Multimodal Approaches to Analgesia in Enhanced Recovery After Surgery Pathways

Exploring the impact of music on response to ketamine/esketamine: A scoping review

Music and ketamine are both known to affect therapeutic outcomes, but few studies have investigated their co-administration. This scoping review describes the existing literature on the joint use of music and ketamine-or esketamine (the S(+) enantiomer of ketamine)-in humans. The review considers that extant studies have explored the intersection of ketamine/esketamine and music in healthy volunteers and in patients of various age groups, at different dosages, through different treatment processes, and have varied the sequence of playing music relative to ketamine/esketamine administration. Studies investigating the use of music during ketamine anesthesia are also included in the review because anesthesia and sedation were the early drivers of ketamine use. Studies pertaining to recreational ketamine use were omitted. The review was limited to articles published in the English language but not restricted by publication year. To the best of our knowledge, this scoping review is the first comprehensive exploration of the interplay between music and ketamine/esketamine and offers valuable insights to researchers interested in designing future studies.

A novel nomogram for predicting the prolonged length of stay in post-anesthesia care unit after elective operation

BACKGROUND

Prolonged length of stay in post-anesthesia care unit (PLOS in PACU) is a combination of risk factors and complications that can compromise quality of care and operating room efficiency. Our study aimed to develop a nomogram to predict PLOS in PACU of patients undergoing elective surgery.

METHODS

Data from 24017 patients were collected. Least absolute shrinkage and selection operator (LASSO) was used to screen variables. A logistic regression model was built on variables determined by a combined method of forward selection and backward elimination. Nomogram was designed with the model. The nomogram performance was evaluated with the area under the receiver operating characteristic curve (AUC) for discrimination, calibration plot for consistency between predictions and actuality, and decision curve analysis (DCA) for clinical application value.

RESULTS

A nomogram was established based on the selected ten variables, including age, BMI < 21 kg/m2, American society of Anesthesiologists Physical Status (ASA), surgery type, chill, delirium, pain, naloxone, operation duration and blood transfusion. The C-index value was 0.773 [95% confidence interval (CI) = 0.765 - 0.781] in the development set and 0.757 (95% CI = 0.744-0.770) in the validation set. The AUC was > 0.75 for the prediction of PLOS in PACU. The calibration curves revealed high consistencies between the predicted and actual probability. The DCA showed that if the threshold probability is over 10% , using the models to predict PLOS in PACU and implement intervention adds more benefit.

CONCLUSIONS

This study presented a nomogram to facilitate individualized prediction of PLOS in PACU for patients undergoing elective surgery.

Intraoperative Dexmedetomidine Decreases Postoperative Pain after Gastric Endoscopic Submucosal Dissection: A Prospective Randomized Controlled Trial

BACKGROUND

Postoperative pain is one of the most common complications after gastric endoscopic submucosal dissection (ESD); however, there have been only a few studies assessing the efficacy of interventions on postoperative pain after gastric ESD. This prospective randomized controlled trial was designed to assess the effect of intraoperative dexmedetomidine (DEX) on postoperative pain after gastric ESD.

MATERIALS AND METHODS

A total of 60 patients undergoing elective gastric ESD under general anesthesia were randomly divided into the DEX group receiving DEX with a loading dose of 1 μg/kg, followed by a maintenance dose of 0.6 μg/kg/h until 30 min before the end of the endoscopic procedure, and the control group receiving normal saline. The primary outcome was the visual analog scale (VAS) score of postoperative pain. Secondary outcomes were the dosage of morphine for postoperative pain control, hemodynamic changes during the observable period, the occurrence of adverse events, lengths of postanesthesia care unit (PACU) and hospital stays, and patient satisfaction.

RESULTS

The incidence of postoperative moderate to severe pain was 27% and 53% in the DEX and control groups, respectively, with a significant difference. Compared to the control group, VAS pain scores at 1 h, 2 h, and 4 h postoperatively, the dosage of morphine in the PACU, and the total dosage of morphine within 24 h postoperatively were significantly decreased in the DEX group. Both incidences of hypotension and use of ephedrine in the DEX group were significantly decreased during surgery, but they were significantly increased in the postoperative period. Postoperative nausea and vomiting scores were decreased in the DEX group; however, the length of PACU stay, patient satisfaction, and duration of hospital stay were not significantly different between groups.

CONCLUSION

Intraoperative DEX can significantly decrease postoperative pain level, with a slightly reduced dosage of morphine and a decreased severity of postoperative nausea and vomiting after gastric ESD.

Opioid-sparing anesthesia and patient-reported outcomes after open gynecologic surgery: a historical cohort study

PURPOSE

Dexmedetomidine and ketamine may be administered intraoperatively as continuous infusions to provide opioid-sparing anesthesia. Recent evidence has yielded controversial results regarding the impact of opioid-free anesthesia on postoperative complications, and there is a gap in knowledge regarding patient-reported outcomes (PROs). This study aimed to determine the impact of opioid-sparing anesthesia and opioid-based anesthesia on PROs among gynecologic patients within an enhanced recovery after surgery (ERAS) program.

METHODS

We formed a single-center historical cohort from patients enrolled in another study who underwent open gynecologic surgery on an ERAS program from November 2014 to December 2020 (n = 2,095). We identified two cohorts based on the type of balanced anesthesia administered: 1) opioid-sparing anesthesia defined as the continuous infusion of dexmedetomidine and ketamine (adjuvants) during surgery or 2) opioid-based anesthesia (no adjuvants). We measured the quality of postoperative recovery using the MD Anderson Symptom Inventory (MDASI), a 29-item validated tool that was administered preoperatively, daily while admitted, and weekly after discharge until week 6. The primary outcome was interference with walking. We matched both cohorts and used a multilevel linear mixed-effect model to evaluate the effect of opioid-sparing anesthesia on the primary outcome.

RESULTS

In total, 498 patients were eligible (159 in the opioid-sparing anesthesia cohort and 339 in the opioid-based anesthesia cohort), of whom 149 matched pairs were included in the final analysis. Longitudinal assessment showed no significant or clinically important difference in interference with walking (P = 0.99), general activity (P = 0.99), or other PROs between cohorts. Median [interquartile range (IQR)] intraoperative opioid administration (expressed as morphine milligram equivalents [MME]) among matched patients in the opioid-sparing anesthesia cohort was 30 [25-55] mg vs 58 [8-70] mg in the opioid-based anesthesia cohort (P < 0.01). Patients in the opioid-sparing anesthesia cohort had a lower opioid consumption in the postanesthesia care unit than those in the opioid-based anesthesia cohort (MME, 3 [0-10] mg vs 5 [0-15] mg; P < 0.01), but there was no significant difference between cohorts in total postoperative opioid consumption (MME, 23 [0-94] mg vs 35 [13-95] mg P = 0.053).

CONCLUSIONS

In this single-center historical cohort study, opioid-sparing anesthesia had no significant or clinically important effects on interference with walking or other PROs in patients undergoing gynecologic surgery compared with opioid-based anesthesia. Opioid-sparing anesthesia was associated with less short-term opioid consumption than opioid-based anesthesia.

Finding the vulnerable postoperative population: A two-step cluster analysis of the PAIN-OUT registry

BACKGROUND

Identifying predictors of poor postoperative outcomes is crucial for planning personalized pain treatments. The aim of this study was to examine pain outcomes using cluster analysis in N=2,678 patients from the PAIN-OUT registry at first postoperative day.

METHODS

Indicator variables of the clustering analysis assessed multiple domains, such as clinical and surgical conditions, analgesic-anesthetic variables, desire for more pain treatment and outcome variables of the International Pain Outcome Questionnaire (IPO) summarized as factor scores.

RESULTS

Two-step cluster identified the three-cluster solution as the optimal. Two empirical groups (C1 and C2) included patients with good postoperative outcomes discriminated by peripheral nerve block use, while the other cluster (C3) grouped patients with the worst outcomes, where all patients desired more pain treatment. C3 comprised about 20% of the participants, mostly lower limb, abdominal and spine procedures. The best predictors of belonging to C3 included younger age, being male, preoperative opioid use, bone and fracture reduction procedures, institution, number of comorbidities and morphine equivalents in the recovery room.

CONCLUSIONS

IPO factor scores can be used to select pain outcomes phenotypes in large clinical databases. Most of the predictors were present before the recovery period so perioperative planning should focus in the preoperative and intraoperative periods.

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.

Liposomal bupivacaine addition versus standard bupivacaine alone for colorectal surgery: a randomized controlled trial

Aim: This study evaluated use of liposomal bupivacaine (LB) versus standard bupivacaine (SB) alone in quadratus lumborum (QL) blocks for laparoscopic colorectal surgery. Materials & methods: In this prospective, randomized controlled trial, patients received QL1 blocks with either LB (40 ml 0.125% SB plus 20 ml of LB) or SB (60 ml of 0.25% SB) with 30 ml per side. Opioid usage, pain scores, side effects and other medications were recorded. Results: For 78 patients (38 LB; 40 SB), all parameters were similar between groups, except that the LB group had a higher 48 h need for metoclopramide. Conclusion: LB provided no analgesic benefit over SB alone for QL blocks. Clinical Trials registration number: NCT03702621.

Purely ropivacaine-based TEA vs single TAP block in pain management after elective laparoscopic colon surgery within an upgraded institutional ERAS program

Background

The aim of this study was to compare thoracic epidural analgesia (TEA) with transversus abdominis plane (TAP) block in post-operative pain management after laparoscopic colon surgery.

Methods

One hundred thirty-six patients undergoing laparoscopic colon resection randomly received either TEA or TAP with ropivacaine only. The primary endpoint was opioid requirement up to 48 h postoperatively. Intensity of pain, time to onset of bowel function, time to mobilization, postoperative complications, length of hospital stay, and patients’ satisfaction with pain management were also assessed.

Results

We observed a significant decrease in opioid consumption on the day of surgery with TEA compared with TAP block (30 mg vs 14 mg, p < 0.001). On the first two postoperative days (POD), the balance shifted to opioid consumption being smaller in the TAP group: on POD 1 (15.2 mg vs 10.6 mg; p = 0.086) and on POD 2 (9.2 mg vs 4.6 mg; p = 0.021). There were no differences in postoperative nausea/vomiting or time to first postoperative bowel movement between the groups. No direct blockade-related complications were observed and the length of stay was similar between TEA and TAP groups.

Conclusion

TEA is more efficient for acute postoperative pain than TAP block on day of surgery, but not on the first two PODs. No differences in pain management-related complications were detected.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08647-z.

Efficacy of Multimodal Analgesia for Postoperative Pain Management in Head and Neck Cancer Patients

Simple Summary

Chronic opioid use is a serious global health problem and surgery is often the point of initial exposure for many chronic opioid users. Multimodal analgesia (MMA) is an approach designed to reduce or eliminate opioid use in surgical patients, but it has not been studied in patients having major head and neck surgery. This study explores the impact of an MMA protocol on opioid prescribing practices in patients having major head and neck surgery with flap reconstruction. The results of this study will provide evidence to inform and guide pain management practice in this important patient population. The results of this study could also be applied to other areas of otorhinolaryngology. MMA is an important tool in the effort to reduce chronic opioid use.

Abstract

Postoperative opioid use has been linked to the subsequent development of opioid dependency. Multimodal analgesia (MMA) can reduce the use of opioids in the postoperative period, but MMA has not been well-studied after major head and neck surgery. Our goal is to explore the association between MMA and postoperative opioid use and pain control in patients undergoing major head and neck surgery. We performed a retrospective study in adult (age ≥ 18 years) patients undergoing primary head and neck cancer resection with free-flap reconstruction. All patients were treated using an established care pathway. The baseline group was treated between January 2015–December 2015 (n = 41), prior to the implementation of MMA, and were compared to an MMA-treated cohort treated between December 2017–June 2019 (n = 97). The primary outcome was the proportion of opioids prescribed and oral morphine equivalents (OMEs) consumed during the hospitalization. The secondary outcome was pain control. We found that the post-MMA group consumed fewer opioids in the postoperative period compared to the pre-MMA group. Prior to post-operative day (POD) 6, pain control was better in the post-MMA group; however, the pain control lines intersect on POD 6 and the pre-MMA group appeared to have better pain control from PODs 7–10. In conclusion, our data suggest MMA is an effective method of pain control and opioid reduction in patients undergoing surgery for head and neck cancer with free flap reconstruction. MMA use was associated with a significant decrease in the quantity of opioids consumed postoperatively. The MMA protocol was associated with improved pain management early in the postoperative course. Finally, the MMA protocol is a feasible method of pain control and may reduce the adverse side effects associated with opioid use.

The Burden of Opioid-Related Adverse Drug Events on Hospitalized Previously Opioid-Free Surgical Patients

OBJECTIVE

Opioid analgesics are a mainstay for acute pain management, but postoperative opioid administration has risks. We examined the prevalence, risk factors, and consequences of opioid-related adverse drug events (ORADEs) in a previously opioid-free surgical population.

METHODS

A retrospective, observational, cohort study using administrative, billing, clinical, and medication administration data from two hospitals. Data were collected for all adult patients who were opioid-free at admission, underwent surgery between October 1, 2015, and September 30, 2016, and received postoperative opioids. Potential ORADEs were determined based on inpatient billing codes or postoperative administration of naloxone. We determined independent predictors of ORADE development using multivariable logistic regression. We measured adjusted inpatient mortality, hospital costs, length of hospital stay, discharge destination, and readmission within 30 days for patients with and without ORADEs.

RESULTS

Among 13,389 hospitalizations where opioid-free patients had a single qualifying surgery, 12,218 (91%) received postoperative opioids and comprised the study cohort. Of these, we identified 1111 (9.1%) with a potential ORADE. Independent predictors of ORADEs included older age, several markers of disease severity, longer surgeries, and concurrent benzodiazepine use. Opioid-related adverse drug events were strongly associated with the route and duration of opioids administered postoperatively: 18% increased odds per day on intravenous opioids. In analyses adjusted for several covariates, presence of an ORADE was associated with 32% higher costs of hospitalization, 45% longer postoperative length of stay, 36% lower odds of discharge home, and 2.2 times the odds of death.

CONCLUSIONS

We demonstrate a high rate and severe consequences of potential ORADEs in previously opioid-free patients receiving postoperative opioids. Knowledge of risk factors and predictors of ORADEs can help develop targeted interventions to minimize the development of these potentially dangerous and costly events.

Postoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial

STUDY OBJECTIVE

Opioid administration for pain in general care floor patients remains common, and can lead to adverse outcomes, including respiratory compromise. The PRODIGY trial found that among ward patients receiving parenteral opioids, 46% experienced ≥1 respiratory depression episode. The objective of this analysis was to evaluate the geographic differences of opioid administration and examine the association between opioid administration characteristics and the occurrence of respiratory depression.

DESIGN

Prospective observational trial.

SETTING

16 general care medical and surgical wards in Asia, Europe, and the United States.

PATIENTS

1335 patients receiving parenteral opioids.

INTERVENTIONS

Blinded, alarm-silenced continuous capnography and pulse oximetry monitoring.

MEASUREMENTS

Opioid-induced respiratory depression, defined as respiratory rate ≤ 5 bpm, SpO₂ ≤ 85%, or ETCO₂ ≤ 15 or ≥ 60 mmHg for ≥3 min; apnea episode lasting >30 s; or any respiratory opioid-related adverse event.

RESULTS

Across all patients, 58% received only long-acting opioids, 16% received only short-acting (<3 h) opioids, and 21% received a combination of short- and long-acting (≥3 h) opioids. The type and median total morphine milligram equivalent (MME) of opioid administered varied significantly by region, with 31.5 (12.5-76.7) MME, 31.0 (6.2-99.0) MME, and 7.2 (1.7-18.7) MME in the United States, Europe, and Asia, respectively (p < 0.001). Considering only postoperative opioids, 54% (N = 119/220) and 45% (N = 347/779) of patients receiving only short-acting opioids or only long-acting opioids experienced ≥1 episode of opioid-induced respiratory depression, respectively. Multivariable analysis identified post-procedure tramadol (OR 0.62, 95% CI 0.424-0.905, p = 0.0133) and post-procedure epidural opioids (OR 0.485, 95% CI 0.322-0.731, p = 0.0005) being associated with a significant reduction in opioid-induced respiratory depression.

CONCLUSIONS

Despite varying opioid administration characteristics between Asia, Europe, and the United States, opioid-induced respiratory depression remains a common global problem on general care medical and surgical wards. While the use of post-procedure tramadol or post-procedure epidural opioids may reduce the incidence of respiratory depression, continuous monitoring is also necessary to ensure patient safety when receiving postoperative opioids. REGISTRATION NUMBER: www.clinicaltrials.gov, ID: NCT02811302.

No Opioids after Septorhinoplasty: A Multimodal Analgesic Protocol

Supplemental Digital Content is available in the text.

Background:

From a public health perspective, nasal surgery accounts for many unused opioids. Patients undergoing septorhinoplasty require few opioids, and efforts to eliminate this need may benefit both patients and the public.

Methods:

A multimodal analgesic protocol consisting of 15 components encompassing all phases of care was implemented for 42 patients.

Results:

Median age and BMI were 34 years and 23, respectively. Most were women (79%), White (79%), primary surgeries (62%), and self-pay (52%). Comorbid conditions were present in 74% of the patients, with anxiety (33%) and depression (21%) being the most common. Septoplasties (67%) and osteotomies (45%) were common. The median operative time was 70 minutes. No patients required opioids in recovery, and median time in recovery was 63 minutes. Ten (24%) patients required an opioid prescription after discharge. In those patients, median time to requirement was 27 hours (range 3–81), and median total requirement was 20 mg morphine equivalents (range 7.5–85). Protocol compliance inversely correlated to opioid use (P = 0.007). Compliance with local and regional anesthetic (20% versus 63%, P = 0.030) as well as ketorolac (70% versus 100%, P = 0.011) was lower in patients who required opioids. Patients who required opioids were less likely to be administered a beta blocker (0% versus 34%, P = 0.041). Pain scores were higher in opioid users on postoperative days 1–5 (P < 0.05). No complications occurred in those requiring opioids, and satisfaction rates were equivalent between groups.

Conclusion:

This protocol allowed us to safely omit opioid prescriptions in 76% of patients following septorhinoplasty, without adverse effects on outcomes or patient satisfaction.

Chronic pain and substance abuse disorders: Preoperative assessment and optimization strategies

There is an ever-increasing number of opioid users among chronic pain patients and safely managing them can be challenging for surgeons, anesthesiologists, pain experts, and addiction specialists. Healthcare providers must be familiar with phenomena typical of opioid users and abusers, including tolerance, physical dependence, hyperalgesia, and addiction. Insufficient pain management is very common in these patients. Patient-centered preoperative communication is integral to setting realistic expectations for postoperative pain, developing successful nonopioid analgesic regimens, minimizing opioid consumption during the postoperative period, and decreasing the number of opioid pills at the risk of diversion. Preoperative evaluation should identify comorbidities and identify risk factors for substance abuse and withdrawal. Intraoperative and postoperative strategies can ensure safe and effective pain management and minimize the potential for morbidity and mortality in this high-risk patient population.

Dexmedetomidine in Enhanced Recovery After Surgery (ERAS) Protocols for Postoperative Pain

PURPOSE OF REVIEW

Effective acute pain management has evolved considerably in recent years and is a primary area of focus in attempts to defend against the opioid epidemic. Persistent postsurgical pain (PPP) has an incidence of up to 30-50% and has negative outcome of quality of life and negative burden on individuals, family, and society. The 2016 American Society of Anesthesiologists (ASA) guidelines states that enhanced recovery after surgery (ERAS) forms an integral part of Perioperative Surgical Home (PSH) and is now recommended to use a multimodal opioid-sparing approach for management of postoperative pain. As such, dexmedetomidine is now being used as part of ERAS protocols along with regional nerve blocks and other medications, to create a satisfactory postoperative outcome with reduced opioid consumption in the Post anesthesia care unit (PACU).

RECENT FINDINGS

Dexmedetomidine, a selective alpha2 agonist, possesses analgesic effects and has a different mechanism of action when compared with opioids. When dexmedetomidine is initiated at the end of a procedure, it has a better hemodynamic stability and pain response than ropivacaine. Dexmedetomidine can be used as an adjuvant in epidurals with local anesthetic sparing effects. Its use during nerve blocks results in reduced postoperative pain. Also, local infiltration of IV dexmedetomidine is associated with earlier discharge from PACU. Perioperative use of dexmedetomidine has significantly improved postoperative outcomes when used as part of ERAS protocols. An in-depth review of the use of dexmedetomidine in ERAS protocols is presented for clinical anesthesiologists.

The effect of preemptive use of pregabalin on postoperative morphine consumption and analgesia levels after laparoscopic colorectal surgery: a controlled randomized trial

PURPOSE

In order to reduce postoperative opioid administration and pain levels in patients submitted to laparoscopic colectomy, we assessed the efficacy of preemptive use of pregabalin (PG), as part of a multimodal analgesia scheme, in a randomized controlled trial setting.

METHODS

Overall, fifty adult patients scheduled for elective laparoscopic colectomy were included and randomized in our trial. In the experimental group, 23 patients received preoperatively 2 doses of 150 mg PG per os, whereas the control group consisted of 27 cases, where a matching to PG placebo was administered at the same scheme. The two groups had identical analgesia and anesthesia regimens otherwise. Our study endpoints included postoperative morphine consumption, postoperative pain, and complication rates.

RESULTS

Patients in the PG group displayed a significantly reduced morphine consumption at 8 h, 24 h, and 48 h postoperatively. The two groups were comparable in terms of postoperative pain (rest and movement assessment) and side effects.

CONCLUSIONS

The preoperative addition of PG resulted in a significant reduction of the postoperative opioid consumption in patients undergoing laparoscopic colectomy. However, an association with the postoperative pain scores was not identified.

Enhanced recovery after surgical repair of incisional hernias

AIM

Enhanced recovery programmes (ERPs) were developed to improve the patient's post-operative comfort and reduce post-operative morbidity after several types of major surgery including the incisional hernia repair. The aim of this review was to describe the features of ERPs in the setting for incisional hernia repair.

METHODS

The literature review was conducted until March 2019, but retrieved very few papers (n = 4) on this topic. All studies were retrospective.

RESULTS

Setting and comorbidities of incisional hernia patients are of such importance in many cases that prehabilitation (including tobacco use cessation, management of obesity, diabetes or malnutrition) should play a greater role compared with other specialties. The other peri-operative measures are similar to other specialties but their implementation was very heterogeneous in the published studies.

CONCLUSIONS

Like in other surgeries, ERPs were feasible and probably efficient to improve the post-operative course of incisional hernia patients. But the level of evidence remains low.

Analysis of predictors of opioid-free analgesia for management of acute post-surgical pain in the United States

OBJECTIVES

Utilization of opioid-free analgesia (OFA) for post-surgical pain is a growing trend to counter the risks of opioid abuse and opioid-related adverse drug events (ORADEs). However, utilization patterns of OFA have not been examined. In this study, we investigated the utilization patterns and predictors of OFA in a surgical population in the United States.

METHODS

Analysis of the Cerner Health Facts database (January 2011 to December 2015) was conducted to describe hospital and patient characteristics associated with OFA. Baseline characteristics, such as age, gender, race, discharge status, year of admission and chronic comorbidities at index admission were collected. Hospital characteristics and payer type at index admission were collected as reported in the electronic health record database. Descriptive statistics and logistic regression were used to identify statistically significant predictors of OFA on patient and institutional levels.

RESULTS

The study identified 10,219 patients, from 187 hospitals, who received post-surgical OFA and 255,196 patients who received post-surgical opioids. OFA rates varied considerably by hospital. Patients more likely to receive OFA were older (OR = 1.06, 95% CI [1.03, 1.10]; p < .001), or had neurological disorders (OR = 1.24, 95% CI [1.10, 1.39]; p < .001), diabetes (OR = 1.20, 95% CI [1.08, 1.33]; p = .001) or psychosis (OR = 1.18, 95% CI [1.01, 1.37]; p = .030). Patients with obesity and depression were less likely to receive OFA (OR = 0.80, 95% CI [0.67, 0.95]; p = .010 OR = 0.85, 95% CI [0.73, 0.98]; p = .030, respectively).

CONCLUSIONS

Use of post-surgical OFA was limited overall and was not favored in some patient groups prone to ORADEs, indicating missed opportunities to reduce opioid use and ORADE incidence. A substantial proportion of OFA patients was contributed by a few hospitals with especially high rates of OFA, suggesting that hospital policies, institutional structure and cross-functional departmental commitment to reducing opioid use may play a large role in the implementation of OFA.

Dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plain (TAP) block for analgesia after abdominal surgery: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To evaluate the analgesic efficacy of dexamethasone added to local anesthetics in ultrasound-guided transversus abdominis plane (TAP) block for the patients after abdominal surgery.

METHODS

PubMed, CENTRAL, EMBASE, Web of science were searched to identify eligible randomized controlled trials (RCTs) that compared dexamethasone added to local anesthetics in ultrasound-guided TAP block with control for postoperative analgesia in adult patients undergoing abdominal surgery. Primary outcomes included postoperative pain intensity, the time to the first request for additional analgesics, and opioid consumption over 24 h after surgery. Secondary outcome was the incidence of postoperative nausea and vomiting. Analysis was performed by RevMan 5.3 software and the quality of evidence was rated using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.

RESULTS

Nine RCTs involving 575 patients were included. Compared to the control, dexamethasone added to local anesthetics in ultrasound-guided TAP block significantly decreased visual analogue scale (VAS) scores at rest at 4h (mean difference [MD] = -1.01; 95% confidence intervals [CI], -1.29 to -0.73; P<0.00001; moderate quality of evidence), 6h (MD = -1.21; 95% CI, -1.74 to -0.69; P<0.00001; low quality of evidence), and 12h after surgery (MD = -0.79; 95% CI, -0.97 to -0.60; P<0.00001; moderate quality of evidence). No difference was found at 2h (MD = -0.64; 95% CI, -1.35 to 0.08; P = 0.08; low quality of evidence) and 24 h (MD = -0.41; 95% CI, -0.91 to 0.09; P = 0.11; moderate quality of evidence) in VAS scores. The time to the first request for additional analgesics was prolonged in the dexamethasone group (MD = 3.08; 95% CI, 2.37 to 3.78; P<0.00001; moderate quality of evidence). Opioid consumption over 24 h after surgery was also reduced (MD = -5.42; 95% CI, -8.20 to -2.63; P = 0.0001; low quality of evidence). Meanwhile, the incidence of postoperative nausea and vomiting was significantly decreased in the dexamethasone group (risk ratios [RR] = 0.40; 95% CI, 0.28 to 0.58; P<0.00001; high quality of evidence). No complications were reported in all the included studies.

CONCLUSIONS

Dexamethasone added to local anesthetics in ultrasound-guided TAP block was a safe and effective strategy for postoperative analgesia in adult patients undergoing abdominal surgery.

Procedure-Specific Pain Management (PROSPECT) - An update

Post-operative pain management protocols may be optimised by examining procedure-specific evidence and outcomes. This recognition led to the formation of the PROcedure-SPECific Pain ManagemenT (PROSPECT) collaboration of anaesthesiologists and surgeons. The aim of PROSPECT is to provide practical and evidence-based recommendations to prevent and treat post-operative pain after specific surgical procedures, thereby overcoming the limitations of generic, non-specific guidelines. Updates in the methodology of PROSPECT in 2017 have placed an increased emphasis on the clinical relevance of studies, including a focus on interventions in the context of multimodal analgesia strategies and consideration of risks and benefits of interventions in specific surgical settings. Evidence-based reviews of analgesic measures, including advice on surgical techniques and adjuvants after diverse surgical procedures, have been completed by the PROSPECT collaboration and are accessible on the website (www.postoppain.org) and published in the peer-reviewed literature. These reviews continue to identify significant gaps in clinically relevant research on post-operative analgesia and are possibly leading to a closing of some of these gaps.

A Dashboard for Monitoring Opioid-Related Adverse Drug Events Following Surgery Using a National Administrative Database

Opioid-related adverse drug events (ORADEs) include a range of complications, from respiratory arrest to ileus and urinary retention. ORADEs correlate to morbidity, mortality, and increased costs. The Centers for Medicare & Medicaid Services database, which represents approximately 35% of hospital discharges. The authors searched for previously published ICD-9 codes that defined ORADEs. A group of surgical diagnosis-related groups (DRGs) were selected. Recurring queries were programmed using these ICD codes and DRGs and used to update an online dashboard. The dashboard presents an estimate of the burden of ORADEs to frontline clinicians and hospital leadership and allows users to compare local data on ORADEs rates to other hospitals. Users are able to refine their search by surgery type or ORADE type. An interface was created, using national administrative claims data, to allow hospitals to access their ORADEs and benchmark local data against national trends.