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Enhanced Recovery after Procedure (ERAP): A Novel Peri-procedure Pain Protocol for Non OR Anesthesia (NORA)
Session: MP-01a
Thurs, April 19, 8-9:45 am
Shubert (Shubert Complex), 6th floor

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There has been a rapid increase in the number of interventional procedures
performed in non-OR locations, with a concomitant increase in the demand for
nonoperating room anesthesia (NORA). Efforts to reduce length of stay and improve
patient satisfaction after surgical procedures has led to the development of evidencebased
protocols for enhanced recovery after surgery (ERAS), which incorporate
multimodal, opioid-sparing analgesia techniques (1,2). These techniques are
underutilized in NORA locations, specifically the interventional radiology (IR) suite,
with many providers defaulting to opioid monotherapy for analgesia.
Hepatocellular carcinoma (HCC) treatment options for patients that are not surgical
candidates include percutaneous liver microwave ablations (MWA) and transarterial
chemoembolizations (TACE). Immediately post procedure these patients experience
significant pain as part of a sequelae from post ablation syndrome (PAS) and post
embolization syndrome (PES) (3,4).
We describe the formulation and implementation of a multimodal, periprocedural
acute pain program for enhanced recovery after procedure (ERAP) based on best
practice guidelines common to ERAS protocols. We piloted this program for patients
undergoing liver MWA and TACE procedures.


This study was undertaken as a quality improvement initiative and did not require
approval from the MGH IRB. Data for patients undergoing liver MWA or TACE
procedures from January to December 2017 was analyzed including baseline
demographics and lab values (Table 1). A local task force comprised of acute pain
anesthesiologists developed the ERAP bundle. The protocol was based on common
components of ERAS protocols (Table 2) (2). Modifications included incorporating
high dose steroid to attenuate post ablation/embolization syndrome, lidocaine patch
and preprocedure tramadol (4). Paravertebral blocks were incorporated as they had
been described for analgesia in liver radiofrequency ablation (RFA) (5). TENS unit
was added for post procedure management (6). Information was consolidated into a
procedure and procedural workflow illustrated in Table 3.
Group lectures were given to the 3 role groups including: IR physicians and fellows,
nurses, and anesthesia staff including the regional anesthesia service. Protocol
reminders were emailed daily to fellows and anesthesia staff. Data was collected on
the adherence to the multimodal protocol based on the use of 1 of 5 pre-procedure
analgesics including regional blocks (Table 4).


Baseline patient demographics are shown in Table 1. Renal function,
coagulation status, including platelets, were within normal limits.
Table 4 demonstrates the baseline preprocedure analgesia utilization
for TACE and MWA patients prior to our study period with 2% and
17% of utilization of preprocedure analgesia, respectively. Utilization
of preprocedure multimodal analgesic regimen after implementation of
ERAP was 78% for TACE and 89% for MWA procedures.


Innovations in acute pain management developed in the OR can be
applied to the NORA patient population. As procedural volume
continues to increase, enhancing patient recovery is of utmost
importance. The ERAP protocol described implements an acute pain
protocol incorporating ERAS principals including regional blocks and
IR specific enhanced recovery elements. Based on patient lab data,
preprocedure analgesics, such as NSAIDs, and regional blocks can be
viable options. Education of NORA clinical role groups is a key
component in implementation of such program including daily
reminders to clinicians.


1. Wick EC et al. Postoperative Multimodal Analgesia Pain Management With Nonopioid
Analgesics and Techniques: A Review. JAMA Surg. 2017 Jul 1;152(7):691-697.
2. Joshi G et al. Peripheral nerve blocks in the management of postoperative pain:
challenges and opportunities. J Clin Anesth. 2016 Dec;35:524-529.
3. Andreano A et al. Percutaneous microwave ablation of hepatic tumors: prospective
evaluation of postablation syndrome and postprocedural pain. J Vasc Interv Radiol. 2014
4. Yang H et al. Dexamethasone Prophylaxis to Alleviate Postembolization Syndrome after
Transarterial Chemoembolization for Hepatocellular Carcinoma: A Randomized, Double-
Blinded, Placebo-Controlled Study. J Vasc Interv Radiol. 2017 Nov;28(11):1503-1511
5. Piccioni F et al. Thoracic paravertebral anesthesia for percutaneous radiofrequency
ablation of hepatic tumors. J Clin Anesth. 2014 Jun;26(4):271-5.
6. Vance, CG et al. Using TENs for Pain Control: The State of the Evidence. Pain
Management. 2014 May; 4(3): 197-209.



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