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Shauly O, Marxen T, Menon A, Swan C, Smearman E, Gould DJ. Multimodal Pain Control in Abdominoplasty: A Systematic Review and Algorithm of Optimal Pain Management. Aesthet Surg J 2024; 44:S22-S30. [PMID: 39147384 DOI: 10.1093/asj/sjad381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024] Open
Abstract
The procedure with the highest rate of opioid prescription in plastic surgery is abdominoplasty. Additionally, plastic surgery patients are at a particularly elevated risk of becoming opioid-dependent. The main objective of this study was to perform a systematic review and create an algorithm for a multimodal pain regimen specific to patients undergoing abdominoplasty. A systematic search of the research literature was performed to summarize the prevailing understanding of multimodal pain control in the management of abdominoplasty. The initial search yielded 448 articles. Sixty-eight manuscripts were identified for full-text review. The effectiveness of current strategies was evaluated by way of pain scores, opioid usage, and length of stay, as well as other measures of physical function such as time to early mobilization. In 32 studies involving 2451 patients, the efficacy of different pain regimens during abdominoplasty was evaluated. Among nontraditional, opioid-sparing analgesia, efficacy of treatment interventions for improved pain and decreased opioid usage was found inall studies. Among local infusion studies, efficacy of treatment interventions for improved pain and decreased opioid usage was found in 78% of studies. Last, among regional block studies, efficacy of treatment interventions for improved pain was found in 87%, with 73% efficacy for decreased opioid usage. Multimodal pain regimens in abdominoplasty have the potential to play an important role in opioid-sparing practices in medicine by incorporating nonopioid pain adjuvants such as nonsteroidal anti-inflammatory drugs and transversus abdominis plane blocks in the preoperative, perioperative, and postoperative periods. LEVEL OF EVIDENCE: 2
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2
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Farishta A, Iancau A, Janis JE, Joshi GP. Use of Muscle Relaxants for Acute Postoperative Pain: A Practical Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5938. [PMID: 38957722 PMCID: PMC11216677 DOI: 10.1097/gox.0000000000005938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/14/2024] [Indexed: 07/04/2024]
Abstract
Background Skeletal muscle relaxants have emerged as a broad category of analgesic adjuncts, aiming to improve pain relief and reduce opioid reliance. These drugs induce muscle relaxation and reduce muscle spasms, and therefore, they are commonly used in surgical procedures involving muscle manipulation, such as abdominal surgery, breast surgery, and spine surgery. However, their analgesic efficacy and opioid-sparing effects are poorly explored. Methods A scoping review of literature was performed with several electronic databases. We used a search string with a sequence of text words and word variants related to central muscle relaxants, pain management, postoperative pain, and specific muscle relaxants. Results Review of literature shows significant heterogeneity among the studies in terms of surgical procedures, patient populations, choice of muscle relaxant, and timing and duration of administration, potentially limiting the generalizability of the findings and the ability for pooled analysis. Conclusions Given the lack of evidence, we recommend that the use of skeletal muscle relaxants be reserved for patients in whom an optimal multimodal analgesic technique is not adequate. Also, there may be a limited role for these drugs in patients at high risk of postoperative pain undergoing surgical procedures with expected high opioid requirements. Due to the concerns of potential adverse effects, the decision to use muscle relaxants in vulnerable populations should be made carefully, weighing the benefits against the risks.
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Affiliation(s)
- Akil Farishta
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Tex
| | - Alex Iancau
- University of Texas Southwestern, Dallas, Tex
| | - Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, Ohio
| | - Girish P. Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Tex
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3
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Elliott ZT, Mann DS, Fiorella M, Christopher V, Givens A, Martin AM, Zhan T, Curry J. Predictors of opioid requirement among patients receiving free flap reconstruction to the head and neck. Am J Otolaryngol 2023; 44:104000. [PMID: 37499343 DOI: 10.1016/j.amjoto.2023.104000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/06/2023] [Accepted: 07/09/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Opioids are a part of standard of care treatment of acute, severe postoperative pain. However, increased opioid requirements have been shown to be associated with increased postoperative complications, morbidity, and mortality. The aim of this study was to identify potential predictive factors associated with increased or decreased opioid requirements after free tissue transfer (FTT) to the head and neck. MATERIALS/METHODS A retrospective review was conducted on subjects who underwent head and neck reconstruction (HNR) from 2015 to 2021 at a single tertiary care center. Patients with inpatient stay over 10 days and those receiving fentanyl for sedation purposes were excluded due to EMR limitations and confounding, respectively. The total dose of opioid medication each patient received was calculated and summed using morphine milligram equivalents (MME). Statistical analysis was conducted using poisson regression and multivariable regression models. RESULTS Two hundred and ninety-one patients were included. The mean opioid requirement for all subjects was 228.6 (SD 250.0) MMEs during their entire postoperative stay and the mean length of stay was 6.0 (SD 1.7) days. An established opioid prescription prior to surgical resection was the greatest predictor of increased risk for opioid requirement according univariate and multivariate analysis 2.356 (2.321-2.392), p ≤ 0.0001 and 1.833 (1.802-1.863), p ≤ 0.0001, respectively. Fibula transfers were associated with higher opioid requirements while scapula transfers were associated with decreased opioid requirements compared to other free tissue transfer types. CONCLUSION Preoperative opioid use was associated with higher postoperative opioid requirements. Multimodal pain management (MMPM) was not associated with a decreased opioid requirement; however, further studies are needed to investigate the hierarchy, dosing, and timing of MMPM in relation to opioid requirements and pain control.
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Affiliation(s)
- Zachary T Elliott
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA.
| | - Derek S Mann
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Michele Fiorella
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Vanessa Christopher
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Alyssa Givens
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Ann Marie Martin
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA 191071, USA
| | - Joseph Curry
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 191071, USA
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List MA, Knackstedt M, Liu L, Kasabali A, Mansour J, Pang J, Asarkar AA, Nathan C. Enhanced recovery after surgery, current, and future considerations in head and neck cancer. Laryngoscope Investig Otolaryngol 2023; 8:1240-1256. [PMID: 37899849 PMCID: PMC10601592 DOI: 10.1002/lio2.1126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/15/2022] [Indexed: 10/31/2023] Open
Abstract
Objectives Review of the current and relevant literature to develop a list of evidence-based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients. Methods Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion. Results A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation. Conclusion Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol. Level of Evidence 2a.
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Affiliation(s)
- Marna A. List
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Mark Knackstedt
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Lucy Liu
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ahmad Kasabali
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- College of MedicineLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Jobran Mansour
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - John Pang
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Ameya A. Asarkar
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
| | - Cherie‐Ann Nathan
- Department of Otolaryngology/HNSLouisiana State University Health‐ShreveportShreveportLouisianaUSA
- Feist‐Weiller Cancer CenterShreveportLouisianaUSA
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Huang CN, Chen YM, Xiao XY, Zhou HL, Zhu J, Qin HM, Jiang X, Li Z, Zhuang T, Zhang GS. Pregabalin can interact synergistically with Kv7 channel openers to exert antinociception in mice. Eur J Pharmacol 2023:175870. [PMID: 37353189 DOI: 10.1016/j.ejphar.2023.175870] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/10/2023] [Accepted: 06/20/2023] [Indexed: 06/25/2023]
Abstract
Chronic pain is a common public health problem and remains an unmet medical need. Currently available analgesics usually have limited efficacy for the treatment of chronic pain, including neuropathic pain and persistent inflammatory pain, or they are accompanied by many adverse side effects. The voltage-gated calcium channel blocker (pregabalin) and potassium channel openers (flupirtine and retigabine) have been widely used for the management of chronic pain, but their effectiveness in combination is unclear. In this research, we evaluated the antinociceptive effects of pregabalin in combination with flupirtine or retigabine in carrageenan-induced inflammatory pain and paclitaxel-induced peripheral neuropathy in mice using the von Frey test. Isobolographic analysis indicated that pregabalin exerted synergistic antinociceptive effects when combined with flupirtine or retigabine in neuropathic and inflammatory pain models. Furthermore, the antinociceptive effects of pregabalin, flupirtine/retigabine, and their combinations were significantly attenuated by the Kv7 channel blocker XE991. The favored dose ratio between pregabalin and flupirtine/retigabine in combinations was also investigated. Finally, we evaluated the motor coordination of their combinations using the rotarod test, and the outcomes underpinned their safety. Collectively, our results support the potential use of pregabalin in combination with flupirtine or retigabine to alleviate chronic pain.
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Affiliation(s)
- Chao-Nan Huang
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang, 222005, China; Co-Innovation Center of Jiangsu Marine Bio-industry Technology, Jiangsu Ocean University, Lianyungang, 222005, China
| | - Yan-Ming Chen
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang, 222005, China; Co-Innovation Center of Jiangsu Marine Bio-industry Technology, Jiangsu Ocean University, Lianyungang, 222005, China
| | - Xin-Yi Xiao
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang, 222005, China; Co-Innovation Center of Jiangsu Marine Bio-industry Technology, Jiangsu Ocean University, Lianyungang, 222005, China
| | - Hui-Ling Zhou
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang, 222005, China
| | - Jin Zhu
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang, 222005, China; Co-Innovation Center of Jiangsu Marine Bio-industry Technology, Jiangsu Ocean University, Lianyungang, 222005, China
| | - Hui-Min Qin
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang, 222005, China
| | - Xue Jiang
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang, 222005, China
| | - Zongzheng Li
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang, 222005, China
| | - Tao Zhuang
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang, 222005, China; Co-Innovation Center of Jiangsu Marine Bio-industry Technology, Jiangsu Ocean University, Lianyungang, 222005, China.
| | - Gui-Sen Zhang
- Jiangsu Key Laboratory of Marine Biological Resources and Environment, Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening, School of Pharmacy, Jiangsu Ocean University, Lianyungang, 222005, China; Co-Innovation Center of Jiangsu Marine Bio-industry Technology, Jiangsu Ocean University, Lianyungang, 222005, China.
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6
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Shamsunder MG, Chu JJ, Taylor E, Polanco TO, Allen RJ, Moo TA, Disa JJ, Mehrara BJ, Tokita HK, Nelson JA. Paravertebral Blocks in Tissue Expander Breast Reconstruction: Propensity-Matched Analysis of Opioid Consumption and Patient Outcomes. Plast Reconstr Surg 2023; 151:542e-551e. [PMID: 36729942 PMCID: PMC10065883 DOI: 10.1097/prs.0000000000009981] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The paravertebral block (PVB) is an adjunctive perioperative pain control method for patients undergoing breast reconstruction that may improve perioperative pain control and reduce narcotic use. This study determined the efficacy of preoperative PVBs for perioperative pain management in patients undergoing tissue expander breast reconstruction. METHODS A retrospective review was performed of patients who underwent tissue expander breast reconstruction from December of 2017 to September of 2019. Two patients with PVBs were matched using propensity scoring to one no-block patient. Perioperative analgesic use, pain severity scores on days 2 to 10 after discharge, and BREAST-Q Physical Well-Being scores before surgery and at 2 weeks, 6 weeks, and 3 months after surgery were compared between the two groups. RESULTS The propensity-matched cohort consisted of 471 patients (314 PVB and 157 no block). The PVB group used significantly fewer morphine milligram equivalents than the no-block group (53.7 versus 69.8; P < 0.001). Average daily postoperative pain severity scores were comparable, with a maximum difference of 0.3 points on a 0-point to 4-point scale. BREAST-Q Physical Well-Being scores were significantly higher for the PVB group than the no-block group at 6 weeks after surgery (60.6 versus 51.0; P = 0.015) but did not differ significantly at 2 weeks or 3 months after surgery. CONCLUSIONS PVBs may help reduce perioperative opioid requirements but did not reduce pain scores after discharge when used as part of an expander-based reconstruction perioperative pain management protocol. Continued research should examine additional or alternative regional block procedures as well as financial cost and potential long-term impact of PVBs. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Meghana G. Shamsunder
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jacqueline J. Chu
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Erin Taylor
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Thais O. Polanco
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert J. Allen
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Tracy-Ann Moo
- Anesthesiology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joseph J. Disa
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hanae K. Tokita
- Anesthesiology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
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7
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Wagner KJ, Beck JJ, Carsen S, Crepeau AE, Cruz AI, Ellis HB, Mayer SW, Niu E, Pennock AT, Stinson ZS, VandenBerg C, Ellington MD. Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction. J Pediatr Orthop 2023; 43:e278-e283. [PMID: 36728478 DOI: 10.1097/bpo.0000000000002344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons. METHODS A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics. RESULTS Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols. CONCLUSIONS Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
| | | | - Sasha Carsen
- Children's Hospital of Eastern Ontario, ON, Canada
| | | | | | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical School, Dallas, TX
| | | | - Emily Niu
- Children's National Medical Center, Washington DC
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Zhang KK, Blum K, Chu JJ, Zewdu A, Janse S, Skoracki R, Janis JE, Barker JC. A Personalized Opioid Prescription Model for Predicting Postoperative Discharge Opioid Needs. Plast Reconstr Surg 2023; 151:450-460. [PMID: 36696335 PMCID: PMC10449368 DOI: 10.1097/prs.0000000000009865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Opioid overprescribing after surgery is common. There is currently no universal predictive tool available to accurately anticipate postdischarge opioid need in a patient-specific manner. This study examined the efficacy of a patient-specific opioid prescribing framework for estimating postdischarge opioid consumption. METHODS A total of 149 patients were evaluated for a single-center retrospective cohort study of plastic and reconstructive surgery patients. Patients with length of stay of 2 to 8 days and quantifiable inpatient opioid consumption (n = 116) were included. Each patient's daily postoperative inpatient opioid consumption was used to generate a personalized logarithmic regression model to estimate postdischarge opioid need. The validity of the personalized opioid prescription (POP) model was tested through comparison with actual postdischarge opioid consumption reported by patients 4 weeks after surgery. The accuracy of the POP model was compared with two other opioid prescribing models. RESULTS The POP model had the strongest association (R2 = 0.899; P < 0.0001) between model output and postdischarge opioid consumption when compared to a procedure-based (R2 = 0.226; P = 0.025) or a 24-hour (R2 = 0.152; P = 0.007) model. Accuracy of the POP model was unaffected by age, gender identity, procedure type, or length of stay. Odds of persistent use at 4 weeks increased, with a postdischarge estimated opioid need at a rate of 1.16 per 37.5 oral morphine equivalents (P = 0.010; 95% CI, 1.04 to 1.30). CONCLUSIONS The POP model accurately estimates postdischarge opioid consumption and risk of developing persistent use in plastic surgery patients. Use of the POP model in clinical practice may lead to more appropriate and personalized opioid prescribing.
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Affiliation(s)
- Kevin K. Zhang
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Kevin Blum
- Center for Regenerative Medicine, Nationwide Children’s Hospital, Columbus, OH
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH
| | - Jacqueline J. Chu
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Abeba Zewdu
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Sarah Janse
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Medical Center, Columbus, OH
| | - Roman Skoracki
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Jeffrey E. Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
| | - Jenny C. Barker
- Department of Plastic and Reconstructive Surgery, The Ohio State University Medical Center, Columbus, OH
- Center for Regenerative Medicine, Nationwide Children’s Hospital, Columbus, OH
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9
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Armstrong VL, Hammond JB, Jogerst KM, Kosiorek HE, Teven C, Cronin P, Ahmad S, Rebecca A, Casey W, Pockaj B. The Impact of Same-Day Discharge and Enhanced Recovery on Patient Quality of Life After Mastectomy with Implant Reconstruction. Ann Surg Oncol 2023; 30:2873-2880. [PMID: 36705818 PMCID: PMC9882739 DOI: 10.1245/s10434-022-13019-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/01/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND This study aimed to evaluate how enhanced recovery (ER) protocols and same-day discharge (SDD) influences patients' postoperative quality of life (QOL). METHODS Patients who underwent mastectomy with implant-based breast reconstruction from 2008 to 2020 were identified in a prospective database. The study assessed QOL with BREAST-Q and Was It Worth It? (WIWI) questionnaires. Responses were compared between the ER and pre-ER groups and between the SDD and hospital stay (HS) groups using one-way analysis of variance (ANOVA) and chi-square tests. RESULTS The inclusion criteria were met by 568 patients, with a 43% response rate, and 217 patients were included for analysis. Chest physical well-being was lower for the ER cohort, but postoperative breast satisfaction was higher. Psychosocial status, sexual well-being, and satisfaction with information given did not differ significantly between the ER group and the pre-ER or SDD group. In the compared groups, QOL did not differ significantly. CONCLUSIONS Enhanced recovery with SDD after mastectomy using implant-based reconstruction did not have an adverse impact on patient postoperative QOL.
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Affiliation(s)
- Valerie L. Armstrong
- Department of General Surgery. Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, USA
| | - Jacob B. Hammond
- Department of General Surgery. Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, USA
| | - Kristen M. Jogerst
- Department of General Surgery. Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, USA
| | - Heidi E. Kosiorek
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, USA
| | - Chad Teven
- Department of Surgery. Division of Plastic Surgery, Mayo Clinic Arizona, Phoenix, USA
| | - Patricia Cronin
- Department of General Surgery. Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, USA
| | - Sarwat Ahmad
- Department of General Surgery. Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, USA
| | - Alanna Rebecca
- Department of Surgery. Division of Plastic Surgery, Mayo Clinic Arizona, Phoenix, USA
| | - William Casey
- Department of Surgery. Division of Plastic Surgery, Mayo Clinic Arizona, Phoenix, USA
| | - Barbara Pockaj
- Department of General Surgery. Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, USA
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10
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Stahl S, Santos Stahl A, Feng YS, Estler A, Swoboda K, Buiculescu F, Seabra Robalo Gomes Jorge AC. Enhanced Recovery After Aesthetic Breast Surgery Under Sedation, Intercostal Block and Tumescent Anaesthesia: A Prospective Cohort Study of the Early Postoperative Phase. Aesthetic Plast Surg 2022; 47:979-997. [PMID: 36544050 PMCID: PMC9770569 DOI: 10.1007/s00266-022-03214-w] [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: 09/01/2022] [Accepted: 11/26/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia. METHODS This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients' satisfaction were systematically assessed with standardized self-assessment questionnaires. RESULTS Altogether, 48 patients [median (IQR) age: 30 (36-25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34-2) mg/kg lidocaine and 2.3 (2.5-2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48-4.26) mg/kg/h and 0.27 (0.39-0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43-1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h. CONCLUSIONS Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care. 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 .
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Affiliation(s)
- Stéphane Stahl
- CenterPlast Private Practice, Bahnhofstraße 36, 66111, Saarbrücken, Germany
| | | | - You-Shan Feng
- Institute for Clinical Epidemiology and Applied Biometrics, Medical University of Tübingen, Silcherstraße 5, 72076, Tübingen, Germany
| | - Arne Estler
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Kamil Swoboda
- CenterPlast Private Practice, Bahnhofstraße 36, 66111, Saarbrücken, Germany
| | - Florian Buiculescu
- CenterPlast Private Practice, Bahnhofstraße 36, 66111, Saarbrücken, Germany
| | - Ana Cristina Seabra Robalo Gomes Jorge
- Department of General, Visceral, Vascular, and Pediatric Surgery, Saarland University Hospital, Kirrberger Straße 100, 66421, Homburg, Saarland, Germany.
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11
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Office-based Plastic Surgery-Evidence-based Clinical and Administrative Guidelines. Plast Reconstr Surg Glob Open 2022; 10:e4634. [PMID: 36381487 PMCID: PMC9645793 DOI: 10.1097/gox.0000000000004634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/08/2022] [Indexed: 12/15/2022]
Abstract
Outpatient procedures are extremely prevalent in plastic surgery, with an estimated 82% of cosmetic plastic surgery occurring in this setting. Given that patient safety is paramount, this practical review summarizes major contemporary, evidence-based recommendations regarding office-based plastic surgery. These recommendations not only outline clinical aspects of patient safety guidelines, but administrative, as well, which in combination will provide the reader/practice with a structure and culture that is conducive to the commitment to patient safety. Proper protocols to address potential issues and emergencies that can arise in office-based surgery, and staff familiarity with thereof, are also necessary to be best prepared for such situations.
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Uribe AA, Weaver TE, Echeverria-Villalobos M, Periel L, Pasek J, Fiorda-Diaz J, Palettas M, Skoracki RJ, Poteet SJ, Heard JA. Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study. Front Med (Lausanne) 2022; 9:975080. [PMID: 36045918 PMCID: PMC9420942 DOI: 10.3389/fmed.2022.975080] [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] [Received: 06/21/2022] [Accepted: 07/21/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Alberto A. Uribe
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Tristan E. Weaver
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | | | - Luis Periel
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Joshua Pasek
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Marilly Palettas
- Department of Biomedical Informatics, The Ohio State University, Center of Biostatistics, Columbus, OH, United States
| | - Roman J. Skoracki
- Department of Plastic Surgery, The Ohio State University Medical Center, Columbus, OH, United States
| | - Stephen J. Poteet
- Department of Plastic Surgery, The Ohio State University Medical Center, Columbus, OH, United States
| | - Jarrett A. Heard
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
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Impact of Opioid Restriction Legislation on Prescribing Practices for Outpatient Plastic and Reconstructive Surgery. Plast Reconstr Surg 2022; 150:213-221. [PMID: 35588099 DOI: 10.1097/prs.0000000000009239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Overprescription of opioids for acute postoperative pain, plastic surgery procedures included, is contributing to the pervasive opioid epidemic in the United States. This study examines the effect of a statewide legislation limiting postoperative opioids on opioid prescription behavior among providers following outpatient plastic surgery procedures at a high-volume academic center. METHODS Retrospective review of all outpatient surgical encounters between June 1, 2016, and November 30, 2018, was performed. Encounters were grouped into two cohorts: prepolicy and postpolicy. Primary outcomes included total oral morphine equivalents prescribed on the day of surgery and proportion of patients prescribed greater than 210 oral morphine equivalents. Secondary outcomes included proportion of patients requiring an opioid refill within 30 days following surgery, and number of refills required. RESULTS The mean oral morphine equivalents prescribed on the day of surgery was reduced from 271.8 to 150.37 oral morphine equivalents ( p < 0.001) following implementation of the legislation, with an associated decrease in the standard deviation of oral morphine equivalents prescribed from 225.35 to 196.71 ( p < 0.001), suggesting a decrease in the variability of prescriber practices. Time series analysis demonstrated the decrease in oral morphine equivalents remained significant when accounting for baseline level of change in opioid prescription patterns. CONCLUSION This study provides evidence that legislation at the state level restricting postoperative opioid prescriptions is associated with a decrease in opioid prescriptions without an increase in the need for refills in the acute postoperative setting following outpatient plastic surgery procedures.
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14
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Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies. Plast Reconstr Surg Glob Open 2022; 10:e4310. [PMID: 35572190 PMCID: PMC9094416 DOI: 10.1097/gox.0000000000004310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 12/13/2022]
Abstract
Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control. Methods A review study based on multimodal analgesia was conducted. Results We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices. Conclusion This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.
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Seify H. Sufentanil Sublingual Tablet Reduces Postoperative Opioid Use Following Outpatient Plastic Surgery. Aesthet Surg J Open Forum 2022; 4:ojac040. [PMID: 35747464 PMCID: PMC9212086 DOI: 10.1093/asjof/ojac040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The emphasis on better pain control with less narcotic use represents an ongoing challenge for outpatient plastic surgery procedures. Intravenous (IV) bolus opioids during surgery can lead to short-term relief, but often repeat dosing is required in the postanesthesia care unit (PACU), prolonging recovery time. The sufentanil sublingual tablet (SST) has recently shown efficacy in reducing overall opioid use and postsurgical recovery time for outpatient general surgery procedures. Objectives To examine the effect of SST on PACU opioid use, adverse events, and recovery time compared with traditional IV opioid drug regimens in patients undergoing aesthetic surgical procedures. Methods A retrospective chart review was performed on SST patients (n = 61) receiving a single 30 mcg SST 30 minutes before surgery (for short procedures) or 45 minutes before surgical extubation (longer procedures). A control group (n = 32) underwent similar surgical procedures utilizing standard IV opioid treatment without SST. Results Control and study groups were of similar age and sex. Procedure duration (approximately 3 hours) and intraoperative opioid administration were similar in both groups, with 92% of patients receiving SST before extubation due to the length of the case. Almost all control patients (90.6%) required rescue opioids during recovery in the PACU compared with a few SST patients (16.4%; P < 0.001), averaging 5-fold higher dosing in the control group. Recovery duration did not differ between groups as factors other than pain management and adverse events affected discharge. Conclusions SST substantially reduced opioid administration in the PACU for patients undergoing outpatient plastic surgery procedures. Level of Evidence 3
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Affiliation(s)
- Hisham Seify
- Corresponding Author:Dr Hisham Seify, Newport Plastic Surgery, 20301 SW Birch St, Suite 100, Newport Beach, CA 92660, USA. E-mail: ; Instagram: @newportplastic
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Ludwig K, Wexelman B, Chen S, Cheng G, DeSnyder S, Golesorkhi N, Greenup R, James T, Lee B, Pockaj B, Vuong B, Fluharty S, Fuentes E, Rao R. Home Recovery After Mastectomy: Review of Literature and Strategies for Implementation American Society of Breast Surgeons Working Group. Ann Surg Oncol 2022; 29:5799-5808. [PMID: 35503389 DOI: 10.1245/s10434-022-11799-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/07/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Practices regarding recovery after mastectomy vary significantly, including overnight stay versus discharge same day. Expanded use of Enhanced Recovery After Surgery (ERAS) algorithms and the recent COVID pandemic have led to increased number of patients who undergo home recovery after mastectomy (HRAM). METHODS The Patient Safety Quality Committee of the American Society of Breast Surgeons created a multispecialty working group to review the literature evaluating HRAM after mastectomy with and without implant-based reconstruction. A literature review was performed regarding this topic; the group then developed guidance for patient selection and tools for implementation. RESULTS Multiple, retrospective series have reported that patients discharged day of mastectomy have similar risk of complications compared with those kept overnight, including risk of hematoma (0-5.1%). Multimodal strategies that improve nausea and analgesia improve likelihood of HRAM. Patients who undergo surgery in ambulatory surgery centers and by high-volume breast surgeons are more likely to be discharged day of surgery. When evaluating unplanned return to care, the only significant factors are African American race and increased comorbidities. CONCLUSIONS Review of current literature demonstrates that HRAM is a safe option in appropriate patients. Choice of method of recovery should consider patient factors, such as comorbidities and social situation, and requires input from the multidisciplinary team. Preoperative education regarding pain management, drain care, and after-hour access to medical care are crucial components to a successful program. Additional investigation is needed as these programs become more prevalent to assess quality measures such as unplanned return to care, complications, and patient satisfaction.
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Affiliation(s)
- Kandice Ludwig
- Indiana University School of Medicine, Indianapolis, IN, USA.
| | | | | | - Gloria Cheng
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Ted James
- Harvard Medical School, Boston, MA, USA
| | | | | | - Brooke Vuong
- Kaiser Permanente Medical Center, Sacramento, CA, USA
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Opioid Prescribing Practices Among Plastic Surgeons: Results of the 2019 American Society of Plastic Surgeons Opioid Survey. Ann Plast Surg 2022; 88:665-673. [PMID: 35502956 DOI: 10.1097/sap.0000000000003145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Health care providers play an important role in the national opioid crisis with 40% of opioid-related deaths being attributed to prescription medications (Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. 2018) and as many as half of the opioid pills prescribed after outpatient plastic surgery may go unused (Plast Reconstr Surg 2019;143:929-938). The purpose of this study was to provide broad foundational data regarding postoperative analgesic prescribing patterns among members of the American Society of Plastic Surgeons (ASPS) to facilitate inclusion of opioid data fields in the ASPS Tracking Operations and Outcomes for Plastic Surgeons database for longitudinal evaluation. METHODS A survey regarding opioid prescribing practices was electronically distributed to a representative cohort of 2555 ASPS members. Two hundred seventy-nine responses (11% response rate) were received. RESULTS The majority of respondents reported prescribing opioids following 1 or more types of cosmetic and reconstructive procedures (90.2% and 81.7%, respectively; p = 0.0057), most commonly oxycodone and hydrocodone. Most (61.9%) reported less than 5% of patients request an opioid refill. Nonopioid medications, most commonly acetaminophen and ibuprofen/naproxen, were also prescribed but less commonly so for cosmetic (80.7-85.8%) than reconstructive (86.3-91.5%) procedures. Local anesthetic was less commonly used for mastopexy (83.7%) than augmentation (91.8%, p = 0.02). CONCLUSIONS Based on survey responses, potential areas of improvement to reduce opioid prescribing and use include provider education on the use of multimodal pain regimens including nonopioid medication and "as needed" rather than scheduled dosing, use of local anesthetic blocks, as well as patient education on opioid safety and proper disposal of unused medication.
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18
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Nair L, Duggan RP, Moliver CL. The Opioid Epidemic in the Age of the COVID-19 Pandemic. Aesthet Surg J 2022; 42:325-326. [PMID: 34653243 PMCID: PMC8844992 DOI: 10.1093/asj/sjab367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Lakshmi Nair
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Robert P Duggan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
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19
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Analysis of Adverse Effects of Multimodal Gabapentin in Abdominal Wall Reconstruction. Plast Reconstr Surg 2022; 149:733-739. [PMID: 35041638 DOI: 10.1097/prs.0000000000008836] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Multimodal analgesia, a key component of enhanced recovery after surgery protocols, emphasizes the use of nonopioid analgesics. Preoperative and postoperative gabapentin is often included within multimodal analgesia because it has been shown to reduce postoperative opioid use. However, the role of gabapentin has been questioned because of concerns of adverse effects, particularly in the elderly. In an effort to better understand the specific role of gabapentin within the context of an established enhanced recovery after surgery protocol, the authors studied the prevalence of its adverse effects in patients undergoing abdominal wall reconstruction. METHODS Following institutional review board approval, a retrospective review of a prospectively collected database of 267 consecutive patients who underwent abdominal wall reconstruction performed by a single surgeon was conducted. Demographic variables; operative details; postoperative analgesic use; the presence of dizziness, lightheadedness, or altered mental status; hypotension; negative Richmond Agitation Sedation Scale scores; and postoperative falls were recorded and analyzed according to postoperative gabapentin administration. RESULTS Two hundred thirteen patients (80 percent) met inclusion criteria, of which 138 (65 percent) received postoperative gabapentin. Postoperative gabapentin use was not associated with dizziness, lightheadedness, or altered mental status; hypotension; negative Richmond Agitation Sedation Scale scores; or falls. Furthermore, even among those aged 65 years or older, postoperative gabapentin use was not significantly associated with these adverse events. CONCLUSIONS In patients undergoing abdominal wall reconstruction, postoperative gabapentin administration was not associated with an increase in adverse effects. Further prospective analysis may better allow the characterization of the adverse effects of perioperative gabapentin. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Faulkner HR, Coopey SB, Sisodia R, Kelly BN, Maurer LR, Ellis D. Does An ERAS Protocol Reduce Postoperative Opiate Prescribing in Plastic Surgery? JPRAS Open 2021; 31:22-28. [PMID: 34869817 PMCID: PMC8626793 DOI: 10.1016/j.jpra.2021.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/20/2021] [Indexed: 11/04/2022] Open
Abstract
Background Enhanced recovery after surgery (ERAS) protocols are effective at reducing inpatient opiate use. There is a paucity of studies on the effects of an ERAS protocol on outpatient opiate prescriptions. The aim of this study was to determine whether an ERAS protocol for plastic and reconstructive surgery would reduce opiate use in the outpatient postoperative setting. Methods A statewide (Massachusetts, USA) controlled substance prescription monitoring database was retrospectively reviewed to assess the prescribing patterns of a single academic plastic surgeon performing common plastic surgical outpatient operations. The time period prior to implementation of the ERAS protocol was then compared with the time period following protocol implementation. An additional three months of post-implementation data were then compared with those of each of the previous time periods to investigate whether the results were sustained. Results A comparison of opiate prescriptions in pre-ERAS, immediate post-ERAS procedures, and follow-up ERAS implementation procedures revealed a statistically significant decrease in opiate prescriptions after ERAS protocol implementation. This decrease in the quantity of opiates prescribed was sustained over time. Conclusions ERAS protocols are effective at reducing outpatient opiate prescriptions after a variety of plastic surgery operations. Appropriate patient and physician education is paramount for success.
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Affiliation(s)
- Heather R Faulkner
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Suzanne B Coopey
- Division of Surgical Oncology, Allegheny Health Network, Wexford, Pennsylvania, USA
| | - Rachel Sisodia
- Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Bridget N Kelly
- Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Lydia R Maurer
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Dan Ellis
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Kutlu Yalcin E, Araujo-Duran J, Turan A. Emerging drugs for the treatment of postsurgical pain. Expert Opin Emerg Drugs 2021; 26:371-384. [PMID: 34842026 DOI: 10.1080/14728214.2021.2009799] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Postoperative pain is a distressful experience and remains to be a significant concern after surgery. Current agents either fail to prevent or minimize postoperative pain or cause a series of adverse effects, addiction, or abuse. Opioids have been the gold standard in the treatment of postoperative pain despite their well-described adverse effects. Many new agents with different mechanisms of action have been recently introduced to address this issue. AREAS COVERED This current review summarizes the list of new and emerging drugs investigated for their efficacy in controlling the postoperative pain and decreasing the need for rescue opioid use, adverse effect profile, abuse, and addiction potential. EXPERT OPINION Opioids have unrivaled analgesic efficacy. However adverse effects of opioids led to the search for better options. In mild pain most of the emerging drugs have been shown to control postoperative pain and decrease the use of rescue opioid, however fail to control pain after major surgeries causing severe pain. Specific agents such as Oliceridine, new local anesthetics, etc., are effective in controlling severe pain and hold a promise to replace opioids in the near future.
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Affiliation(s)
- Esra Kutlu Yalcin
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | | | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.,Department of General Anaesthesia, Cleveland Clinic, Cleveland, OH, USA
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22
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Opioid-sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3932. [PMID: 34796086 PMCID: PMC8594660 DOI: 10.1097/gox.0000000000003932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 12/30/2022]
Abstract
Introduction: Pain and discomfort are frequently experienced following mastectomy with concomitant breast implant- or tissue expander-based alloplastic breast reconstruction (AlBR). Unfortunately, postoperative opioids have decreased efficacy in AlBR, short-term complication profiles, and are fraught by long-term dependence. This systematic review aims to identify opioid-sparing pain management strategies in AlBR. Methods: A systematic literature search of MEDLINE, Embase, Web of Science, and Cochrane Central Register was performed in September 2018. PRISMA guidelines were followed, and the review was prospectively registered in PROSPERO (CRD42018107911). The search identified 1184 articles. Inclusion criteria were defined as patients 18 years or older undergoing AlBR. Results: Fourteen articles were identified assessing opioid-sparing strategies in AlBR. This literature included articles evaluating enhanced recovery protocols (two), intercostal blocks (two), paravertebral blocks (four), liposomal bupivacaine (three), diclofenac (one), and local anesthesia infusion pumps (two). The literature included five randomized trials and nine cohort studies. Study characteristics, bias (low to high risk), and reporting outcomes were extensively heterogeneous between articles. Qualitative analysis suggests reduced opioid utilization in enhanced recovery after surgery (ERAS) pathways, paravertebral blocks, and use of liposomal bupivacaine. Conclusions: A variety of opioid-sparing strategies are described for pain management in AlBR. Multimodal analgesia should be provided via ERAS pathways as they appear to reduce pain and spare opioid use. Targeted paravertebral blocks and liposomal bupivacaine field blocks appear to be beneficial in sparing opioids and should be considered as essential components of ERAS protocols. Additional prospective, randomized trials are necessary to delineate the efficacy of other studied modalities.
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Klifto KM, Elhelali A, Payne RM, Cooney CM, Manahan MA, Rosson GD. Perioperative systemic nonsteroidal anti-inflammatory drugs (NSAIDs) in women undergoing breast surgery. Cochrane Database Syst Rev 2021; 11:CD013290. [PMID: 34753201 PMCID: PMC8577884 DOI: 10.1002/14651858.cd013290.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Breast surgery encompasses oncologic, reconstructive, and cosmetic procedures. With the recent focus on the over-prescribing of opioids in the literature, it is important to assess the effectiveness and safety of non-opioid pain medication regimens including nonsteroidal anti-inflammatory drugs (NSAIDs) or NSAID pain medications. Clinicians have differing opinions on the safety of perioperative (relating to, occurring in, or being the period around the time of a surgical operation) NSAIDs for breast surgery given the unclear risk/benefit ratio. NSAIDs have been shown to decrease inflammation, pain, and fever, while potentially increasing the risks of bleeding complications. OBJECTIVES To assess the effects of perioperative NSAID use versus non-NSAID analgesics (other pain medications) in women undergoing any form of breast surgery. SEARCH METHODS The Cochrane Breast Information Specialist searched the Cochrane Breast Cancer Group (CBCG) Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, The WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to 21 September 2020. Full articles were retrieved for potentially eligible trials. SELECTION CRITERIA We considered all randomized controlled trials (RCTs) looking at perioperative NSAID use in women undergoing breast surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies, extracted data and assessed risk of bias, and certainty of the evidence using the GRADE approach. The main outcomes were incidence of breast hematoma within 90 days (requiring reoperation, interventional drainage, or no treatment) of breast surgery and pain intensity 24 hours following surgery, incidence rate or severity of postoperative nausea, vomiting or both, bleeding from any location within 90 days, need for blood transfusion, other side effects of NSAID use, opioid use within 24 hours of surgery, length of hospital stay, breast cancer recurrence, and non-prescribed NSAID use. Data were presented as risk ratios (RRs) for dichotomous outcomes and standardized mean differences (SMDs) for continuous outcomes. MAIN RESULTS We included 12 RCTs with a total of 1596 participants. Seven studies compared NSAIDs (ketorolac, diclofenac, flurbiprofen, parecoxib and celecoxib) to placebo. Four studies compared NSAIDs (ketorolac, flurbiprofen, ibuprofen, and celecoxib) to other analgesics (morphine, hydrocodone, hydromorphone, fentanyl). One study compared NSAIDs (diclofenac) to no intervention. NSAIDs compared to placebo Most outcomes are judged to have low-certainty evidence unless stated otherwise. There may be little to no difference in the incidence of breast hematomas within 90 days of breast surgery (RR 0.33, 95% confidence interval (CI) 0.05 to 2.02; 2 studies, 230 participants; I2 = 0%). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery compared to placebo (SMD -0.26, 95% CI -0.49 to -0.03; 3 studies, 310 participants; I2 = 73%). There may be little to no difference in the incidence rates or severities of postoperative nausea, vomiting, or both (RR 1.15, 95% CI 0.58 to 2.27; 4 studies, 939 participants; I2 = 81%), bleeding from any location within 90 days (RR 1.05, 95% CI 0.89 to 1.24; 2 studies, 251 participants; I2 = 8%), or need for blood transfusion compared to placebo groups, but we are very uncertain (RR 4.62, 95% CI 0.23 to 91.34; 1 study, 48 participants; very low-certainty evidence). There may be no difference in other side effects (RR 1.12, 95% CI 0.44 to 2.86; 2 studies, 251 participants; I2 = 0%). NSAIDs may reduce opioid use within 24 hours of surgery compared to placebo (SMD -0.45, 95% CI -0.85 to -0.05; 4 studies, 304 participants; I2 = 63%). NSAIDs compared to other analgesics There is little to no difference in the incidence of breast hematomas within 90 days of breast surgery, but we are very uncertain (RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; very low-certainty evidence). NSAIDs may reduce pain intensity 24 (± 12) hours following surgery (SMD -0.68, 95% CI -0.97 to -0.39; 3 studies, 200 participants; I2 = 89%; low-certainty evidence) and probably reduce the incidence rates or severities of postoperative nausea, vomiting, or both compared to other analgesics (RR 0.18, 95% CI 0.06 to 0.57; 3 studies, 128 participants; I2 = 0%; moderate-certainty evidence). There is little to no difference in the development of bleeding from any location within 90 days of breast surgery or in other side effects, but we are very uncertain (bleeding: RR 0.33, 95% CI 0.01 to 7.99; 1 study, 100 participants; other side effects: RR 0.11, 95% CI 0.01 to 1.80; 1 study, 48 participants; very low-certainty evidence). NSAIDs may reduce opioid use within 24 hours of surgery compared to other analgesics (SMD -6.87, 95% CI -10.93 to -2.81; 3 studies, 178 participants; I2 = 96%; low-certainty evidence). NSAIDs compared to no intervention There is little to no difference in pain intensity 24 (± 12) hours following surgery compared to no intervention, but we are very uncertain (SMD -0.54, 95% CI -1.09 to 0.00; 1 study, 60 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Low-certainty evidence suggests that NSAIDs may reduce postoperative pain, nausea and vomiting, and postoperative opioid use. However, there was very little evidence to indicate whether NSAIDs affect the rate of breast hematoma or bleeding from any location within 90 days of breast surgery, the need for blood transfusion and incidence of other side effects compared to placebo or other analgesics. High-quality large-scale RCTs are required before definitive conclusions can be made.
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Affiliation(s)
- Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, University of Missouri School of Medicine, Columbia, USA
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ala Elhelali
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Rachael M Payne
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Michele A Manahan
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Gedge D Rosson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
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Chen Y, Zhang GZ. Evaluation on curative effects of gabapentin for the prevention of chronic pain in adults following surgery: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27558. [PMID: 34678894 PMCID: PMC8542158 DOI: 10.1097/md.0000000000027558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Chronic pain is a common postsurgery symptom. It has an adverse impact on patients' overall wellbeing. Chronic pain after an operation is caused by intricate mechanisms that have not been well understood. The predictability of most surgical methods has enabled scholars to conduct randomized controlled trials (RCTs) involving pharmacological interventions to prevent chronic pain after a surgery. Therefore, the present study aims to evaluate the curative effects of gabapentin to prevent chronic pain in adults after surgery. METHODS The authors will collect RCTs related to the use of gabapentin to prevent chronic pain in adults following surgery. Accordingly, a comprehensive search will be performed in 4 online databases to find English language articles, including Cochrane Library, EMBASE, Web of Science, and PubMed. In addition, the search also includes 3 Chinese language databases: VIP data, WanFang database, and China National Knowledge Infrastructure. Each of the RCT published from their inception to September 2021 will be considered. The authors will carry out a meta-analysis of RCTs after screening the studies. Subsequently, the authors will use RevMan (v 5.3) to perform an assessment of bias risk, data synthesis, and subgroup analysis, provided inclusion criteria are met. RESULTS The results will provide clinical evidence for the curative effects of gabapentin to prevent chronic pain in adults after surgery. CONCLUSION The summary provided in this systematic review will judge whether gabapentin intervention is effective and feasible to prevent chronic pain in adults following surgery.Registration number: 10.17605/OSF.IO/XG4CK.
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Affiliation(s)
- Yao Chen
- Edong Healthcare City Hospital of Traditional Chinese Medicine (Infectious Disease Hospital); Ezhou, Hubei, China
| | - Guang-Zhi Zhang
- Department of Pain Management, People's Hospital of Dongxihu District, Wuhan, Hubei, China
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Opioid Overprescribing and Procedure-Specific Opioid Consumption Patterns for Plastic and Reconstructive Surgery Patients. Plast Reconstr Surg 2021; 147:669e-679e. [PMID: 33761520 DOI: 10.1097/prs.0000000000007782] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioid prescribing practices contribute to opioid misuse, dependency, and diversion. There are currently no comprehensive and quantitative evidence-based guidelines that give procedure-specific recommendations regarding opioid prescribing in plastic surgery. METHODS A retrospective review of 479 plastic surgery patients encompassing 23 different plastic surgery procedure categories was performed. Opioid prescribing patterns and patient-reported opioid use at 1 and 3 months postoperatively are reported. RESULTS Opioid overprescribing was common, averaging an excess of 13 pills per patient across all procedure categories (prescribed versus consumed, 25.4 ± 23.1 versus 12.1 ± 19.7; p = 3.0 × 10-19), with a total excess of 5895 pills (30,967 oral morphine equivalents) for the study's sample. Fifty-two percent of all opioid pills prescribed went unused. Opioid consumption ranged between four and 37 pills across procedure categories. A greater proportion of patients who reported a history of preoperative opioid use were still using opioids at the time of their 1-month and 3-month follow-up appointments (62 percent versus 9 percent at 1 month, and 31 percent versus 1 percent at 3 months). Most patients (83 percent) did not store opioids in a locked location, and 64 percent did not dispose of opioids at 1 month. CONCLUSIONS Opioids are commonly overprescribed by plastic surgery providers. This study determined procedure-specific opioid consumption patterns, which can help providers reduce opioid waste. In addition, patients do not properly store or dispose of opioids, demonstrating the need for better patient education.
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Singh AM, Kirsch JM, Patel MS, Gutman M, Harper T, Lazarus M, Horneff JG, Namdari S, Voskeridjian A, Abboud JA. Effect of perioperative acetaminophen on pain management in patients undergoing rotator cuff repair: a prospective randomized study. J Shoulder Elbow Surg 2021; 30:2014-2021. [PMID: 33774169 DOI: 10.1016/j.jse.2021.03.132] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 02/21/2021] [Accepted: 03/07/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Limiting opioid use in perioperative pain management is currently an important focus in orthopedic surgery. The ability of acetaminophen to reduce postoperative opioid consumption while providing acceptable pain management has not been thoroughly investigated in patients undergoing rotator cuff repair (RCR). METHODS Patients undergoing primary arthroscopic RCR were prospectively randomized to 1 of 3 treatment groups: Group 1 (control) received both 5 mg of oxycodone every 6 hours as needed and 1000 mg of acetaminophen orally every 6 hours as needed after surgery and had the option to take either medication or both. Group 2 (control) received only 5 mg of oxycodone every 6 hours as needed without any additional acetaminophen after surgery. Group 3 received 1000 mg of acetaminophen orally every 6 hours for 1 day prior to and after surgery, which was subsequently decreased to administration every 8 hours during postoperative days 2-5. Group 3 patients were also allowed to take 5 mg of oxycodone every 6 hours as needed after surgery. All patients received interscalene blocks with liposomal bupivacaine (Exparel). Opioid use, pain scores, side effects, and overall satisfaction were assessed daily for the first week after surgery. RESULTS A total of 57 patients (mean age, 57.8 ± 9.55 years) were included in this study. Baseline demographic characteristics including age, sex, and body mass index were similar between the groups (P > .05). Patients in group 3 took significantly fewer narcotics overall (P = .017) and took significantly fewer pills each day compared with group 2. Group 3 also reported significantly better overall pain control compared with the other groups (P = .040). There were no significant differences in overall patient satisfaction between the groups (P > .05). Additionally, there were no significant differences between groups regarding postoperative medication-associated side effects (P > .05). CONCLUSION Perioperative acetaminophen represents an important component of multimodal analgesia in appropriately selected patients undergoing shoulder surgery. In this study, the use of perioperative acetaminophen significantly decreased opioid consumption and improved overall pain control after primary arthroscopic RCR.
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Affiliation(s)
- Arjun M Singh
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Jacob M Kirsch
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Manan S Patel
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Michael Gutman
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Thomas Harper
- College of Medicine, Penn State University, Hershey, PA, USA
| | - Mark Lazarus
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - John G Horneff
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Armen Voskeridjian
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.
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Go BC, Go CC, Chorath K, Moreira A, Rajasekaran K. Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review. Otolaryngol Head Neck Surg 2021; 166:820-831. [PMID: 34372726 DOI: 10.1177/01945998211032910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Postoperative pain after head and neck cancer surgery is commonly treated with opioids, which are associated with considerable side effects. The objective of this study is to analyze the safety and efficacy of using multimodal analgesia (MMA) for patients undergoing head and neck cancer surgery with free flap reconstruction. DATA SOURCES A systematic search was conducted in PubMed, Cochrane, Embase, Scopus, and clinicaltrials.gov. REVIEW METHODS All studies comparing patients receiving MMA (gabapentin, corticosteroids, local anesthetic, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) vs patients receiving opioids for head and neck cancer surgery with free flap reconstruction were screened. The primary outcome was postoperative opioid usage. Secondary outcomes included length of stay, subjective pain scores, surgical/medical complications, adverse effects, and 30-day outcomes. RESULTS A total of 10 studies representing 1253 patients (MMA, n = 594; non-MMA, n = 659) met inclusion criteria. Gabapentinoids were the most commonly used intervention (72.9%) followed by NSAIDs (44.6%), acetaminophen (44.3%), corticosteroids (25.1%), ketamine (7.2%), and nerve block (3.4%). Eight studies reported a significant decrease in postoperative opioid usage in the MMA groups. Subjective pain had wider variation, with most studies citing significant pain improvement. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates. CONCLUSION With the rise of the opioid epidemic, MMA may play an important role in the treatment of postoperative pain after head and neck cancer surgery. A growing body of literature demonstrates a variety of effective perioperative regimens.
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Affiliation(s)
- Beatrice C Go
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cammille C Go
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin Chorath
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alvaro Moreira
- Department of Pediatrics, Division of Neonatology, University of Texas Health-San Antonio, San Antonio, Texas, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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An Analgesic Regimen for Opioid Reduction in Elective Plastic Surgery: A Randomized Prospective Study. Plast Reconstr Surg 2021; 147:325e-330e. [PMID: 33565839 DOI: 10.1097/prs.0000000000007592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Prescription opioid misuse has been recognized as a national epidemic. The implications of this problem are especially important to consider, as postoperative opioid abuse can give rise to true addiction for surgical patients. The concept of enhanced recovery after surgery is increasingly used across various specialties to decrease the overabundance of postoperative opioid use. METHODS This study prospectively examined 143 patients undergoing cosmetic elective surgery. Patients were randomized into one of two groups based on postoperative pain management regimen: multimodal (enhanced recovery after surgery) analgesia or traditional opioid analgesia. Data regarding postoperative pain scores, amount of postoperative opioids consumed, and duration of postoperative pain pill use were analyzed. RESULTS Multimodal (enhanced recovery after surgery) regimen patients experienced a 13.0 percent reduction in their pain scores after admission to the postanesthesia care unit and a 34.2 percent reduction in pain score at discharge, compared with traditional opioid patients (p = 0.049 and p = 0.0036, respectively). Enhanced recovery after surgery patients experienced a 35 percent reduction in the number of pills taken in the postoperative period and an 18.4 percent reduction in the duration of consumption (p = 0.0007 and p = 0.0539, respectively). CONCLUSIONS The results demonstrate that multimodal postoperative pain management is an important tool for decreasing the amount of opioids prescribed and needed in the postoperative period. The overprescribing of opioids after surgery is a precursor to abuse and the increase in the national opioid reservoir. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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29
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Straughan DM, Lindsey JT, McCarthy M, Legendre D, Lindsey JT. Enhanced Recovery After Surgery Protocol With Ultrasound-Guided Regional Blocks in Outpatient Plastic Surgery Patients Leads to Decreased Opioid Prescriptions and Consumption. Aesthet Surg J 2021; 41:NP1105-NP1114. [PMID: 33730152 DOI: 10.1093/asj/sjab137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Opioids are a mainstay of pain management. To limit the use of opioids, enhanced recovery after surgery (ERAS) protocols implement multimodal approaches to treat postoperative pain. OBJECTIVES The aim of this paper was to be the first to assess the efficacy of an ERAS protocol for plastic surgery outpatients that includes ultrasound-guided, surgeon-led regional blocks. METHODS A retrospective review of patients undergoing outpatient plastic surgery on an ERAS protocol was performed. These patients were compared to a well-matched group not on an ERAS protocol (pre-ERAS). Endpoints included the amounts of opioid, antinausea, and antispasmodic medication prescribed. ERAS patients were given a postoperative questionnaire to assess both pain levels (0-10) and opioid consumption. ERAS patients anticipated to have higher levels of pain received ultrasound-guided anesthetic blocks. RESULTS There were 157 patients in the pre-ERAS group and 202 patients in the ERAS group. Patients in the pre-ERAS group were prescribed more opioid (332.3 vs 100.3 morphine milligram equivalents (MME)/patient; P < 0.001), antinausea (664 vs 16.3 mg of promethazine/patient; P < 0.001), and antispasmodic (401.3 vs 31.2 mg of cyclobenzaprine/patient; P < 0.001) medication. Patients on the ERAS protocol consumed an average total of 22.7 MME/patient postoperatively. Average pain scores in this group peaked at 5.32 on postoperative day 1 and then decreased significantly daily. CONCLUSIONS Implementation of an ERAS protocol for plastic surgery outpatients with utilization of ultrasound-guided regional anesthetic blocks is feasible and efficacious. The ability to significantly decrease prescribed opioids in this unique patient population is noteworthy. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- David M Straughan
- Dr Straughan is a fellow, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - John T Lindsey
- Mr Lindsey Jr is a medical student, Louisiana State University Medical School, New Orleans, LA, USA
| | | | - Davey Legendre
- Dr Legendre is a doctor of pharmacy, Comprehensive Pharmacy Services, Woodstock, GA, USA
| | - John T Lindsey
- Dr Lindsey Sr is an associate clinical professor of surgery, Tulane University, New Orleans, LA, USA
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Smith MJ, Lee J, Brodsky AL, Figueroa MA, Stamm MH, Giard A, Luker N, Friedman S, Huncke T, Jain SK, Pothuri B. Optimizing Robotic Hysterectomy for the Patient Who Is Morbidly Obese with a Surgical Safety Pathway. J Minim Invasive Gynecol 2021; 28:2052-2059.e3. [PMID: 34139329 DOI: 10.1016/j.jmig.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/24/2021] [Accepted: 06/09/2021] [Indexed: 01/04/2023]
Abstract
STUDY OBJECTIVE Obesity is a growing worldwide epidemic, and patients classified as obese undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI [Body Mass Index] Pathway (HBP) for patients with BMI ≥40 kg/m2 undergoing planned robotic hysterectomy. Our primary outcome was the rate of all-cause perioperative complications in patients undergoing surgery with the use of the HBP. DESIGN A retrospective cohort study. SETTING An academic teaching hospital. PATIENTS A total of 138 patients classified as morbidly obese (BMI ≥40 kg/m2) undergoing robotic hysterectomy. INTERVENTIONS The HBP was developed by a multidisciplinary team and was instituted on January 1, 2016, as a quality improvement project. Patients classified as morbidly obese undergoing robotic hysterectomy after this date were compared with consecutive historical controls. MEASUREMENTS AND MAIN RESULTS Seventy-two patients underwent robotic hysterectomies on the HBP and were compared with 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of the HBP, there has been a decrease in anesthesia time (-57.0 minutes; p = .001) and total operating room time (-47.0 min; p = .020), as well as lower estimated blood loss (median 150 mL [interquartile range 100-200] vs 200 mL [interquartile range 100-300]; p = .002) and reduction in overnight hospital admissions (33.3% vs 63.6%; p <.001). In the HBP group, there were fewer all-cause complications (19.4% vs 37.9%; p = .023) and infectious complications (8.3% vs 33.3%; p = .001), and there was no increase in the readmission rates (p = .400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio 0.353; p = .010) after controlling for the covariate (total time in the operating room). CONCLUSION The HBP is a feasible method of optimizing the outcome for patients classified as morbidly obese undergoing major gynecologic surgery. Initiation of the HBP can lead to decreased anesthesia and operating times, all-cause complications, and overnight hospital admissions without increasing readmission rates.
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Affiliation(s)
- Maria J Smith
- Department of Obstetrics and Gynecology, NYU Langone Health (Dr. Smith), New York, NY
| | - Jessica Lee
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Texas Southwestern Medical Center (Drs. Lee), Dallas, TX
| | - Allison L Brodsky
- Department of Obstetrics and Gynecology, University of California San Diego (Drs. Brodsky), San Diego, CA
| | - Melissa A Figueroa
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Matthew H Stamm
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Audra Giard
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Nadia Luker
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Steven Friedman
- Department of Population Health, NYU Langone Health (Mr. Friedman)
| | - Tessa Huncke
- Department of Anesthesiology, NYU Langone Health (Drs. Huncke and Jain), New York, NY
| | - Sudheer K Jain
- Department of Anesthesiology, NYU Langone Health (Drs. Huncke and Jain), New York, NY
| | - Bhavana Pothuri
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, NYU Langone Health (Dr. Pothuri).
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Identify patients who are candidates for headache surgery. 2. Counsel the patient preoperatively with regard to success rates, recovery, and complications. 3. Develop a surgical plan for primary and secondary nerve decompression. 4. Understand the surgical anatomy at all trigger sites. 5. Select appropriate International Classification of Diseases, Tenth Revision, and CPT codes. SUMMARY Headache surgery encompasses release of extracranial peripheral sensory nerves at seven sites. Keys to successful surgery include correct patient selection, detailed patient counseling, and meticulous surgical technique. This article is a practical step-by-step guide, from preoperative assessment to surgery and postoperative recovery. International Classification of Diseases, Tenth Revision, and CPT codes, in addition to complications and salvage procedures, are discussed. Intraoperative photographs, videos, and screening questionnaires are provided.
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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Hallman MJ, Dorinsky N, Wang Y, Li Q, Isaak R, Kolarczyk L, Kim HJ, Lobonc AJ. Objective postoperative pain assessment using incentive spirometry values: a prospective observational study. Pain Manag 2021; 11:315-324. [PMID: 33533288 DOI: 10.2217/pmt-2020-0080] [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: 11/21/2022] Open
Abstract
Aim: Determine if incentive spirometry (IS) values correlate with postoperative pain control. Design: Prospective observational study. Setting & participants: A total of 100 patients undergoing major abdominal procedures at the University of North Carolina Medical Center. Interventions: Patients studied as a single cohort. All patients received thoracic epidural analgesia preoperatively. Outcome: Preoperative and daily postoperative numeric pain scores, subjective pain description and IS values were collected for all patients. Results: There was a strong correlation with IS values relative to baseline for both the numeric pain scores (p < 0.0001), postoperative day (p < 0.0001) and the subjective pain score (p < 0.0007). Conclusion: IS values are an objective surrogate data point for pain control after surgery, particularly when followed over time and compared with a preoperative baseline value.
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Affiliation(s)
- Matthew J Hallman
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599-7010, USA
| | - Nancy Dorinsky
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599-7010, USA
| | - Yueting Wang
- Department of Biostatistics, University of North Carolina Gillings School of Public Health, Chapel Hill, NC 27599-7400, USA
| | - Quefeng Li
- Department of Biostatistics, University of North Carolina Gillings School of Public Health, Chapel Hill, NC 27599-7400, USA
| | - Robert Isaak
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599-7010, USA
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599-7010, USA
| | - Hong J Kim
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27599-7050, USA
| | - Andrew J Lobonc
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599-7010, USA
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34
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Valeberg BT, Dihle A, Småstuen MC, Endresen AO, Rustøen T. The effects of a psycho-educational intervention to improve pain management after day surgery: A randomised clinical trial. J Clin Nurs 2021; 30:1132-1143. [PMID: 33432643 DOI: 10.1111/jocn.15659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 11/17/2020] [Accepted: 12/31/2020] [Indexed: 12/17/2022]
Abstract
AIMS AND OBJECTIVES To evaluate the effectiveness of a psycho-educational intervention for shoulder and breast day surgery patients in decreasing pain intensity and pain interference with function and strengthening adherence with the analgesic regimen; and further to identify factors that influence average pain intensity and pain interference with function. BACKGROUND Pain is one of the most prevalent symptoms after day surgery. However, pain management is left to the patients and family, and interventions to help patients are needed. DESIGN Randomised clinical trial with an intervention (n = 101) and a usual care group (n = 119) using multiple measurements during 6 months postoperatively. The CONSORT checklist is used. METHODS Patients in the intervention group received a booklet about pain and pain management and coaching by research nurses on postoperative days 2, 3 and 7. Differences between groups were identified using the chi-squared analysis and t tests. Changes with time were identified using a linear mixed model with repeated measures. RESULTS After controlling for covariates, group differences at any time in average pain intensity and pain interference with function were not statistically significant. Changes over time within any one group in average pain intensity and pain interference with function were statistically significant and decreased with time. Higher levels of average pain intensity and pain interference over time were associated with shoulder surgery, female, younger, pain expectation, preoperative pain and poorer adherence. CONCLUSIONS No group differences related to the intervention were revealed, and preoperative teaching together with a pain management booklet and coaching may help to strengthen the intervention's effects. Further research on interventions directed towards pain management is needed. RELEVANCE TO CLINICAL PRACTICE Day surgery patients' postoperative pain and pain management is not satisfactorily handled. To encourage and educate patients to use the prescribed analgesics in the immediate postoperative days may be necessary to enhance pain management. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT01595035).
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Affiliation(s)
- Berit T Valeberg
- Oslo Metropolitan University, Oslo, Norway.,University of South-East, Borre, Norway
| | | | - Milada C Småstuen
- Oslo Metropolitan University, Oslo, Norway.,University in Oslo, Oslo, Norway
| | | | - Tone Rustøen
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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Pelzer D, Burgess E, Cox J, Baker R. Preoperative Intravenous Versus Oral Acetaminophen in Outpatient Surgery: A Double-Blinded, Randomized Control Trial. J Perianesth Nurs 2020; 36:162-166. [PMID: 33262012 DOI: 10.1016/j.jopan.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Preoperative acetaminophen is recognized as an effective part of the multimodal approach to perioperative pain management. The present study, conducted between April 12, 2018 and February 14, 2019, examined whether there are differences in patient-reported pain, postoperative opioid consumption, negative opioid effects, length of postanesthesia care unit stay, and patient satisfaction with pain control between patients who receive intravenous (IV) acetaminophen and patients who receive oral acetaminophen. DESIGN This double-blinded, randomized controlled trial was conducted among 120 patients undergoing outpatient surgery. METHODS Patients were randomized to receive preoperatively either intravenous (IV) acetaminophen (and oral placebo) or oral acetaminophen (and IV placebo). Results were analyzed using SPSS statistical software; statistical analyses consisted of Mann-Whitney U test, independent samples t test, and χ2 test. In all analyses, a P value less than .05 was considered significant. FINDINGS There were no significant differences in any outcome measures based on the route of acetaminophen administration. CONCLUSIONS The findings of the present study support the practice of administering oral acetaminophen, as opposed to IV acetaminophen, preoperatively as part of the multimodal approach to manage postoperative pain in patients able to tolerate preoperative oral medications.
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Affiliation(s)
- Diana Pelzer
- TriHealth Bethesda Butler Hospital, Hamilton, OH.
| | | | - Jennifer Cox
- TriHealth Bethesda Butler Hospital, Hamilton, OH
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36
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Williams L, Iteld L. Moving Toward Opioid-Free Breast Surgery: Regional Blocks and a Novel Technique. Clin Plast Surg 2020; 48:123-130. [PMID: 33220899 DOI: 10.1016/j.cps.2020.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Perioperative pain control is of increasing importance as awareness regarding the risks of under-controlled pain and opioid abuse rise. Enhanced recovery protocols and multimodal analgesia, including regional blocks, are useful tools for the plastic surgeon. The thoracic paravertebral block, pectoralis nerve I and pectoralis nerve II blocks, and proximal intercostal blocks are 3 described methods that provide regional anesthesia for breast surgery. The widespread use of these methods may be limited by the requirements for ultrasound equipment and anesthesiologists skilled in regional blocks. This article describes a novel technique of the intercostal field block under direct visualization that is safe and efficient.
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Affiliation(s)
- Lydia Williams
- Plastic & Reconstructive Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Lawrence Iteld
- Plastic & Reconstructive Surgery, University of Chicago Medicine, Chicago, IL, USA; Iteld Plastic Surgery, 939 West North Avenue, Suite 600, Chicago, IL 606042, USA.
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37
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Predictors of Opioid Consumption in Immediate, Implant-Based Breast Reconstruction. Plast Reconstr Surg 2020; 146:734-741. [DOI: 10.1097/prs.0000000000007150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Increases in opioid prescribing over the last several decades is correlated with an alarming increase in opioid-related morbidity and mortality owing to both prescription opioid misuse and abuse as well as heroin abuse. Prescribing after surgery is commonly in excess, and leftover pills are an important driver of opioid use disorders owing to diversion and misuse. Creating evidence-based prescribing guidelines based on patient-centered outcomes and encouraging safe opioid storage and disposal is critical to curbing opioid-related morbidity and mortality going forward and to ensure safe and appropriate postoperative pain management.
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Affiliation(s)
- Lily A Upp
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109, USA
| | - Jennifer F Waljee
- Michigan Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109, USA; Department of Plastic Surgery, University of Michigan Medical School, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Our Collective Responsibility in Battling the Opioid Crisis. Plast Reconstr Surg 2020; 146:713-715. [PMID: 32842122 DOI: 10.1097/prs.0000000000007082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Enhanced Recovery After Surgery (ERAS): Protocols in Post-Mastectomy Breast Reconstruction. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00378-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Brenin DR, Dietz JR, Baima J, Cheng G, Froman J, Laronga C, Ma A, Manahan MA, Mariano ER, Rojas K, Schroen AT, Tiouririne NAD, Wiechmann LS, Rao R. Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons. Ann Surg Oncol 2020; 27:4588-4602. [PMID: 32783121 DOI: 10.1245/s10434-020-08892-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.
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Affiliation(s)
- David R Brenin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Baima
- Department of Physical Medicine and Rehabilitation, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gloria Cheng
- Department of Anesthesia, University of Texas Southwestern, Dallas, TX, USA
| | - Joshua Froman
- Department of Surgery, Mayo Clinic, Owatonna, MN, USA
| | | | - Ayemoethu Ma
- Surgery and Integrative Medicine, Scripps Health, La Jolla, CA, USA
| | - Michele A Manahan
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward R Mariano
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Anneke T Schroen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Lisa S Wiechmann
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshni Rao
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Quantifying the Crisis: Opioid-Related Adverse Events in Outpatient Ambulatory Plastic Surgery. Plast Reconstr Surg 2020; 145:687-695. [PMID: 32097308 DOI: 10.1097/prs.0000000000006570] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The United States is currently in the midst of an opioid epidemic precipitated, in part, by the excessive outpatient supply of opioid pain medications. Accordingly, this epidemic has necessitated evaluation of practice and prescription patterns among surgical specialties. The purpose of this study was to quantify opioid-related adverse events in ambulatory plastic surgery. METHODS A retrospective review of 43,074 patient profiles captured from 2001 to 2018 within an American Association for Accreditation of Ambulatory Surgery Facilities quality improvement database was conducted. Free-text search terms related to opioids and overdose were used to identify opioid-related adverse events. Extracted profiles included information submitted by accredited ambulatory surgery facilities and their respective surgeons. Descriptive statistics were used to quantify opioid-related adverse events. RESULTS Among our cohort, 28 plastic surgery patients were identified as having an opioid-related adverse event. Overall, there were three fatal and 12 nonfatal opioid-related overdoses, nine perioperative opioid-related adverse events, and four cases of opioid-related hypersensitivities or complications secondary to opioid tolerance. Of the nonfatal cases evaluated in the hospital (n = 17), 16 patients required admission, with an average 3.3 ± 1.7 days' hospital length of stay. CONCLUSIONS Opioid-related adverse events are notable occurrences in ambulatory plastic surgery. Several adverse events may have been prevented had different diligent medication prescription practices been performed. Currently, there is more advocacy supporting sparing opioid medications when possible through multimodal anesthetic techniques, education of patients on the risks and harms of opioid use and misuse, and the development of societal guidance regarding ambulatory surgery prescription practices.
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Basics and Best Practices of Multimodal Pain Management for the Plastic Surgeon. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2833. [PMID: 33154874 PMCID: PMC7605865 DOI: 10.1097/gox.0000000000002833] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/17/2020] [Indexed: 12/18/2022]
Abstract
Pain management is a central focus for the plastic surgeon’s perioperative planning, and it no longer represents a postoperative afterthought. Protocols that rely on opioid-only pain therapy are outdated and discouraged, as they do not achieve optimal pain relief, increase postoperative morbidity, and contribute to the growing opioid epidemic. A multimodal approach to pain management using non-opioid analgesic techniques is an integral component of enhanced recovery after surgery protocols. Careful perioperative planning for optimal pain management must be achieved in multidisciplinary collaboration with the perioperative care team including anesthesiology. This allows pain management interventions to occur at 3 critical opportunities—preoperative, intraoperative, and postoperative settings.
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Decreasing Opioid Prescriptions in Women Undergoing Mastectomy and Breast Reconstruction. Pain Manag Nurs 2020; 21:339-344. [PMID: 32280011 DOI: 10.1016/j.pmn.2020.02.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/12/2020] [Accepted: 02/23/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Florida enacted legislation limiting opioid prescriptions and affecting the management of acute pain in the postoperative patient. Patients in a reconstructive surgery practice were receiving prescriptions for opioids as their primary method of pain management. Clinic providers identified a need to limit opioid prescriptions. AIM The aim of this quality improvement initiative was to decrease the number of opioids prescribed while effectively managing pain in women undergoing mastectomy and breast tissue expander placement. DESIGN This is a quality improvement project. METHODS The Model for Improvement was used as a framework for this project. An evidence-based pain management plan was developed after a review of the breast reconstruction surgery literature. The plan incorporated preoperative patient and family education and the standard use of preemptive analgesia, intraoperative nerve blocks, and postoperative multimodal analgesia in all patients undergoing mastectomy with breast tissue expander placement. Patient and family education and perioperative pain management were provided to patients, and the number of opioid tablets prescribed was tracked. RESULTS Between January 2018 and August 2019, the average number of opioid tablets prescribed per patient decreased from 84.7 to 8.4. CONCLUSIONS Opioid prescriptions can be decreased in women undergoing breast reconstruction with the use of patient education and multimodal analgesia.
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46
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Reducing Opioid Prescribing After Ambulatory Plastic Surgery With an Opioid-Restrictive Pain Protocol. Ann Plast Surg 2020; 84:S431-S436. [DOI: 10.1097/sap.0000000000002272] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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47
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Pharmacological strategies in multimodal analgesia for adults scheduled for ambulatory surgery. Curr Opin Anaesthesiol 2019; 32:720-726. [DOI: 10.1097/aco.0000000000000796] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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48
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Foley PL, Kendall LV, Turner PV. Clinical Management of Pain in Rodents. Comp Med 2019; 69:468-489. [PMID: 31822323 PMCID: PMC6935704 DOI: 10.30802/aalas-cm-19-000048] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/28/2019] [Accepted: 07/26/2019] [Indexed: 12/15/2022]
Abstract
The use of effective regimens for mitigating pain remain underutilized in research rodents despite the general acceptance of both the ethical imperative and regulatory requirements intended to maximize animal welfare. Factors contributing to this gap between the need for and the actual use of analgesia include lack of sufficient evidence-based data on effective regimens, under-dosing due to labor required to dose analgesics at appropriate intervals, concerns that the use of analgesics may impact study outcomes, and beliefs that rodents recover quickly from invasive procedures and as such do not need analgesics. Fundamentally, any discussion of clinical management of pain in rodents must recognize that nociceptive pathways and pain signaling mechanisms are highly conserved across mammalian species, and that central processing of pain is largely equivalent in rodents and other larger research species such as dogs, cats, or primates. Other obstacles to effective pain management in rodents have been the lack of objective, science-driven data on pain assessment, and the availability of appropriate pharmacological tools for pain mitigation. To address this deficit, we have reviewed and summarized the available publications on pain management in rats, mice and guinea pigs. Different drug classes and specific pharmacokinetic profiles, recommended dosages, and routes of administration are discussed, and updated recommendations are provided. Nonpharmacologic tools for increasing the comfort and wellbeing of research animals are also discussed. The potential adverse effects of analgesics are also reviewed. While gaps still exist in our understanding of clinical pain management in rodents, effective pharmacologic and nonpharmacologic strategies are available that can and should be used to provide analgesia while minimizing adverse effects. The key to effective clinical management of pain is thoughtful planning that incorporates study needs and veterinary guidance, knowledge of the pharmacokinetics and mechanisms of action of drugs being considered, careful attention to individual differences, and establishing an institutional culture that commits to pain management for all species as a central component of animal welfare.
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Affiliation(s)
- Patricia L Foley
- Division of Comparative Medicine, Georgetown University, Washington, DC;,
| | - Lon V Kendall
- Laboratory Animal Resources, Colorado State University, Fort Collins, Colorado
| | - Patricia V Turner
- Charles River, Wilmington, Massachusetts, Dept of Pathobiology, University of Guelph, Guelph, Canada
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49
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Erector Spinae Plane Block Decreases Pain and Opioid Consumption in Breast Surgery: Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2525. [PMID: 31942313 PMCID: PMC6908334 DOI: 10.1097/gox.0000000000002525] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/11/2019] [Indexed: 12/16/2022]
Abstract
Adequate control of acute postoperative pain is crucial in breast surgeries, as it is a significant factor in the development of persistent chronic pain. Inadequate postoperative pain control increases length of hospital stays and risk of severe complications. Erector spinae plane block (ESPB) is a novel regional block that has the ability to sufficiently block unilateral multidermatomal sensation from T1 to L3. By reviewing the literature on ESPB, this paper aimed to elucidate its efficacy in breast surgery analgesia and its role in addressing the opioid crisis in North America.
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50
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Fisher AH, Powelson IA, Wampler AT, Doughty H, Freed GL. Analgesic Use Following Bilateral Breast Reduction. Ann Plast Surg 2019; 85:110-114. [PMID: 31688122 DOI: 10.1097/sap.0000000000002088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The opioid epidemic in the United States resulted in 42,000 deaths in 2016, 40% of which involved a prescription opioid. It is estimated that 2 million patients become opioid-dependent after elective, ambulatory surgery each year. There has been increased interest in quantifying the need for postoperative narcotic pain medications for a variety of surgical procedures. However, studies have been limited. We sought to quantify the analgesic usage after one of the most common operations performed in plastic surgery, bilateral breast reduction.In this prospective, observational study, sequential breast reduction patients were contacted by telephone on the evening of postoperative days 3 and 7. Patients were queried as to which analgesic medications were used on the day of the phone call. Data relating to dosage, frequency, and satisfaction with pain control were sought. Patients taking chronic narcotics, postoperative complications requiring surgical intervention, and those unable to be reached after multiple attempts were excluded.Complete data were obtained for 40 patients. Narcotic prescriptions were written for oxycodone, hydromorphone and tramadol, with the number prescribed ranging from 0 to 20 tablets. The median total number used was 6 tablets. Eighty percent of patients used a total of 10 tablets or less. Fifty percent of patients were using only nonnarcotic analgesia by postoperative day 3. Patient-reported satisfaction with pain control was overwhelmingly positive, with 95% being either somewhat satisfied or very satisfied with postoperative pain control. Of those taking any medication on postoperative day 3, only half were using a nonsteroidal anti-inflammatory drug (NSAID) as part of their pain regimen.The number of tablets prescribed after breast reduction surgery varies considerably, and there is no consensus regarding the appropriate number to prescribe. Currently, few patients use all the medication prescribed to them, indicating a high rate of overprescribing. The overwhelming majority are satisfied with their pain control. Most patients use less than 10 tablets of narcotic pain medication after surgery. Acetaminophen is widely used as an adjunct but NSAIDs remain underutilized. Based on these data, we recommend that breast reduction patient's pain is best managed with acetaminophen, NSAIDs, and expectation management.
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Affiliation(s)
- Alec H Fisher
- From the Geisel School of Medicine at Dartmouth, Hanover
| | - Ian A Powelson
- Department of Plastic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | - Hayden Doughty
- From the Geisel School of Medicine at Dartmouth, Hanover
| | - Gary L Freed
- Department of Plastic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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