A novel enhanced recovery protocol, combining multimodal analgesia with liposomal bupivacaine and pharmacologic intervention, reduces parenteral opioid use and hospital length of stay after colectomy – A cohort study

Decreasing Opioid Prescriptions in Women Undergoing Mastectomy and Breast Reconstruction

BACKGROUND

Florida enacted legislation limiting opioid prescriptions and affecting the management of acute pain in the postoperative patient. Patients in a reconstructive surgery practice were receiving prescriptions for opioids as their primary method of pain management. Clinic providers identified a need to limit opioid prescriptions.

AIM

The aim of this quality improvement initiative was to decrease the number of opioids prescribed while effectively managing pain in women undergoing mastectomy and breast tissue expander placement.

DESIGN

This is a quality improvement project.

METHODS

The Model for Improvement was used as a framework for this project. An evidence-based pain management plan was developed after a review of the breast reconstruction surgery literature. The plan incorporated preoperative patient and family education and the standard use of preemptive analgesia, intraoperative nerve blocks, and postoperative multimodal analgesia in all patients undergoing mastectomy with breast tissue expander placement. Patient and family education and perioperative pain management were provided to patients, and the number of opioid tablets prescribed was tracked.

RESULTS

Between January 2018 and August 2019, the average number of opioid tablets prescribed per patient decreased from 84.7 to 8.4.

CONCLUSIONS

Opioid prescriptions can be decreased in women undergoing breast reconstruction with the use of patient education and multimodal analgesia.

Implementation of liposomal bupivacaine transversus abdominis plane blocks into the colorectal enhanced recovery after surgery protocol: a natural experiment

BACKGROUND

Enhanced recovery after surgery (ERAS) programs are now standard of care for colorectal surgery. Efforts have been aimed at decreasing postoperative opioid consumption. The goal of this study is to evaluate the effect of liposomal bupivacaine transversus abdominis plane (TAP) blocks on opioid use and its downstream effect on rates of ileus and hospital length of stay (LOS).

METHODS

We performed a retrospective pre- and postintervention time-trend analysis (2016-2018) of ERAS patients undergoing laparoscopic colorectal surgery at two academic medical centers within the same hospital system. The intervention was liposomal bupivacaine TAP blocks versus standard local infiltration with bupivacaine with a primary outcome of total morphine milligram equivalents (MME) administered within 72 h of surgery. Secondary outcomes included hospital LOS and rate of postoperative ileus.

RESULTS

There were 556 patients included at the control hospital, and 384 patients were included at the treatment hospital. Patients at both hospitals were similar with regard to age, body mass index, comorbidities, and surgical indication. In an adjusted time-trend analysis, the treatment hospital was associated with a significant decrease in MME administered (- 15.9 mg, p = 0.04) and hospital LOS (- 0.8 days, p < 0.001). There was no significant decrease in the rate of ileus at the treatment hospital (- 6.9%, p = 0.08).

CONCLUSIONS

In a time-trend analysis, the addition of liposomal bupivacaine TAP blocks into the ERAS protocol resulted in significantly reduced opioid use and shorter hospital LOS for patients undergoing surgery at the treatment hospital. Liposomal bupivacaine TAP blocks should be considered for inclusion in the standard ERAS protocol.