Epidural anesthesia is no longer the standard of care in abdominal surgery with ERAS. What are the alternatives?

Epidural anesthesia has been considered the gold standard for perioperative analgesia, but the implementation of enhanced recovery after surgery (ERAS) protocols and a shift from open to laparoscopic surgery have diminished the advantage of epidural anesthesia. The authors summarize data from two newer meta-analyses and discuss the consequences for the role of epidural anesthesia (EA) in the perioperative setting. These meta-analyses enabled to distinguish between pre- and post-ERAS outcomes. Endpoints related to open and laparoscopic abdominal surgery were retrieved. General data, also applicable on abdominal surgery, were included. Data on other types of surgery were ignored. Two meta-analyses met the subject and inclusion criteria of the search. They demonstrate no difference between epidural analgesia and the control for most investigated endpoints. Analgesia employing epidural techniques is often not clinically superior to its alternatives; is associated with a small but relevant number of serious complications; and has a relatively high failure rate. Data show that the distinction between pre-ERAS and ERAS is essential for understanding the role of EA in intestinal surgery. Since ERAS was introduced, the advantages of epidural anesthesia vanished while the incidence of serious neurological complications is higher than previously thought. The authors conclude that epidural anesthesia in abdominal surgery has become less preferred and is limited to patients and types of surgery known to be accompanied with difficult pain management. This requires the use of other methods for analgesia, such as intravenous ketamine, peripheral nerve blocks, continuous wound infiltration, intrathecal morphine, and intravenous, and non-invasive PCA.

Quantifying the Adequacy of Opioid Analgesic Consumption Globally: An Updated Method and Early Findings.

Opioid analgesics are the mainstay for treatment of moderate and severe pain but, in many countries, the consumption of these medicines is inadequate. Over time, various groups have published opioid analgesic metrics, including authors from the World Health Organization. They linked consumption to a level considered adequate based on the actual consumption in developed countries. In this study, we present our current results on the adequacy of opioid analgesic consumption. We included statistics for 18 controlled opioid medicines that are primarily used as analgesics, and we developed the Adequacy of Opioid Consumption (AOC) Index. The average of the 20 most developed countries for 2015 is set as equal to an AOC Index of 100. An AOC Index of 100 or higher is considered adequate consumption. The average opioid analgesic consumption of the top-20 countries of the Human Development Index increased from 84 morphine milligram equivalents per capita (2000) to 256 morphine milligram equivalents per capita (2015). The extremes we found for 2015 were Germany (AOC Index: 304) and Nigeria (AOC Index: 0.0069). These extremes differ by 44 000 times. Adequacy of opioid analgesic consumption continues to be problematic around the world.

Access to Strong Opioid Analgesics in the Context of Legal and Regulatory Barriers in Eleven Central and Eastern European Countries.

BACKGROUND: In 2011-2013, >95% of the global opioid analgesics consumption occurred in three regions, accounting for 15% of the world population. Despite abundant literature on barriers to access, little is known on the correlation between actual access to opioid analgesics and barriers to access, including legal and regulatory barriers. OBJECTIVE: This study aimed to evaluate the correlation between access to strong opioid analgesics and barriers to access in national legislation and regulations in 11 central and eastern European countries that participated in the Access to Opioid Medication in Europe (ATOME) project. DESIGN: Two variables were contrasted to assess their correlation: the country level of access to strong opioid analgesics indicated by the Adequacy of Consumption Measure (ACM) and the number of potential legal and regulatory barriers identified by an external review of legislation and regulations. MEASUREMENTS: A linear correlation was evaluated using a squared linear correlation coefficient. RESULTS: Evaluation of the correlation between the ACM and the number of potential barriers produces an R2 value of 0.023 and a correlation plot trend line gradient of -0.075, indicating no correlation between access to strong opioid analgesics and the number of potential barriers in national legislation and regulations in the countries studied. CONCLUSIONS: No correlation was found, which indicates that other factors besides potential legal and regulatory barriers play a critical role in withholding prescribers and patients essential pain medication in the studied countries. More research is needed toward better understanding of the complex interplay of factors that determine access to strong opioid analgesics.

How health professionals rate painfulness of childhood injuries and illnesses: a survey study.

Pediatric pain management has become well established in developed countries but may lag behind in developing countries, where potentially painful diseases such as gastroenteritis and meningitis are even more common. This survey asked health care givers in the developed and developing worlds to rate pain intensity of 12 common childhood diseases and to inventory the pharmacological and nonpharmacological treatment modalities in their settings. A survey was distributed online (Surveygizmo 3.0) to pediatric health caregivers who rated perceived painfulness of 12 diseases on a 0 to 10 numerical rating scale or stated that the disease was primarily discomforting in their opinion. Also they inventoried the pharmacological and nonpharmacological interventions they utilize in their setting. Sixty-five respondents completed the survey, of whom almost three thirds (72.3%) came from developed countries. Median painfulness scores ranged from 5 (chickenpox) to 9 (compound tibial fracture). The respondents considered a number of diseases that are more often seen in developing countries as painful. Pediatric pain management in the developing world should be improved in view of the high incidences of potentially painful diseases and the lack of (non)pharmacological interventions.