Quality of Postoperative Pain Management After Maxillofacial Fracture Repair:

Perioperative Management of Patients with Craniomaxillofacial Trauma

Successful surgical management of patients with facial fractures requires a detailed preoperative evaluation and postoperative management that differs from elective surgical patients. This review presents evidence-based recommendations from the surgical and anesthesiology literature that address many of the clinical questions that arise during the perioperative management of this group of patients. Surgeons and anesthesiologists must work together at numerous points and make joint decisions, especially where airway and pain management challenges may arise. The multidisciplinary nature of the decision-making process is emphasized.

The effect of transversus abdominis plane block application on postoperative analgesia quality and patient satisfaction after varicocele surgery: a randomized clinical trial

Background

Postoperative pain management is an important aspect of anesthesia care and multimodal analgesic techniques are generally recommended.

Objective

To compare the effect of spinal anesthesia + transversus abdominis plane (TAP) block application on postoperative analgesia quality and patient satisfaction with spinal anesthesia + intrathecal morphine (ITM) application.

Methods

A total of 70 patients were randomly separated into 2 groups as spinal anesthesia + TAP block (TAP block group, n = 34) and spinal anesthesia + ITM group (ITM group, n = 36). The groups were compared in respect of age, body mass index values, and visual analog scale (VAS) values at 0 h, 2 h, 6 h, 12 h, and 18 h, and patient satisfaction was scored by Quality Improvement in Postoperative Pain Management at 24 h.

Results

The mean age of the patients was 32.52 ± 6.50 years in the TAP block group and 30.11 ± 5.62 years in the ITM group, with no statistically significant difference determined. There was no statistically significant difference in terms of VAS values at 0 h, 2 h, 6 h, 12 h, and 18 h. When the factors affecting postoperative patient satisfaction were evaluated, feeling fatigue after the surgery (r = -0.811, P = 0.001) and postoperative complications such as nausea, vomiting, and itching (r = -0.831, P = 0.001) were found to have a negative effect on patient satisfaction.

Conclusion

Due to low complication rates, TAP block is an effective application for postoperative analgesia management in varicocele operations that increases patient satisfaction postoperatively.

Reduction of Opioid Prescriptions in Maxillofacial Trauma Following North Carolina STOP Act

Study Design

Retrospective cohort study.

Objective

On January 1, 2018, the Strengthen Opioid Misuse Prevention (STOP) Act was implemented to increase oversight over opioid prescriptions in North Carolina. The aim of this study is to evaluate the legislation's efficacy in reducing opioid prescriptions following facial fracture repair.

Methods

A retrospective chart review of patients who sustained maxillofacial fractures and underwent repair from January 1, 2015 through December 31, 2019 at a level 1 trauma center was performed. The North Carolina Controlled Substance Database was used to quantify perioperative opioid prescriptions in morphine milligram equivalents (MME). Average MME per patient was compared between 2 groups, patients who underwent surgery before the NC STOP Act came into effect and patients who underwent treatment after. This comparison was also performed on case type subgroups including surgically treated fractures of the orbit, mandible, midface, and multiple regions. A student's t-test was used to compare before and after groups in all analyses.

Results

Of the 253 patients who met inclusion criteria, 146 were in the before group, and 107 were in the after group. There was a statistically significant, 30.9% decrease in overall average MME prescribed after the NC STOP Act was enacted. A statistically significant decrease was noted in patients who had facial fractures of multiple regions.

Conclusion

Since the implementation of the NC STOP Act in 2018, there have been statistically and clinically significant decreases in the amount of opioids prescribed following surgical management of facial fractures.

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

OBJECTIVE

Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families.

PURPOSE

The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients.

ACTION STATEMENTS

The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Anesthetic Considerations in Facial Transplantation: Experience at NYU Langone Health and Systematic Review

Anesthetic considerations are integral to the success of facial transplantation (FT), yet limited evidence exists to guide quality improvement. This study presents an institutional anesthesia protocol, defines reported anesthetic considerations, and provides a comprehensive update to inform future directions of the field.