Enhanced Recovery After Surgery Protocol With Ultrasound-Guided Regional Blocks in Outpatient Plastic Surgery Patients Leads to Decreased Opioid Prescriptions and Consumption

The effect of a local anesthetic cocktail in a serratus anterior plane and PECS 1 block for implant-based breast reconstruction

Introduction

Enhanced recovery after surgery (ERAS) protocols have been implemented to decrease opioid use and decrease patient hospital length of stay (LOS, days). Serratus anterior plane (SAP) blocks anesthetize the T2 through T9 dermatomes of the breast and can be applied intraoperatively. The purpose of this study was to compare postoperative opioid (OME) consumption and LOS between a control group, an ERAS group, and an ERAS/local anesthetic cocktail group in patients who underwent implant-based breast reconstruction.

Methods

In this study, 142 women who underwent implant-based breast reconstruction between 2004 and 2020 were divided into Group A (46 patients), a historical cohort; Group B (73 patients), an ERAS/no-block control group; and Group C (23 patients), an ERAS/anesthetic cocktail study group. Primary outcomes of interest were postanesthesia care unit (PACU), inpatient and total hospital OME consumption, and PACU LOS.

Results

A significant decrease was observed from Group A to C in PACU LOS (103.3 vs. 80.2 vs. 70.5; p = 0.011), OME use (25.1 vs. 11.4 vs. 5.7; p < 0.0001), and total hospital OME (120.3 vs. 95.2 vs. 35.9; p < 0.05). No difference was observed in inpatient OMEs between the three groups (95.2 vs. 83.8 vs. 30.8; p = 0.212). Despite not reaching statistical significance, Group C consumed an average of 50-60 % less opioids per patient than did Group B in PACU, inpatient, and total hospital OMEs.

Conclusion

Local anesthetic blocks are important components of ERAS protocols. Our results demonstrate that a combination regional block with a local anesthetic cocktail in an ERAS protocol can decrease opioid consumption in implant-based breast reconstruction.

Local Infiltration Anesthesia Versus Ultrasound-Guided Pectoralis (PEC1) + Serratus Anterior Plane (SAP) Blocks on Postanesthetic Care Unit Pain Control in Patients Undergoing Primary Submuscular Augmentation Mammoplasty

BACKGROUND

Ultrasound-guided regional field blocks are not widely used in outpatient plastic surgeries. The efficacy of truncal blocks (PEC1 + SAP) has not been established in plastic surgery. The purpose of this study was to analyze the outcomes of these newer anesthetic techniques compared with traditional blind local anesthetic infiltration in patients undergoing breast augmentation.

METHODS

This retrospective institutional review board-approved cohort study compared the outcomes of the different practices of 2 plastic surgeons at the same accredited outpatient surgery center between 2018 and 2022. Group 1 received an intraoperative blind local infiltration anesthetic. Group 2 underwent surgeon-led, intraoperative, ultrasound-guided PEC1 (Pectoralis 1) + SAP (serratus anterior plane) blocks. Patients who underwent any procedure other than primary submuscular augmentation mammoplasty were excluded from the study. The outcomes measured included operative time, opioid utilization in morphine milligram equivalents (MME), pain level at discharge, and time spent in the post anesthetic care unit (PACU).

RESULTS

Sixty patients met the inclusion criteria for each group for a total of 120 patients. The study groups were similar to each other. Patients receiving PEC1 + SAP blocks (group 2) had significantly lower average MME requirements in the PACU (3.04 MME vs 4.52 MME, P = 0.041) and required a shorter average PACU stay (70.13 minutes vs 80.38 minutes, P = 0.008). There were no significant differences in the pain level at discharge, operative time, or implant size between the 2 groups.

CONCLUSIONS

Surgeon-led, intraoperative, ultrasound-guided PEC1 + SAP blocks significantly decreased opioid utilization in the PACU by 33% and patient time in the PACU by 13%, while achieving similar patient pain scores and operating times.

Ultrasound-Guided Transversus Abdominis Plane Blocks Versus Local Infiltration Anesthesia on Postanesthesia Care Unit Pain Control in Patients Undergoing Abdominoplasty

GOALS/PURPOSE

The goal of this study was to compare ultrasound-guided transversus abdominis plane (TAP) blocks to local infiltration anesthesia with or without blind rectus sheath blocks in patients who underwent abdominoplasty at an outpatient surgery center.

METHODS/TECHNIQUE

A retrospective review was conducted of patients who underwent outpatient abdominoplasty performed by the senior surgeon (J.T.L.). Group 1 received local infiltration anesthesia with or without blind rectus sheath blocks between April 2009 and December 2013. Group 2 received surgeon-led, intraoperative, ultrasound-guided, 4-quadrant TAP blocks between January 2014 and December 2021. Outcomes measured were opioid utilization (morphine milligram equivalents), pain level at discharge, and time spent in postanesthesia care unit (PACU).

RESULTS

Sixty patients in each of the 2 study groups met the study criteria for a total of 120 patients. The study groups were similar except for a lower average age in group 1. Patients who received TAP blocks (group 2) had significantly lower morphine milligram equivalent requirements in the PACU (3.07 vs 8.93, P = 0.0001) and required a shorter stay in PACU (95.4 vs 117.18 minutes, P = 0.0001). There were no significant differences in pain level at discharge.

CONCLUSIONS

Surgeon-led, intraoperative, ultrasound-guided, 4-quadrant TAP blocks statistically significantly reduced opioid utilization in PACU by 65.6% and average patient time in the PACU by 18.5% (21.8 minutes).

Opioid-Sparing Pain Control after Rhinoplasty: Updated Review of the Literature

Rhinoplasty is one of the most performed elective surgeries, and given the opioid crisis, increasing research and studies are focused on successful pain control with multimodality opioid-sparing techniques, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin. Although limiting overuse of opioids is critical, this cannot be at the expense of inadequate pain control, particularly as insufficient pain control can be correlated with patient dissatisfaction and the postoperative experience in elective surgery. There is likely significant opioid overprescription, as patients often report taking less than 50% of their prescribed opioids. Furthermore, excess opioids provide opportunities for misuse and opioid diversion if not disposed of properly. To optimize postoperative pain control and minimize opioid requirements, interventions must occur at the preoperative, intraoperative, and postoperative time points. Preoperative counseling is imperative to set expectations for pain and to screen for predisposing factors for opioid misuse. Intraoperatively, use of local nerve blocks and long-acting analgesia in conjunction with modified surgical techniques can lead to prolonged pain control. Postoperatively, pain should be managed with a multimodal approach, incorporating acetaminophen, NSAIDs, and potentially gabapentin with opioids reserved for rescue analgesia. Rhinoplasty represents a category of short-stay, low/medium pain, and elective procedures highly susceptible to overprescription and consequently, are readily amenable to opioid minimization through standardized perioperative interventions. Recent literature on regimens and interventions to help limit opioids after rhinoplasty are reviewed and discussed here.

Faster Return to Daily Activities and Better Pain Control: A Prospective Study of Enhanced Recovery After Surgery Protocol in Breast Augmentation

BACKGROUND

Enhanced recovery after surgery (ERAS) has been proven to decrease the amount of opioid use and reduce postoperative pain for a variety of surgeries, including breast reconstruction. However, data on ERAS in breast augmentation is lacking.

OBJECTIVES

This study aims to investigate the effectiveness and safety of ERAS for breast augmentation.

METHODS

A standardized ERAS protocol was established with full consideration of all aspects of perioperative care. Patients undergoing implant-based breast augmentation were prospectively recruited between December 2020 and January 2023, and assigned to either the ERAS or non-ERAS group randomly. The primary outcome was the activity of daily living after surgery. The secondary was postoperative pain and other outcomes included time to freely elevation, vomiting frequency, the use of analgesics, and complications.

RESULTS

A total of 122 patients were included, with 70 in the ERAS group and 52 in the non-ERAS group. Compared to non-ERAS patients, ERAS patients had a shorter time to freely elevation of upper limbs (2.3 d vs. 5.5 d, P < 0.001). For ERAS patients, the pain scores were significantly lower on postoperative days 1 to 3, the activity of daily living index was significantly higher on postoperative days 1 to 3 and the opioids consumption was decreased (7.1 mg vs. 46.2 mg, P = 0.018). No difference was observed in complication and hospital costs between the two groups.

CONCLUSION

The ERAS protocol significantly reduced postoperative pain and the use of opioids and promoted a return to daily activities without increasing complications in breast augmentation.

LEVEL OF EVIDENCE IV

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

Updates on Enhanced Recovery after Surgery protocols for plastic surgery of the breast and future directions

Introduction

Perioperative pain control is an important component of any plastic surgery practice. Due to the incorporation of Enhanced Recovery after Surgery (ERAS) protocols, reported pain level, opioid consumption, and hospital length of stay numbers have decreased significantly. This article provides an up-to-date review of current ERAS protocols in use, reviews individual aspects of ERAS protocols, and discusses future directions for the continual improvement of ERAS protocols and control of postoperative pain.

ERAS components

ERAS protocols have proven to be excellent methods of decreasing patient pain, opioid consumption, and postanesthesia care unit (PACU) and/or inpatient length of stay. ERAS protocols have three phases: preoperative education and pre-habilitation, intraoperative anesthetic blocks, and a postoperative multimodal analgesia regimen. Intraoperative blocks consist of local anesthetic field blocks and a variety of regional blocks, with lidocaine or lidocaine cocktails. Various studies throughout the surgical literature have demonstrated the efficacy of these aspects and their relevance to the overall goal of decreasing patient pain, both in plastic surgery and other surgical fields. In addition to the individual ERAS phases, ERAS protocols have shown promise in both the inpatient and outpatient sectors of plastic surgery of the breast.

Conclusion

ERAS protocols have repeatedly been shown to provide improved patient pain control, decreased hospital or PACU length of stay, decreased opioid use, and cost savings. Although protocols have most commonly been utilized in inpatient plastic surgery procedures of the breast, emerging evidence points towards similar efficacy when used in outpatient procedures. Furthermore, this review demonstrates the efficacy of local anesthetic blocks in controlling patient pain.

Assessing the quality of reporting on quality improvement initiatives in plastic surgery: A systematic review

BACKGROUND

There has been a recent increase in the number and complexity of quality improvement studies in plastic surgery. To assist with the development of thorough quality improvement reporting practices, with the goal of improving the transferability of these initiatives, we conducted a systematic review of studies describing the implementation of quality improvement initiatives in plastic surgery. We used the SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guideline to appraise the quality of reporting of these initiatives.

METHODS

English-language articles published in Embase, MEDLINE, CINAHL, and the Cochrane databases were searched. Quantitative studies evaluating the implementation of quality improvement initiatives in plastic surgery were included. The primary endpoint of interest in this review was the distribution of studies per SQUIRE 2.0 criteria scores in proportions. Abstract screening, full-text screening, and data extraction were completed independently and in duplicate by the review team.

RESULTS

We screened 7046 studies, of which 103 full texts were assessed, and 50 met inclusion criteria. In our assessment, only 7 studies (14%) met all 18 SQUIRE 2.0 criteria. SQUIRE 2.0 criteria that were met most frequently were abstract, problem description, rationale, and specific aims. The lowest SQUIRE 2.0 scores appeared in funding, conclusion, and interpretation criteria.

CONCLUSIONS

Improvements in QI reporting in plastic surgery, especially in the realm of funding, costs, strategic trade-offs, project sustainability, and potential for spread to other contexts, will further advance the transferability of QI initiatives, which could lead to significant strides in improving patient care.

Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study

Background

Pectoralis nerve blocks (PECS) have been shown in numerous studies to be a safe and effective method to treat postoperative pain and reduce postoperative opioid consumption after breast surgery. However, there are few publications evaluating the PECS block effectiveness in conjunction with multimodal analgesia (MMA) in outpatient breast surgery. This retrospective study aims to evaluate the efficacy of PECS's blocks on perioperative pain management and opioid consumption.

Methods

We conducted a retrospective study to assess the efficacy of preoperative PECS block in addition to preoperative MMA (oral acetaminophen and/or gabapentin) in reducing opioid consumption in adult female subjects undergoing outpatient elective breast surgery between 2015 and 2020. A total of 228 subjects were included in the study and divided in two groups: PECS block group (received PECS block + MMA) and control Group (received only MMA). The primary outcome was to compare postoperative opioid consumption between both groups. The secondary outcome was intergroup comparisons of the following: postoperative nausea and vomiting (PONV), incidence of rescue antiemetic medication, PACU non-opioid analgesic medication required, length of PACU stay and the incidence of 30-day postoperative complications between both groups.

Results

Two hundred and twenty-eight subjects (n = 228) were included in the study. A total of 174 subjects were allocated in the control group and 54 subjects were allocated in the PECS block group. Breast reduction and mastectomy/lumpectomy surgeries were the most commonly performed procedures (48% and 28%, respectively). The total amount of perioperative (intraoperative and PACU) MME was 27 [19, 38] in the control group and 28.5 [22, 38] in the PECS groups (p = 0.21). PACU opioid consumption was 14.3 [7, 24.5] MME for the control group and 17 [8, 23] MME (p = 0.732) for the PECS group. Lastly, the mean overall incidence of postsurgical complications at 30 days was 3% (N = 5), being wound infection, the only complication observed in the PECS groups (N = 2), and hematoma (N = 2) and wound dehiscence (N = 1) in the control group.

Conclusion

PECS block combined with MMA may not reduce intraoperative and/or PACU opioid consumption in patients undergoing outpatient elective breast surgery.

Sustained reduction of discharge opioid prescriptions in an enhanced recovery after thoracic surgery program: A multilevel generalized linear model

BACKGROUND

Enhanced Recovery After Surgery programs have been shown to effectively reduce opioid prescriptions at discharge after their implementation in several institutions, but little is known regarding the sustainability of this effect. Understanding opioid prescribing patterns after long-term implementation of Enhanced Recovery After Surgery initiatives may help guide further opioid prescription reduction and improvements. Our group aimed to determine whether reductions in opioid prescriptions at discharge are sustained in an Enhanced Recovery After Surgery program for thoracic surgery.

METHODS

This retrospective cohort included 2,081 patients undergoing thoracic surgery within a 4-year Enhanced Recovery After Surgery program from March 2016 through April 2020. Our Enhanced Recovery After Surgery protocol included a standardized multimodal analgesic regimen (ie, preoperative gabapentin, tramadol, intercostal nerve block with liposomal bupivacaine, and intraoperative acetaminophen, and ketorolac) and the rest of the interventions recommended by the Enhanced Recovery After Surgery society guidelines. Our primary outcomes were the presence of opioid prescriptions at discharge (hydrocodone, hydromorphone, and oxycodone) and the total opioid amount prescribed (morphine equivalent daily dose). Multilevel generalized linear models were used to account for surgeon variabilities and types of thoracic resection.

RESULTS

Over the study period, the rate of opioid prescriptions at discharge reduced from 35% (Mar 2016) to 25% (Apr 2020), and the amount of opioid prescribed declined from 184 ± 321 morphine equivalent daily dose to 94 ± 251 morphine equivalent daily dose. In multilevel generalized linear models, there was a sustained downward trend in opioid prescriptions over the study period (β -11.8 morphine equivalent daily dose per year, P = .048), which was also directly correlated with the use of minimally invasive surgery (β -84.9 morphine equivalent daily dose for video-assisted thoracoscopic surgery, P < .001; β -139.2 morphine equivalent daily dose for robotic-assisted thoracic surgery, P < .001), intraoperative opioid administration (β -1.4 morphine equivalent daily dose per 1 morphine equivalent dose, P = .026), and the amount of postoperative acetaminophen (β -18.2 morphine equivalent daily dose per 1 g, P = .026). The sustained reduction of opioid prescriptions at discharge did not impact hospital readmission rates within 30 days (odds ratio 1.17, 95% confidence interval 0.86-1.59, P = .306). Subgroup analysis showed a significant, sustained decrease in hydromorphone (β -10.9 morphine equivalent daily dose per year, P = .004), but not for hydrocodone prescriptions (β -5.7 morphine equivalent daily dose per year, P = .168) or oxycodone (β +4.78 morphine equivalent daily dose per year, P = .183).

CONCLUSION

Our Enhanced Recovery After Surgery program for thoracic surgery contributed to a sustained reduction of opioid prescriptions at discharge, which positively correlated with the duration of its implementation and the use of minimally invasive surgical techniques but was negatively impacted by the amount of intraoperative opioid administration.