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Smith RB, Biller E, Hu C, Mahnert ND, Womack AS, Galhotra S, Mourad J. Impact of pneumoperitoneum pressure during laparoscopic hysterectomy: A randomized controlled trial. Eur J Obstet Gynecol Reprod Biol 2023; 280:73-77. [PMID: 36434823 DOI: 10.1016/j.ejogrb.2022.11.011] [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: 10/04/2022] [Revised: 11/08/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Minimally invasive hysterectomy is a commonly performed gynecologic procedure with associated postoperative pain managed with opioid medications. Uncontrolled postoperative pain leads to increased opioid use/abuse, longer hospital stays, increase in healthcare visits, and may negatively affect patient satisfaction. Current data suggests that reduced pneumoperitoneum insufflation pressure during laparoscopic surgery may impact postoperative pain. Given the current opioid epidemic, surgeons are proactively finding ways to reduce postoperative pain. It is unclear how reduced pneumoperitoneum pressure impacts the surgeon. We investigated the impact of reduced pneumoperitoneum insufflation pressure on surgeon satisfaction. STUDY DESIGN This was a pilot, double-blinded, randomized controlled trial from March 2020 to July 2021 comparing pneumoperitoneum pressure of 15 mmHg to reduced pressures of 12 mmHg and 10 mmHg during laparoscopic hysterectomy. RESULTS A total of 40 patients were randomized (13 - 15 mmHg, 13 - 12 mmHg, and 14 - 10 mmHg). The primary outcome was surgeon satisfaction. Secondary outcomes included patient satisfaction, operative time, blood loss, postoperative pain, opioid usage, and discharge timing. There were no differences in baseline demographics or perioperative characteristics. Surgeon satisfaction was negatively impacted with lower pneumoperitoneum pressures greatest with 10 mmHg, including overall satisfaction (p =.01), overall effect of the pneumoperitoneum (p =.04), and quality of visualization (p =.01). There was an apparent although not statistically significant difference in operative time (p =.06) and blood loss (p =.054). There was no difference in patient satisfaction, postoperative pain scores, opioid usage, or time to discharge. CONCLUSION(S) Reduced pneumoperitoneum insufflation pressure during laparoscopic hysterectomy negatively impacted surgeon satisfaction with a trend towards longer operative times and greater blood loss, and did not positively impact patient satisfaction, postoperative pain, opioid demand, or discharge timing.
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Affiliation(s)
- Rachael B Smith
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery University of Arizona College of Medicine - Phoenix, Banner University Medical Center - Phoenix, 1111 East McDowell Road, Phoenix, AZ 85006, USA.
| | - Emily Biller
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery University of Arizona College of Medicine - Phoenix, Banner University Medical Center - Phoenix, 1111 East McDowell Road, Phoenix, AZ 85006, USA
| | - Chengcheng Hu
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N Martin Ave, Tucson, AZ 85724, USA
| | - Nichole D Mahnert
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery University of Arizona College of Medicine - Phoenix, Banner University Medical Center - Phoenix, 1111 East McDowell Road, Phoenix, AZ 85006, USA
| | - Ashley S Womack
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery University of Arizona College of Medicine - Phoenix, Banner University Medical Center - Phoenix, 1111 East McDowell Road, Phoenix, AZ 85006, USA
| | - Sheena Galhotra
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery University of Arizona College of Medicine - Phoenix, Banner University Medical Center - Phoenix, 1111 East McDowell Road, Phoenix, AZ 85006, USA
| | - Jamal Mourad
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery University of Arizona College of Medicine - Phoenix, Banner University Medical Center - Phoenix, 1111 East McDowell Road, Phoenix, AZ 85006, USA
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Ma GY, Shi S, Ma HY, Zhang ZG. Roles of Beclin1 protein expression in cervical cancer: a meta-analysis and bioinformatics analysis. J OBSTET GYNAECOL 2022; 42:2643-2651. [PMID: 35815559 DOI: 10.1080/01443615.2022.2091924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Beclin1 is a key regulator of a family of autophagy-related proteins. The aim of our study was to elucidate the clinicopathological and prognostic significance of Beclin1 expression which is a positive regulator of autophagy in cervical cancer. The results showed that a total of 2682 patients were enrolled in 21 case-control studies. The results showed that, as for Beclin1 expression, significant differences were found in cervical cancer vs. normal cervical tissues (p<.00001) and cancer tissues with vs. no lymph node metastasis (p<.00001); tumour diameter no less than vs. less than 4 cm (p=.001), myometrial invasion depth no less than vs. less than 1/2 and FIGO I vs. II (p=.02); relationship between Beclin1 expression and prognosis of cervical cancer (p=.03). Kaplan-Meier's plotter showed that Beclin1 expression was negative. It was associated with overall, post-progressive and distant metastatic survival. According to the Oncomine database, Beclin1 mRNA expression in cervical cancer tissues was higher than that in normal tissues. Cox multivariate showed that lymph node metastasis and TNM stage were important factors affecting the survival time of patients. Beclin1 expression can be used as an indicator of prognosis in patients, and provide methods and ideas for prevention and treatment.
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Affiliation(s)
- Guan-Ying Ma
- Department of Clinical Pathology, Chengde Medical University, Chengde, China
| | - Shuai Shi
- Department of Pathology, Cangzhou People's Hospital, Cangzhou, China
| | - Hong-Yan Ma
- Department of Pathology, Cangzhou People's Hospital, Cangzhou, China
| | - Zhi-Gang Zhang
- Department of Pathology, Cangzhou People's Hospital, Cangzhou, China
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McGrail K, Chapple AG, Stone G, Sutton EF, Chappell NR. Systematic Review and Meta-Analysis of Perioperative Administration of Acetazolamide for Management of Postoperative Pain after Laparoscopy. JSLS 2022; 26:JSLS.2022.00032. [PMID: 36071992 PMCID: PMC9385114 DOI: 10.4293/jsls.2022.00032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background and Objective To perform a systematic review and meta-analysis to evaluate the efficacy of perioperative acetazolamide (ACTZ) administration with laparoscopy for reducing postoperative referred pain. Methods The following databases were searched from inception to March 1, 2020: Cochrane, PubMed, PubMed Central, Ovid, and Embase. Electronic search used: Acetazolamide AND (laparoscopy OR laparoscopic OR Celioscopy OR Celioscopies OR Peritoneoscopy OR Peritoneoscopies). No limits or filters were used. We included only studies of patients who underwent abdominal laparoscopy (LSC), had a pain assessment at approximately 24 hours postoperatively, and included a treatment with ACTZ group and a no-treatment or minimal-treatment comparison group. Results Five studies met inclusion criteria, with a combined total of 253 participants, 116 in the ACTZ group and 137 in the control group. A Bayesian hierarchical model was assumed for the study specific treatment effects. Posterior sampling was conducted via Markov Chain Monte Carlo methods, and posterior inference carried out on the hierarchical treatment effect. ACTZ significantly decreased average pain scores compared to control group by -0.726 points (95% confidence interval -1.175-0.264). The posterior probability that ACTZ decreases mean pain scores by ≥ 0.5 was 0.846. Conclusion Current available evidence demonstrates that perioperative ACTZ may provide a modest improvement in postoperative referred pain following LSC.
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Affiliation(s)
- Kaitlin McGrail
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Baton Rouge, Louisiana
| | - Andrew G Chapple
- Department of Biostatics, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Gabrielle Stone
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Baton Rouge, Louisiana
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Edwards A, Ramirez AC, Scime NV, Kim-Fine S, Brennand EA. Authors' Reply. J Minim Invasive Gynecol 2022; 29:576-577. [PMID: 35101630 DOI: 10.1016/j.jmig.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Allison Edwards
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada.
| | - Alison Carter Ramirez
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Natalie V Scime
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Shunaha Kim-Fine
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Erin A Brennand
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
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Chen S, Du W, Zhuang X, Dai Q, Zhu J, Fu H, Wang J, Huang L. Description and Comparison of Acute Pain Characteristics After Laparoscope-Assisted Vaginal Hysterectomy, Laparoscopic Myomectomy and Laparoscopic Adnexectomy. J Pain Res 2021; 14:3279-3288. [PMID: 34703303 PMCID: PMC8541747 DOI: 10.2147/jpr.s335089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/07/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine the characteristics of the acute pain after laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic myomectomy (LM), and laparoscopic adnexectomy (LA) and compare them with each other. Patients and Methods Patients undergoing LAVH, LM, and LA under general anaesthesia at the First Affiliated Hospital of Wenzhou Medical University between December 2017 and December 2019 were selected. Their data were collected before, during, and after the surgery. We evaluated the degrees of pain in each group of patients and compared them. Results There were differences in the baseline characteristics of the patients in the LAVH, LM, and LA groups. The severity and incidence of postoperative pain were higher in the LAVH group than in the LM and LA groups, followed by the LM and LA groups. Compared with the LA group, the postoperative pain in the LAVH and LM groups was more complicated. The LA group had the lowest incidence of two or more types of moderate to severe pain. The LAVH and LM groups mainly had visceral pain and low back pain, and the LA group mainly had incisional pain. Shoulder pain had the lowest incidence in the three groups. Conclusion There were different postoperative pain characteristics after the LAVH, LM, and LA, and we should clinically adjust analgesia programs for different gynaecological laparoscopic surgeries.
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Affiliation(s)
- Sijia Chen
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Wenwen Du
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Xiuxiu Zhuang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Qinxue Dai
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Jingwen Zhu
- Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Haifeng Fu
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Junlu Wang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Luping Huang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
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Marchand GJ, Coriell C, Taher A, King A, Ruther S, Brazil G, Cieminski K, Calteux N, Ulibarri H, Parise J, Arroyo A, Sainz K. Systematic review of the effect of implementing enhanced recovery after surgery on selected attributes of surgical recovery in gynecology. Turk J Obstet Gynecol 2021; 18:245-257. [PMID: 34580992 PMCID: PMC8480214 DOI: 10.4274/tjod.galenos.2021.47717] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This study aimed to systematically review the available literature on enhanced recovery after surgery (ERAS) following gynecologic procedures performed either as an open surgery or as a minimally invasive gynecological surgery (MIGS) in terms of outcomes. This review revealed the results of published literature and assessed the benefits and diverse outcomes of ERAS implementation in patients undergoing MIGS or other gynecologic surgeries. In this review, we sought to examine the efficacy of entire ERAS protocols, faithfully performed, to determine whether they were successful in improving individual attributes of surgical recovery. Electronic databases of PubMed, Cochrane, Web of Science, Scopus, MEDLINE, and ClinicalTrials.gov were systematically searched in January 2021 for relevant studies. Data were extracted from eligible studies including LOS, change in the quality-of-life and recovery over time, postoperative complications including nausea and vomiting, opioid or anesthesia use, hospital cost, patient satisfaction, postoperative pain, and readmission rate as outcomes. Many of the included studies reported a significant reduction in the LOS as well as in readmission rates, hospital cost, and occurrence of nausea and vomiting postoperatively. Moreover, a clinically significant increase was noted in patient satisfaction in studies that have used tools that measure patient satisfaction. No studies have reported a significant increase in the overall quality of recovery using appropriately validated tools. Following ERAS implementation, patients’ postoperative rehabilitation, including postoperative discomfort, readmission rates, and satisfaction, showed a clinically significant improvement.
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Affiliation(s)
- Greg J Marchand
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Catherine Coriell
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Ahmed Taher
- Fayoum University Faculty of Medicine, Fayoum, Egypt
| | - Alexa King
- International University of Health Sciences, Basseterre, St. Kitts
| | - Stacy Ruther
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Giovanna Brazil
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | | | - Nicolas Calteux
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Hollie Ulibarri
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Julia Parise
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Amanda Arroyo
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Katelyn Sainz
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
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Moawad GN, Klebanoff JS, Muldoon O, North A, Amdur R, Tyan P. Patterns of narcotic utilization in women undergoing hysterectomy for benign indications. J Gynecol Obstet Hum Reprod 2021; 50:102181. [PMID: 34129992 DOI: 10.1016/j.jogoh.2021.102181] [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: 08/22/2020] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine whether perioperative narcotic utilization at the time of hysterectomy has decreased since 2012. STUDY DESIGN Retrospective cohort study. SETTING Academic university hospital. PATIENTS Patients who underwent a laparoscopic hysterectomy for benign indications between January 2012 and December 2018. INTERVENTIONS Perioperative narcotics administration. MEASUREMENTS AND MAIN RESULTS We identified 651 patients who underwent a hysterectomy for benign indications from 2012 to 2018. Of these, 377 surgeries were performed using robotic-assistance (58%) and the remainder (42%) were performed by conventional laparoscopy. Narcotic utilization declined significantly by year for both intra-operative and post-operative periods (both p<.001). The largest decline for intraoperative morphine milligram equivalents (MME) was between 2016 and 2017, while for post-operative MME, it was between 2012 and 2013. The pattern remained significant after adjusting for covariates. Intraoperative MME administration was correlated with postoperative MME use (Spearman r = 0.23, p<.001). Of the demographic variables only Body Mass Index was significantly associated with perioperative narcotic administration. CONCLUSION Administration of opioids for intraoperative and postoperative pain after minimally invasive hysterectomy substantially decreased from 2012 to 2018. Intraoperative narcotic utilization was correlated with immediate postoperative narcotic consumption. Heightened awareness of opioid administration practices during and immediately following surgery is critically important to decreasing risk of chronic opioid dependence and providing the best possible care for the patients we serve.
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Affiliation(s)
- Gaby N Moawad
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, The George Washington University Hospital, Washington, DC, United States.
| | - Jordan S Klebanoff
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, The George Washington University Hospital, Washington, DC, United States
| | - Olga Muldoon
- Department of Obstetrics and Gynecology, Vanderbilt University, Nashville, TN, United States
| | - Alexandra North
- The University of South Carolina Medical School Greenville Campus, Greenville, SC, United States
| | - Richard Amdur
- Department of Surgery, The George Washington University Hospital, Washington, DC, United States
| | - Paul Tyan
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, United States
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Benabou K, Kim S, Tierney CH, Messom JE, Kyriakides TC, Kashani SM, Silasi DA, Azodi M, Seifi F. Laparoscopic Posterior Versus Lateral Transversus Abdominis Plane Block in Gynecology. JSLS 2021; 24:JSLS.2020.00032. [PMID: 32831540 PMCID: PMC7434395 DOI: 10.4293/jsls.2020.00032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background and Objectives Transversus abdominis plane (TAP) block is a safe and effective type of regional anesthesia technique used in laparoscopic gynecologic surgery to minimize postoperative pain. Our study aimed to compare the analgesic effects of the posterior versus lateral approaches to laparoscopic-assisted TAP block in minimally invasive gynecologic surgery. Methods We performed a randomized controlled trial with 82 patients allocated to either posterior (n = 38) or lateral (n = 44) TAP block groups. Laparoscopic-assisted posterior or lateral TAP block was administered using liposomal bupivacaine mixture. All subjects were asked to fill out a questionnaire, which included postoperative pain scores at 6 h, 12 h, 24 h, 48 h, and 72 h, as well as narcotic utilization postoperatively. Both groups were compared for postoperative pain scores, opioid consumption, perioperative, and demographic characteristics. Results A total of 67 patients were analyzed in our study (n = 33 in posterior arm, n = 34 in lateral arm). Demographic characteristics including race, body mass index, comorbidities, American Society of Anesthesiologists classification, pre-operative diagnosis, complication rates, length of stay, and estimated blood loss were comparable between the two groups. The distribution of different operative procedures was similar between the two groups. There was no statistically significant difference in pain scores at 6 h, 12 h, 24 h, 48 h, and 72 h postoperatively between the two groups. However, patients receiving posterior TAP had a significant reduction in narcotic intake (p = 0.0009). Conclusion Laparoscopic-assisted TAP block is a safe and effective option for regional analgesia in laparoscopic gynecologic surgery. Posterior TAP block may help to reduce narcotic usage postoperatively.
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Affiliation(s)
- Kelly Benabou
- Department of Obstetrics and Gynecology, Yale University School of Medicine
| | - Soorin Kim
- Department of Obstetrics and Gynecology, Yale University School of Medicine
| | | | - Joel E Messom
- Department of Obstetrics and Gynecology, Yale University School of Medicine
| | | | - Shabnam M Kashani
- Department of Obstetrics and Gynecology, Yale University School of Medicine
| | - Dan-Arin Silasi
- Department of Obstetrics and Gynecology, Yale University School of Medicine
| | - Masoud Azodi
- Department of Obstetrics and Gynecology, Yale University School of Medicine
| | - Farinaz Seifi
- Department of Obstetrics and Gynecology, Yale University School of Medicine
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Perioperative Opioid and Nonopioid Prescribing Patterns in AVF/AVG Creation. Ann Vasc Surg 2020; 72:290-298. [PMID: 32949735 DOI: 10.1016/j.avsg.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND To evaluate postoperative opioid prescribing patterns in patients undergoing hemodialysis access creation. METHODS Operative logs were reviewed to identify patients undergoing creation of arteriovenous fistula (AVF) or graft (AVG) from September 2016 to January 2018. Immediate postoperative opioid prescriptions were compared for ambulatory patients versus inpatients. Opioid prescriptions at the time of discharge for inpatients were recorded. Rates of opioid prescribing were standardized by conversion to morphine milligram equivalents (MMEs). Opioid use postoperatively and at the time of discharge based on anesthetic technique, general anesthesia versus regional or local anesthesia with sedation were compared. Alternative pain medications administered and pain scores were recorded. Comparisons were made between the percentage of opioid use and doses administered between AVF and AVG patient groups, ambulatory and inpatients, and type of anesthetic technique used. Statistical analysis was performed with chi-square and t-tests. RESULTS We identified 164 patients undergoing AV access creation but not receiving chronic opioid therapy. A significantly higher percentage of inpatients received opioids in the immediate postoperative period than ambulatory patients (AVF: 72% vs. 19%, P < 0.001; AVG: 62% vs. 25%, P = 0.001). Overall, all AVG patients were more likely to be discharged with an opioid prescription than all AVF patients (37% vs. 8%, P < 0.001). Of AVG patients managed in the ambulatory setting, 48% were discharged with an opioid prescription. The mean total opioid postoperative dose prescribed to inpatients was significantly higher than that prescribed to ambulatory patients for both fistulas (28.73 MMEs vs. 1.27 MMEs, P < 0.001) and grafts (22.11 MMEs vs. 2.16 MMEs, P = 0.005). General anesthesia patient groups were more likely to receive opioids postoperatively than local anesthesia with sedation patients for both AVF (54% vs. 24%, P = 0.027) and AVG creation (61% vs. 17% P < 0.001). Postoperative alternative medication use in the hospital was low with 18% acetaminophen and 1% nonsteroidal anti-inflammatory drug use for AVF patient groups and 24% acetaminophen and 0% nonsteroidal anti-inflammatory drug use for AVG patient groups. The percentage of patients reporting postoperative pain in the recovery room and on the inpatient units was comparable between ambulatory and inpatient settings (AVF: 21% vs. 28%, P = 0.534; AVG: 23% vs. 44%, P = 0.061). CONCLUSIONS A higher percentage of inpatients undergoing hemodialysis access received opioids when compared with ambulatory patients in the immediate postoperative period. Inpatients were prescribed higher mean doses than ambulatory patients. AVG patient groups were prescribed more opioids than AVF patient groups. Alternative analgesic agent use was low, suggesting an opportunity for improved pain control and opioid reduction. Dialysis access creation represents an opportunity to improve on opioid prescribing patterns.
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Tyan P, Klebanoff JS, Smith S, Amdur R, North A, Maassen MS, Moawad GN. Perioperative Narcotic Trends in Women Undergoing Minimally Invasive Myomectomy. J Minim Invasive Gynecol 2020; 27:1383-1388.e1. [DOI: 10.1016/j.jmig.2019.09.787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 01/27/2023]
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Ramirez-Caban L, Kannan A, Goggins ER, Shockley ME, Haddad LB, Chahine EB. Factors that Lengthen Patient Hospitalizations Following Laparoscopic Hysterectomy. JSLS 2020; 24:JSLS.2020.00029. [PMID: 32714003 PMCID: PMC7362931 DOI: 10.4293/jsls.2020.00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To establish descriptive observations associated with prolonged hospitalization after laparoscopic hysterectomy prior to the implementation of a department-wide Enhanced Recovery After Surgery protocol. Methods A retrospective cohort study at three academic affiliated hospitals in the southeastern United States was conducted evaluating length of hospitalization by patient, surgical, and physician factors for 384 patients who underwent total laparoscopic hysterectomy, laparoscopic assisted vaginal hysterectomy, and robotic assisted total laparoscopic hysterectomy for benign conditions by general and subspecialized gynecologists from 2010 to 2015. Results Among 384 patients, 19.5% experienced prolonged hospitalization, defined as greater than one day. After adjusting for covariates, robotic assisted total laparoscopic hysterectomy (aOR 3.13), dietary restrictions on postoperative day 1 (aOR 4.42), postoperative nausea or vomiting (aOR 2.01), and postoperative complications (aOR 3.58) were associated with prolonged hospitalization. Conclusion Data from this study were collected prior to implementation of department-wide enhanced recovery after surgery protocols and highlights areas for improvement. Implementation of specific aspects of these protocols, including aggressive prevention of postoperative nausea and vomiting and early feeding, are easily made changes which may help to effectively decrease length of stay after laparoscopic hysterectomy. Patient and provider education on enhanced recovery protocols is also key to reducing length of stay.
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Boza A, Urman B, Vatansever D, Ceyhan M, Mısırlıoglu S, Koca S, Çapraz K, Tunga Dogan A, Taskıran C. Mini-Laparoscopic Gynecological Surgery Using Smaller Ports Minimizes Incisional Pain and Postoperative Scar Size: A Paired Sample Analysis. Surg Innov 2020; 27:455-460. [PMID: 32501743 DOI: 10.1177/1553350620923526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objective. The aim of this study was to assess postoperative incisional pain and cosmetic scores in mini-laparoscopic gynecological surgeries undertaken with different port sizes. Material and Method. In this prospective study, all women who underwent mini-laparoscopic gynecological surgery with 2.4-, 3-, and 5-mm lateral ports for benign gynecological conditions between March 2017 and April 2019 were included. The primary outcome was postoperative incisional pain at rest, walking, and after a provoked Valsalva maneuver assessed by numeric rating scale scores at 6 hours, 12 hours, 24 hours, and 3 days and 7 days after surgery. Secondary outcome measures included cosmetic scores of each port site (evaluated by using patient-observer scar assessment scale [POSAS]), operation time, and intra- and postoperative complications. Results. A total of 330 lateral port sites in 110 patients who underwent benign gynecological surgery via mini-laparoscopy were assessed for pain and cosmetic appearance. Pain scores at each time point were significantly lower for 2.4- and 3-mm ports than those for 5-mm ports; however, no significant difference was detected between 2.4-mm and 3-mm port sites (P = .6). The difference was more evident at 24 hours when routine analgesic drugs were stopped (P = .004). For POSAS scores, both 2.4-mm and 3-mm ports were superior to 5-mm port sites (P = .002); however, there was no significant difference between 2.4-mm and 3-mm port sites (P = .2). There were 2 port-related complications: one subcutaneous emphysema and one bleeding from a 5-mm trocar site 1 hour after surgery. Conclusion. Mini-laparoscopic gynecologic surgery using smaller ports resulted in decreased postoperative incisional pain and superior cosmetic appearance.
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Affiliation(s)
- Aysen Boza
- Womens' Health Center, 64090American Hospital, Turkey
| | - Bulent Urman
- Womens' Health Center, 64090American Hospital, Turkey
| | - Dogan Vatansever
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 145809Koc University, Turkey
| | - Mehmet Ceyhan
- Womens' Health Center, 64090American Hospital, Turkey
| | - Selim Mısırlıoglu
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 145809Koc University, Turkey
| | - Sema Koca
- Womens' Health Center, Division of Gynecologic Oncology, 64090American Hospital, Turkey
| | - Kevser Çapraz
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 145809Koc University, Turkey
| | - Alper Tunga Dogan
- Department of Anesthesiology and Reanimation, 64090American Hospital, Turkey
| | - Cagatay Taskıran
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, 145809Koc University, Turkey.,Womens' Health Center, Division of Gynecologic Oncology, 64090American Hospital, Turkey
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the most recent evidence-based interventions for perioperative pain management in minimally invasive gynecologic surgery. RECENT FINDINGS With particular emphasis on preemptive interventions in recent studies, we found preoperative counseling, nutrition, exercise, psychological interventions, and a combination of acetaminophen, celecoxib, and gabapentin are highly important and effective measures to reduce postoperative pain and opioid demand. Intraoperative local anesthetics may help at incision sites, as a paracervical block, and a transversus abdominus plane block. Postoperatively, an effort should be made to utilize non-narcotic interventions such as abdominal binders, ice packs, simethicone, bowel regimens, gabapentin, and scheduled NSAIDs and acetaminophen. When prescribing narcotics, providers should be aware of recommended amounts of opioids required per procedure so as to avoid overprescribing. SUMMARY Our findings emphasize the evolving importance of preemptive interventions, including prehabilitation and pharmacologic agents, to improve postoperative pain after minimally invasive gynecologic surgery. Additionally, a multimodal approach to nonnarcotic intraoperative and postoperative interventions decreases narcotic requirement and improves opioid stewardship.
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Yang Z, Yin Q, Li X. Influences of UGT2B7 rs7439366 and rs12233719 Polymorphisms on Fentanyl Sensitivity in Chinese Gynecologic Patients. Med Sci Monit 2020; 26:e924153. [PMID: 32401749 PMCID: PMC7245057 DOI: 10.12659/msm.924153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background This study discussed potential influences of UDP glucuronosyltransferase family 2 member B7 (UGT2B7) rs7439366 and rs12233719 polymorphisms on fentanyl sensitivity among Chinese gynecologic patients. Material/Methods UGT2B7 polymorphisms were genotyped by polymerase chain reaction (PCR) and direct sequencing. Before surgery, baseline latency to pain perception (PPLpre) and pain perception latency of the dominant hand (PPLpost) at 3 minutes after injecting fentanyl were measured by cold pressor-induced pain test. Perioperative fentanyl adoption referred to the total of fentanyl administration during and after operation. Intensity of spontaneous pain was appraised adopting 100-mm visual analog scale (VAS). Factorial analysis was performed by Mann-Whitney U test and Kruskal-Wallis H test. Results Significant differences of PPLpost (CC/CT/TT, P=0.038) and preoperative analgesic effect (CC/CT/TT, P=0.028) were discovered between the rs7439366 genotypes. PPLpost was significantly different between the CT and TT groups (P=0.009) and the CC+CT and TT groups (P=0.026). Preoperative analgesic effect was significantly different between the CT and TT groups (P=0.007) and the CC+CT and TT groups (P=0.009). All of the clinical features studied had no close association with rs12233719 SNP. Conclusions Gynecologic patients with rs7439366 TT genotype had significantly lower fentanyl sensitivity than the other 2 genotype carriers.
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Affiliation(s)
- Zhenling Yang
- The Pain Management Department, The First Affiliated Hospital of Henan University, Kaifeng, Henan, China (mainland)
| | - Qingfeng Yin
- Institute of Evidence-Based Medicine and Clinical Transformation, Henan University, Kaifeng, Henan, China (mainland)
| | - Xiaodong Li
- Institutes of Evidence-Based Medicine and Knowledge Translation, Henan University, Kaifeng, Henan, China (mainland).,Huaihe Hospital of Henan University, Kaifeng, Henan, China (mainland)
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Weston E, Noel M, Douglas K, Terrones K, Grumbine F, Stone R, Levinson K. The impact of an enhanced recovery after minimally invasive surgery program on opioid use in gynecologic oncology patients undergoing hysterectomy. Gynecol Oncol 2020; 157:469-475. [DOI: 10.1016/j.ygyno.2020.01.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/31/2020] [Indexed: 01/01/2023]
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Zdravkovic M, Kamenik M. A prospective randomized controlled study of combined spinal-general anesthesia vs. general anesthesia for laparoscopic gynecological surgery: Opioid sparing properties. J Clin Anesth 2020; 64:109808. [PMID: 32305787 DOI: 10.1016/j.jclinane.2020.109808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/20/2020] [Accepted: 04/04/2020] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVE We aimed to determine the magnitude of peri-operative opioid sparing effect when general anesthesia is combined with spinal analgesia for laparoscopic gynecological surgery. DESIGN A prospective randomized controlled study; a three-group trial with two comparisons (each intervention group to control). SETTING Operating room and postoperative recovery area. PATIENTS Patients aged between 18 and 65 years with American Society of Anesthesiologists physical status 1 or 2 who were scheduled for inpatient elective laparoscopic gynecological surgery with expected pneumoperitoneum duration of at least 20 min. Of 102 randomized patients, 99 completed the study. INTERVENTIONS Patients were randomized to general anesthesia alone (control group) or combined with very-low-dose (levobupivacaine 3.75 mg; sufentanil 2.5 μg) or low-dose (levobupivacaine 7.5 mg; sufentanil 2.5 μg) spinal analgesia. MEASUREMENTS Primary endpoints were perioperative opioid consumption and pain scores (11-point numeric rating scale) at 30 min, 1 h, 2 h, 4 h and 24 h post-surgery. Secondary endpoints were patient satisfaction with anesthetic care and participation in research, sevoflurane consumption and adverse effects. MAIN RESULTS Intra-operative sufentanil (median [95% CI]) consumption was 16.1 (10.5-22.6) μg/h in the control group versus 4.7 (3.2-9.2) μg/h in the very-low-dose and versus 2.9 (0.0-4.0) μg/h in the low-dose spinal analgesia groups (p < 0.001, for both comparisons). Median (95% CI) piritramide consumption at 24 h post-surgery was 7.5 (3-8) mg in the control group versus 5 (0-7.5) mg in the very-low dose spinal analgesia group (p = 0.182) and versus 2 (0-2.5) mg in the low-dose spinal analgesia group (p = 0.001). Postoperative pain scores were consistently <3 only in the low dose spinal analgesia group. Patient satisfaction with anesthetic care and participation in research was very high in all groups. CONCLUSIONS Low-dose spinal analgesia in combination with general anesthesia reduces peri-operative opioid consumption in laparoscopic gynecological surgery in immediate postoperative period.
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Affiliation(s)
- Marko Zdravkovic
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia; Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia.
| | - Mirt Kamenik
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia; Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia
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Takmaz O, Bastu E, Ozbasli E, Gundogan S, Karabuk E, Kocyigit M, Dede S, Naki M, Kose F, Gungor M. Perioperative Duloxetine for Pain Management After Laparoscopic Hysterectomy: A Randomized Placebo-Controlled Trial. J Minim Invasive Gynecol 2020; 27:665-672. [DOI: 10.1016/j.jmig.2019.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 01/22/2023]
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18
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Aoyama Y, Sakura S, Abe S, Wada M, Saito Y. Analgesic effects and distribution of cutaneous sensory blockade of quadratus lumborum block type 2 and posterior transversus abdominis plane block: an observational comparative study. Korean J Anesthesiol 2020; 73:326-333. [PMID: 32008278 PMCID: PMC7403112 DOI: 10.4097/kja.19404] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/18/2020] [Indexed: 12/14/2022] Open
Abstract
Background The posterior transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB) were developed for postoperative pain control after lower abdominal surgery. However, there is little data regarding their effects. Their analgesic effects and the distribution of the cutaneous sensory blockade were observed in patients undergoing laparoscopic gynecologic surgery. Methods After an induction of general anesthesia, patients alternately received bilateral ultrasound-guided QLB type 2 (QLB2) or posterior TAPB using 20 ml of 0.375% levobupivacaine on each side. The measurements included visual analogue pain scores (VAS), cutaneous sensory blockade in each dermatome, demands for postoperative analgesics, and complications for up to 48 h after the block. Our primary endpoint was VAS at 24 h after the block. Results Forty patients completed the study. The VAS at rest was significantly lower after QLB2 than that after TAPB at 48 h, but not at 24 h. Neither group differed in VAS when coughing at any point in time. Postoperative demands for fentanyl and other analgesics also did not differ for either block. The majority of injections produced a cutaneous sensory blockade in the T11 and T12 dermatomes in both groups. The median number of dermatomes blocked was limited to three dermatomes after either block. No severe complication related to either block was observed. Conclusions The analgesic effects of QLB2 and posterior TAPB did not differ in patients undergoing laparoscopic gynecologic surgery. The cutaneous sensory blockade produced was limited to three dermatomal levels in the majority of patients. However, these findings need to be confirmed through a larger comparative study.
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Affiliation(s)
- Yuki Aoyama
- Department of Anesthesiology, Shimane University, Izumo City, Shimane, Japan
| | - Shinichi Sakura
- Department of Anesthesiology, Shimane University, Izumo City, Shimane, Japan
| | - Shoko Abe
- Department of Anesthesiology, Shimane University, Izumo City, Shimane, Japan
| | - Minori Wada
- Department of Anesthesiology, Shimane University, Izumo City, Shimane, Japan
| | - Yoji Saito
- Department of Anesthesiology, Shimane University, Izumo City, Shimane, Japan
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Opioid use after laparoscopic hysterectomy: prescriptions, patient use, and a predictive calculator. Am J Obstet Gynecol 2019; 220:259.e1-259.e11. [PMID: 30837064 DOI: 10.1016/j.ajog.2018.10.022] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/16/2018] [Accepted: 10/18/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND In the setting of America's opioid epidemic, judicious postoperative opioid prescribing is important. Gynecologists lack standard guidelines about postoperative opioid prescriptions. OBJECTIVES The objectives of the study were to describe opioid prescribing practices by a group of minimally invasive gynecologic surgeons, to measure postoperative opioid use after minimally invasive hysterectomy, and to identify preoperative factors that could predict whether a patient will be a low or high postoperative opioid user. STUDY DESIGN This was a prospective survey-based study including 125 women undergoing laparoscopic hysterectomy for benign indications at 2 community teaching hospitals. Patients were preoperatively surveyed about demographics, past medical history, and current and expected pain scores and were screened for anxiety, depression, and pain catastrophizing. At 1 and 2 weeks after surgery, patients were surveyed about their pain and pain medication use. RESULTS Ninety-eight percent of patients were prescribed an opioid for acute postoperative pain. The median opioid prescription was for 150 morphine milligram equivalents, equivalent to 20 tablets of oxycodone 5 mg, while median patient postoperative use was 37.5 morphine milligram equivalents, equivalent to 5 tablets of oxycodone 5 mg. Ninety percent of patients had leftover opioids at 2 weeks after surgery, and most leftover opioids were stored in an unsecure location. Preoperative factors that were most strongly correlated with postoperative opioid use included a history of chronic pelvic pain or endometriosis, preoperative opioid use, anxiety, depression, pain catastrophizing, preoperative pain score, anticipated postoperative pain score, and anticipated postoperative pain medication needs. A predictive calculator was developed based on these factors to help identify patients who are likely to be a high opioid user (defined as taking greater than 112.5 morphine milligram equivalents) or a low opioid user (defined as taking 37.5 morphine milligram equivalents or less). CONCLUSION On average, surgeons prescribed 4 times the amount of opioids than was needed for patients undergoing laparoscopic hysterectomy for acute postoperative pain control. Individualizing patients' opioid prescriptions based on preoperative risk factors could help reduce excess prescription opioids.
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Cheng C, Healey M, Dior U. Regarding "Managing Postoperative Pain After Minimally Invasive Gynecologic Surgery in the Era of the Opioid Epidemic". J Minim Invasive Gynecol 2019; 26:988. [PMID: 30790706 DOI: 10.1016/j.jmig.2019.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 01/09/2019] [Indexed: 11/28/2022]
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Johnson CM, Makai GE. A Systematic Review of Perioperative Opioid Management for Minimally Invasive Hysterectomy. J Minim Invasive Gynecol 2019; 26:233-243. [DOI: 10.1016/j.jmig.2018.08.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/24/2018] [Accepted: 08/25/2018] [Indexed: 12/12/2022]
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Urman RD, Boing EA, Pham AT, Khangulov V, Fain R, Nathanson BH, Zhang X, Wan GJ, Lovelace B, Cirillo J. Improved Outcomes Associated With the Use of Intravenous Acetaminophen for Management of Acute Post-Surgical Pain in Cesarean Sections and Hysterectomies. J Clin Med Res 2018; 10:499-507. [PMID: 29707092 PMCID: PMC5916539 DOI: 10.14740/jocmr3380w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 02/26/2018] [Indexed: 12/30/2022] Open
Abstract
Background Post-surgical pain impacts many patient outcomes. Effective pain management increasingly relies on multimodal analgesia regimens in which acetaminophen (APAP) is a key component. The aim of our study was to examine the impact of oral APAP versus intravenous (IV) APAP as a component of post-surgical pain management after Cesarean sections and hysterectomies. Methods A retrospective analysis of the Cerner HealthFacts® database (from January, 2011 to December, 2015) was conducted to compare outcomes of Cesarean section and hysterectomy surgery patients who received oral APAP to those who received IV APAP post-surgically. Length of stay (LOS), daily morphine milligram equivalent (MME) consumption, the presence of potential opioid-related adverse events (ORADEs), and total pharmacy costs were assessed. Adjusted results were derived using inverse probability weighted regression adjustment (IPW-RA) estimators based on covariates that included demographics, comorbidities, patient clinical characteristics, and hospital characteristics. Results The study identified 29,124 Cesarean section patients (24,612 oral APAP; 4,512 IV APAP) and 9,767 hysterectomy surgery patients (5,586 oral APAP; 4,181 IV APAP). Compared to the oral APAP group, the IV APAP group had reductions in adjusted LOS (Cesarean section: -11.7% days (P < 0.001), hysterectomy: -11.8% days (P = 0.005)), lowered adjusted daily MME consumption from day 0 to day 3 (Cesarean section: -1.6 mg (P < 0.001), hysterectomy: -1.7 mg (P = 0.014)), and reduced risk of ORADEs for Cesarean sections (relative risk of 0.45, P < 0.001). Total pharmacy costs were not significantly different between the two APAP groups. Conclusions Post-surgical pain managed with IV APAP in patients undergoing Cesarean section or hysterectomy was associated with shorter LOS, reduced risk of ORADEs, and lower opioid consumption compared to patients managed with oral APAP, without adversely impacting total pharmacy costs.
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Affiliation(s)
- Richard D Urman
- Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
| | - Elaine A Boing
- Health Economics and Outcomes Research Department, Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
| | - An T Pham
- School of Pharmacy, University of California San Francisco, San Francisco, CA, USA. This author was an employee of Mallinckrodt Pharmaceuticals during the conduct of this study
| | | | - Randi Fain
- Medical Affairs Department, Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
| | | | - Xuan Zhang
- Boston Strategic Partners, Inc., Boston, MA, USA
| | - George J Wan
- Health Economics and Outcomes Research Department, Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
| | - Belinda Lovelace
- Health Economics and Outcomes Research Department, Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
| | - Jessica Cirillo
- Health Economics and Outcomes Research Department, Mallinckrodt Pharmaceuticals, Bedminster, NJ, USA
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