Postoperative pain management of the obese patient

The association of obesity with post-cesarean inpatient opioid consumption

BACKGROUND

Obesity and prescription opioid misuse are important public health concerns in the United States. A common intersection occurs when women with obesity undergo cesarean birth and receive narcotic medications for postpartum pain.

OBJECTIVE

To examine the association between obesity and inpatient opioid use after cesarean birth.

METHODS

A retrospective cohort study of patients that underwent cesarean birth in 2015-2018. Primary outcome was post-cesarean delivery opioid consumption starting 24 h after delivery measured as morphine milliequivalents per hour (MME/h). Secondary outcome was MME/h consumption in the highest quartile of all subjects. Opioid consumption was compared between three BMI groups: non-obese BMI 18.5-29.9 kg/m2; obese BMI 30.0-39.9 kg/m2; and morbidly obese BMI ≥ 40.0 kg/m2 using univariable and multivariable analyses.

RESULTS

Of 1620 patients meeting inclusion criteria, 496 (30.6%) were in the non-obese group, 753 (46.5%) were in the obese group, and 371 (22.9%) were in the morbidly obese group. In the univariate analysis, patients with obesity and morbid obesity required higher MME/h than patients in the non-obese group [1.3 MME/h (IQR 0.1, 2.4) vs. 1.6 MME/h (IQR 0.5, 2.8) vs. 1.8 MME/h (IQR 0.8, 2.9), for non-obese, obese, and morbidly obese groups respectively, p < 0.001]. In the multivariable analysis, this association did not persist. In contrast, subjects in the obese and morbidly obese groups were more likely to be in the highest quartile of MME/h opioid consumption compared with those in the non-obese group (23.5% vs. 48.1% vs. 28.4%, p < 0.001, respectively); with aOR 1.42 (95% CI 1.07-1.89, p = 0.016) and aOR 1.60 (95% CI 1.16-2.22, p = 0.005) for patients with obesity and morbid obesity, respectively.

CONCLUSION

Maternal obesity was not associated with higher hourly MME consumption during inpatient stay after cesarean birth. However, patients with obesity and morbid obesity were significantly more likely to be in the top quartile of MME hourly consumption.

Ultrasonography Guided Modified BRILMA (Blocking the Cutaneous Branches of Intercostal Nerves in the Middle Axillary Line) Block in Bariatric Surgery

Background: Postoperative pain is one of the major problems after laparoscopic sleeve gastrectomy besides complications. Management of pain control is still unclear in the obese population. Modified BRILMA (blocking the cutaneous branches of intercostal nerves in the middle axillary line) is a new analgesia technique which is performed by ultrasonography guided through the way between eighth and ninth rib level. This study is to evaluate the efficiency of modified BRILMA in bariatric patients while comparing with trocar site infiltration. Materials and Methods: This is a prospective designed retrospective data analysis study. Patients undergoing laparoscopic sleeve gastrectomy between June 2019 and January 2020 were divided into two groups. One group underwent BRILMA block; the other group used traditional trocar site injection. Postoperative pain was followed by using visual analogue scale (VAS) (at 1, 3, 6, 12, 24, 36, 48 hours postoperatively). Results: Thirty patients were included in the study. Twenty-four (80%) of the patients were women, and 6 (20%) of the patients were men. Mean body mass index of patients were 39.83 ± 4.02 kg/m2. Mean operational time was calculated 86.16 ± 19.94 minutes. When the patients' VAS was compared, 12th hour VAS value was statistically less in the BRILMA group. There were no significant differences in other hours' VAS between two groups. When compared with the use of opioid amount, there were no statistically significant difference between the two groups (P = .66), but BRILMA group had less amount. Conclusion: Modified BRILMA is an alternative technique to the use of trocar site bupivacain injection in bariatric surgery. It is new technique that is tried in bariatric population, which is also cost-effective and has less opioid consumption.

Simultaneous selection and inference for varying coefficients with zero regions: a soft-thresholding approach

Varying coefficient models have been used to explore dynamic effects in many scientific areas, such as in medicine, finance, and epidemiology. As most existing models ignore the existence of zero regions, we propose a new soft-thresholded varying coefficient model, where the coefficient functions are piecewise smooth with zero regions. Our new modeling approach enables us to perform variable selection, detect the zero regions of selected variables, obtain point estimates of the varying coefficients with zero regions, and construct a new type of sparse confidence intervals that accommodate zero regions. We prove the asymptotic properties of the estimator, based on which we draw statistical inference. Our simulation study reveals that the proposed sparse confidence intervals achieve the desired coverage probability. We apply the proposed method to analyze a large-scale preoperative opioid study.

Predictors of post-discharge pain and satisfaction with pain management after laparoscopic bariatric surgery: a prospective cohort study

BACKGROUND

Pain management after bariatric surgery remains challenging given the risk for analgesia-related adverse events (e.g., opioid use disorder, marginal ulcers). Identifying modifiable factors associated with patient-reported pain outcomes may improve quality of care. We evaluated the extent to which patient and procedural factors predict 7-day post-discharge pain intensity, pain interference, and satisfaction with pain management after bariatric surgery.

METHODS

This prospective cohort study included adults undergoing laparoscopic bariatric surgery at two university-affiliated hospitals and one private clinic. Preoperative assessments included demographics, Pain Catastrophizing Scale (score range 0-52), Patient Activation Measure (low [< 55.1] vs. high [≥ 55.1]), pain expectation (0-10), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) anxiety and depression scales. At 7 days post-discharge, assessments included PROMIS-29 pain intensity (0-10) and pain interference scales (41.6-75.6), and satisfaction with pain management (high [10-9] vs. lower [8-0]). Linear and logistic regression were used to assess the association of pain outcomes with potential predictors.

RESULTS

Three hundred and fifty-one patients were included (mean age = 44 ± 11 years, BMI = 45 ± 8 kg/m2, 77% female, 71% sleeve gastrectomy). At 7 days post-discharge, median (IQR) patient-reported pain intensity was 2.5 (1-5), pain interference was 55.6 (52.0-61.2), and 76% of patients reported high satisfaction with pain management. Pain intensity was predicted by preoperative anxiety (β + 0.04 [95% CI + 0.01 to + 0.07]) and pain expectation (+ 0.15 [+ 0.05 to + 0.25]). Pain interference was predicted by preoperative anxiety (+ 0.22 [+ 0.11 to + 0.33]), pain expectation (+ 0.47 [+ 0.10 to + 0.84]), and age (- 0.09 [- 0.174 to - 0.003]). Lower satisfaction was predicted by low patient activation (OR 1.94 [1.05-3.58]), higher pain catastrophizing (1.03 [1.003-1.05]), 30-day complications (3.27 [1.14-9.38]), and age (0.97 [0.948-0.998]).

CONCLUSION

Patient-related factors are important predictors of post-discharge pain outcomes after bariatric surgery. Our findings highlight the value of addressing educational, psychological, and coping strategies to improve postoperative pain outcomes.

A Comparative Study of the Effect of Labetalol and Remifentanil on Pain Control After Bariatric Surgery

Background

Finding the optimal combination of anesthetics to maintain hemodynamic stability during surgery can be challenging. Traditionally, strong opioid analgesics such as fentanyl and its newer analogs have been used. However, the use of narcotics is associated with certain side effects.

Objectives

This study compares the effects of labetalol and remifentanil in pain control after bariatric surgery in Hazrat Rasool Akram Hospital.

Methods

This randomized, double-blind clinical trial was conducted on 48 laparoscopic bariatric surgery patients. The participants were randomly divided into two groups receiving remifentanil or labetalol. Postoperative pain was measured in the recovery unit using the numerical rating scale (NRS). This score was recorded upon entering recovery, and 30 minutes, 60 minutes, and 120 minutes after surgery for each patient. Also, the duration of anesthesia, the duration of the operation, the recovery time, the dose of the administered opioids, the volume of intravenous fluids, and the dose of administered propofol were recorded for each patient. Nausea and vomiting after the operation were also recorded as outcomes.

Results

There were no significant differences between the two groups regarding the mean duration of surgery and anesthesia, dose of the administered anesthetics, recovery period, nausea and vomiting, and the dose of analgesics after the operation. The mean pain intensity during the given period and also the trend of pain intensity changes between the two groups demonstrated no statistically significant differences (P = 0.112). During the operation, 9 subjects (37.5%) in the labetalol group and 16 (66.7%) in the remifentanil group needed more analgesics (rescue drug); in this regard, a significant difference was observed between the two groups (P = 0.043).

Conclusions

Based on the study's findings, there were no significant differences between labetalol and remifentanil in post and perioperative pain control. However, rescue drugs needed to maintain hemodynamic stability during laparoscopic surgery were significantly lower in patients who received labetalol than remifentanil. Postoperative complications were also comparable between labetalol and remifentanil.

Virtual Reality as a Surgical Care Package for Patients Undergoing Weight Loss Surgery: A Narrative Review of the Impact of an Emerging Technology

While bariatric surgery is regarded as the most effective treatment for people with severe and morbid obesity, its pathway is regarded as a complex one due to the multidisciplinary approaches required from pre-surgery education until long-term management. This is essential to maintain weight loss and improve the quality of life after bariatric surgery. Although these approaches are broadened, patient education, pre-operative preparation, behavioural therapy, rehabilitation, and dietary changes are regarded as the main domains in such complex care. With the increase in technological adaptation in medical services, virtual reality (VR) has shown many benefits that can be utilized in the care of bariatric patients undergoing surgery. However, VR has not been innovated to be a multidomain care package in which bariatric patients could benefit throughout their journey from the pre-operative optimization, recovery, and long-term follow-up. This review aims to give a brief description of some of the applications of VR technology and question whether it has the potential to be considered as a virtual ecosystem to improve the bariatric patients’ experience and pathway throughout surgery and follow-up.

Postoperative Respiratory Compromise following Cesarean Birth: The Impact of Obesity and Systemic Opioids

Objective  The aim of this study was to measure the effect of obesity and systemic opioids on respiratory events within the first 24 hours following cesarean. Methods  Opioid-naive women undergoing cesarean between January 2016 and December 2017 were included in this retrospective cohort study. The primary outcome was the proportion of women experiencing at least one composite respiratory outcome (oxygen saturation less than 95% lasting 30+ seconds or need for respiratory support) within 24 hours of cesarean. The impact of obesity and total systemic opioid dose in 24 hours (measured in morphine milligram equivalents [MMEs]) on the composite respiratory compromise outcome were evaluated. Results  Of 2,230 cesarean births, 790 women had at least one composite respiratory event. Predictors of the composite respiratory outcome included body mass index (BMI) as a continuous variable (odds ratio = 1.063 for every one unit increase in BMI [95% confidence interval (CI): 1.021-1.108], p  = 0.003), and MME (odds ratio = 1.005 [95% CI: 1.002-1.008], p  = 0.003), adjusting for magnesium sulfate use. The interaction between obesity and opioid dose demonstrated an odds ratio of 1.000 (95% CI: 0.999-1.000, p  = 0.030). Conclusion  The proportion of women experiencing respiratory events following cesarean birth increases with the degree of obesity and opioid dose. Key Points Respiratory events increase with obesity.Respiratory events increase with systemic opioid use.Odds ratio of respiratory events is 1.063/unit BMI increase.

Comparison of three intraoperative analgesic strategies in laparoscopic bariatric surgery: a retrospective study of immediate postoperative outcomes

Introduction and objectives

Multimodal Analgesia (MMA) has shown promising results in postoperative outcomes across a broad spectrum of surgeries, including bariatric surgery. We compared the analgesic effect immediately after Laparoscopic Bariatric Surgery (LBS) of the combined effect of MMA and methadone against two techniques that were based mainly on the use of high-potency medium-acting opioids.

Methods

Two hundred seventy-one patients were retrospectively reviewed. The primary outcome was postoperative pain score > 3/10 measured by the Verbal Numeric Scale (VNS) during the Postanesthetic Care Unit (PACU) stay. The three protocols of intraoperative analgesia were: (P1) sufentanil at anesthetic induction followed by remifentanil infusion; (P2) sufentanil at induction followed by dexmedetomidine infusion; and (P3) remifentanil at induction followed by MMA including dexmedetomidine, magnesium, lidocaine, and methadone. Only P1 and P2 patients received morphine toward the end of surgery. Poisson regression was used to adjust confounding factors and calculate Prevalence Ratio (PR).

Results

Postoperative VNS > 3 was recorded in 135 (49.81%) patients, of which 93 (68.89%) were subjected to P1, 25 (18.56%) to P2, and 17 (12.59%) to P3. In the final adjusted model, both anesthetic techniques (P3) (PR = 0.10; 95% CI [0.03–0.28]), and (P2) (PR = 0.42%; 95% CI [0.20–0.90]) were associated with lower occurrence of VNS > 3, whereas age range 20–29 was associated to higher occurrence of VNS > 3 (PR = 3.21; 95% CI [1.22–8.44]) in PACU. Postoperative Nausea and Vomiting (PONV) was distributed as follows: (P1) 20.3%, (P2) 31.25% and (P3) 6.77%; (P3 < P1, P2; p < 0.05). Intraoperative hypotension occurred more often in P3 (39%) compared to P2 (20.31%) and P1 (17.46%) (p < 0.05).

Conclusion

MMA + methadone was associated with higher incidence of intraoperative hypotension and lower incidence of moderate/severe pain in PACU after LBS.

A Prospective Observational Study of High-Dose Intrathecal Diamorphine in Laparoscopic Bariatric Surgery: a Single-Centre Experience

BACKGROUND

Post-operative pain management following laparoscopic bariatric surgery can be challenging. There are concerns regarding the use of opioids. The rate of cardiorespiratory problems following neuraxial opioids is unclear. There is little published data on their use in bariatric surgery. This study aimed to assess technique feasibility, pain outcomes, patient acceptability, and the side effects and complications of a 'high-dose' (1.0 mg) intrathecal diamorphine technique for patients undergoing primary laparoscopic bariatric surgery.

MATERIALS AND METHODS

Fifty patients were included. Eleven patients (22%) had a diagnosis of OSA. All patients had a spinal anaesthetic with 2.0 mL of 0.25% isobaric bupivacaine containing 1.0 mg diamorphine. General anaesthesia followed together with multi-modal analgesia and anti-emesis. Post-operative pain scores, complications, and side effects in the first 24 h post-operative period were documented. Patients were followed up 6 to 8 weeks after discharge.

RESULTS

All patients had a working spinal anaesthetic with thirty-nine insertions (78%) on the first attempt. Pain scores were similar to previously published data where they were found to be superior to a non-spinal analgesic regime. The median 24 h post-operative oral morphine equivalent consumption was 5 mg. Eight patients (16%) required urinary catheterisation. Four patients (8%) complained of pruritus. Eighteen patients (36%) had post-operative nausea or vomiting. Thirty-three patients (66%) responded to the follow-up request. Thirty of the thirty-three patients (91%) stated they would have the spinal anaesthetic again.

CONCLUSION

We have demonstrated that neuraxial blockade is a simple, practical, and feasible technique to adopt. Our case series demonstrated a high level of patient acceptability.

OPRM1 and COMT polymorphisms: implications on postoperative acute, chronic and experimental pain after cardiac surgery

Aim: Investigate the potential role of OPRM1 (mu-opioid receptor) and COMT (catechol-O-methyltransferase enzyme) polymorphisms in postoperative acute, chronic and experimental thermal pain. Methods: A secondary analysis of 125 adult cardiac surgery patients that were randomized between fentanyl and remifentanil during surgery and genotyped. Results: Patients in the fentanyl group with the COMT high-pain sensitivity haplotype required less postoperative morphine compared with the average-pain sensitivity haplotype (19.4 [16.5; 23.0] vs 34.6 [26.2; 41.4]; p = 0.00768), but not to the low-pain sensitivity group (30.1 [19.1; 37.7]; p = 0.13). No association was found between COMT haplotype and other pain outcomes or OPRM1 polymorphisms and the different pain modalities. Conclusion: COMT haplotype appears to explain part of the variability in acute postoperative pain in adult cardiac surgery patients.

Does the Implementation of Enhanced Recovery After Surgery (ERAS) Guidelines Improve Outcomes of Bariatric Surgery? A Propensity Score Analysis in 464 Patients

BACKGROUND

The aim of this study was to investigate whether the implementation of enhanced recovery after surgery (ERAS) guidelines according to Thorell and co. in our tertiary referral bariatric center might improve post-operative outcomes.

METHODS

ERAS program was introduced in our center since January 1, 2017. Retrospective review of a prospectively collected database identified patients who underwent laparoscopic primary and revisional bariatric surgeries from October 2005 to January 2018. Patients exposed to ERAS program ("ERAS group") were matched in a 1:1 ratio with patients exposed to conventional care (control group) using a propensity score based on age, gender, preoperative body mass index (BMI), diabetes mellitus, and the type of procedures. The primary outcome was total hospital length of stay (LOS) and the secondary outcomes included the post-operative complications and readmission rates.

RESULTS

During the study period, 464 patients were included, 232 in each group. Implementation of the ERAS protocol was significantly associated with a reduction of LOS (2.47 ± 1.7 vs 5.39 ± 1.9 days, p < 0.00001). One-third of patients was discharged (77/232, 33%) on the first postoperative day (POD) and more than three quarter of patients on POD 2 (182/232, 77%). At the opposite, no patients of the control group were discharged on POD 2. Overall 30-day and 90-day morbidity and readmission rates were the same in both groups. There was no death in each group.

CONCLUSIONS

This large case-matched study using a propensity score analysis suggests that implementation of ERAS program significantly reduced length of hospital stay without significant increases on overall morbidity, and readmission rates.

Pain Intensity in the First 96 Hours After Abdominal Surgery: A Prospective Cohort Study

OBJECTIVE

Multimodal pain management strategies aim to improve postoperative pain control. The purpose of this study was to analyze pain scores and risk factors for acute postoperative pain after various abdominal surgery procedures.

METHODS

Data on 11 different abdominal surgery procedures were prospectively recorded. Pain intensity (rest, mobilization) and patient satisfaction at discharge were assessed using a visual analog scale (VAS; 0-10), and analgesic consumption was recorded until 96 hours postoperation. Demographic, surgery-related, and pain management-related univariate risk factors for insufficient pain control (VAS ≥ 4) were entered in a multivariate logistic regression model.

RESULTS

A total of 1,278 patients were included. Overall, mean VAS scores were <3 at all time points, and scores at mobilization were consistently higher than at rest (P < 0.05). Thirty percent of patients presented a prolonged VAS score ≥4 at mobilization at 24 hours, significantly higher than at rest (14%, P < 0.05). High pain scores correlated with high opioid consumption, whereas a variability of pain scores was observed in patients with low opioid consumption. The only independent risk factor for moderate and severe pain (VAS ≥ 4) was younger age (<70 years, P = 0.001). The mean satisfaction score was 8.18 ± 1.29.

CONCLUSIONS

Among 1,278 patients, pain was controlled adequately during the first four postoperative days, resulting in high levels of patient satisfaction. Pain levels were higher at mobilization. Younger age was the only independent risk factor for insufficient pain control. Preventive treatment in patients <70 years old and before mobilization could be evaluated for potential improvement.

Comparison of Intravenous Ibuprofen and Paracetamol for Postoperative Pain Management after Laparoscopic Sleeve Gastrectomy. A Randomized Controlled Study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is defined as the first-step bariatric surgery for the treatment of obesity. Opioid analgesics are often preferred for pain management because of their strong analgesic potentials. However, opioids have undesirable adverse effects.

OBJECTIVES

The objective of this study is to evaluate and compare the influence of IV forms of ibuprofen and paracetamol on pain management and opioid consumption on patients undergoing LSG surgery.

SETTING

This study was conducted at Istanbul Medipol University Hospital.

METHODS

Patients were stratified into three groups. Group I (group ibuprofen, n = 30) was administered 800 mg of IV ibuprofen, group P (group paracetamol, n = 30) was administered 1000 mg of IV paracetamol, and group C (control group, n = 30) was given 100 ml of saline solution. We evaluated opioid consumption and VAS scores postoperatively.

RESULTS

This study included 90 patients who underwent LSG. The use of rescue medication in group I was statistically lower than the other groups. VAS scores in group I and group P at recovery and at 2, 4, 8, 12, and 24 h were lower than those in group C. In particular, the VAS scores in group I at the first 2 h postoperatively were significantly lower than those in group P (p < 0.05). Opioid consumption in group C was significantly higher than the other groups (p < 0.05).

CONCLUSION

Our study suggested that IV ibuprofen resulted in lower pain scores compared to paracetamol by reducing postoperative opioid use in the first 24 h in patients undergoing LSG surgery.

Impact of Elevated Body Mass Index on Surgical Outcomes for Patients Undergoing Cervical Fusion Procedures: A Systematic Review and Meta-Analysis

To investigate whether high body mass index (BMI) had adverse effects on the postoperative outcomes for patients who underwent anterior or posterior cervical fusion procedures. A literature search were conducted in PubMed, Embase, and Web of Science. Comparative or controlled studies that examined the influences of high BMI on postoperative outcomes after cervical fusion procedures were included. Using a fixed‐effect model or random‐effect model, the effects of high BMI were determined by weight mean difference (WMD) with 95% confidence interval (95% CI) or risk ratio (RR) with 95% CI. A total of seven studies were included in this meta‐analysis. The pooled estimate showed that high BMI was associated with longer hospital stay (WMD = 1.61 days, 95% CI: 0.51, 2.71; P = 0.004), longer surgical time (WMD = 4.55, 95% CI: 1.04, 8.07; P = 0.011), higher mortality rate (RR = 3.01, 95% CI: 2.75, 3.29; P < 0.001), and higher postoperative rates of cardiac complication (RR = 1.30, 95% CI: 1.11, 1.52; P = 0.001), deep venous thromboembolism (RR = 2.29, 95% CI: 1.36, 3.86; P = 0.002), and wound complication (RR = 1.69, 95% CI: 1.26, 2.28; P < 0.001). However, there was no significant differences between high and normal BMI groups in terms of Neck Disability Index (WMD = 1.49, 95% CI: −2.34, 5.32; P = 0.447), SF‐36 Mental Component Score (MCS) (WMD = −0.87, 95% CI: −2.09, 0.35; P = 0.164), overall complications (RR = 1.18, 95% CI: 0.80, 1.76; P = 0.399), central nervous system (CNS) complications (RR = 0.68, 95% CI: 0.17, 2.76; P = 0.586), pulmonary complications (RR = 1.46, 95% CI: 0.87, 2.46; P = 0.150), and septic complications (RR = 0.87, 95% CI: 0.32, 2.38; P = 0.785).High BMI seemed to be associated with longer hospital stay, surgical time, and higher postoperative complication rates compared to normal BMI. Therefore, high BMI patients should be counseled carefully regarding the risk of postoperative complications and surgical outcomes after cervical fusion procedures.

The use of high-dose intrathecal diamorphine in laparoscopic bariatric surgery: a single-centre retrospective cohort study

Introduction

The use of intrathecal diamorphine is not commonplace in laparoscopic bariatric surgery. At our institution, a major UK bariatric centre, high-dose intrathecal diamorphine is routinely utilised.

Methods

Data were analysed retrospectively. Fifty-three patients who had a spinal anaesthetic were matched against age, sex, body mass index and surgical procedure type to generate controls. Pain scores were recorded in the post-anaesthetic care unit on arrival, after 1 hour and on discharge to the ward. Post-operative nausea and vomiting; post-operative hypertension; pruritus; 24-hour morphine consumption and length of stay were measured.

Results

Pain scores were better in the spinal anaesthetic group in all measured categories (p = 0.033, p < 0.01, p < 0.01); post-operative nausea and vomiting was less common in the spinal anaesthetic group (p < 0.01); post-operative hypertension was less common in the spinal anaesthetic group (p = 0.25); pruritus was more common in the spinal anaesthetic group (p < 0.01); morphine consumption was less common in the spinal anaesthetic group (p = 0.037). Length of hospital stay was reduced by 12.4 hours (p = 0.025).

Conclusion

We propose that this is a practical and safe technique to adopt. A randomised-control trial will need to be conducted in order to find the most efficacious volume of local anaesthetic and dose of diamorphine.

Provider preferences for postoperative analgesia in obese and non-obese patients undergoing ambulatory surgery

Background

Few guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting.

Methods

Providers from five academic medical centers within a single US city were surveyed from May–September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar’s tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher’s exact tests were performed to compare preferences based on experience: > 15 years vs. ≤15 years in practice, and attending vs. resident physicians.

Results

A total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (p = 0.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (p = 0.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (p < 0.001). Less experienced physicians are more likely to prefer an opioid for obese patients with moderate pain: 70 (62.0%) attending physicians with > 15 years in practice vs. 86 (74.5%) with ≤15 years (p = 0.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (p = 0.002).

Conclusions

While there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians.

Evaluation of pain relief sufficiency using the Cumulative Analgesic Consumption Score (CACS) and its modification (MACS)

Postoperative pain is one of the major complications in general and bariatric surgery, associated with ongoing problems such as ileus, pneumonia and prolonged mobilization. In this study, patients undergoing bariatric surgery were analyzed according to their postoperative pain relief regime. In one group patients were treated with a patient-controlled analgesia (PCA) device, while the other group was treated with oral and intravenous analgesic medication. The aim of this study was to analyze which postoperative pain relief therapy would be more appropriate. We chose the Cumulative Analgesic Consumption Score (CACS) and Numeric Rating Scale (NRS) for pain measurement. For better comparison, we performed a modification of CACS according to PCA treatment. We observed better pain relief in the PCA group. Furthermore, we observed an advantage of treatment with laxatives in patients treated with PCA. In conclusion, PCA devices are appropriate instruments for postoperative pain relief in bariatric patients. CACS is a practical tool for postoperative pain measurement, describing individual pain sensation more objectively, although holding further potential in modification.

Impact of body mass index on surgical outcomes, narcotics consumption, and hospital costs following anterior cervical discectomy and fusion

OBJECTIVE Given the increasing prevalence of obesity, more patients with a high body mass index (BMI) will require surgical treatment for degenerative spinal disease. In previous investigations of lumbar spine pathology, obesity has been associated with worsened postoperative outcomes and increased costs. However, few studies have examined the association between BMI and postoperative outcomes following anterior cervical discectomy and fusion (ACDF) procedures. Thus, the purpose of this study was to compare surgical outcomes, postoperative narcotics consumption, complications, and hospital costs among BMI stratifications for patients who have undergone primary 1- to 2-level ACDF procedures. METHODS The authors retrospectively reviewed a prospectively maintained surgical database of patients who had undergone primary 1- to 2-level ACDF for degenerative spinal pathology between 2008 and 2015. Patients were stratified by BMI as follows: normal weight (< 25.0 kg/m²), overweight (25.0-29.9 kg/m²), obese I (30.0-34.9 kg/m²), or obese II-III (≥ 35.0 kg/m²). Differences in patient demographics and preoperative characteristics were compared across the BMI cohorts using 1-way ANOVA or chi-square analysis. Multivariate linear or Poisson regression with robust error variance was used to determine the presence of an association between BMI category and narcotics utilization, improvement in visual analog scale (VAS) scores, incidence of complications, arthrodesis rates, reoperation rates, and hospital costs. Regression analyses were controlled for preoperative demographic and procedural characteristics. RESULTS Two hundred seventy-seven patients were included in the analysis, of whom 20.9% (n = 58) were normal weight, 37.5% (n = 104) were overweight, 24.9% (n = 69) were obese I, and 16.6% (n = 46) were obese II-III. A higher BMI was associated with an older age (p = 0.049) and increased comorbidity burden (p = 0.001). No differences in sex, smoking status, insurance type, diagnosis, presence of neuropathy, or preoperative VAS pain scores were found among the BMI cohorts (p > 0.05). No significant differences were found among these cohorts as regards operative time, intraoperative blood loss, length of hospital stay, and number of operative levels (p > 0.05). Additionally, no significant differences in postoperative narcotics consumption, VAS score improvement, complication rates, arthrodesis rates, reoperation rates, or total direct costs existed across BMI stratifications (p > 0.05). CONCLUSIONS Patients with a higher BMI demonstrated surgical outcomes, narcotics consumption, and hospital costs comparable to those of patients with a lower BMI. Thus, ACDF procedures are both safe and effective for all patients across the entire BMI spectrum. Patients should be counseled to expect similar rates of postoperative complications and eventual clinical improvement regardless of their BMI.

Fast-Track in Bariatric and Metabolic Surgery: Feasibility and Cost Analysis Through a Matched-Cohort Study in a Single Centre

BACKGROUND

Due to the rise in severe obesity in Western countries and the increase in bariatric surgery, enhanced recovery (ER) pathways should be developed and promoted.

METHODS

A monocentric prospective series of 103 bariatric surgery patients managed with the ER pathway (group ER) was compared with a retrospective and immediately previous series of 103 patients managed with standard care (group CS). The aim of the present study was to assess and compare the differences in terms of mean postoperative length of stay (LOS), costs for surgery and recovery, and the differences in terms of complications, readmission, and reoperation rate in the short term between the ER and CS groups.

RESULTS

The mean LOS was 4.18 days in group CS and 1.79 days in group ER (p < 0.0001). The mean operative time (OT) per patient was 190.20 min in the group CS and 133.54 min in the group ER, resulting in an average cost of 7272.57€ per patient in group CS and 5424.09€ per patient in group ER. The average recovery cost was 1809.94€ for the group CS series and 775.07 for the group ER one. Overall complications (Clavien-Dindo up to II) occurred in 6 patients (5.8 %) in group CS and in 2 patients (1.9 %) in group ER (p = 0.149) and specific complications (Clavien-Dindo IIIb) occurred for 9 patients (8.7 %) in Group CS and for 14 patients (13.5 %) in group ER (p = 0.268) after hospital discharge within 1-month of follow-up. Twelve patients (11.5 %) in group CS and 13 (12.5 %) in group ER were readmitted after discharge (p = 0.831) within 1-month of follow-up; 8 patients (7.7 %) in group CS versus 9 patients (8.8 %) in group ER needed to be reoperated (p = 0.800) within 1-month follow-up.

CONCLUSIONS

Enhanced recovery pathway reduces significantly LOS in bariatric surgical patients and shortens the mean OT of the procedure, with no significant differences in terms of surgical outcomes. Furthermore, recovery charges were lower and operative time was shorter allowing for procedural cost reduction.

Effect of adding intrathecal morphine to a multimodal analgesic regimen for postoperative pain management after laparoscopic bariatric surgery: a prospective, double-blind, randomized controlled trial

BACKGROUND

Pain control after bariatric surgery is a major challenge. Our objective was to study the efficacy and safety of intrathecal (IT) morphine 0.3 mg added to bupivacaine 0.5% for postoperative pain after laparoscopic bariatric surgery.

METHODS

After local ethics committee approval, 100 morbidly obese patients scheduled for laparoscopic bariatric surgery were enrolled in this study. Patients were randomly assigned into two groups: Group I received IT 0.3 mg morphine (0.3 mL) added to 1.2 mL of bupivacaine 0.5%; Group II received IT 0.3 mL saline added to 1.2 mL of bupivacaine 0.5%, immediately before induction of general anaesthesia. For both groups, 60 mg ketorolac and 1000 mg paracetamol were infused 30 minutes before the end of surgery. After wound closure, 20 mL bupivacaine 0.25% was infiltrated at wound edges.

RESULTS

Visual Analogue Scale (VAS) score was significantly lower in group I immediately, 30 minutes and 1 hour postoperatively. Time to first ambulation, return of intestinal sounds and hospital stay were shorter in group I than group II (p < 0.05); total morphine consumption was significantly lower in group I than group II (p < 0.05). Sedation score was significantly higher in group I immediately postoperatively, while at 30 minutes, 1, 2 and 6 hours postoperatively sedation scores were significantly higher in group II. Itching was significantly higher in group I.

CONCLUSION

The addition of IT morphine to a multimodal analgesic regimen after laparoscopic bariatric surgery was an effective and safe method that markedly reduced postoperative pain, systemic opioid consumption and length of hospital stay.

Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care

BACKGROUND

Due to the increased incidence of morbid obesity, the demand for bariatric surgery is increasing. Therefore, the methods for optimising perioperative care for the improvement of surgical outcome and to increase efficacy are necessary. The aim of this prospective matched cohort study is to objectify the effect of the fast-track surgery (FTS) programme in patients undergoing primary Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) surgery compared to conventional perioperative care (CPC).

METHODS

This study compared the perioperative outcome data of two groups of 75 consecutive morbid obese patients who underwent a primary LRYGB according to international guidelines in the periods January 2011-April 2011 (CPC group) and April 2012-June 2012 (FTS group). The two groups were matched for age and sex. Primary endpoints were surgery and hospitalisation time, while secondary endpoints were intraoperative medication use and complication rates.

RESULTS

Baseline patient characteristics for age, sex, weight and ASA classification were similar (p > 0.05) for CPC and FTS patients. BMI and waist circumference were significantly lower (p < 0.05) in the FTS compared to CPC. The total time from arrival at the operating room to the arrival at the recovery was reduced from 119 to 82 min (p < 0.001). Surgery time was reduced from 80 to 56 min (p < 0.001); mean hospital stay was reduced from 65 to 43 h (p < 0.001). Major complications occurred in 3 versus 4 % in the FTS and CPC, respectively.

CONCLUSIONS

The introduction of a fast-track programme after primary LRYGB improves short-term recovery and may reduces direct hospital-related resources.

Perioperative lung protective ventilation in obese patients

The perioperative use and relevance of protective ventilation in surgical patients is being increasingly recognized. Obesity poses particular challenges to adequate mechanical ventilation in addition to surgical constraints, primarily by restricted lung mechanics due to excessive adiposity, frequent respiratory comorbidities (i.e. sleep apnea, asthma), and concerns of postoperative respiratory depression and other pulmonary complications. The number of surgical patients with obesity is increasing, and facing these challenges is common in the operating rooms and critical care units worldwide. In this review we summarize the existing literature which supports the following recommendations for the perioperative ventilation in obese patients: (1) the use of protective ventilation with low tidal volumes (approximately 8 mL/kg, calculated based on predicted -not actual- body weight) to avoid volutrauma; (2) a focus on lung recruitment by utilizing PEEP (8–15 cmH₂O) in addition to recruitment maneuvers during the intraoperative period, as well as incentivized deep breathing and noninvasive ventilation early in the postoperative period, to avoid atelectasis, hypoxemia and atelectrauma; and (3) a judicious oxygen use (ideally less than 0.8) to avoid hypoxemia but also possible reabsorption atelectasis. Obesity poses an additional challenge for achieving adequate protective ventilation during one-lung ventilation, but different lung isolation techniques have been adequately performed in obese patients by experienced providers. Postoperative efforts should be directed to avoid hypoventilation, atelectasis and hypoxemia. Further studies are needed to better define optimum protective ventilation strategies and analyze their impact on the perioperative outcomes of surgical patients with obesity.

Intravenous acetaminophen in bariatric surgery: effects on opioid requirements

BACKGROUND

Opioids are commonly used after bariatric surgery for pain control because of their potent analgesic effects. Nevertheless, the morbidly obese patient has increased risk for developing adverse effects produced by opioids (such as sedation, apnea, hypoxemia, ileus, and vomiting). Intravenous acetaminophen (IVA) has been evaluated in some specialties showing a reduction in opioid consumption. The purpose of this study was to evaluate the effect on opioid consumption when IVA is administered in bariatric surgery patients.

MATERIAL AND METHODS

A retrospective study was performed in patients who underwent bariatric surgery. Group A included those patients who received IVA perioperatively and group B those who did not. The amount of opioids administered was calculated and compared for each group.

RESULTS

Group A included 38 cases (44.7%) and group B included 47 cases (55.3%). A comparison was performed in terms of age (P = 0.349), body mass index (P = 0.311), gender (P = 0.890), American Society of Anesthesiologist score (P = 0.438), total surgical time (P = 0.497), perioperative complications (P = 0.786), number of procedures per surgeon (P = 0.08), and type of surgical procedure (P ≤ 0.01). Group A had a mean 24-h total opioid dose of 99.5 mg, whereas group B of 164.6 mg (P = 0.018). Group A received 39.5% less opioids than group B. A post hoc analysis determined a statistical power of 0.74.

CONCLUSIONS

IVA used perioperatively can decrease opioid consumption in patients after bariatric surgery. Randomized trials are needed to corroborate these results.

Postoperative pain control

The effective relief of pain is of the utmost importance to anyone treating patients undergoing surgery. Pain relief has significant physiological benefits; hence, monitoring of pain relief is increasingly becoming an important postoperative quality measure. The goal for postoperative pain management is to reduce or eliminate pain and discomfort with a minimum of side effects. Various agents (opioid vs. nonopioid), routes (oral, intravenous, neuraxial, regional) and modes (patient controlled vs. "as needed") for the treatment of postoperative pain exist. Although traditionally the mainstay of postoperative analgesia is opioid based, increasingly more evidence exists to support a multimodal approach with the intent to reduce opioid side effects (such as nausea and ileus) and improve pain scores. Enhanced recovery protocols to reduce length of stay in colorectal surgery are becoming more prevalent and include multimodal opioid sparing regimens as a critical component. Familiarity with the efficacy of available agents and routes of administration is important to tailor the postoperative regimen to the needs of the individual patient.

Challenges in the optimisation of post-operative pain management with opioids in obese patients: a literature review

An increasing number of obese patients are undergoing surgery, particularly bariatric and orthopaedic surgery. The physiological differences between obese and normal-weight subjects may modify not only anaesthetic requirements during surgery but also post-operative analgesic management, raising a number of challenges in a critical period. In this review, we analyse studies of post-operative pain management with opioids in obese subjects. We discuss the genetic factors common to pain and obesity and the factors potentially modifying opioid pharmacokinetics and pharmacodynamics in obese patients, and we analyse the overall efficacy and safety of opioids for pain management during the post-operative period in obese patients. Both modifications to surgical methods and additional analgesic treatments to decrease the requirement for opioids may improve early rehabilitation and quality of care and reduce adverse effects in obese patients.

The value of continuous wound infusion systems for postoperative pain control following laparoscopic Roux-en-Y gastric bypass: an analysis of outcomes and cost

BACKGROUND

Current health-care reform is focusing on improving patient outcomes while cutting health-care costs, and as such, surgeons should consider that postoperative pain management techniques can contribute to the overall value of care delivered to patients. The current study aims to evaluate the value of continuous wound infusion systems (CWIS) in patients following laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

Records of all consecutive patients who underwent elective LRYGB by a single surgeon from January 2008 until June 2010 were reviewed. The presence of CWIS, patient pain scores, postanesthesia care unit (PACU) times, postoperative narcotic and antiemetic requirements, postoperative complications, and hospital length of stay (LOS) were recorded. Clinical data were subsequently linked and correlated with hospital financial data to determine overall hospital costs.

RESULTS

Forty-four LRYGB patients were reviewed; 24 (54.5 %) received CWIS for postoperative pain control. There was no significant difference in PACU times, postoperative LOS, or postoperative complications. Patients with CWIS required significantly less narcotics (36.7 vs. 55.5 mg IV morphine equivalents for total LOS; p = 0.03) and antiemetics (5.0 vs. 12.4 mg ondansetron for total LOS; p = 0.02); however, patients with CWIS did not report better pain control and had slightly higher hospital costs ($13,627.00 vs. $13,395.05, p = 0.68).

CONCLUSIONS

Data from the current study suggest that the value of CWIS for postoperative pain control following LRYGB is limited. As the environment for hospital reimbursement is changing to be one which is value driven, surgeons should consider analyses such as this when making decisions on which treatments to offer their patients.

Challenges in the management of acute postsurgical pain

The majority of patients who undergo surgery will require drug therapy for the management of acute postsurgical pain. Effective control of acute postsurgical pain is essential for the patient not only in the short term but also in the long term to prevent the development of chronic pain, which can occur if early acute pain is prolonged. Currently, opioid analgesics are widely used for the management of acute postsurgical pain. Although opioids provide effective postsurgical pain relief, their use is associated with a number of risks, including the development of opioid-related adverse drug events (ORADEs). This review investigates the prevalence of opioid use in the postsurgical setting, the incidence of ORADEs, and the impact of these ORADEs on patient outcomes, length of stay, and costs after common surgeries. According to a national analysis of ORADE incidence, almost 20% of patients treated with opioids experienced an ORADE, with the most common being gastrointestinal effects, central nervous system effects, pruritus, or urinary retention. Studies show that the risk of developing an ORADE is higher in patients receiving higher doses of opioids and in patients undergoing orthopedic or gynecologic surgery compared with patients undergoing general surgery. Elderly patients and those with comorbidities (e.g., obesity, sleep apnea, respiratory disease, urinary disorders) may be particularly vulnerable to ORADE development. Both hospital costs and length of stay are increased in patients with an ORADE versus those without an ORADE. Strategies to reduce the use of opioids after surgery are likely to result in positive outcomes by reducing the incidence of ORADEs and, as a result, reducing treatment costs associated with surgery and improving patient care.

Optimizing perioperative care in bariatric surgery patients

Enhanced recovery after surgery (ERAS) programs have been shown to minimise morbidity in other types of surgery, but comparatively less data exist investigating ERAS in bariatric surgery. This article reviews the existing literature to identify interventions which may be included in an ERAS program for bariatric surgery. A narrative literature review was conducted. Search terms included 'bariatric surgery', 'weight loss surgery', 'gastric bypass', 'ERAS', 'enhanced recovery', 'enhanced recovery after surgery', 'fast-track surgery', 'perioperative care', 'postoperative care', 'intraoperative care' and 'preoperative care'. Interventions recovered by the database search, as well as interventions garnered from clinical experience in ERAS, were used as individual search terms. A large volume of evidence exists detailing the role of multiple interventions in perioperative care. However, efficacy and safety for a proportion of these interventions for ERAS in bariatric surgery remain unclear. This review concludes that there is potential to implement ERAS programs in bariatric surgery.

Managing pain in obese patients

Obesity has become an epidemic in American healthcare. Comorbidities such as diabetes and cardiac disease increase the mortality and morbidity for these patients. Obesity-related pain conditions can limit the patient's efforts at increasing activity and limit quality of life. This article will offer information on these conditions and treatment options.