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Farishta A, Iancau A, Janis JE, Joshi GP. Use of Muscle Relaxants for Acute Postoperative Pain: A Practical Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5938. [PMID: 38957722 PMCID: PMC11216677 DOI: 10.1097/gox.0000000000005938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/14/2024] [Indexed: 07/04/2024]
Abstract
Background Skeletal muscle relaxants have emerged as a broad category of analgesic adjuncts, aiming to improve pain relief and reduce opioid reliance. These drugs induce muscle relaxation and reduce muscle spasms, and therefore, they are commonly used in surgical procedures involving muscle manipulation, such as abdominal surgery, breast surgery, and spine surgery. However, their analgesic efficacy and opioid-sparing effects are poorly explored. Methods A scoping review of literature was performed with several electronic databases. We used a search string with a sequence of text words and word variants related to central muscle relaxants, pain management, postoperative pain, and specific muscle relaxants. Results Review of literature shows significant heterogeneity among the studies in terms of surgical procedures, patient populations, choice of muscle relaxant, and timing and duration of administration, potentially limiting the generalizability of the findings and the ability for pooled analysis. Conclusions Given the lack of evidence, we recommend that the use of skeletal muscle relaxants be reserved for patients in whom an optimal multimodal analgesic technique is not adequate. Also, there may be a limited role for these drugs in patients at high risk of postoperative pain undergoing surgical procedures with expected high opioid requirements. Due to the concerns of potential adverse effects, the decision to use muscle relaxants in vulnerable populations should be made carefully, weighing the benefits against the risks.
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Affiliation(s)
- Akil Farishta
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Tex
| | - Alex Iancau
- University of Texas Southwestern, Dallas, Tex
| | - Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, Ohio
| | - Girish P. Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Tex
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2
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Yessaillian A, Reese M, Clark RC, Becker M, Lopes K, Alving-Trinh A, Llaneras J, McPherson M, Gosman A, Reid CM. A systematic review of morphine equivalent conversions in plastic surgery: Current methods and future directions. J Plast Reconstr Aesthet Surg 2024; 95:142-151. [PMID: 38909598 DOI: 10.1016/j.bjps.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/16/2024] [Accepted: 06/01/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Protocols surrounding opioid reduction have become commonplace in plastic surgery to improve peri-operative outcomes. Within such protocols, opioid requirement is a frequently analyzed outcome. Though often examined, there is no literature standard conversion for morphine milligram equivalents (MME) at present, leading to questionable external validity. We hypothesized significant heterogeneity in MME reporting would exist within plastic surgery literature. METHODS Following the PRISMA guidelines, the authors conducted a systematic review of 16 journals. Clinical studies focused on opioid reduction within plastic surgery were identified. Primary outcomes included reporting of morphine equivalents (ME) delivery (IV/oral), operative ME, inpatient ME, outpatient ME, timeline, and method of calculation. RESULTS Among the 101 studies analyzed, 73% reported opioid requirements in the form of ME. Among those that used ME, 3% reported IV ME, 41% reported oral, 32% reported both, and 25% gave no indication of either. Operative ME were reported in 19% of studies. Furthermore, 54% of studies reported inpatient ME whereas 32% of studies reported outpatient ME. Only 19% reported the number of days opioids were consumed postoperatively. Moreover, 27% of the studies reported the actual method of ME conversion, with 17 unique methods described. Only 8 studies (8%) reported using the Center for Disease Control and Prevention guidelines for ME conversion. CONCLUSION There is significant variability among the reported ME conversion methodology within plastic surgery literature. Highlighting these discrepancies is an essential step in creating and implementing a single, standard method to mitigate opioid morbidity in plastic surgery and to optimize enhanced recovery protocols.
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Affiliation(s)
- Andrea Yessaillian
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - McKay Reese
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Robert Craig Clark
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Miriam Becker
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Kelli Lopes
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Alexandra Alving-Trinh
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Jason Llaneras
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Mary McPherson
- University of Maryland School of Pharmacy, 20 N Pine St, Baltimore, MD 21201, United States
| | - Amanda Gosman
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Chris M Reid
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States.
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Ma C, He L. Trend and hotspots of plastic surgery guidelines: A bibliometric and visualization analysis. J Plast Reconstr Aesthet Surg 2024; 93:242-245. [PMID: 38723509 DOI: 10.1016/j.bjps.2024.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 06/05/2024]
Affiliation(s)
- Chenhao Ma
- Division of Plastic Surgery, Plastic Surgery Hospital/Institute, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100144, China; Division of Plastic Surgery, Massachusetts General Hospital-Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Leren He
- Department of Auricular Reconstruction, Plastic Surgery Hospital/Institute, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 10144, China.
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Abstract
Lip augmentation can correct lip asymmetries, reduce fine lines, define lip shape and Cupid's bow, and add natural fullness to the lips. Achieving a perfect result when injecting lip filler is an art that combines the desire of the patient with the skill of the practitioner and the practitioner's understanding of the surrounding anatomy. It is essential for aesthetic practitioners to prioritize open communication, provide custom-tailored treatments, and have a strong commitment to achieving natural and harmonious results. By following these principles, patients can enjoy the benefits of enhanced lips that boost their self-confidence while maintaining their unique beauty.
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Affiliation(s)
- Yalda Soroush
- Yalda Soroush, MSN, AGACNP-BC, CANS, is a nurse practitioner, Rejuvenation Clinic, Vienna, VA
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5
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Azoury SC, Matros E. Top 25 Medications the Plastic and Reconstructive Surgery Trainee Should Know for an Emergency Medicine Department Consult. Plast Reconstr Surg 2024; 153:474e-489e. [PMID: 37141488 DOI: 10.1097/prs.0000000000010609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
SUMMARY Plastic surgery trainees are often called to render care in the emergency department (eg, for established patients, trauma, burns). Broad-based knowledge in pharmacotherapeutics during these encounters is critical. This includes an understanding of pain medications, anxiolytics, local anesthetics, antibiotics, anticoagulants, antidotes, and more to ensure optimal patient care. The purpose of this report is to describe 25 frequently used and other important medications that plastic surgery trainees should know for an adult emergency department encounter.
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Affiliation(s)
- Saïd C Azoury
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Evan Matros
- Division of Plastic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center
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Ciudad P, Escandón JM, Manrique OJ, Escobar H, Pejerrey Mago B, Arredondo Malca A. Efficacy of Combined Spinal-Epidural Anesthesia for Lower Extremity Microvascular Reconstruction. J Surg Res 2023; 291:700-710. [PMID: 37562232 DOI: 10.1016/j.jss.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/13/2023] [Accepted: 07/12/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Some surgeons have raised concerns regarding the sympathectomy-like effect of epidural anesthesia during lower limb microvascular reconstruction. The combined spinal-epidural (CSE) anesthetic technique incorporates several benefits of spinal and epidural techniques in a single approach. The aim of this study was to analyze the postoperative outcomes of patients undergoing soft-tissue reconstruction of the lower limb by implementing the CSE anesthesia approach. METHODS We reviewed medical records from patients who underwent lower limb reconstructive procedures under CSE anesthesia with free tissue transfer from January 2017 to December 2020. We evaluated the postoperative outcomes. RESULTS Thirty-eight patients underwent microvascular reconstructive procedures of the lower extremity over the study period. The average age and BMI were 38.4-year and 28 kg/m2. All patients only had one postoperative rescue dose with epidural anesthesia. The most common type of flap used was the anterolateral thigh flap (53%). The average splinting time and length of stay (LoS) were 8.4 days and 18.4 days, respectively. Donor-site complications included wound dehiscence (3%) and surgical site infection (3%). Recipient-site complications included partial flap loss (8%) and total flap loss (10%). No pro re nata morphine analgesia was used. Tramadol and/or ketoprofen were administered for postoperative analgesia. The average time to start physiotherapy and to resume daily activities were 10 days and 29 days, respectively. CONCLUSIONS The CSE anesthesia for microvascular reconstruction of the lower limb demonstrated a similar success rate compared to historical records. CSE provided adequate pain management and none of the patients required postoperative monitoring in the ICU.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru.
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Hugo Escobar
- Department of Anesthesiology and Perioperative Medicine, Arzobispo Loayza National Hospital, Lima, Peru
| | - Bertha Pejerrey Mago
- Department of Anesthesiology and Perioperative Medicine, Arzobispo Loayza National Hospital, Lima, Peru
| | - Aida Arredondo Malca
- Department of Anesthesiology and Perioperative Medicine, Arzobispo Loayza National Hospital, Lima, Peru
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Shamsunder MG, Chu JJ, Taylor E, Polanco TO, Allen RJ, Moo TA, Disa JJ, Mehrara BJ, Tokita HK, Nelson JA. Paravertebral Blocks in Tissue Expander Breast Reconstruction: Propensity-Matched Analysis of Opioid Consumption and Patient Outcomes. Plast Reconstr Surg 2023; 151:542e-551e. [PMID: 36729942 PMCID: PMC10065883 DOI: 10.1097/prs.0000000000009981] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The paravertebral block (PVB) is an adjunctive perioperative pain control method for patients undergoing breast reconstruction that may improve perioperative pain control and reduce narcotic use. This study determined the efficacy of preoperative PVBs for perioperative pain management in patients undergoing tissue expander breast reconstruction. METHODS A retrospective review was performed of patients who underwent tissue expander breast reconstruction from December of 2017 to September of 2019. Two patients with PVBs were matched using propensity scoring to one no-block patient. Perioperative analgesic use, pain severity scores on days 2 to 10 after discharge, and BREAST-Q Physical Well-Being scores before surgery and at 2 weeks, 6 weeks, and 3 months after surgery were compared between the two groups. RESULTS The propensity-matched cohort consisted of 471 patients (314 PVB and 157 no block). The PVB group used significantly fewer morphine milligram equivalents than the no-block group (53.7 versus 69.8; P < 0.001). Average daily postoperative pain severity scores were comparable, with a maximum difference of 0.3 points on a 0-point to 4-point scale. BREAST-Q Physical Well-Being scores were significantly higher for the PVB group than the no-block group at 6 weeks after surgery (60.6 versus 51.0; P = 0.015) but did not differ significantly at 2 weeks or 3 months after surgery. CONCLUSIONS PVBs may help reduce perioperative opioid requirements but did not reduce pain scores after discharge when used as part of an expander-based reconstruction perioperative pain management protocol. Continued research should examine additional or alternative regional block procedures as well as financial cost and potential long-term impact of PVBs. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Meghana G. Shamsunder
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jacqueline J. Chu
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Erin Taylor
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Thais O. Polanco
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert J. Allen
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Tracy-Ann Moo
- Anesthesiology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joseph J. Disa
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hanae K. Tokita
- Anesthesiology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
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Santosa KB, Wang CS, Hu HM, Mullen CR, Brummett CM, Englesbe MJ, Bicket MC, Myers PL, Waljee JF. Opioid Coprescribing with Sedatives after Implant-Based Breast Reconstruction. Plast Reconstr Surg 2022; 150:1224e-1235e. [PMID: 36103669 PMCID: PMC9712174 DOI: 10.1097/prs.0000000000009726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Skeletal muscle relaxants and benzodiazepines are thought to mitigate against postoperative muscle contraction. The Centers for Disease Control and Prevention and the Food and Drug Administration warn against coprescribing them with opioids because of increased risks of overdose and death. The authors evaluated the frequency of coprescribing of opioids with skeletal muscle relaxants or benzodiazepines after implant-based reconstruction. METHODS The authors examined health care claims to identify women (18 to 64 years old) who underwent implant-based breast reconstruction between January of 2008 and June of 2019 to determine the frequency of coprescribing, factors associated with coprescribing opioids and skeletal muscle relaxants or benzodiazepines, and the impact on opioid refills within 90 days of reconstruction. RESULTS A total of 86.7 percent of women ( n = 7574) who had implant-based breast reconstruction filled an opioid prescription perioperatively. Of these, 27.7 percent of women filled prescriptions for opioids and benzodiazepines, 14.4 percent for opioids and skeletal muscle relaxants, and 2.4 percent for opioids, benzodiazepines, and skeletal muscle relaxants. Risk factors for coprescribing opioids and benzodiazepines included use of acellular dermal matrix, immediate reconstruction, and history of anxiety. Women who filled prescriptions for opioids and skeletal muscle relaxants, opioids and benzodiazepines, and opioids with skeletal muscle relaxants and benzodiazepines were significantly more likely to refill opioid prescriptions, even when controlling for preoperative opioid exposure. CONCLUSIONS Nearly half of women filled an opioid prescription with a benzodiazepine, skeletal muscle relaxant, or both after implant-based breast reconstruction. Coprescribing of opioids with skeletal muscle relaxants may potentiate opioid use after surgery and should be avoided given the risks of sedation. Identifying strategies that avoid sedatives to manage pain after breast reconstruction is critical to mitigate high-risk prescribing practices. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Katherine B. Santosa
- House Officer, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Christine S. Wang
- House Officer, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Hsou-Mei Hu
- Analyst, Michigan Opioid Prescribing Engagement Network (Michigan OPEN), University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Connor R. Mullen
- House Officer, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Chad M. Brummett
- Professor, Division of Pain Research, Department of Anesthesiology, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Michael J. Englesbe
- Professor of Surgery, Section of Transplantation, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Mark C. Bicket
- Assistant Professor, Division of Pain Research, Department of Anesthesiology University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Paige L. Myers
- Assistant Professor, Section of Plastic Surgery, Department of Surgery, University Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Jennifer F. Waljee
- Associate Professor, Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; 1500 E. Medical Center Drive, Ann Arbor, MI, USA
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Office-based Plastic Surgery-Evidence-based Clinical and Administrative Guidelines. Plast Reconstr Surg Glob Open 2022; 10:e4634. [PMID: 36381487 PMCID: PMC9645793 DOI: 10.1097/gox.0000000000004634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/08/2022] [Indexed: 12/15/2022]
Abstract
Outpatient procedures are extremely prevalent in plastic surgery, with an estimated 82% of cosmetic plastic surgery occurring in this setting. Given that patient safety is paramount, this practical review summarizes major contemporary, evidence-based recommendations regarding office-based plastic surgery. These recommendations not only outline clinical aspects of patient safety guidelines, but administrative, as well, which in combination will provide the reader/practice with a structure and culture that is conducive to the commitment to patient safety. Proper protocols to address potential issues and emergencies that can arise in office-based surgery, and staff familiarity with thereof, are also necessary to be best prepared for such situations.
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10
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Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews. J Clin Med 2022; 11:jcm11195628. [PMID: 36233497 PMCID: PMC9572852 DOI: 10.3390/jcm11195628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022] Open
Abstract
The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.
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11
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Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies. Plast Reconstr Surg Glob Open 2022; 10:e4310. [PMID: 35572190 PMCID: PMC9094416 DOI: 10.1097/gox.0000000000004310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 12/13/2022]
Abstract
Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control. Methods A review study based on multimodal analgesia was conducted. Results We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices. Conclusion This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.
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12
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Building a Center for Abdominal Core Health: The Importance of a Holistic Multidisciplinary Approach. J Gastrointest Surg 2022; 26:693-701. [PMID: 35013880 DOI: 10.1007/s11605-021-05241-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/31/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND This article seeks to be a collection of evidence and experience-based information for health care providers around the country and world looking to build or improve an abdominal core health center. Abdominal core health has proven to be a chronic condition despite advancements in surgical technique, technology, and equipment. The need for a holistic approach has been discussed and thought to be necessary to improve the care of this complex patient population. METHODS Literature relevant to the key aspects of building an abdominal core health center was thoroughly reviewed by multiple members of our abdominal core health center. This information was combined with our authors' experiences to gather relevant information for those looking to build or improve a holistic abdominal core health center. RESULTS An abundance of publications have been combined with multiple members of our abdominal core health centers members experience's culminating in a wide breadth of information relevant to those looking to build or improve a holistic abdominal core health center. CONCLUSIONS Evidence- and experience-based information has been collected to assist those looking to build or grow an abdominal core health center.
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13
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Analysis of Adverse Effects of Multimodal Gabapentin in Abdominal Wall Reconstruction. Plast Reconstr Surg 2022; 149:733-739. [PMID: 35041638 DOI: 10.1097/prs.0000000000008836] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Multimodal analgesia, a key component of enhanced recovery after surgery protocols, emphasizes the use of nonopioid analgesics. Preoperative and postoperative gabapentin is often included within multimodal analgesia because it has been shown to reduce postoperative opioid use. However, the role of gabapentin has been questioned because of concerns of adverse effects, particularly in the elderly. In an effort to better understand the specific role of gabapentin within the context of an established enhanced recovery after surgery protocol, the authors studied the prevalence of its adverse effects in patients undergoing abdominal wall reconstruction. METHODS Following institutional review board approval, a retrospective review of a prospectively collected database of 267 consecutive patients who underwent abdominal wall reconstruction performed by a single surgeon was conducted. Demographic variables; operative details; postoperative analgesic use; the presence of dizziness, lightheadedness, or altered mental status; hypotension; negative Richmond Agitation Sedation Scale scores; and postoperative falls were recorded and analyzed according to postoperative gabapentin administration. RESULTS Two hundred thirteen patients (80 percent) met inclusion criteria, of which 138 (65 percent) received postoperative gabapentin. Postoperative gabapentin use was not associated with dizziness, lightheadedness, or altered mental status; hypotension; negative Richmond Agitation Sedation Scale scores; or falls. Furthermore, even among those aged 65 years or older, postoperative gabapentin use was not significantly associated with these adverse events. CONCLUSIONS In patients undergoing abdominal wall reconstruction, postoperative gabapentin administration was not associated with an increase in adverse effects. Further prospective analysis may better allow the characterization of the adverse effects of perioperative gabapentin. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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14
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Faulkner HR, Coopey SB, Sisodia R, Kelly BN, Maurer LR, Ellis D. Does An ERAS Protocol Reduce Postoperative Opiate Prescribing in Plastic Surgery? JPRAS Open 2021; 31:22-28. [PMID: 34869817 PMCID: PMC8626793 DOI: 10.1016/j.jpra.2021.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/20/2021] [Indexed: 11/04/2022] Open
Abstract
Background Enhanced recovery after surgery (ERAS) protocols are effective at reducing inpatient opiate use. There is a paucity of studies on the effects of an ERAS protocol on outpatient opiate prescriptions. The aim of this study was to determine whether an ERAS protocol for plastic and reconstructive surgery would reduce opiate use in the outpatient postoperative setting. Methods A statewide (Massachusetts, USA) controlled substance prescription monitoring database was retrospectively reviewed to assess the prescribing patterns of a single academic plastic surgeon performing common plastic surgical outpatient operations. The time period prior to implementation of the ERAS protocol was then compared with the time period following protocol implementation. An additional three months of post-implementation data were then compared with those of each of the previous time periods to investigate whether the results were sustained. Results A comparison of opiate prescriptions in pre-ERAS, immediate post-ERAS procedures, and follow-up ERAS implementation procedures revealed a statistically significant decrease in opiate prescriptions after ERAS protocol implementation. This decrease in the quantity of opiates prescribed was sustained over time. Conclusions ERAS protocols are effective at reducing outpatient opiate prescriptions after a variety of plastic surgery operations. Appropriate patient and physician education is paramount for success.
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Affiliation(s)
- Heather R Faulkner
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Suzanne B Coopey
- Division of Surgical Oncology, Allegheny Health Network, Wexford, Pennsylvania, USA
| | - Rachel Sisodia
- Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Bridget N Kelly
- Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Lydia R Maurer
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Dan Ellis
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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15
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Sharif-Askary B, Abdou SA, Singh T, Song DH. Are US Plastic Surgery Residents Equipped to Face the Opioid Epidemic? A National Survey. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3761. [PMID: 34476156 PMCID: PMC8382490 DOI: 10.1097/gox.0000000000003761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/22/2021] [Indexed: 11/25/2022]
Abstract
The United States opioid epidemic is among this century’s most profound threats to public health and demands that all physicians consider their role in reversing its trajectory. Previous literature demonstrated that plastic surgery trainees lack vital practices that promote opioid stewardship. However, it is not understood why this practice gap exists. This is a national survey-based study evaluating the availability and effectiveness of opioid education in US plastic surgery programs. A total of 91 residents completed the survey. Our study found that there is an unmet need for practical and comprehensive training regarding safe opioid prescribing among plastic surgery trainees. “Informal training,” defined as the “learn as you go” method, was found to be more common than formal training and considerably more valuable according to trainees. Trainees cited real-world applicability of informal training and that it comes from teachers whom they know and trust as valuable attributes of this type of education. Furthermore, the severity of the opioid epidemic has not translated into improved trainee education, as there was no significant difference in knowledge on safe opioid prescribing practices between junior and senior residents. To change the course of the epidemic, plastic surgery programs need to better train younger generations who believe they are critical stakeholders. This study lays the framework for the “formalization of informal training,” and the creation of practical and efficacious educational initiatives.
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Affiliation(s)
- Banafsheh Sharif-Askary
- MedStar Georgetown University Hospital Department of Plastic and Reconstructive Surgery, Washington, D.C
| | - Salma A Abdou
- MedStar Georgetown University Hospital Department of Plastic and Reconstructive Surgery, Washington, D.C
| | - Tanvee Singh
- MedStar Georgetown University Hospital Department of Plastic and Reconstructive Surgery, Washington, D.C
| | - David H Song
- MedStar Georgetown University Hospital Department of Plastic and Reconstructive Surgery, Washington, D.C
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16
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Cho MJ, Garza R, Teotia SS, Haddock NT. Utility of ERAS Pathway in Nonabdominal-Based Microsurgical Breast Reconstruction: Efficacy in PAP Flap Reconstruction? J Reconstr Microsurg 2021; 38:371-377. [PMID: 34454407 DOI: 10.1055/s-0041-1733993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are effective in decreasing hospital length of stay and inpatient opioid consumption. Implementation of these protocols in abdominally based breast reconstruction has been successful. When a patient is a poor candidate for abdominally based flaps a popular secondary option is the profunda artery perforator (PAP) flap. We present our experience with implementation of our ERAS protocol in patients treated with PAP flaps for breast reconstruction. METHODS Retrospective review of patients treated with autologous breast reconstruction using PAP flaps before and after ERAS implementation were performed. Patient characteristics, postoperative oral morphine equivalents (OMEs), and flap data were collected. RESULTS A total of 87 patients were included in this study (58 patients in pre-ERAS and 29 patients in ERAS group). There was no statistical difference in patient age, comorbidities, smoking, and radiation between two groups. The ERAS group had statistically lower hospital length of stay (2.6 vs. 3.8 days), procedure time (315 vs. 433 minutes), postoperative day 0 (54.8 vs. 96.3), postoperative day 1 (29.9 vs. 57.7), and total opioid consumption (103.7 vs. 192.1). There was no statistical difference in average pain scores between two groups. Multivariate analysis revealed that procedure time significantly increased the amount of opioid consumption while ERAS implementation significantly reduced LOS and opioid consumption. CONCLUSION Use of an ERAS protocol in PAP flap breast reconstruction has not been previously studied. Our work shows that ERAS implementation in PAP flap breast reconstruction significantly reduces inpatient opioid use and length of hospital stay.
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Affiliation(s)
- Min-Jeong Cho
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ricardo Garza
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sumeet S Teotia
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicholas T Haddock
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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17
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Perez ME, Hoyos AE. Invited Discussion on: Evaluation of the Effect of Erector Spinae Plane Block in Patients Undergoing Belt Lipectomy Surgery. Aesthetic Plast Surg 2020; 44:2143-2146. [PMID: 33033879 DOI: 10.1007/s00266-020-01944-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Affiliation(s)
| | - Alfredo E Hoyos
- Dhara Clinic, Carrera 15 #83-33, Suite 304, Bogota, Colombia.
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18
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Williams L, Iteld L. Moving Toward Opioid-Free Breast Surgery: Regional Blocks and a Novel Technique. Clin Plast Surg 2020; 48:123-130. [PMID: 33220899 DOI: 10.1016/j.cps.2020.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Perioperative pain control is of increasing importance as awareness regarding the risks of under-controlled pain and opioid abuse rise. Enhanced recovery protocols and multimodal analgesia, including regional blocks, are useful tools for the plastic surgeon. The thoracic paravertebral block, pectoralis nerve I and pectoralis nerve II blocks, and proximal intercostal blocks are 3 described methods that provide regional anesthesia for breast surgery. The widespread use of these methods may be limited by the requirements for ultrasound equipment and anesthesiologists skilled in regional blocks. This article describes a novel technique of the intercostal field block under direct visualization that is safe and efficient.
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Affiliation(s)
- Lydia Williams
- Plastic & Reconstructive Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Lawrence Iteld
- Plastic & Reconstructive Surgery, University of Chicago Medicine, Chicago, IL, USA; Iteld Plastic Surgery, 939 West North Avenue, Suite 600, Chicago, IL 606042, USA.
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