. 2015;2015(6):CD003348.

50. Scott MJ, McEvoy MD, Gordon DB, et al. American Society for Enhanced Restoration (ASER) and Perioperative High quality Initiative (POQI) joint consensus assertion on optimum analgesia inside an enhanced restoration pathway for colorectal surgical procedure: half 2-from PACU to the transition house. Perioper Med (Lond). 2017;6:7. doi:10.1186/s13741-017-0063-6

51. Grond S, Sablotzki A. Medical pharmacology of tramadol. Clin Pharmacokinet. 2004;43(13):879–923. doi:10.2165/00003088-200443130-00004

52. Ohashi N, Kohno T. Analgesic impact of acetaminophen: a assessment of recognized and novel mechanisms of motion. Entrance Pharmacol. 2020;11:580289. doi:10.3389/fphar.2020.580289

53. Toms L, McQuay HJ, Derry S, Moore RA. Single dose oral paracetamol (Acetaminophen) for postoperative ache in adults. Cochrane Database Syst Rev. 2008;(4). doi:10.1002/14651858.CD004602.pub2

54. Derry CJ, Derry S, Moore RA. Single dose oral ibuprofen plus paracetamol (Acetaminophen) for acute postoperative ache. Cochrane Database Syst Rev. 2013;2013(6):CD010210.

55. Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (Acetaminophen) with nonsteroidal antiinflammatory medicine: a qualitative systematic assessment of analgesic efficacy for acute postoperative ache. Anesth Analg. 2010;110(4):1170–1179. doi:10.1213/ANE.0b013e3181cf9281

56. Remy C, Marret E, Bonnet F. Results of acetaminophen on morphine side-effects and consumption after main surgical procedure: meta-analysis of randomized managed trials. Br J Anaesth. 2005;94(4):505–513. doi:10.1093/bja/aei085

57. Jebaraj B, Maitra S, Baidya DK, Khanna P. Intravenous paracetamol reduces postoperative opioid consumption after orthopedic surgical procedure: a scientific assessment of scientific trials. Ache Res Deal with. 2013;2013:1–6. doi:10.1155/2013/402510

58. Maund E, McDaid C, Rice S, Wright Okay, Jenkins B, Woolacott N. Paracetamol and selective and non-selective non-steroidal anti-inflammatory medicine for the discount in morphine-related side-effects after main surgical procedure: a scientific assessment. Br J Anaesth. 2011;106(3):292–297. doi:10.1093/bja/aeq406

59. Elia N, Lysakowski C, Tramèr M. Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory medicine, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine provide benefits over morphine alone? Meta-analyses of randomized trials. Anesthesiology. 2005;103(6):1296–1304. doi:10.1097/00000542-200512000-00025

60. McNicol ED, Ferguson MC, Haroutounian S, Carr DB, Schumann R. Single dose intravenous paracetamol or intravenous propacetamol for postoperative ache. Cochrane Database Syst Rev. 2016;2016(5):CD007126.

61. Valentine AR, Carvalho B, Lazo TA, Riley ET. Scheduled acetaminophen with as-needed opioids in comparison with as-needed acetaminophen plus opioids for post-cesarean ache administration. Int J Obstet Anesth. 2015;24(3):210–216. doi:10.1016/j.ijoa.2015.03.006

62. Singla NK, Parulan C, Samson R, et al. Plasma and cerebrospinal fluid pharmacokinetic parameters after single-dose administration of intravenous, oral, or rectal Acetaminophen. Ache Pract. 2012;12(7):523–532. doi:10.1111/j.1533-2500.2012.00556.x

63. Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus oral acetaminophen for ache: systematic assessment of present proof to assist scientific decision-making. Can J Hosp Pharm. 2015;68(3):238–247. doi:10.4212/cjhp.v68i3.1458

64. Derry CJ, Derry S, Moore RA, McQuay HJ. Single dose oral ibuprofen for acute postoperative ache in adults. Cochrane Database Syst Rev. 2009;2009(3):CD001548.

65. Derry S, Moore RA. Single dose oral celecoxib for acute postoperative ache in adults. Cochrane Database Syst Rev. 2013;(10):CD004233.

66. McNicol ED, Ferguson MC, Schumann R. Single‐dose intravenous ketorolac for acute postoperative ache in adults. Cochrane Database Syst Rev. 2021;17(5):CD013263.

67. Wong I, St John-Inexperienced C, Walker SM, Lonnqvist P-A. Opioid-sparing results of perioperative paracetamol and nonsteroidal anti-inflammatory medicine (NSAIDs) in youngsters. Paediatr Anaesth. 2013;23(6):475–495. doi:10.1111/pan.12163

68. Bainbridge D, Cheng DC, Martin JE, Novick R. NSAID-analgesia, ache management and morbidity in cardiothoracic surgical procedure. Can J Anaesthes. 2006;53(1):46–59. doi:10.1007/BF03021527

69. Bell S, Rennie T, Marwick CA, Davey P. Results of peri-operative nonsteroidal anti-inflammatory medicine on post-operative kidney perform for adults with regular kidney perform. Cochrane Database Syst Rev. 2018;11(11). doi:10.1002/14651858.CD011274.pub2

70. Strom BL, Berlin JA, Kinman JL, et al. Parenteral ketorolac and threat of gastrointestinal and operative website bleeding. A postmarketing surveillance examine. JAMA. 1996;275(5):376. doi:10.1001/jama.1996.03530290046036

71. Nussmeier NA, Whelton AA, Brown MT, et al. Problems of the COX-2 inhibitors parecoxib and valdecoxib after cardiac surgical procedure. N Engl J Med. 2005;352(11):1081–1091. doi:10.1056/NEJMoa050330

72. Dodwell ER, Latorre JG, Parisini E, et al. NSAID publicity and threat of nonunion: a meta-analysis of case-control and cohort research. Calcif Tissue Int. 2010;87(3):193–202. doi:10.1007/s00223-010-9379-7

73. Sivaganesan A, Chotai S, White-Dzuro G, McGirt MJ, Devin CJ. The impact of NSAIDs on spinal fusion: a cross-disciplinary assessment of biochemical, animal, and human research. Eur Backbone J. 2017;26(11):2719–2728. doi:10.1007/s00586-017-5021-y

74. Li Q, Zhang Z, Cai Z. Excessive-dose ketorolac impacts grownup spinal fusion: a meta-analysis of the impact of perioperative nonsteroidal anti-inflammatory medicine on spinal fusion. Backbone. 2011;36(7):E461–E468. doi:10.1097/BRS.0b013e3181dfd163

75. Debono B, Wainwright TW, Wang MY, et al. Consensus assertion for perioperative care in lumbar spinal fusion: Enhanced Restoration After Surgical procedure (ERAS(R)) Society suggestions. Backbone J. 2021;21(5):729–752. doi:10.1016/j.spinee.2021.01.001

76. Gorissen KJ, Benning D, Berghmans T, et al. Threat of anastomotic leakage with non-steroidal anti-inflammatory medicine in colorectal surgical procedure. Br J Surg. 2012;99(5):721–727. doi:10.1002/bjs.8691

77. Hakkarainen TW, Steele SR, Bastaworous A, et al. Nonsteroidal anti-inflammatory medicine and the chance for anastomotic failure: a report from Washington State’s Surgical Care and Outcomes Evaluation Program (SCOAP). JAMA Surg. 2015;150(3):223. doi:10.1001/jamasurg.2014.2239

78. Kverneng Hultberg D, Angenete E, Lydrup ML, Rutegard J, Matthiessen P, Rutegard M. Nonsteroidal anti-inflammatory medicine and the chance of anastomotic leakage after anterior resection for rectal most cancers. Eur J Surg Oncol. 2017;43(10):1908–1914. doi:10.1016/j.ejso.2017.06.010

79. Huang Y, Tang SR, Younger CJ. Nonsteroidal anti-inflammatory medicine and anastomotic dehiscence after colorectal surgical procedure: a meta-analysis. ANZ J Surg. 2018;88(10):959–965. doi:10.1111/ans.14322

80. Modasi A, Tempo D, Godwin M, Smith C, Curtis B. NSAID administration put up colorectal surgical procedure will increase anastomotic leak charge: systematic assessment/meta-analysis. Surg Endosc. 2019;33(3):879–885. doi:10.1007/s00464-018-6355-1

81. Hurley RW, Cohen SP, Williams KA, Rowlingson AJ, Wu CL. The analgesic results of perioperative gabapentin on postoperative ache: a meta-analysis. Reg Anesth Ache Med. 2006;31(3):237–247. doi:10.1016/j.rapm.2006.01.005

82. Tiippana EM, Hamunen Okay, Kontinen VK, Kalso E. Do surgical sufferers profit from perioperative gabapentin/pregabalin? A scientific assessment of efficacy and security. Anesth Analg. 2007;104(6):1545–1556. doi:10.1213/01.ane.0000261517.27532.80

83. Peng PW, Wijeysundera DN, Li CC. Use of gabapentin for perioperative ache management – a meta-analysis. Ache Res Manag. 2007;12(2):85–92. doi:10.1155/2007/840572

84. Doleman B, Heinink TP, Learn DJ, Faleiro RJ, Lund JN, Williams JP. A scientific assessment and meta-regression evaluation of prophylactic gabapentin for postoperative ache. Anaesthesia. 2015;70(10):1186–1204. doi:10.1111/anae.13179

85. Mishriky BM, Waldron NH, Habib AS. Impression of pregabalin on acute and chronic postoperative ache: a scientific assessment and meta-analysis. Br J Anaesth. 2015;114(1):10–31. doi:10.1093/bja/aeu293

86. Lam DMH, Choi SW, Wong SSC, Irwin MG, Cheung CW. Efficacy of pregabalin in acute postoperative ache underneath totally different surgical classes: a meta-analysis. Drugs. 2015;94(46):e1944. doi:10.1097/MD.0000000000001944

87. Eipe N, Penning J, Yazdi F, et al. Perioperative use of pregabalin for acute pain-a systematic assessment and meta-analysis. Ache. 2015;156(7):1284–1300. doi:10.1097/j.ache.0000000000000173

88. Clarke H, Bonin RP, Orser BA, Englesakis M, Wijeysundera DN, Katz J. The prevention of power postsurgical ache utilizing gabapentin and pregabalin: a mixed systematic assessment and meta-analysis. Anesth Analg. 2012;115(2):428–442. doi:10.1213/ANE.0b013e318249d36e

89. Chaparro LE, Smith SA, Moore RA, Wiffen PJ, Gilron I. Pharmacotherapy for the prevention of power ache after surgical procedure in adults. Cochrane Database Syst Rev. 2013;2013(7):CD008307.

90. Fabritius ML, Geisler A, Petersen PL, et al. Gabapentin for post-operative ache administration – a scientific assessment with meta-analyses and trial sequential analyses. Acta Anaesthesiol Scand. 2016;60(9):1188–1208. doi:10.1111/aas.12766

91. Fabritius ML, Strøm C, Koyuncu S, et al. Profit and hurt of pregabalin in acute ache remedy: a scientific assessment with meta-analyses and trial sequential analyses. Br J Anaesth. 2017;119(4):775–791. doi:10.1093/bja/aex227

92. Verret M, Lauzier F, Zarychanski R, et al. Perioperative use of gabapentinoids for the administration of postoperative acute ache: a scientific assessment and meta-analysis. Anesthesiology. 2020;133(2):265–279. doi:10.1097/ALN.0000000000003428

93. Straube S, Derry S, Moore RA, Wiffen PJ, McQuay HJ. Single dose oral gabapentin for established acute postoperative ache in adults. Cochrane Database Syst Rev. 2010;2010(5):CD008183.

94. Cavalcante AN, Sprung J, Schroeder DR, Weingarten TN. Multimodal analgesic remedy with gabapentin and its affiliation with postoperative respiratory melancholy. Anesth Analg. 2017;125(1):141–146. doi:10.1213/ANE.0000000000001719

95. Pöpping DM, Elia N, Marret E, Wenk M, Tramèr MR. Clonidine as an adjuvant to native anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology. 2009;111(2):406–415. doi:10.1097/ALN.0b013e3181aae897

96. Krishnamoorthy Okay, Ravi S, Ganesan I. Analysis of efficacy of epidural clonidine with 0.5% bupivacaine for postoperative analgesia for orthopaedic decrease limb surgical procedures. J Clin Diagn Res. 2015;9(9):UC14–8. doi:10.7860/JCDR/2015/14964.6457

97. Kirksey Ma, Haskins SC, Cheng J, Liu SS, Schwentner C. Native anesthetic peripheral nerve block adjuvants for prolongation of analgesia: a scientific qualitative assessment. PLoS One. 2015;10(9):e0137312. doi:10.1371/journal.pone.0137312

98. Zhang X, Wang D, Shi M, Luo Y. Efficacy and security of dexmedetomidine as an adjuvant in epidural analgesia and anesthesia: a scientific assessment and meta-analysis of randomized managed trials. Clin Drug Investig. 2017;37(4):343–354. doi:10.1007/s40261-016-0477-9

99. Schnabel A, Reichl SU, Weibel S, et al. Efficacy and security of dexmedetomidine in peripheral nerve blocks: a meta-analysis and trial sequential evaluation. Eur J Anaesthesiol. 2018;35(10):745–758. doi:10.1097/EJA.0000000000000870

100. Blaudszun G, Lysakowski C, Elia N, Tramèr MR. Impact of perioperative systemic α2 agonists on postoperative morphine consumption and ache depth: systematic assessment and meta-analysis of randomized managed trials. Anesthesiology. 2012;116(6):1312–1322. doi:10.1097/ALN.0b013e31825681cb

101. Jessen Lundorf L, Korvenius Nedergaard H, Møller AM. Perioperative dexmedetomidine for acute ache after stomach surgical procedure in adults. Cochrane Database Syst Rev. 2016;2. doi:10.1002/14651858.CD010358.pub2

102. Feng M, Chen X, Liu T, Zhang C, Wan L, Yao W. Dexmedetomidine and sufentanil mixture versus sufentanil alone for postoperative intravenous patient-controlled analgesia: a scientific assessment and meta-analysis of randomized managed trials. BMC Anesthesiol. 2019;19(1). doi:10.1186/s12871-019-0756-0

103. Peng Okay, Zhang J, Meng XW, Liu HY, Ji FH. Optimization of postoperative intravenous patient-controlled analgesia with opioid-dexmedetomidine combos: an up to date meta-analysis with trial sequential evaluation of randomized managed trials. Ache Doctor. 2017;20(7):569–596.

104. Bell RF, Kalso EA. Ketamine for ache administration. Ache Rep. 2018;3(5):e674. doi:10.1097/PR9.0000000000000674

105. Laskowski Okay, Stirling A, McKay WP, Lim HJ. A scientific assessment of intravenous ketamine for postoperative analgesia. Can J Anaesth. 2011;58(10):911–923. doi:10.1007/s12630-011-9560-0

106. Jouguelet-Lacoste J, La Colla L, Schilling D, Chelly JE. The usage of intravenous infusion or single dose of low-dose ketamine for postoperative analgesia: a assessment of the present literature. Ache Med. 2015;16(2):383–403. doi:10.1111/pme.12619

107. Wang L, Johnston B, Kaushal A, Cheng D, Zhu F, Martin J. Ketamine added to morphine or hydromorphone patient-controlled analgesia for acute postoperative ache in adults: a scientific assessment and meta-analysis of randomized trials. Can J Anaesth. 2016;63(3):311–325. doi:10.1007/s12630-015-0551-4

108. Brinck EC, Tiippana E, Heesen M, et al. Perioperative intravenous ketamine for acute postoperative ache in adults. Cochrane Database Syst Rev. 2018;12(12). doi:10.1002/14651858.CD012033.pub4

109. Assouline B, Tramèr MR, Kreienbühl L, Elia N. Profit and hurt of including ketamine to an opioid in a patient-controlled analgesia system for the management of postoperative ache: systematic assessment and meta-analyses of randomized managed trials with trial sequential analyses. Ache. 2016;157(12):2854–2864. doi:10.1097/j.ache.0000000000000705

110. Pendi A, Area R, Farhan SD, Eichler M, Bederman SS. Perioperative ketamine for analgesia in backbone surgical procedure: a meta-analysis of randomized managed trials. Backbone. 2018;43(5):E299–E307. doi:10.1097/BRS.0000000000002318

111. Ding X, Jin S, Niu X, et al. Morphine with adjuvant ketamine versus larger dose of morphine alone for acute ache: a meta-analysis. Int J Clin Exp Med. 2014;7(9):2504–2510.

112. Laulin JP, Maurette P, Corcuff JB, Rivat C, Chauvin M, Simonnet G. The position of ketamine in stopping fentanyl-induced hyperalgesia and subsequent acute morphine tolerance. Anesth Analg. 2002;94(5):1263–1269. doi:10.1097/00000539-200205000-00040

113. McNicol ED, Schumann R, Haroutounian S. A scientific assessment and meta-analysis of ketamine for the prevention of persistent post-surgical ache. Acta Anaesthesiol Scand. 2014;58(10):1199–1213. doi:10.1111/aas.12377

114. Schwenk ES, Viscusi ER, Buvanendran A, et al. Consensus tips on using intravenous ketamine infusions for acute ache administration from the American Society of Regional Anesthesia and Ache Drugs, the American Academy of Ache Drugs, and the American Society of Anesthesiologists. Reg Anesth Ache Med. 2018;43(5):456–466.

115. Barreveld AM, Correll DJ, Liu X, et al. Ketamine decreases postoperative ache scores in sufferers taking opioids for power ache: outcomes of a potential, randomized, double-blind examine. Ache Med. 2013;14(6):925–934. doi:10.1111/pme.12086

116. City MK, Ya Deau JT, Wukovits B, Lipnitsky JY. Ketamine as an adjunct to postoperative ache administration in opioid tolerant sufferers after spinal fusions: a potential randomized trial. HSS J. 2008;4(1):62–65. doi:10.1007/s11420-007-9069-9

117. van der Wal SE, van den Heuvel SA, Radema SA, et al. The in vitro mechanisms and in vivo efficacy of intravenous lidocaine on the neuroinflammatory response in acute and power ache. Eur J Ache. 2016;20(5):655–674. doi:10.1002/ejp.794

118. Kranke P, Jokinen J, Tempo NL, et al. Steady intravenous perioperative lidocaine infusion for postoperative ache and restoration. Cochrane Database Syst Rev. 2015;(7). doi:10.1002/14651858.CD009642.pub2

119. Ventham NT, Kennedy ED, Brady RR, et al. Efficacy of intravenous lidocaine for postoperative analgesia following laparoscopic surgical procedure: a meta-analysis. World J Surg. 2015;39(9):2220–2234. doi:10.1007/s00268-015-3105-6

120. Vigneault L, Turgeon AF, Côté D, et al. Perioperative intravenous lidocaine infusion for postoperative ache management: a meta-analysis of randomized managed trials. Can J Anaesthes. 2011;58(1):22–37. doi:10.1007/s12630-010-9407-0

121. McCarthy GC, Megalla SA, Habib AS. Impression of intravenous lidocaine infusion on postoperative analgesia and restoration from surgical procedure: a scientific assessment of randomized managed trials. Medicine. 2010;70(9):1149–1163. doi:10.2165/10898560-000000000-00000

122. Marret E, Rolin M, Beaussier M, Bonnet F. Meta-analysis of intravenous lidocaine and postoperative restoration after stomach surgical procedure. Br J Surg. 2008;95(11):1331–1338. doi:10.1002/bjs.6375

123. Weibel S, Jelting Y, Tempo NL, et al. Steady intravenous perioperative lidocaine infusion for postoperative ache and restoration in adults. Cochrane Database Syst Rev. 2018;6(6). doi:10.1002/14651858.CD009642.pub3

124. Hamilton TW, Athanassoglou V, Trivella M, et al. Liposomal bupivacaine peripheral nerve block for the administration of postoperative ache. Cochrane Database Syst Rev. 2016;2016(8):CD011476.

125. Ilfeld BM, Eisenach JC, Gabriel RA. Medical effectiveness of liposomal bupivacaine administered by infiltration or peripheral nerve block to deal with postoperative ache. Anesthesiology. 2021;134(2):283–344. doi:10.1097/ALN.0000000000003630

126. Bingham AE, Fu R, Horn JL, Abrahams MS. Steady peripheral nerve block in contrast with single-injection peripheral nerve block: a scientific assessment and meta-analysis of randomized managed trials. Reg Anesth Ache Med. 2012;37(6):583–594. doi:10.1097/AAP.0b013e31826c351b

127. Williams BA, Kentor ML, Vogt MT, et al. Economics of nerve block ache administration after anterior cruciate ligament reconstruction: potential hospital price financial savings by way of related postanesthesia care unit bypass and same-day discharge. Anesthesiology. 2004;100(3):697–706.

128. Richman JM, Liu SS, Courpas G, et al. Does steady peripheral nerve block present superior ache management to opioids? A meta-analysis. Anesth Analg. 2006;102(1):248–257. doi:10.1213/01.ANE.0000181289.09675.7D

129. Chan EY, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative ache after knee alternative surgical procedure. Cochrane Database Syst Rev. 2014;2014(5):CD009941.

130. Ullah H, Samad Okay, Khan FA. Steady interscalene brachial plexus block versus parenteral analgesia for postoperative ache reduction after main shoulder surgical procedure. Cochrane Database Syst Rev. 2014;2014(2). doi:10.1002/14651858.CD007080.pub2

131. Liu Q, Chelly JE, Williams JP, Gold MS. Impression of peripheral nerve block with low dose native anesthetics on analgesia and practical outcomes following complete knee arthroplasty: a retrospective examine. Ache Med. 2015;16(5):998–1006. doi:10.1111/pme.12652

132. Yeung JH, Gates S, Naidu BV, Wilson MJ, Gao Smith F. F.G. S. Paravertebral block versus thoracic epidural for sufferers present process thoracotomy. Cochrane Database Syst Rev. 2016;2(2). doi:10.1002/14651858.CD009121.pub2

133. Desai N, El-Boghdadly Okay, Albrecht E. Epidural vs. transversus abdominis aircraft block for stomach surgical procedure – a scientific assessment, meta-analysis and trial sequential evaluation. Anaesthesia. 2021;76(1):101–117. doi:10.1111/anae.15068

134. Weinstein EJ, Levene JL, Cohen MS, et al. Native anaesthetics and regional anaesthesia versus typical analgesia for stopping persistent postoperative ache in adults and youngsters. Cochrane Database Syst Rev. 2018;4(4). doi:10.1002/14651858.CD007105.pub3

135. Hamilton GM, Tierney S, Ramlogan R, McCartney CJL, Bromley LA, McIsaac DI. Persistent postoperative opioid prescription achievement and peripheral nerve blocks for ambulatory shoulder surgical procedure: a retrospective cohort examine. Anesthesiology. 2021;135:829–841. doi:10.1097/ALN.0000000000003962

136. Kandasami M, Kinninmonth AW, Sarungi M, Baines J, Scott NB. Femoral nerve block for complete knee alternative – a phrase of warning. Knee. 2009;16(2):98–100. doi:10.1016/j.knee.2008.10.007

137. Ilfeld BM, Duke KB, Donohue MC. The affiliation between decrease extremity steady peripheral nerve blocks and affected person falls after knee and hip arthroplasty. Anesth Analg. 2010;111(6):1552–1554. doi:10.1213/ANE.0b013e3181fb9507

138. Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL. Problems of femoral nerve block for complete knee arthroplasty. Clin Orthop Relat Res. 2010;468(1):135–140. doi:10.1007/s11999-009-1025-1

139. Wainwright TW, Gill M, McDonald DA, et al. Consensus assertion for perioperative care in complete hip alternative and complete knee alternative surgical procedure: Enhanced Restoration After Surgical procedure (ERAS((R))) Society suggestions. Acta Orthop. 2020;91(1):3–19. doi:10.1080/17453674.2019.1683790

140. Memtsoudis SG, Cozowicz C, Bekeris J, et al. Peripheral nerve block anesthesia/analgesia for sufferers present process major hip and knee arthroplasty: suggestions from the Worldwide Consensus on Anesthesia-Associated Outcomes after Surgical procedure (ICAROS) group based mostly on a scientific assessment and meta-analysis of present literature. Reg Anesth Ache Med. 2021;46(11):971–985.

141. Soffin EM, Gibbons MM, Ko CY, et al. Proof assessment performed for the company for healthcare analysis and high quality security program for bettering surgical care and restoration: deal with anesthesiology for complete hip arthroplasty. Anesth Analg. 2019;128(3):441–453.

142. Sogbein OA, Sondekoppam RV, Bryant D, et al. Ultrasound-guided motor-sparing knee blocks for postoperative analgesia following complete knee arthroplasty: a randomized blinded examine. J Bone Joint Surg Am. 2017;99(15):1274–1281. doi:10.2106/JBJS.16.01266

143. Zhang Z, Wang Y, Liu Y. Effectiveness of steady adductor canal block versus steady femoral nerve block in sufferers with complete knee arthroplasty: a PRISMA guided systematic assessment and meta-analysis. Drugs. 2019;98(48):e18056.

144. Walker KJ, McGrattan Okay, Aas-Eng Okay, Smith AF. Ultrasound steering for peripheral nerve blockade. Cochrane Database Syst Rev. 2009;(4):CD006459. doi:10.1002/14651858.CD006459.pub2

145. Lewis SR, Value A, Walker KJ, McGrattan Okay, Smith AF. Ultrasound steering for higher and decrease limb blocks. Cochrane Database Syst Rev. 2015;2015(9). doi:10.1002/14651858.CD006459.pub3

146. Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290(18):2455. doi:10.1001/jama.290.18.2455

147. Marret E, Remy C, Bonnet F. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgical procedure. Br J Surg. 2007;94(6):665–673. doi:10.1002/bjs.5825

148. Pöpping DM, Elia N, Van Aken HK, et al. Impression of epidural analgesia on mortality and morbidity after surgical procedure: systematic assessment and meta-analysis of randomized managed trials. Ann Surg. 2014;259(6):1056–1067. doi:10.1097/SLA.0000000000000237

149. Guay J, Kopp SL, Kopp SL. Epidural native anesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting, and ache after stomach surgical procedure: a Cochrane assessment. Anesth Analg. 2016;123(6):1591–1602. doi:10.1213/ANE.0000000000001628

150. Guay J, Kopp S. Epidural ache reduction versus systemic opioid-based ache reduction for stomach aortic surgical procedure. Cochrane Database Syst Rev. 2016;2016(1):CD005059.

151. Guay J, Kopp S. Epidural analgesia for adults present process cardiac surgical procedure with or with out cardiopulmonary bypass. Cochrane Database Syst Rev. 2019;3(3). doi:10.1002/14651858.CD006715.pub3

152. Salicath JH, Yeoh EC, Bennett MH. Epidural analgesia versus patient-controlled intravenous analgesia for ache following intra-abdominal surgical procedure in adults. Cochrane Database Syst Rev. 2018;8(8). doi:10.1002/14651858.CD010434.pub2

153. Feldheiser A, Aziz O, Baldini G, et al. Enhanced Restoration After Surgical procedure (ERAS) for gastrointestinal surgical procedure, half 2: consensus assertion for anaesthesia follow. Acta Anaesthesiol Scand. 2016;60(3):289–334. doi:10.1111/aas.12651

154. Gustafsson UO, Scott MJ, Hubner M, et al. Tips for perioperative care in elective colorectal surgical procedure: Enhanced Restoration After Surgical procedure (ERAS((R))) Society Suggestions: 2018. World J Surg. 2019;43(3):659–695. doi:10.1007/s00268-018-4844-y

155. Low DE, Allum W, De Manzoni G, et al. Tips for perioperative care in esophagectomy: Enhanced Restoration After Surgical procedure (ERAS ®) Society Suggestions. World J Surg. 2019;43(2):299–330. doi:10.1007/s00268-018-4786-4

156. Nygren J, Thacker J, Carli F, et al. Tips for perioperative care in elective rectal/pelvic surgical procedure: Enhanced Restoration After Surgical procedure (ERAS®) Society suggestions. Clin Nutr. 2012;31(6):801–816. doi:10.1016/j.clnu.2012.08.012

157. Cerantola Y, Valerio M, Persson B, et al. Tips for perioperative care after radical cystectomy for bladder most cancers: Enhanced Restoration After Surgical procedure (ERAS((R))) society suggestions. Clin Nutr. 2013;32(6):879–887. doi:10.1016/j.clnu.2013.09.014

158. Nelson G, Bakkum-Gamez J, Kalogera E, et al. Tips for perioperative care in gynecologic/oncology: Enhanced Restoration After Surgical procedure (ERAS) Society recommendations-2019 replace. Int J Gynecol Most cancers. 2019;29(4):651–668. doi:10.1136/ijgc-2019-000356

159. Melloul E, Hubner M, Scott M, et al. Tips for perioperative look after liver surgical procedure: Enhanced Restoration After Surgical procedure (ERAS) Society Suggestions. World J Surg. 2016;40(10):2425–2440. doi:10.1007/s00268-016-3700-1

160. Halabi WJ, Kang CY, Nguyen VQ, et al. Epidural analgesia in laparoscopic colorectal surgical procedure: a nationwide evaluation of use and outcomes. JAMA Surg. 2014;149(2):130. doi:10.1001/jamasurg.2013.3186