A collaborative, checklist-driven, multimodal protocol called the ComfortSafe anesthetic technique can provide effective postoperative pain relief and enhanced recovery after surgery (ERAS) while preventing complications associated with opioid analgesics. Getting anesthesiologists to adopt a less narcotic-heavy view of analgesia has become a crusade for one of the researchers who devised the protocol.
“We’ve been using our technique for about 10 years, especially for extremely sick patients who just will not tolerate the use of narcotics,” said Joseph Myers, MD, associate professor of anesthesiology and chief of obstetric anesthesia at Georgetown University Medical Center in Washington, D.C. “And we’ve found that these patients don’t need narcotics. It takes some guts to figure that out, but the payoff is avoidance of opioid side effects.”
The technique is built around the ComfortSafe Pyramid, which functions largely as a checklist to be completed by anesthesia and surgical teams before wound closure (Figure). On the basis of risk–benefit ratios, the analgesic choices near the base of the pyramid have the fewest side effects, beginning with reduced-sensation patients, who may not require analgesics. The pyramid’s next level is wound infiltration with a local anesthetic. Liver or kidney disease and the risk for bleeding are discussed before the next level—nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetaminophen or ketorolac—is reached. Finally, opioids are the last resort, and only given if the other analgesic levels prove unsuccessful.
Figure. The ComfortSafe Pyramid.
The ComfortSafe Pyramid is used as a checklist and completed by the anesthesia and surgical teams before wound closure. Analgesic choices near the base of the pyramid have fewer potential side effects. Patients with reduced or absent sensation may not require any analgesics. If appropriate, the surgeon may infiltrate the wound with a local anesthetic. Liver or kidney disease and the risk for bleeding are discussed before NSAIDs are administered. Opioids and their side effects can be avoided by addressing pain in a multimodal fashion.
NSAID, nonsteroidal anti-inflammatory drug
An Above-the-Knee Amputation With No Intraoperative Narcotics
To demonstrate the efficacy of the ComfortSafe technique, Dr. Myers and his colleagues presented a series of three patients undergoing lower extremity surgical procedures: an above-the-knee amputation, a calcanectomy and free flap with placement of an external fixator. Each patient presented with multiple comorbidities, especially morbid obesity with oxygen dependence and chronic pain. What’s more, the patient who underwent free flap would not have survived if vasoconstrictors had been used, so hypotension had to be avoided.
As Dr. Myers reported at the 2015 World Congress of Enhanced Recovery After Surgery and Perioperative Medicine, each patient underwent general anesthesia with propofol and sevoflurane. Preemergence analgesia was composed of acetaminophen and ketorolac in all three patients; the above-the-knee amputation was also infiltrated with 20 mL of bupivacaine liposome injectable suspension (Exparel, Pacira), and the calcanectomy with 20 mL of 0.5% bupivacaine. Surgical times ranged from one hour, 55 minutes to seven hours, 56 minutes. The amputation patient only required two 0.5-mg doses of hydromorphone in the PACU, whereas the calcanectomy patient required no postoperative pain medication. Finally, the patient undergoing the free flap with an external fixator, a procedure lasting nearly eight hours, received no intraoperative opioids and required only 50 mcg of fentanyl and 0.5 mg of hydromorphone in the PACU.
“We’ve successfully treated many patients with this technique, but we chose these three because they are demonstrative of how successful the ComfortSafe technique can be,” he told Anesthesiology News. “I mean, we cut off someone’s leg above the knee, don’t give them any intraoperative narcotics and they have minimal amounts of pain in the recovery room. I’m still amazed by the technique.”
Despite the success of the ComfortSafe technique—and other ERAS-based protocols—Dr. Myers remains surprised that so many anesthesiologists turn to opioids so quickly. “Many go right to fentanyl at the start of the case and continue to administer it for the entire case, even though there are analgesics with far fewer side effects,” he said. “To me, that is just opening the door to problems such as nausea and vomiting, iatrogenic addiction and respiratory depression. In a patient who’s morbidly obese and oxygen dependent, that could lead to mechanical ventilation in the ICU for a day or more.”
Trust in the Alternatives
Nevertheless, changing practice is easier said than done. “We get entrenched in certain ideas, like thinking that narcotics are the best way to treat pain,” he added. “But the danger of dogma is that times change. It’s a new playing field now. We have liposomal bupivacaine, IV acetaminophen and ketorolac, which weren’t available 10 years ago. But people develop a way of giving anesthesia with narcotics that becomes a reflex; they don’t even think about it.”
Adopting the ComfortSafe technique should not prove particularly onerous for clinicians who open their minds to change, he said. “It’s based on Occam’s razor, so the simpler the better. In the end, it’s hard to argue with more collaboration and communication in the operating room [OR]. But we also need to trust the opioid-alternative medications, which is a leap of faith that many practitioners are unwilling to take.”
Eugene R. Viscusi, MD, echoed Dr. Myers’ concern about overuse of opioids, both in the OR and beyond. “We have a huge pro-opioid bias in America; we are 5% of the world’s population but consume 85% of the world’s opioids,” said the professor of anesthesiology and director of acute pain management at Thomas Jefferson University in Philadelphia. “The bias extends to perioperative management, including how we use opioids in the OR.
“While we have recognized the value of opioid reduction through multimodal analgesia, convincing our colleagues and distilling the essence to an applicable form has remained a challenge. Here, Dr. Myers has formulated a tool that brings multimodal therapy to the next level, applying it within an ERAS pathway. This allows us to better track outcome benefits. This is at the heart of the perioperative surgical home, which I believe is the future of anesthesiology.”