Article Text

Download PDFPDF
Preserved Analgesia With Reduction in Opioids Through the Use of an Acute Pain Protocol in Enhanced Recovery After Surgery for Open Hepatectomy
  1. Michael C. Grant, MD*,
  2. Philip M. Sommer, MD*,
  3. Cathy He, MD*,
  4. Sylvia Li, MD*,
  5. Andrew J. Page, MD,
  6. Alexander B. Stone, BA*,
  7. Deborah Hobson, BSN,
  8. Elizabeth Wick, MD§ and
  9. Christopher L. Wu, MD*
  1. *Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD; †Department of Surgery, Piedmont Healthcare, Atlanta, GA; ‡Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD; and §Department of Surgery University of California, San Francisco, CA
  1. correspondence: Michael C. Grant, MD, Department of Anesthesiology, Zayed 6208-P, The Johns Hopkins Medical Institutions, 1800 Orleans St, Baltimore, MD 21287 (e-mail: mgrant17{at}


Background Enhanced recovery after surgery (ERAS) pathways are designed to restore baseline physiology, mitigate surgical stressors, and hasten recovery. Paramount to this approach is optimal pain control through multimodal analgesia and limiting reliance on opioid-based medications. Recent studies have fostered growing controversy surrounding the use of epidural analgesia in the ERAS setting, especially for higher-risk procedures. We examine the analgesic end points associated with the use of epidural within the ERAS framework for open hepatectomy.

Methods From November 2013 through March 2016, postoperative analgesic end points including daily morphine equivalent administration and self-reported pain scores were prospectively collected and analyzed for 180 consecutive patients scheduled for open hepatectomy. Patients whose surgeries performed prior to July 2014 were managed using traditional strategy (pre-ERAS, n = 60), and those after July 1 underwent a comprehensive perioperative ERAS pathway (ERAS, n = 120).

Results Patients managed using the ERAS pathway had a significant reduction in morphine equivalent requirements at 24 hours (median, 10.0 vs 116.0 mg; P < 0.001), 48 hours (median, 10.1 vs 85.4 mg; P < 0.001), and 72 hours (median, 2.5 vs 60.0 mg; P < 0.001) compared with pre-ERAS counterparts with a reduction in average pain scores at 24 hours (numeric pain rating scale, 4.1 ± 1.6 vs 5.1 ± 1.8) and similar scores at other time points. Within ERAS, patients who received epidural (n = 87) required significantly less morphine equivalents at 24 hours (median, 2.7 vs 65.0 mg; P < 0.001) and 48 hours (median, 8.0 vs 50.0 mg; P < 0.001) but not at 72 hours (median, 1.3 vs 4.5 mg; P = 0.56), as well as improved pain scores at 24 hours (visual analog scale score, 3.8 ± 1.3 vs 5.0 ± 1.8; P < 0.001) and 48 hours (3.4 ± 1.8 vs 4.7 ± 1.9; P = 0.001) compared with those who did not receive epidural (n = 33). Other associated postoperative end points including provision of fluids, rates of clinically significant hypotension, and lengths of stay between epidural and nonepidural groups were similar.

Conclusions A novel ERAS protocol for open hepatectomy successfully reduced reliance on perioperative opioids without expensing adequate analgesia compared with traditional care. Patients within ERAS benefitted from application of epidural, which further reduced opioid requirements and optimized pain control without increasing complication rates. Epidurals should remain an integral part of ERAS protocols for liver resection surgery.

Statistics from


  • Interim data from this work were presented at the 2016 Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine in New Orleans, March 31 to April 2, 2016.

    The authors declare no conflict of interest.

    Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.