The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse

Postsurgical Pain Risk Stratification to Enhance Pain Management Workflow in Adult Patients: Design, Implementation, and Pilot Evaluation

BACKGROUND

Exposure to opioids after surgery is the initial contact for some people who develop chronic opioid use disorder. Hence, effective postoperative pain management, with less reliance on opioids, is critical. The Perioperative Opioid Quality Improvement (POQI) program developed (1) a digital health platform leveraging patient-survey-reported risk factors and (2) a postsurgical pain risk stratification algorithm to personalize perioperative care by integrating several commercially available digital health solutions into a combined platform. Development was reduced in scope by the COVID-19 pandemic.

OBJECTIVE

This pilot study aims to assess the screening performance of the risk algorithm, quantify the use of the POQI platform, and evaluate clinicians' and patients' perceptions of its utility and benefit.

METHODS

A POQI platform prototype was implemented in a quality improvement initiative at a Canadian tertiary care center and evaluated from January to September 2022. After surgical booking, a preliminary risk stratification algorithm was applied to health history questionnaire responses. The estimated risk guided the patient assignment to a care pathway based on low or high risk for persistent pain and opioid use. Demographic, procedural, and medication administration data were extracted retrospectively from the electronic medical record. Postoperative inpatient opioid use of >90 morphine milligram equivalents per day was the outcome used to assess algorithm performance. Data were summarized and compared between the low- and high-risk groups. POQI use was assessed by completed surveys on postoperative days 7, 14, 30, 60, 90, and 120. Semistructured patient and clinician interviews provided qualitative feedback on the platform.

RESULTS

Overall, 276 eligible patients were admitted for colorectal procedures. The risk algorithm stratified 203 (73.6%) as the low-risk group and 73 (26.4%) as the high-risk group. Among the 214 (77.5%) patients with available data, high-risk patients were younger than low-risk patients (age: median 53, IQR 40-65 years, vs median 59, IQR 49-69 years, median difference five years, 95% CI 1-9; P=.02) and were more often female patients (45/73, 62% vs 80/203, 39.4%; odds ratio 2.5, 95% CI 1.4-4.5; P=.002). The risk stratification was reasonably specific (true negative rate=144/200, 72%) but not sensitive (true positive rate=10/31, 32%). Only 39.7% (85/214) patients completed any postoperative quality of recovery questionnaires (only 14, 6.5% patients beyond 60 days after surgery), and 22.9% (49/214) completed a postdischarge medication survey. Interviewed participants welcomed the initiative but noted usability issues and poor platform education.

CONCLUSIONS

An initial POQI platform prototype was deployed operationally; the risk algorithm had reasonable specificity but poor sensitivity. There was a significant loss to follow-up in postdischarge survey completion. Clinicians and patients appreciated the potential impact of preemptively addressing opioid exposure but expressed shortcomings in the platform's design and implementation. Iterative platform redesign with additional features and reevaluation are required before broader implementation.

Opioid-free anaesthesia with dexmedetomidine and lidocaine versus remifentanil-based anaesthesia in cardiac surgery: study protocol of a French randomised, multicentre and single-blinded OFACS trial

INTRODUCTION

Intraoperative opioids have been used for decades to reduce negative responses to nociception. However, opioids may have several, and sometimes serious, adverse effects. Cardiac surgery exposes patients to a high risk of postoperative complications, some of which are common to those caused by opioids: acute respiratory failure, postoperative cognitive dysfunction, postoperative ileus (POI) or death. An opioid-free anaesthesia (OFA) strategy, based on the use of dexmedetomidine and lidocaine, may limit these adverse effects, but no randomised trials on this issue have been published in cardiac surgery.We hypothesised that OFA versus opioid-based anaesthesia (OBA) may reduce the incidence of major opioid-related complications after cardiac surgery.

METHODS AND ANALYSIS

Multicentre, randomised, parallel and single-blinded clinical trial in four cardiac surgical centres in France, including 268 patients scheduled for coronary artery bypass grafting under cardiac bypass, with or without aortic valve replacement. Patients will be randomised to either a control OBA protocol using remifentanil or an OFA protocol using dexmedetomidine/lidocaine. The primary composite endpoint is the occurrence of at least one of the following: (1) postoperative cognitive disorder evaluated by the Confusion Assessment Method for the Intensive Care Unit test, (2) POI, (3) acute respiratory distress or (4) death within the first 48 postoperative hours. Secondary endpoints are postoperative pain, morphine consumption, nausea-vomiting, shock, acute kidney injury, atrioventricular block, pneumonia and length of hospital stay.

ETHICS AND DISSEMINATION

This trial has been approved by an independent ethics committee (Comité de Protection des Personnes Ouest III-Angers on 23 February 2021). Results will be submitted in international journals for peer reviewing.

TRIAL REGISTRATION NUMBER

NCT04940689, EudraCT 2020-002126-90.

Factors Associated With New Analgesic Requirements Following Critical Illness

BACKGROUND

Chronic opioid use represents a significant burden to global healthcare with adverse long-term outcomes. Elevated patient reported pain levels and analgesic prescriptions have been reported following discharge from critical care. We describe analgesic requirements following discharge from hospital and identify if a critical care admission is a significant factor for stronger analgesic prescriptions.

METHODS

This retrospective observational cohort study identified patients in the UK Biobank with a registered admission to any UK hospital between January 1, 2010 and December 31, 2015 and information on prescriptions drawn both prior to and following hospital discharge. Two matched cohorts were created from the dataset: critical care patients and hospital patients admitted without a critical care encounter. Outcomes were analgesic requirements following hospital discharge and factors associated with increased analgesic prescriptions. Multivariable logistic regression was used to identify factors associated with prescriptions from higher steps on the World Health Organization (WHO) analgesic ladder.

RESULTS

In total, 660 formed the total study population. Strong opioid prescriptions following discharge were significantly higher in the critical care cohort (P value <.001). Critical care admission (OR = 1.45) and increasing Townsend deprivation (OR = 1.04) index were significantly associated with increasing strength of analgesic prescriptions following discharge.

CONCLUSIONS

Critical care patients require stronger analgesic prescriptions in the 12 months following hospital discharge. Patients from areas of high socioeconomic deprivation may also be associated with increased analgesic requirements. Multidisciplinary support is required for patients who may be at risk of chronic opioid use and could be delivered within critical care recovery programs.

Regional Anesthesia Techniques in Modern Neuroanesthesia Practice: A Narrative Review of the Clinical Evidence

Neurosurgical procedures are often associated with significant postoperative pain that is both underrecognized and undertreated. Given the potentially undesirable side effects associated with general anesthesia and with various pharmacological analgesic regimens, regional anesthetic techniques have gained in popularity as alternatives for providing both anesthesia and analgesia for the neurosurgical patient. The aim of this narrative review is to present an overview of the regional techniques that have been incorporated and continue to be incorporated into modern neuroanesthesia practice, presenting in a comprehensive way the evidence, where available, in support of such practice for the neurosurgical patient.

Comparative Analysis of Temperature-Responsive Hydrogel (PF 72) for Postoperative Pain After Bimaxillary Surgery: A Retro-spective Study

Bimaxillary surgery is a painful invasive procedure in plastic surgery. Pain control is typically achieved using intravenous analgesics. We aimed to investigate the efficacy of a novel temperature-responsive hydrogel, PF72, mixed with ropivacaine, as a local pain management solution when applied directly to the surgical site following orthognathic surgery. The study was conducted from October 2022 to July 2023 and included a cohort of 40 candidates for orthognathic surgery, encompassing LeFort I maxillary ostectomy and sagittal split ramus osteotomy. The participants were divided into an Injection group (n = 20), where PF72 was administered at the surgical site before the orthognathic surgery, and a Control group (n = 20), which relied solely on intravenous analgesics. Pain was evaluated at 3, 6, 24, 48, and 72 h after surgery using a numerical rating scale (NRS). The mean NRS scores at 24 h were 6.35 and 4 for the Control and Injection groups, respectively. The mean NRS scores at 72 h were 3.4 and 2.55 for the Control and Injection groups, respectively. Patients who received PF72 experienced less pain than those who received intravenous analgesics. These findings underscore the potential of PF72 as an effective alternative for enhancing pain management in patients undergoing orthognathic surgery.Level of Evidence III Therapeutic study. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effect of opioid-free anesthesia on post-operative period in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a propensity score matched study

BACKGROUND

Postoperative pain after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is important. It appears essential to reduce postoperative pain and morphine consumption.

METHODS

Retrospective study in a university hospital comparing patient benefiting from CRS-HIPEC under opioid-free anesthesia (OFA; dexmedetomidine) to those anesthetized with opioid anesthesia (OA; remifentanil) using a propensity score matching method. The main objective was the impact of OFA on postoperative morphine consumption in the first 24 h after surgery.

RESULTS

102 patients were included, matching on the propensity score allowed selecting 34 unique pairs analyzed. Morphine consumption was lower in the OFA group than in the OA group (3.0 [0.00-11.0] mg/24 h vs. 13.0 [2.5-25.0] mg/24 h; p = 0.02). In multivariable analysis, OFA was associated with a reduction of 7.2 [0.5-13.9] mg of postoperative morphine (p = 0.04). The rate of renal failure with a KDIGO-score > 1 was lower in the OFA group than in the OA group (12% vs. 38%; p = 0.01). There was no difference between groups concerning length of surgery/anesthesia, norepinephrine infusion, volume of fluid therapy, post-operative complications, rehospitalization or ICU readmission within 90 days, mortality, and postoperative rehabilitation.

CONCLUSION

Our results suggest that OFA for CRS-HIPEC patients appears safe and is associated with less postoperative morphine use and acute kidney injury.

The Future of Social Media, Anesthesiology, and the Perioperative Physician

Social media has rapidly developed in the past decade to become a powerful and influential force for patients, physicians, health systems, and the academic community. While the use of social media in health care has produced many positive changes, such as rapid dissemination of information, crowd-sourced sharing of knowledge, learning, and social interaction, social media in health care has also negative effects. Recent examples of negative impacts of social media include rapid and unchecked information dissemination leading to patient misinformation and inadvertent reputational harm for health care professionals due to engaging in controversial topics on public platforms. Members of the anesthesiology community, like other medical specialties, have rapidly adopted social media at many different levels. However, most anesthesiologists, health systems, and academic communities have little education, preparation, and guidelines on optimizing the use of social media technology while minimizing the risks of social media. Anesthesiology has been and will continue to be impacted by the forces of technology and the cultural influences of social media for the foreseeable future. The purpose of this article was to examine the recent history of social media adoption in anesthesiology and perioperative medicine, understand the current impact of social media across our specialty, and consider how the future development of technology and evolving social and cultural dynamic influences of social media will have on anesthesiology over the next quarter century.

Opioid-sparing Anesthesia Decreases In-hospital and 1-year Postoperative Opioid Consumption Compared With Traditional Anesthesia: A Propensity-matched Cohort Study

STUDY DESIGN

Propensity-matched cohort.

OBJECTIVE

The aim of this study was to determine if opioid-sparing anesthesia (OSA) reduces in-hospital and 1-year postoperative opioid consumption.

SUMMARY OF BACKGROUND DATA

The recent opioid crisis highlights the need to reduce opioid exposure. We developed an OSA protocol for lumbar spinal fusion surgery to mitigate opioid exposure.

MATERIALS AND METHODS

Patients undergoing lumbar fusion for degenerative conditions over one to four levels were identified. Patients taking opioids preoperatively were excluded. OSA patients were propensity-matched to non-OSA patients based on age, sex, smoking status, body mass index, American Society of Anesthesiologists grade, and revision versus primary procedure. Standard demographic and surgical data, daily in-hospital opioid consumption, and opioid prescriptions 1 year after surgery were compared.

RESULTS

Of 296 OSA patients meeting inclusion criteria, 172 were propensity-matched to non-OSA patients. Demographics were similar between cohorts (OSA: 77 males, mean age=57.69 yr; non-OSA: 67 males, mean age=58.94 yr). OSA patients had lower blood loss (326 mL vs. 399 mL, P =0.014), surgical time (201 vs. 233 min, P <0.001) emergence to extubation time (9.1 vs. 14.2 min, P< 0.001), and recovery room time (119 vs. 140 min, P =0.0.012) compared with non-OSA patients. Fewer OSA patients required nonhome discharge (18 vs. 41, P =0.001) compared with the non-OSA cohort, but no difference in length of stay (90.3 vs. 98.5 h, P =0.204). Daily opioid consumption was lower in the OSA versus the non-OSA cohort from postoperative day 2 (223 vs. 185 morphine milligram equivalents, P =0.017) and maintained each day with lower total consumption (293 vs. 225 morphine milligram equivalents, P =0.003) throughout postoperative day 4. The number of patients with active opioid prescriptions at 1, 3, 6, and 12 months postoperative was statistically fewer in the OSA compared with the non-OSA patients.

CONCLUSIONS

OSA for lumbar spinal fusion surgery decreases in-hospital and 1-year postoperative opioid consumption. The minimal use of opioids may also lead to shorter emergence to extubation times, shorter recovery room stays, and fewer discharges to nonhome facilities.

Effectiveness of a Novel Temperature-Responsive Hydrogel (PF72) for Postoperative Pain Relief in Breast Augmentation

Breast augmentation can cause severe postoperative pain, leading to an increased length of hospital stay. Postoperative pain management following breast surgery has traditionally involved intravenous and oral analgesics. However, the misuse of opioids can cause severe complications. As a result, several alternative methods have been suggested. Fifty patients were included in this study. All the patients underwent dual-plane pocket dissection using the transaxillary approach and received smooth-type breast implants. The intervention group included 25 patients who received PF72 combined with ropivacaine, and the control group included 25 patients who received only bupivacaine. The Numerical Rating Scale (NRS) score was used to evaluate each patient's pain. Three hours after the surgery, the average NRS scores of the control and intervention groups were 3.75 and 2.48, respectively. Six hours after the operation, the NRS scores of the control and intervention groups increased to 4.77 and 3.02, respectively. PF72 combined with ropivacaine was more effective than only bupivacaine for pain control in patients who underwent breast augmentations.

Macromastia and Reduction Mammaplasty: Analysis of Outpatient Cost of Care and Opioid Consumption at 5 Years Postoperatively

BACKGROUND

Macromastia is associated with increased opioid consumption, which could potentially be the initial exposure for patients with an opioid use disorder amid an escalating opioid crisis in the United States.

OBJECTIVES

The purpose of this study was to evaluate outpatient cost of care and opioid consumption in patients with macromastia and compare those who underwent reduction mammaplasty vs those who did not have surgery.

METHODS

PearlDiver, a database encompassing a national cohort of private payers with 153 million unique patients, was queried. The study cohort included patients diagnosed with macromastia who did or did not undergo reduction mammaplasty utilizing both ICD-9 and ICD-10 and CPT codes. Outpatient cost of care and morphine milligram equivalents (MME) were calculated up to 5 years postoperatively for both cohorts.

RESULTS

At 1 to 3 years postoperatively, there was no statistically significant difference in outpatient cost of care between cohorts. At every follow-up thereafter, outpatient cost of care was higher among macromastia patients who did not undergo reduction mammaplasty, with cohort differences of US$240.68 and US$349.90 at 4 years and 5 years, respectively (P < .05). MME consumption was greater in patients who underwent reduction mammaplasty up to 30 days postoperatively (P < .01). Beyond that, there was no significant difference in MME consumption between cohorts. However, patients who did not undergo surgery had opioid consumption levels above 50 MME/day until 3 years after diagnosis of macromastia.

CONCLUSIONS

Patients with macromastia who undergo reduction mammaplasty have lower outpatient care costs than patients who do not undergo reduction mammaplasty, with safer long-term opioid consumption in alignment with current Centers for Disease Control and Prevention guidelines.

Benefits of Music Intervention on Anxiety, Pain, and Physiologic Response in Adults Undergoing Surgery: A Systematic Review and Meta-analysis

PURPOSE

Evidence on factors influencing the variations of music's effect on anxiety and pain in surgical patients is unclear. We aimed to elucidate the effects of music intervention on anxiety and pain throughstudy characteristics.

METHODS

We conducted a search on the PubMed, CINAHL, Embase, Cochrane, and Web of Science databases from March 7 to April 21, 2022, for randomized controlled trials (RCTs) for the effect of music intervention on anxiety, pain, and physiological responses in surgical patients. We included studies published within the last 10 years. We assessed the risk of bias in the study using the Cochrane risk of bias tool for randomized trials and performed meta-analyses using a random-effects model for all outcomes. We used change-from-baseline scores as summary statistics and computed bias-corrected standardized mean differences (Hedges'g) for anxiety and pain outcomes and mean differences (MD) for blood pressure and heart rate.

RESULTS

Of the 454 records retrieved, 30 RCTs involving 2280 participants were found to be eligible. Music intervention was found to be superior to standard care in reducing anxiety (Hedges' g = -1.48, 95% confidence interval: -1.97 to -0.98), pain (Hedges's g = -0.67, -1.11 to -0.23), systolic blood pressure (MD = -4.62, -7.38 to -1.86), and heart rate (MD = -3.37, -6.65 to -0.10) in surgical patients. The impact of music on anxiety and pain relief varied significantly depending on the duration of the intervention. The largest effect was observed in interventions lasting between 30 and 60 minutes, with a decrease in anxiety and pain.

CONCLUSIONS

Music intervention is an effective way to reduce anxiety, pain, and physiological responses in surgical patients. Future reviews examining the influence of different types of surgery on the effects of music would add to the body of knowledge in this field. This study has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) under the number CRD42022340203, with a registration date of July 4, 2022.

The analgesic effects of bilateral superficial cervical plexus block in thyroid surgery: A systematic review and meta-analysis

Background and Aims

Thyroid surgery is moderately painful, and many techniques to reduce postoperative pain have been studied. Regional techniques are a part of multimodal analgesia employed for various surgical cases. Bilateral superficial cervical plexus block (BSCPB) is a commonly used regional anaesthesia technique for analgesia for thyroid surgery. A previous meta-analysis by this group had left questions about some facets of the technique, to which further trials have contributed.

Methods

The systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO) CRD42022315499. It is an update to a previously published paper in 2018. An updated systematic search, critical appraisal, and analysis of clinical trials were performed. Trials investigating preoperative or postoperative BSCPB compared to control in patients undergoing thyroid surgery were included in the search. The primary outcome was postoperative opioid consumption. The secondary outcomes were the duration of analgesia (time to request of analgesia), Visual Analogue Scale (VAS) pain scores at 0, 4, 12, and 24 h, postoperatively, rates of postoperative nausea and vomiting (PONV), postoperative rescue analgesic consumption, and intraoperative morphine use.

Results

A total of 31 studies and 2,273 patients were included in this analysis. BSCPB significantly reduced post-thyroidectomy opioid consumption (P < 0.001). Additionally, the duration of analgesia was prolonged following BSCPB. VAS scores for 24 h (postoperatively), intraoperative morphine use, and rescue analgesia (postoperatively) remained significantly lower in patients who received BSCPB. There was also a statistically significant reduction in PONV (P = 0.02).

Conclusion

BSCPB offers superior postoperative analgesia with a reduction in opioid use, reduction in PONV, and improvement in VAS scores.

Regional Anesthesia in Upper-Limb Surgery

BACKGROUND

Local and regional anesthesia is associated with numerous clinical and institutional advantages relative to general anesthesia. As anesthesiologists and surgeons increasingly integrate local and regional anesthesia into their clinical practice, an understanding of the principles, evolution, and trends underpinning modern anesthetic techniques continues to be relevant.

METHODS

A review of the literature in databases Medline, PubMed, and EMBASE identified recent developments, ongoing trends, and historical milestones in upper-limb regional anesthesia.

RESULTS

Advances in regional anesthetic techniques in the last century have led to reduced postoperative pain, improved safety, and improved outcomes in upper-limb surgery. The development of ultrasound-guided techniques, as well as pharmacological advances in local anesthetic drugs and adjuncts, has further advanced the role of regional anesthesia. Wide-awake local anesthesia with no tourniquet has allowed certain procedures to be performed on select patients in outpatient and low-resource settings.

CONCLUSIONS

This review provides an overview of local and regional anesthesia in the upper-limb from its historical origins to its contemporary applications in upper-limb surgery, particularly during the COVID-19 pandemic.

Team Approach: Use of Opioids in Orthopaedic Practice

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The opioid epidemic represents a serious health burden on patients across the United States.

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This epidemic is particularly pertinent to the field of orthopaedics because it is one of the fields providing the highest volume of opioid prescriptions.

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The use of opioids before orthopaedic surgery has been associated with decreased patient-reported outcomes, increased surgery-related complications, and chronic opioid use.

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Several patient-level factors, such as preoperative opioid consumption and musculoskeletal and mental health conditions, contribute to the prolonged use of opioids after surgery, and various screening tools for identifying high-risk drug use patterns are available.

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The identification of these high-risk patients should be followed by strategies aimed at mitigating opioid misuse, including patient education, opioid use optimization, and a collaborative approach between health care providers.

Preoperative transversus abdominis plane block decreases intraoperative opiate consumption during minimally invasive cholecystectomy

BACKGROUND

The ongoing epidemic of prescription opiate abuse is one of the most pressing health issues in the United States today. Consequently, analgesic adjuncts, such as multimodal drug regimens and regional anesthetic blocks (like transversus abdominis plane (TAP) block), have been introduced to the perioperative period in hopes of decreasing postoperative opiate use. However, the effect of these interventions on intraoperative opiate use has not been examined. We hypothesized that preoperative TAP block would be associated with decreased intraoperative opiate use during minimally invasive cholecystectomy.

METHODS

This was a retrospective review of patients undergoing minimally invasive cholecystectomy between June 2018 and January 2021. Perioperative data, operative times, and medication administration data were collected. Intraoperative opiate use was calculated in total morphine equivalent doses (MED) for each patient and adjusted for operative time. Univariate analysis and multivariate linear regression were performed to determine factors affecting intraoperative opiate requirements.

RESULTS

261 patients were included in this study, of which 62 (23.8%) received preoperative TAP block and 199 (76.2%) did not. Preoperative TAP block was associated with decreased intraoperative opiate use (0.199 vs 0.312, p < 0.001), while there were no statistically significant differences associated with other analgesic adjuncts including preoperative acetaminophen (p = 0.485), celecoxib (p = 0.112), gabapentin (p = 0.165), or intraoperative ketorolac (p = 0.200). On multivariate analysis, preoperative TAP block was independently associated with decreased intraoperative opiate use (< 0.001), while chronic cholecystitis on final pathology was associated with increased intraoperative opiate use (p = 0.002).

CONCLUSION

The use of preoperative TAP block was associated with decreased intraoperative opiate use during minimally invasive cholecystectomy and should be considered for routine use. Future research should investigate whether preoperative TAP blocks and a subsequent decrease of intraoperative opiates, also result in a decrease in postoperative opiate use and improvements in postoperative outcomes.

Postsurgical Opioid Use Among Veterans Discharged to Skilled Care Facilities Compared to Veterans Discharged to Home After Orthopedic Surgery

OBJECTIVES

To compare opioid use patterns among Veterans who were discharged to a skilled care facility vs home after orthopedic surgery at a VA hospital.

DESIGN

We conducted a retrospective cohort study of Veterans who had orthopedic surgery at the Salt Lake City VA Medical Center (VAMC) between January 2018 and December 2021 and were followed by a transitional pain service. The principal outcome of interest was the time to stop opioid use after discharge from the hospital.

SETTING AND PARTICIPANTS

Veterans not already on chronic opioid therapy who had orthopedic surgery at the Salt Lake City VAMC and were followed by a transitional pain service.

METHODS

448 patients were included in the study, of which 371 (83%) were discharged to home and 77 (17%) were discharged to a skilled care facility. Median days to opioid cessation were estimated using the Kaplan-Meier method with 95% CIs and compared with discharge disposition using a log-rank test. Time to opioid cessation following hospital discharge was compared to baseline characteristics using univariable and multivariable Cox proportional hazards models.

RESULTS

Patients who were discharged to a skilled care facility used opioids for twice as long as those who were discharged home [median days (interquartile range)]: 22 (19, 26) vs 11 (10, 12), P < .001, respectively. When controlling for baseline characteristics in the multivariable analysis, discharge to a skilled care facility was significantly associated with continued opioid use at all time points [hazard ratio 0.63 (95% CI 0.44, 0.89), P = .009].

CONCLUSIONS AND IMPLICATIONS

Veterans discharged to a skilled care facility after orthopedic surgery used opioids for twice as long as those who were discharged to home. As postsurgical pain management guidelines change to focus on nonopioid pain modalities and opioid reduction, skilled care providers should adapt those strategies for their facilities.

Changing patterns of opioid initiation for pain management in Ontario, Canada: A population-based cross-sectional study

INTRODUCTION

The recent publication of a national guideline and quality standards in Canada have provided clinicians with new, evidence-based recommendations on safe, appropriate opioid use. We sought to characterize how well opioid initiation practices aligned with these recommendations before and following their release.

METHODS

We conducted a population-based study among people initiating opioids prior to the release of national guidelines (April 2015-March 2016; fiscal year [FY] 2015) and in the most recent year available (January-December 2019) in Ontario, Canada. We used linked administrative claims data to ascertain the apparent indication for opioid therapy, and characterized the initial daily dose (milligrams morphine or equivalent; MME) and prescription duration for each indication.

RESULTS

In FY2015, 653,885 individuals commenced opioids, compared to 571,652 in 2019. Over time, there were small overall reductions in the prevalence of initial daily doses exceeding 50MME (23.9% vs. 20.1%) and durations exceeding 7 days (17.4% vs. 14.8%); but the magnitude of the reductions varied widely by indication. The prevalence of high dose (>50MME) initial prescriptions reduced significantly across all indications, with the exception of dentist-prescribed opioids (13.6% vs. 12.1% above 50MME). In contrast, there was little change in initial durations exceeding 7 days across most indications, with the exception of some surgical indications (e.g. common excision; 9.3% vs. 6.2%) and among those in palliative care (35.2% vs. 29.2%).

CONCLUSION

Despite some modest reductions in initiation of high dose and long duration prescription opioids between 2015 and 2019, clinical practice is highly variable, with opioid prescribing practices influenced by clinical indication. These findings may help identify medical specialties well-suited to targeted interventions to promote safer opioid prescribing.

Opioid-sparing anesthesia and patient-reported outcomes after open gynecologic surgery: a historical cohort study

PURPOSE

Dexmedetomidine and ketamine may be administered intraoperatively as continuous infusions to provide opioid-sparing anesthesia. Recent evidence has yielded controversial results regarding the impact of opioid-free anesthesia on postoperative complications, and there is a gap in knowledge regarding patient-reported outcomes (PROs). This study aimed to determine the impact of opioid-sparing anesthesia and opioid-based anesthesia on PROs among gynecologic patients within an enhanced recovery after surgery (ERAS) program.

METHODS

We formed a single-center historical cohort from patients enrolled in another study who underwent open gynecologic surgery on an ERAS program from November 2014 to December 2020 (n = 2,095). We identified two cohorts based on the type of balanced anesthesia administered: 1) opioid-sparing anesthesia defined as the continuous infusion of dexmedetomidine and ketamine (adjuvants) during surgery or 2) opioid-based anesthesia (no adjuvants). We measured the quality of postoperative recovery using the MD Anderson Symptom Inventory (MDASI), a 29-item validated tool that was administered preoperatively, daily while admitted, and weekly after discharge until week 6. The primary outcome was interference with walking. We matched both cohorts and used a multilevel linear mixed-effect model to evaluate the effect of opioid-sparing anesthesia on the primary outcome.

RESULTS

In total, 498 patients were eligible (159 in the opioid-sparing anesthesia cohort and 339 in the opioid-based anesthesia cohort), of whom 149 matched pairs were included in the final analysis. Longitudinal assessment showed no significant or clinically important difference in interference with walking (P = 0.99), general activity (P = 0.99), or other PROs between cohorts. Median [interquartile range (IQR)] intraoperative opioid administration (expressed as morphine milligram equivalents [MME]) among matched patients in the opioid-sparing anesthesia cohort was 30 [25-55] mg vs 58 [8-70] mg in the opioid-based anesthesia cohort (P < 0.01). Patients in the opioid-sparing anesthesia cohort had a lower opioid consumption in the postanesthesia care unit than those in the opioid-based anesthesia cohort (MME, 3 [0-10] mg vs 5 [0-15] mg; P < 0.01), but there was no significant difference between cohorts in total postoperative opioid consumption (MME, 23 [0-94] mg vs 35 [13-95] mg P = 0.053).

CONCLUSIONS

In this single-center historical cohort study, opioid-sparing anesthesia had no significant or clinically important effects on interference with walking or other PROs in patients undergoing gynecologic surgery compared with opioid-based anesthesia. Opioid-sparing anesthesia was associated with less short-term opioid consumption than opioid-based anesthesia.

A Web-based Educational Intervention to Increase Perianesthesia Nurses' Knowledge, Attitude, and Intention to Promote Safe Use, Storage, and Disposal of Opioids

PURPOSE

The purpose of this study was to determine if a web-based educational intervention increased knowledge, attitudes, and intention of perianesthesia nurses regarding opioid discharge education (including safe use, storage, and disposal of opioids). Secondary outcomes were to determine Perceived Behavioral Control, subjective norms, and familiarity with American Society of PeriAnesthesia Nurses (ASPAN) guidance on opioid education.

DESIGN

A pre-test, post-test longitudinal design.

METHODS

An email described the study and had a link for those choosing to participate. The intervention was a web-based voiceover module with patient education scenarios focused on information required for patients before discharge home. Responses to the evidence-based pre-survey, post-survey one, and post-survey two were collected. The survey was developed using components of the Theory of Planned Behavior. Data analysis included descriptive summary and evaluation of changes in knowledge and domains of Theory of Planned Behavior using repeated measures mixed modeling.

FINDINGS

The participants were invited to complete a pre-test survey (n = 672), the immediate post-test (n = 245), and the 4-week post-test (n = 172). The analysis presented is limited to 245 who completed at least the first post-survey. Most were staff nurses (82%), and the majority had a BSN (62%); participants most typically worked in a hospital-based PACU (73%). For all outcomes, there was an immediate increase in the measure following the intervention; this pairwise difference (between pretest and the immediate post-test) was significant in all but one of the models. The immediate and 4-week post-test scores exceeded the corresponding pre-test score, though for Perceived Behavioral Control, attitude, and intention, the degree of increase between baseline and week 4 was not significant.

CONCLUSIONS

In all cases, both the immediate and 4-week post-test scores exceeded the corresponding pre-test score, though, for three of the TPB constructs, the difference between baseline and week 4 was not significant, while nearly all of the increases between baseline and immediately following the intervention were significant. These findings suggest a more intensive intervention, possibly with the inclusion of booster sessions, may be needed.

Actual situation and prescribing patterns of opioids by pain physicians in South Korea

Background

Use of opioids for chronic intractable pain is increasing globally, and their proper use can improve patients’ quality of life. In contrast, opioid use disorders, such as abuse or addiction, caused by prescribing opioids, are a worldwide issue. This study aimed to understand current opioid prescribing patterns and pain physicians’ experiences with opioid use in South Korea.

Methods

Pain physicians in 42 university hospitals in South Korea were asked to complete anonymous questionnaires regarding opioid prescriptions.

Results

A total of 69 surveys were completed. Most pain physicians started prescribing opioids at a pain score of 7/10 and aimed to reduce pain by 50%. Most physicians (73.1%) actively explained the prescribed medications and possible side effects, and 61.2% of physicians preferred the prescription interval of 4 weeks. Immediate-release opioids were the most popular treatment for breakthrough pain (92.6%). The most common side effect encountered by physicians was constipation (43.3%), followed by nausea/vomiting (34.3%). Of the physicians, 56.5% replied that addiction and misuse prevalences were less than 5%. However, the most concerning side effect was addiction (33.0%).

Conclusions

The survey results showed that the prescribing patterns of pain physicians generally followed Korean guidelines. Physicians were most interested in the safety and effectiveness of opioid prescriptions. They were most concerned about respiratory depression and abuse or addiction. A significant number of physicians agreed that the NHIS regulations needed improvement for patient convenience and safe and effective treatment, though there were pros and cons of the NHIS restrictions on prescription conditions.

Prevention, diagnosis, and treatment of opioid use disorder under the supervision of opioid stewardship programs: it's time to act now

The third opium war may have already started, not only due to illicit opioid trafficking from the Golden Crescent and Golden Triangle on the international front but also through indiscriminate opioid prescription and opioid diversion at home. Opioid use disorder (OUD), among unintentional injuries, has become one of the top 4 causes of death in the United States (U.S.). An OUD is defined as a problematic pattern of opioid use resulting in clinically significant impairment or distress, consisting of 2 or more of 11 problems within 1 year, as described by the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition. Observation of aberrant behaviors of OUD is also helpful for overworked clinicians. For the prevention of OUD, the Opioid Risk Tool and the Current Opioid Misuse Measure are appropriate screening tests before and during opioid administration, respectively. Treatment of OUD consists of 3 opioid-based U.S. Food and Drug Administration-approved medications, including methadone, buprenorphine, and naltrexone, and non-opioid-based symptomatic medications for reducing opioid withdrawal syndromes, such as α2 agonists, β-blockers, antidiarrheals, antiemetics, non-steroidal anti-inflammatory drugs, and benzodiazepines. There are at least 6 recommendable guidelines and essential terms related to OUD. Opioid stewardship programs are now critical to promoting appropriate use of opioid medications, improving patient outcomes, and reducing misuse of opioids, influenced by the successful implementation of antimicrobial stewardship programs. Despite the lack of previous motivation, now is the critical time for trying to reduce the risk of OUD.

Neutrophil-to-Lymphocyte Ratio as an Indicator of Opioid-Induced Immunosuppression After Thoracoscopic Surgery: A Randomized Controlled Trial

Purpose

The neutrophil-to-lymphocyte ratio (NLR) is a useful prognostic marker for various diseases and surgery-induced immunosuppression. While opioids are important in general anesthesia, the association between immediate perioperative immune monitoring and opioid consumption for postoperative analgesia after video-assisted thoracoscopic surgery (VATS) is unknown. We aimed to investigate the effect of analgesic techniques on opioid-induced immune perturbation, and the feasibility of NLR as an indicator of opioid-induced immune changes.

Patients and Methods

Patients were randomly assigned to two groups: Group P (n=40) or Group C (n=40). Patients in group P received ultrasound-guided paravertebral block (PVB) before surgery, and followed by sufentanil patient-controlled intravenous analgesia (PCIA) after surgery, and group C received sufentanil PCIA only. The total and differential white blood cell counts, including CD4+ T lymphocyte counts, CD8+ T lymphocyte were recorded before surgery and at 24 and 72 hours after surgery. NLR was determined using the frequencies of lymphocyte subpopulations. The cumulative dose of sufentanil were recorded at 24 and 24h after surgery while the 40-item quality of recovery questionnaire (QoR-40) score were assessed at 48h after the surgery.

Results

At 24 and 48 hours after surgery, a lower sufentanil consumption, and higher QoR-40 recovery scores were found in group P than in group C (P<0.05). In biochemical analyses, the values of NLR were lower in group P compared to group C (p<0.0001) and ratio of CD4/CD8 were higher in group P compared to group C (p<0.05) on day three after surgery. NLR showed excellent predictive capability for immunosuppression, with an area under the curve (AUC) of 0.92 [95% confidence interval (CI), 0.86-0.98, P < 0.0001].

Conclusion

Opioid-sparing pain management strategies may affect postoperative immunosuppression and NLR could be a reliable indicator of opioid-related immunosuppression. Moreover, opioid-sparing pain management strategies could improve patient's satisfaction in VATS.

Feasibility of Prospectively Comparing Opioid Analgesia With Opioid-Free Analgesia After Outpatient General Surgery: A Pilot Randomized Clinical Trial

IMPORTANCE

The overprescription of opioids to surgical patients is recognized as an important factor contributing to the opioid crisis. However, the value of prescribing opioid analgesia (OA) vs opioid-free analgesia (OFA) after postoperative discharge remains uncertain.

OBJECTIVE

To investigate the feasibility of conducting a full-scale randomized clinical trial (RCT) to assess the comparative effectiveness of OA vs OFA after outpatient general surgery.

DESIGN, SETTING, AND PARTICIPANTS

This parallel, 2-group, assessor-blind, pragmatic pilot RCT was conducted from January 29 to September 3, 2020 (last follow-up on October 2, 2020). at 2 university-affiliated hospitals in Montreal, Quebec, Canada. Participants were adult patients (aged ≥18 years) undergoing outpatient abdominal (ie, cholecystectomy, appendectomy, or hernia repair) or breast (ie, partial or total mastectomy) general surgical procedures. Exclusion criteria were contraindications to drugs used in the trial, preoperative opioid use, conditions that could affect assessment of outcomes, and intraoperative or early complications requiring hospitalization.

INTERVENTIONS

Patients were randomized 1:1 to receive OA (around-the-clock nonopioids and opioids for breakthrough pain) or OFA (around-the-clock nonopioids with increasing doses and/or addition of nonopioid medications for breakthrough pain) after postoperative discharge.

MAIN OUTCOMES AND MEASURES

Main outcomes were a priori RCT feasibility criteria (ie, rates of surgeon agreement, patient eligibility, patient consent, treatment adherence, loss to follow-up, and missing follow-up data). Secondary outcomes included pain intensity and interference, analgesic intake, 30-day unplanned health care use, and adverse events. Between-group comparison of outcomes followed the intention-to-treat principle.

RESULTS

A total of 15 surgeons were approached; all (100%; 95% CI, 78%-100%) agreed to have patients recruited and adhered to the study procedures. Rates of patient eligibility and consent were 73% (95% CI, 66%-78%) and 57% (95% CI, 49%-65%), respectively. Seventy-six patients were randomized (39 [51%] to OA and 37 [49%] to OFA) and included in the intention-to-treat analysis (mean [SD] age, 55.5 [14.5] years; 50 [66%] female); 40 (53%) underwent abdominal surgery, and 36 (47%) underwent breast surgery. Seventy-five patients (99%; 95% CI, 93%-100%) adhered to the allocated treatment; 1 patient randomly assigned to OFA received an opioid prescription. Seventeen patients (44%) randomly assigned to OA consumed opioids after discharge. Seventy-three patients (96%; 95% CI, 89%-99%) completed the 30-day follow-up. The rate of missing questionnaires was 37 of 3724 (1%; 95% CI, 0.7%-1.4%). All the a priori RCT feasibility criteria were fulfilled.

CONCLUSIONS AND RELEVANCE

The findings of this pilot RCT support the feasibility of conducting a robust, full-scale RCT to inform evidence-based prescribing of analgesia after outpatient general surgery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04254679.

Preoperative transversus abdominis plane block decreases intraoperative opiate use during pancreatoduodenectomy

BACKGROUND

Multimodal analgesia and regional anesthetic blocks, such as transversus abdominis plane (TAP) block, decrease postoperative opiate consumption but their effect on intraoperative opiates is unknown.

METHODS

This was a retrospective review of patients undergoing pancreatoduodenectomy between June 2018 and February 2021, in which perioperative data, operative times, and medication administration data were collected. Intraoperative opiate use was calculated in total morphine equivalent doses (MED) for each patient and adjusted for operative time. Univariate analysis and multivariate linear regression were performed to determine factors affecting intraoperative opiate requirements.

RESULTS

Of the 169 patients in the study, 51 (30.2%) received pre-surgical TAP blocks and 118 (69.8%) did not. There were no statistically significant differences in intraoperative opiate use with preoperative acetaminophen (p = 0.527), celecoxib (p = 0.553), gabapentin (p = 0.308), intraoperative ketorolac (p = 0.698) or epidural placement (p = 0.086). Minimally invasive surgery had lower intraoperative opiate use compared to open (p = 0.011), as well as pre-surgical TAP block compared to no pre-surgical block (5.24 vs 7.27 MED/hour, p < 0.001). On multivariate linear regression, pre-surgical TAP block (p = 0.001) was independently associated with decreased intraoperative opiate use.

CONCLUSION

Preoperative TAP blocks were associated with decreased intraoperative opiate use during pancreatoduodenectomy and should be considered for routine use.

Analgesic Effect of Ropivacaine Pumped in the Sub Rectus Abdominis Muscle Sheath after Abdominoplasty

BACKGROUND

Abdominoplasty is a major surgical procedure in plastic surgery. It removes excess skin and fat, tightens abdominal muscles and fascia, restores normal abdominal anatomy and reshapes the distorted abdominal contour. According to the statistics released annually by International Society of Aesthetic Plastic Surgery (ISAPS) in 2020, there are more than 900, 000 abdominal wall plastic surgeries performed every year worldwide. However, the most commonly used analgesic methods, such as oral administration, intravenous analgesia and local infiltration anesthesia, do not provide the satisfactory analgesic results. We found that intra-sheath injection of ropivacaine of the rectus abdomen was effective in reducing postoperative pain.

OBJECTIVES

To retrospectively study the analgesic effect of continuous pumping ropivacaine into the intra-sheath space of rectus abdominis after abdominoplasty.

METHODS

A retrospective study was conducted on 67 patients with total abdominal wall plastic surgery admitted to Plastic Surgery Hospital of Chinese Academy of Medical Sciences from February 2020 to August 2021. The patients were from 25 to 56 years old, with a mean age of 38.5, ASA grade 1-2, BMI 27-33kg/m2, and rectus abdominis muscle separation range of 4-8cm. Based on the methods of postoperative analgesia, we divided patients into the following two groups: 29 patients in the conventional intravenous analgesic group (group A) and 38 patients in the rectus abdominis intrathecal analgesic group (group B). Group A received PCA with sufentanil 1.0μg/kg+ normal saline diluted to 100ml. Group B received continuous pumping of ropivacaine (0.2625%) through the rectus sheath internal tube in 100mL of normal saline and continued pumping at a rate of 2mL /h. Visual analog pain score (VAS score), analgesic pump pressure times and the degree of postoperative satisfaction were recorded at T1 (24h) and T2 (48h). The incidence of adverse drug reactions and complications related to nerve block within one week after operation were also recorded.

RESULTS

The clinical data of patients with total abdominal wall plastic surgery in two groups were collected and analyzed. The patients in group B overall had lower postoperative VAS score, less analgesic pump usage, less nausea, vomiting, drowsiness and restlessness and a higher degree of postoperative satisfaction than those in group A.

CONCLUSION

Continuous pumping of ropivacaine through rectus sheath can effectively relieve postoperative pain, reduce postoperative adverse reactions and improve postoperative satisfaction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online instructions to Authors www.springer.com/00266 . Body Contouring LOE IV.

Novel temperature-responsive hydrogel injected to the incision site for postoperative pain relief in laparoscopic abdominal surgery: a single-blind, randomized, pivotal clinical trial

BACKGROUND

A temperature-responsive hydrogel (PF-72; TGel Bio, Inc., Ltd, Seoul, Korea), developed as a sustained drug delivery device, can be mixed with ropivacaine to reduce pain in the incision area. The hydrogel is soluble at low temperatures (2-8 °C) and is converted into a gel at high temperatures (> 30 °C). We aimed to evaluate whether the administration of ropivacaine using PF-72 at incision sites reduces pain until 72 h postoperatively in patients undergoing laparoscopic stomach or colorectal surgery.

METHODS

Patients were randomly assigned to the control group (0.75% ropivacaine) or PF-72 group (PF-72 mixed with 0.75% ropivacaine). Before surgical incision closure, 0.75% ropivacaine or PF-72 mixed with 0.75% ropivacaine was injected into the subcutaneous fat and muscle of all incisions. Postoperative pain was evaluated by the Numerical Rating Scale (NRS, 0 = no pain, 10 = most severe pain) for wound pain at 3, 6, 24, 48, and 72 h after the end of surgery.

RESULTS

Ninety-nine patients (control, n = 51; PF-72, n = 48) were included in the analysis. The areas under the curve of NRS for wound pain until 72 h in the control group and the PF-72 group were 188.7 ± 46.1 and 135.3 ± 49.9 h, respectively (P < 0.001). The frequency of the administration of rescue analgesics in the general ward was similar between the two groups.

CONCLUSION

PF-72 mixed with 0.75% ropivacaine reduced postoperative pain until 72 h in patients undergoing laparoscopic surgery. Although the study population was not large enough for safety evaluation, no adverse events associated with PF-72 were observed.

Perioperative Opioids, the Opioid Crisis, and the Anesthesiologist

This review summarizes current evidence related to perioperative opioid prescription fulfillment and use and discusses the role of personalized anesthesia care in mitigating opioid-related harms without compromising analgesia.

Opioid-Sparing Analgesia Impacts the Perioperative Anesthetic Management in Major Abdominal Surgery

Background and Objectives: The management of acute postoperative pain (APP) following major abdominal surgery implies various analgetic strategies. Opioids lie at the core of every analgesia protocol, despite their side effect profile. To limit patients’ exposure to opioids, considerable effort has been made to define new opioid-sparing anesthesia techniques relying on multimodal analgesia. Our study aims to investigate the role of adjuvant multimodal analgesic agents, such as ketamine, lidocaine, and epidural analgesia in perioperative pain control, the incidence of postoperative cognitive dysfunction (POCD), and the incidence of postoperative nausea and vomiting (PONV) after major abdominal surgery. Materials and Methods: This is a clinical, observational, randomized, monocentric study, in which 80 patients were enrolled and divided into three groups: Standard group, C (n = 32), where patients received perioperative opioids combined with a fixed regimen of metamizole/acetaminophen for pain control; co-analgetic group, Co-A (n = 26), where, in addition to standard therapy, patients received perioperative systemic ketamine and lidocaine; and the epidural group, EA (n = 22), which included patients that received standard perioperative analgetic therapy combined with epidural analgesia. We considered the primary outcome, the postoperative pain intensity, assessed by the visual analogue scale (VAS) at 1 h, 6 h, and 12 h postoperatively. The secondary outcomes were the total intraoperative fentanyl dose, total postoperative morphine dose, maximal intraoperative sevoflurane concentration, confusion assessment method for intensive care units score (CAM-ICU) at 1 h, 6 h, and 12 h postoperatively, and the postoperative dose of ondansetron as a marker for postoperative nausea and vomiting (PONV) severity. Results: We observed a significant decrease in VAS score, as the primary outcome, for both multimodal analgesic regimens, as compared to the control. Moreover, the intraoperative fentanyl and postoperative morphine doses were, consequently, reduced. The maximal sevoflurane concentration and POCD were reduced by EA. No differences were observed between groups concerning PONV severity. Conclusions: Multimodal analgesia concepts should be individualized based on the patient’s needs and consent. Efforts should be made to develop strategies that can aid in the reduction of opioid use in a perioperative setting and improve the standard of care.

Single-dose premedication enhances multimodal analgesia after knee arthroplasty

BACKGROUND

With the current trend to reduce postoperative opioid use to enhance recovery and address perioperative opioid addiction concerns, the challenge of managing pain after total knee arthroplasty has increased. This study examined the effect of adding a preoperative medication regime to a multimodal postoperative analgesia protocol that included regional anaesthesia.

MATERIALS AND METHODS

Sixty patients undergoing elective first-time unilateral knee arthroplasty received celecoxib 100mg, gabapentin 600mg and dexamethasone 10mg po one hour before skin incision. They were compared to a sequential retrospective cohort of 49 patients. All patients routinely received acetaminophen 650mg po q6h, ibuprofen 400mg po q8h, patient-controlled opioid analgesia and continuous adductor canal blocks postoperatively. Pain scores and opioid consumption were recorded at 4, 8, 12, 24 and 48h.

RESULTS

Pain scores and cumulative opioid use were statistically and clinically significantly reduced at all time points up to 48h.

CONCLUSIONS

Combining preoperative oral celecoxib, gabapentin and dexamethasone had a clinically significantly effect in reducing pain scores and opioid use for at least 48h. Most of this effect is probably due to dexamethasone.

The Intraoperative Adherence to Multimodal Analgesia of Anesthesiologists: A Retrospective Study

Introduction

Multimodal analgesia (MMA) is a critical component of enhanced recovery after surgery (ERAS). However, little research revealed its intraoperative implementation by anesthesiologists, who are on the front line defending against surgical pain. Therefore, the objective of our study is to assess the adherence of anesthesiologists to MMA comprehensively.

Methods

A retrospective study was conducted involving patients undergoing lung resection, knee arthroplasty, and radical mastectomy from pre/post-implementation year of MMA (Jan 1, 2013, to Dec 31, 2013, vs. 2019). Intraoperative analgesia regimens (analgesic mode) and hourly rated morphine milligram equivalents (MME) were compared. In addition, patient characteristics associated with continued opioid use after surgery, surgical types, and position level of anesthesiologists (attending-junior; above attending-senior) were also analyzed.

Results

After MMA initiation, the rate of multimodal analgesic regimen (mode ≥ 2) was significantly increased (post- vs. pre-implementation, 31.57 vs. 21.50%, p < 0.05). However, MME did not show significant difference (post- vs. pre-implementation, 0.402 vs. 0.456, p > 0.05). Patient-level predictors of persistent opioid use after surgery were not related to increased analgesic mode. Lung resection [coefficient, − 0.538; 95% confidence interval (CI), − 0.695 to − 0.383, p < 0.001] and knee arthroplasty (coefficient, − 1.143; 95% CI, − 1.366 to − 0.925, p < 0.001) discouraged multiple analgesic mode, while senior anesthesiologists (coefficient, 0.674; 95% CI 0.548–0.800, p < 0.001) promoted it.

Conclusions

Although anesthesiologists used more analgesics after promoting MMA, the “opioid-sparing” principle was not followed properly. The analgesic mode was not instructed by patients’ characteristics appropriately. In addition, surgeries with cumbersome preparation/process impeded the use of multiple analgesic modes, while senior anesthesiologists preferred multiple analgesic modes.

Updates in Enhanced Recovery Pathways for Gynecologic Surgery

Gynecologic surgery encompasses over a quarter of inpatient surgical procedures for US women, and current projections estimate an increase of the US female population by nearly 50% in 2050. Over the last decade, US hospitals have embraced enhanced recovery pathways in many specialties. They have increasingly been used in multiple institutions worldwide, becoming the standard of care for patient optimization. According to the last updated enhanced recovery after surgery (ERAS) guideline published in 2019, there are several new considerations behind each practice in ERAS protocols. This article discusses the most updated evidence regarding ERAS programs for gynecologic surgery.

Opioid-free anesthesia in oncologic surgery: the rules of the game

BACKGROUND

Opioids are frequently used in the postoperative period due to their analgesic properties. While these drugs reduce nociceptive somatic, visceral, and neuropathic pain, they may also lead to undesirable effects such as respiratory depression, urinary retention, nausea and vomiting, constipation, itching, opioid-induced hyperalgesia, tolerance, addiction, and immune system disorders. Anesthesiologists are in the critical position of finding balance between using opioids when they are necessary and implementing opioid-sparing strategies to avoid the known harmful effects. This article aims to give an overview of opioid-free anesthesia.

MAIN BODY

This paper presents an overview of opioid-free anesthesia and opioid-sparing anesthetic techniques. Pharmacological and non-pharmacological strategies are discussed, highlighting the possible advantages and drawbacks of each approach.

CONCLUSIONS

Choosing the best anesthetic protocol for a patient undergoing cancer surgery is not an easy task and the available literature provides no definitive answers. In our opinion, opioid-sparing strategies should always be implemented in routine practice and opioid-free anesthesia should be considered whenever possible. Non-pharmacological strategies such as patient education, while generally underrepresented in scientific literature, may warrant consideration in clinical practice.

Review of Perioperative Music Medicine: Mechanisms of Pain and Stress Reduction Around Surgery

Clinical-experimental considerations and an approach to understanding the autonomic basis of improved surgical outcomes using Perioperative Music Medicine (PMM) are reviewed. Combined surgical, psycho-physiological, and experimental perspectives on Music Medicine (MM) and its relationship to autonomic nervous system (ANS) function are discussed. Considerations are given to the inter-related perioperative effects of MM on ANS, pain, and underlying vagal and other neural circuits involved in emotional regulation and dysregulation. Many surgical procedures are associated with significant pain, which is routinely treated with post-operative opioid medications, which cause detrimental side effects and delay recovery. Surgical trauma shifts the sympathetic ANS to a sustained activation impairing physiological homeostasis and causing psychological stress, as well as metabolic and immune dysfunction that contribute to postoperative mortality and morbidity. In this article, we propose a plan to operationalize the study of mechanisms mediating the effects of MM in perioperative settings of orthopedic surgery. These studies will be critical for the implementation of PMM as a routine clinical practice and to determine the potential limitations of MM in specific cohorts of patients and how to improve the treatment.

Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management

While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.

Preclinical Discovery and Development of oliceridine (Olinvyk®) for the Treatment of Post-Operative Pain

INTRODUCTION

Opioids acting at the MOP(mu:µ) receptor produce analgesia but also side-effects. There is debate suggesting opioid receptors produce analgesia via G-protein and side-effects via β-arrestin-2 pathways. Opioids targeting G-proteins over the arrestins (bias) offer potential therapeutic advantages. Oliceridine is a putative MOP, G-protein biased agonist.

AREAS COVERED

Oliceridine is selective for MOP receptors with greater activity at G-proteins over arrestins. A substantial body of evidence now points to a simpler pharmacological descriptor of partial agonist. Pre-clinical in vivo data indicates a robust antinociceptive response of shorter duration than morphine. Apollo trials (Phase-III RCT-bunionectomy/abdominoplasty) describe good analgesic efficacy that was non-inferior to morphine with good tolerability and side-effect profile. There is evidence for improved respiratory safety profile. Oliceridine is approved by the FDA.

EXPERT OPINION

Oliceridine will be an important addition to the clinical armamentarium for use for the management of acute pain severe enough to require an intravenous opioid analgesic and for whom alternative treatments are inadequate. Respiratory advantage and the possibility of reduced abuse potential are possible advantages over the use of traditional opioids. Based on a number of excellent, highly detailed studies, oliceridine should be described as a partial agonist; this 'label' does not matter.

Implementation of a restrictive opioid prescription protocol after minimally invasive gynecologic oncology surgery

OBJECTIVES

Opioids are routinely prescribed after minimally invasive gynecologic oncology surgery, with minimal data to inform the ideal dose. The aim of this study was to evaluate the impact of a restrictive opioid prescription protocol on the median morphine milligram equivalents prescribed and pain control in patients undergoing minimally invasive surgery.

METHODS

A restrictive opioid prescription protocol was implemented from January through December 2020 at a single tertiary cancer center in Ontario, Canada. Consecutive patients undergoing minimally invasive hysterectomy for suspected malignancy were included. Simultaneously, we implemented use of multimodal analgesia, patient and provider education, pre-printed standardized prescriptions, and tracking of opioid prescriptions. Total median morphine milligram equivalents prescribed were compared between pre- and post-intervention cohorts. Patients were surveyed regarding opioid use and pain control at 30 days post-surgery.

RESULTS

A total of 101 women in the post-intervention cohort were compared with 92 consecutive pre-intervention controls. Following protocol implementation, median morphine milligram equivalents prescribed decreased from 50 (range 9-100) to 25 (range 8-75) (p<0.001). In the post-intervention cohort, 75% (76/101) used 10 median morphine milligram equivalents or less and 55 patients (54%) used 0 median morphine milligram equivalent. There was no additional increase in opioid refill requests after implementation of our strategy. Overall, patients reported a median pain score of 3/10 at 30 days post-surgery; the highest pain scores and most of the pain occurred in the first week after surgery.

CONCLUSIONS

Implementation of a restrictive opioid prescription protocol led to a significant reduction in opioid use after minimally invasive gynecologic oncology surgery, with over 50% of patients requiring no opioids postoperatively.

Effects of Patient and Surgery Characteristics on Persistent Postoperative Pain: A Mediation Analysis

OBJECTIVE

Acute postoperative pain intensity is associated with persistent postsurgical pain (PPP) risk. However, it remains unclear whether acute postoperative pain intensity mediates the relationship between clinical factors and persistent pain.

MATERIALS AND METHODS

Participants from a mixed surgical population completed the Brief Pain Inventory and Pain Catastrophizing Scale before surgery, and the Brief Pain Inventory daily after surgery for 7 days and at 30 and 90 days after surgery. We considered mediation models using the mean of the worst pain intensities collected daily on each of postoperative days (PODs) 1 to 7 against outcomes of worst pain intensity at the surgical site endpoints reflecting PPP (POD 90) and subacute pain (POD 30).

RESULTS

The analyzed cohort included 284 participants for the POD 90 outcome. For every unit increase of maximum acute postoperative pain intensity through PODs 1 to 7, there was a statistically significant increase of mean POD 90 pain intensity by 0.287 after controlling for confounding effects. The effects of female versus male sex (m=0.212, P=0.034), pancreatic/biliary versus colorectal surgery (m=0.459, P=0.012), thoracic cardiovascular versus colorectal surgery (m=0.31, P=0.038), every minute increase of anesthesia time (m=0.001, P=0.038), every unit increase of preoperative average pain score (m=0.012, P=0.015), and every unit increase of catastrophizing (m=0.044, P=0.042) on POD 90 pain intensity were mediated through acute PODs 1 to 7 postoperative pain intensity.

DISCUSSION

Our results suggest the mediating relationship of acute postoperative pain on PPP may be predicated on select patient and surgical factors.

Cost-utility analysis of single nucleotide polymorphism panel-based machine learning algorithm to predict risk of opioid use disorder

Aim: To conduct a cost-utility analysis of a novel genetic diagnostic test (OUDTEST) for risk of developing opioid use disorder for elective orthopedic surgery patients. Materials & Methods: A simulation model assessed cost-effectiveness and quality-adjusted life-years (QALYs) for OUDTEST from private insurer and self-insured employer perspectives over a 5-year time horizon for a hypothetical patient population. Results: OUDTEST was found to cost less and increase QALYs, over a 5-year period for private insurance (savings US$2510; QALYs 0.02) and self-insured employers (-US$2682; QALYs 0.02). OUDTEST was a dominant strategy in 71.1% (private insurance) and 72.7% (self-insured employer) of model iterations. Sensitivity analyses revealed robust results except for physician compliance. Conclusion: OUDTEST was expected to be a cost-effective solution for personalizing postsurgical pain management in orthopedic patients.

Evaluating oliceridine as a treatment option for moderate to severe acute post-operative pain in adults

INTRODUCTION

Despite the advances in regional anesthesia and non-opioid systemic analgesia, opioids remain the primary rescue analgesic for moderate to severe pain. However, the risks and side effects of opioid medications are well documented. Oliceridine is a novel opioid receptor agonist which is thought to have less risk of adverse events, such as postoperative nausea and vomiting (PONV) and respiratory depression.

AREAS COVERED

In this review, the authors discuss the limitations of the current opioid and non-opioid analgesic options. They also review the pharmacokinetics of oliceridine, its analgesic efficacy, and risk of adverse events; and its added clinical value in managing moderate to severe pain.

EXPERT OPINION

Despite the advances in regional anesthesia and multimodal systemic analgesia, opioid free analgesia is only feasible in selected procedures and patients. Oliceridine is effective in the management of moderate to severe pain and appears to be associated with lower risk of nausea and vomiting. The risk of sedation and respiratory depression associated with oliceridine will require further study. The availability of an opioid agonist with a better side effect profile could potentially change the current paradigm of opioid avoidance in postoperative pain management.

Dexmedetomidine Added to Ropivacaine for Ultrasound-guided Erector Spinae Plane Block Prolongs Analgesia Duration and Reduces Perioperative Opioid Consumption After Thoracotomy: A Randomized, Controlled Clinical Study

OBJECTIVES

Single-injection erector spinae plane block (ESPB) provides good control of pain relief after open thoracotomy surgeries. However, the duration of pain relief does not last long. For this purpose, we hypothesized that adding α2-adrenoceptor agonist, dexmedetomidine, for interfascial nerve blockade may increase the duration of analgesia. There are only few studies using dexmedetomidine for interfasical nerve blocks in humans. In this study, our aim is to investigate whether addition of dexmedetomidine to ropivacaine for ESPB could effectively prolong the duration of postoperative analgesia and reduce opioid consumption after open thoracotomy.

MATERIALS AND METHODS

Sixty patients with esophageal cancer were randomized to receive ESPB using 28 mL of 0.5% ropivacaine, with 2 mL of normal saline (group R) or 0.5 µg/kg dexmedetomidine in 2 mL (group RD) administered interfascially. ESPB was performed at the fifth thoracic level under ultrasound guidance. The primary outcome was the duration of analgesia. The secondary outcomes were total postoperative sufentanil consumption, Numeric Rating Scale pain scores, Ramsay Sedation Scale scores and adverse effects.

RESULTS

The duration of analgesia in group RD (505.1±113.9) was longer than that in group R (323.2±75.4) (P<0.001). The total postoperative sufentanil consumption was lower in group RD (23.3±10.0) than in group R (33.8±13.8) (P=0.001). There was no significant difference in the incidence of adverse effects between the 2 groups.

CONCLUSION

After open thoracotomy, addition of dexmedetomidine to ropivacaine for ESPB effectively prolonged the duration of postoperative analgesia and reduced opioid consumption without increasing additional incidence of adverse effects.

Endovascular surgery is not protective against new persistent opioid use development compared to open vascular surgery

OBJECTIVE

Endovascular techniques continue to be increasingly utilized to treat vascular disease, but the effect of these minimally invasive techniques on opioid use following surgery is not known.

METHODS

Using Medicare data, we identified opioid-naive patients undergoing vascular procedures between 2009 and 2017. We selected patients ≥65 years old with continuous enrollment 12 months before and 6 months after surgery and had no additional operations. We defined new persistent opioid use (NPOU) as one or more opioid prescription fills both between 4-90 and 91-180 days postoperatively. Multivariable regression was performed for risk adjustment, and frequencies of NPOU were estimated between endovascular and open techniques to compare surgical approach.

RESULTS

A total of 77,767 patients were identified, with 2.6% of all patients developing new persistent use. In addition to the identification of several risk factors for new persistent use, patients undergoing endovascular carotid or vertebral interventions were found to have higher adjusted frequencies of persistent use compared to those undergoing open interventions (3.0% vs. 1.8%, p < 0.001) as did those undergoing endovenous compared to open vein procedures (2.2%, vs. 1.6%, p = 0.019). We found no difference for peripheral vascular or aortic/iliac procedures.

CONCLUSIONS

Patients undergoing vascular surgery are at high risk for new persistent use. Undergoing endovascular carotid or venous surgery was associated with an increased risk of NPOU, whereas no differences were found between endovascular and open approaches for peripheral arterial or aortic disease.

Effectiveness of Perioperative Opioid Educational Initiatives: A Systematic Review and Meta-Analysis

BACKGROUND

Opioids are the most commonly prescribed analgesics in the United States. Current guidelines have proposed education initiatives to reduce the risk of chronic opioid consumption, yet there is lack of efficacy data on such interventions. Our study evaluates the impact of perioperative opioid education on postoperative opioid consumption patterns including opioid cessation, number of pills consumed, and opioid prescription refills.

METHODS

The MEDLINE/PubMed, Embase, Cochrane Library, Scopus, and Google Scholar databases were systematically searched for randomized controlled trials (RCTs) assessing the impact of perioperative educational interventions (using either paper- or video-based instruments regarding pain management and drug-induced side effects) on postoperative opioid patterns compared to standard preoperative care among patients undergoing elective surgery. Our end points were opioid consumption (number of pills used), appropriate disposal of unused opioids, opioid cessation (defined as no use of opioids), and opioid refills within 15 days, 6 weeks, and 3 months.

RESULTS

In total, 11 RCTs fulfilled the inclusion criteria, totaling 1604 patients (804 received opioid education, while 800 received standard care). Six trials followed patients for 15 days after surgery, and 5 trials followed patients up to 3 months. After 15 days, the opioid education group consumed a lower number of opioid pills than those in the control group (weighted mean difference [WMD], -3.39 pills; 95% confidence interval [CI], -6.40 to -0.37; P =.03; I2 = 69%) with no significant difference in overall opioid cessation (odds ratio [OR], 0.25; 95% CI, 0.04-1.56; P = .14; I2 = 83%). Likewise, perioperative opioid education did not have significant effects on opioid cessation at 6 weeks (OR, 0.69; 95% CI, 0.45-1.05; P = .10; I2 = 0%) and 3 months (OR, 0.59; 95% CI,0.17-2.01; P = .10; I2 = 0%) after surgery, neither reduced the need for opioid refills at 15 days (OR, 0.57; 95% CI, 0.28-1.15; P = .12; I2 = 20%) and 6 weeks (OR, 1.08; 95% CI, 0.59-1.98; P = .80; I2 = 37%). There was no statistically significant difference in the rate of appropriate disposal of unused opioids between both groups (OR, 1.99; 95% CI, 0.66-6.00; P = .22; I2 = 71%). Subgroup analysis by type of educational intervention showed a statistical reduction of opioid consumption at 15 days when implementing multimedia/audiovisual strategies (4 trials: WMD, -4.05 pills; 95% CI, -6.59 to -1.50; P = .002; I2 = 45%), but there was no apparent decrease when using only paper-based strategies (2 trials: WMD, -2.31 pills; 95% CI, -12.21 to 7.59; P = .65; I2 = 80%).

CONCLUSIONS

Perioperative educational interventions reduced the number of opioid pills consumed at 15 days but did not demonstrate a significant effect on opioid cessation or opioid refills at 15 days, 6 weeks, and 3 months. Further randomized trials should focus on evidence-based educational interventions with strict homogeneity of material to draw a more definitive recommendation.

Drug and alcohol positivity of traumatically injured patients related to COVID-19 stay-at-home orders

Background: COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population.Objectives: Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients.Methods: A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date - before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) - and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables.Results: 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, p < .001 and p = .035), amphetamine (10.4% vs. 7.5% and 9.3%, OR = 1.43 and 1.14, p < .001 and p = .023), tetrahydrocannabinol (THC) (13.8% vs. 11.0% and 11.4%, OR = 1.30 and 1.25, p < .001 and p < .001), and 3,4-methylenedioxy methamphetamine (MDMA) (0.8% vs. 0.4% and 0.2%, OR = 2.02 and 4.97, p = .003 and p < .001) positivity compared to PRE-SAH and CONTROL groups. Alcohol concentration and positivity were similar between groups (p > .05).Conclusion: This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic.

Comparison of transversus abdominis plane catheters with thoracic epidurals for cost and length of stay in open colorectal surgeries: a cohort study

BACKGROUND

Thoracic epidural analgesia has long been a common method of postoperative analgesia for major open abdominal surgeries and is frequently used within enhanced recovery after surgery programs. An alternative postoperative analgesia method is the single shot transversus abdominis plane block, which has shown promising outcomes with respect to total length of stay, cost, pain scores, and decreased opioid usage. However, far less is known regarding continuous transversus abdominis plane analgesia using catheters. We evaluated the total cost-effectiveness of transversus abdominis plane catheter analgesia compared to thoracic epidural analgesia for patients undergoing open colorectal surgeries within the enhanced recovery after surgery program at our institution.

METHODS

This cohort study included patients booked under the colorectal surgery enhanced recovery after surgery program from November 2016 through March 2018 who received either bilateral transversus abdominis plane catheters (n = 52) or thoracic epidural analgesia (n = 24).

RESULTS

There was no difference in total direct cost (p = 0.660) and indirect cost (p = 0.220), and median length of stay (p = 0.664) in the transversus abdominis plane catheter group compared to the thoracic epidural group. Additionally, the transversus abdominis plane catheter group received significantly less morphine equivalents compared to the thoracic epidural group (p = 0.008) and had a lower mean body mass index (p = 0.019). There was no significant difference between the two groups for age (p = 0.820), or sex (p = 0.330).

CONCLUSIONS

Transversus abdominis plane catheter analgesia is not associated with increased cost or longer hospital stays when compared to thoracic epidural analgesia in patients undergoing open colorectal surgery within an enhanced recovery after surgery program. Furthermore, transversus abdominis plane catheter analgesia led to decreased opioid consumption while maintaining similar pain scores, suggesting similar pain control between the two modalities.

Comparison of the effect of epidural versus intravenous patient controlled analgesia on inpatient and outpatient functional outcomes after adult degenerative scoliosis surgery: a comparative study

BACKGROUND

Perioperative pain can negatively impact patient recovery after spine surgery and be a contributing factor to increased hospital length of stay and cost. Most data currently available is extrapolated from adolescent idiopathic cases and may not apply to adult and geriatric populations with thoracolumbar spine degeneration.

PURPOSE

Study the impact of epidural analgesia on pain control and outcomes after adult degenerative scoliosis surgery in a large single-institution series of adult patients undergoing thoraco-lumbar-pelvic fusion.

STUDY DESIGN/SETTING

Retrospective single-center review of prospectively collected data.

PATIENT SAMPLE

Patients undergoing thoracolumbar fusion with pelvic fixation.

OUTCOME MEASURES

Self-reported measures: Visual analog scale for pain. Physiologic Measures: Oral pain control requirements converted into daily morphine equivalents. Functional Measures: Ambulation perimeter after surgery, urinary retention and constipation rates.

METHODS

We retrospectively reviewed patient data for the years 2016 and 2017 before the use of patient controlled epidural analgesia (PCEA), and then 2018 and 2019 after its implementation, for all thoracolumbar degenerative procedures, and compared their postoperative outcomes measures.

RESULTS

There were 46 patients in the PCEA group and 37 patients in the intravenous PCA (IVPCA) groups. All patients underwent long segment posterolateral thoracolumbar spinal fusion with pelvic fixation. Patients in the PCEA group had lower pain scores and ambulated greater distances compared with those in the IVPCA group. PCEA patients also had lower urinary retention and constipation rates, but no increased intraoperative or postoperative complications related to catheter placement.

CONCLUSIONS

PCEA can provide optimal pain control after adult degenerative scoliosis spine surgery, and may promote greater early ambulation, while decreasing postoperative constipation and urinary retention rates.

Perioperative Opioid Administration

Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.

Decreased Analgesic Requirements in Super Morbidly Versus Morbidly Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy

Background

Scarce data exists about analgesic requirements in super morbidly obese (SMO) patients who underwent sleeve gastrectomy. We attempted to investigate analgesic requirements for SMO, when compared with morbidly obese (MO) individuals who underwent sleeve gastrectomy and its impact on postoperative outcome.

Methods

We studied 279 consecutive patients (183 MO, 96 SMO) who underwent bariatric surgery. Data analysis included perioperative anaesthetic management, analgesic consumptions, opioids side effects, and ICU admission.

Results

The SMO group showed higher patients with asthma, epilepsy, obstructive sleep apnoea (OSA), and ASA III percentages (P = 0.014, P = 0.016, P ˂ 0.001, and P ˂ 0.001, respectively). There were no significant differences in the total morphine consumption intraoperatively, or after 24 h. However, reduced consumption of intraoperative fentanyl and morphine in SMO when calculated per total body weight (TBW) (P = 0.004 and P = 0.001, respectively). At PACU, tramadol consumption per TBW and lean body mass (LBM) were significantly reduced in SMO (P = 0.001 and P = 0.025, respectively). Paracetamol consumption was significantly reduced in the SMO group (P = 0.04). They showed higher comorbidities (P ˂ 0.001), longer anaesthesia time (P = 0.033), and greater ICU admissions (P ˂ 0.001). Vomiting was higher in the MO group (P = 0.004). Both groups showed comparable pain scores (P = 0.558) and PACU stay time (P = 0.060).

Conclusions

Super morbidly obese patients required fewer opioids and analgesics perioperatively. They exhibited higher comorbidities with greater anaesthesia time and ICU admissions. PACU stay time and pain scores were comparable.