Process, structural, and outcome quality indicators to support perioperative opioid stewardship: a rapid review

Opioids are effective analgesics but can cause harm. Opioid stewardship is key to ensuring that opioids are used effectively and safely. There is no agreed set of quality indicators relating to the use of opioids perioperatively. This work is part of the Yorkshire Cancer Research Bowel Cancer Quality Improvement programme and aims to develop useful quality indicators for the improvement of care and patient outcomes at all stages of the perioperative journey.A rapid review was performed to identify original research and reviews in which quality indicators for perioperative opioid use are described. A data tool was developed to enable reliable and reproducible extraction of opioid quality indicators.A review of 628 abstracts and 118 full-text publications was undertaken. Opioid quality indicators were identified from 47 full-text publications. In total, 128 structure, process and outcome quality indicators were extracted. Duplicates were merged, with the final extraction of 24 discrete indicators. These indicators are based on five topics: patient education, clinician education, pre-operative optimization, procedure, and patient-specific prescribing and de-prescribing and opioid-related adverse drug events.The quality indicators are presented as a toolkit to contribute to practical opioid stewardship. Process indicators were most commonly identified and contribute most to quality improvement. Fewer quality indicators relating to intraoperative and immediate recovery stages of the patient journey were identified. An expert clinician panel will be convened to agree which of the quality indicators identified will be most valuable in our region for the management of patients undergoing surgery for bowel cancer.

Feasibility of opioid-free surgery for inflammatory bowel disease

AIM

Patients undergoing colorectal surgery or those with inflammatory bowel disease (IBD) are particularly at risk for opioid-related complications and progression to long-term opioid dependence. The aim of this work is to explore the real-world possibility of perioperative opioid avoidance in colorectal surgery and IBD.

METHOD

We conducted a retrospective analysis of patients aggregated from two prospective studies on multimodal postoperative pain control conducted at a single tertiary referral centre. All patients underwent major colorectal surgery with bowel resection. Patients with chronic preoperative opioid use were excluded. Opioid use was measured in oral morphine equivalents (OME) each postoperative day (POD) and cumulatively for the first 72 h.

RESULTS

Our cohort of 209 patients included 148 (71%) with IBD and 61 (29%) non-IBD patients. IBD patients required significantly more opioids cumulatively over the first 72 postoperative hours compared with non-IBD patients [median OME 77 mg (interquartile range 33-148 mg) vs. 4 mg (interquartile range 17-82 mg), respectively; p = 0.001]. Five percent of IBD patients achieved opioid-free postoperative pain control during the entire 72 h postoperative period compared with 12% of non-IBD patients. Only 7% of IBD patients avoided opioid use on POD 1 compared with 20% of non-IBD patients (p = 0.02); however the number of IBD patients increased to 16% on POD 2 then 40% on POD 3, closely resembling the non-IBD cohort at 49% (p = 0.22).

CONCLUSION

In the era of modern enhanced recovery protocols and minimally invasive techniques, we show that early postoperative opioid avoidance is feasible in a limited number of IBD patients after colorectal surgery.

Analgesic effects of Phα1β toxin: a review of mechanisms of action involving pain pathways

Phα1β is a neurotoxin purified from spider venom that acts as a high-voltage-activated (HVA) calcium channel blocker. This spider peptide has shown a high selectivity for N-type HVA calcium channels (NVACC) and an analgesic effect in several animal models of pain. Its activity was associated with a reduction in calcium transients, glutamate release, and reactive oxygen species production from the spinal cord tissue and dorsal ganglia root (DRG) in rats and mice. It has been reported that intrathecal (i.t.) administration of Phα1β to treat chronic pain reverted opioid tolerance with a safer profile than ω-conotoxin MVIIA, a highly selective NVACC blocker. Following a recent development of recombinant Phα1β (CTK 01512-2), a new molecular target, TRPA1, the structural arrangement of disulphide bridges, and an effect on glial plasticity have been identified. CTK 01512-2 reproduced the antinociceptive effects of the native toxin not only after the intrathecal but also after the intravenous administration. Herein, we review the Phα1β antinociceptive activity in the most relevant pain models and its mechanisms of action, highlighting the impact of CTK 01512-2 synthesis and its potential for multimodal analgesia.

A Prospective Randomized Trial of Surgeon-Administered Intraoperative Transversus Abdominis Plane Block With Bupivacaine Against Liposomal Bupivacaine: The TINGLE Trial

BACKGROUND

Transversus abdominis plane blocks are increasingly used to achieve opioid-sparing analgesia after colorectal surgery. Traditionally, bupivacaine was the long-acting analgesic of choice, but the addition of dexamethasone and/or epinephrine to bupivacaine may extend block duration. Liposomal bupivacaine has also been suggested to achieve an extended analgesia duration of 72 hours but is significantly more expensive.

OBJECTIVE

The purpose of this study was to compare pain control between laparoscopic transversus abdominis plane blocks using liposomal bupivacaine versus bupivacaine with epinephrine and dexamethasone.

DESIGN

This was a parallel-group, single-institution, randomized clinical trial.

SETTINGS

The study was conducted at a single tertiary medical center.

PATIENTS

Consecutive patients between October 2018 to October 2019, ages 18 to 90 years, undergoing minimally invasive colorectal surgery with multimodal analgesia were included.

INTERVENTIONS

Patients were randomly assigned 1:1 to receive a laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone.

MAIN OUTCOME MEASURES

The primary outcome was total oral morphine equivalents administered in the first 48 hours postoperatively. Secondary outcomes included pain scores, time to ambulation and solid diet, hospital length of stay, and complications.

RESULTS

A total of 102 patients (50 men) with a median age of 42 years (interquartile range, 29-60 y) consented and were randomly assigned. The primary end point, total oral morphine equivalents administered in the first 48 hours, was not significantly different between the liposomal bupivacaine group (median = 69 mg) and the bupivacaine with epinephrine and dexamethasone group (median = 47 mg; difference in medians = 22 mg, (95% CI, -17 to 49 mg); p = 0.60). There were no significant differences in pain scores, time to ambulation, time to diet tolerance, time to bowel movement, length of stay, overall complications, or readmission rate between groups. There were no treatment-related adverse outcomes.

LIMITATIONS

This study was not placebo controlled or blinded.

CONCLUSIONS

This first randomized trial comparing laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone showed that a liposomal bupivacaine block does not provide superior or extended analgesia in the era of standardized multimodal analgesia protocols.See Video Abstract at http://links.lww.com/DCR/B533.

ESTUDIO PROSPECTIVO Y RANDOMIZADO DE BLOQUEO DEL PLANO MUSCULAR TRANSVERSO DEL ABDOMEN REALIZADO POR EL CIRUJANO CON BUPIVACANA VERSUS BUPIVACANA LIPOSOMAL ESTUDIO TINGLE

ANTECEDENTES:El bloqueo anestésico del plano muscular transverso del abdomen se utiliza cada vez más para lograr una analgesia con menos consumo de opioides después de cirugía colorrectal. Tradicionalmente, la Bupivacaína era el analgésico de acción prolongada de elección, pero al agregarse Dexametasona y/o Adrenalina a la Bupivacaína se puede prolongar la duración del bloqueo. También se ha propuesto que la Bupivacaína liposomal logra una duración prolongada de la analgesia de 72 horas, pero es significativamente más cara.OBJETIVO:Comparar el control del dolor entre bloqueo laparoscópico del plano de los transversos del abdomen usando Bupivacaína liposomal versus Bupivacaína con Adrenalina y Dexametasona.DISEÑO:Estudio clínico prospectivo y randomizado de una sola institución en grupos paralelos.AJUSTE:Centro médico terciario único.PACIENTES:Todos aquellos pacientes entre 18 y 90 años sometidos a cirugía colorrectal mínimamente invasiva con analgesia multimodal, entre octubre de 2018 a octubre de 2019 incluidos de manera consecutiva.INTERVENCIONES:Los pacientes fueron seleccionados aleatoriamente 1:1 para recibir un bloqueo laparoscópico del plano de los transversos del abdomen con Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el total de equivalentes de morfina oral administradas en las primeras 48 horas después de la operación. Los resultados secundarios incluyeron puntuaciones de dolor, inicio de dieta sólida, tiempo de inicio a la deambulación, la estadía hospitalaria y las complicaciones.RESULTADOS:Un total de 102 pacientes (50 hombres) con una mediana de edad de 42 años (IQR 29-60) fueron incluidos aleatoriamente. El criterio de valoración principal, equivalentes de morfina oral total administrada en las primeras 48 horas, no fue significativamente diferente entre el grupo de Bupivacaína liposomal (mediana = 69 mg) y el grupo de Bupivacaína con Adrenalina y Dexametasona (mediana = 47 mg; diferencia en medianas = 22 mg, IC del 95% [-17] - 49 mg, p = 0,60). No hubo diferencias significativas en las puntuaciones de dolor, tiempo de inicio a la deambulación, el tiempo de tolerancia a la dieta sólida, el tiempo hasta el primer evacuado intestinal, la duración de la estadía hospitalaria, las complicaciones generales o la tasa de readmisión entre los grupos. No hubo resultados adversos relacionados con el tratamiento.LIMITACIONES:Este estudio no fue controlado con placebo ni de manera cegada.CONCLUSIONES:Este primer estudio prospectivo y randomizado que comparó el bloqueo del plano de los músculos transversos del abdomen por vía laparoscópica, utilizando Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona, demostró que el bloqueo de Bupivacaína liposomal no proporciona ni mejor analgesia ni un efecto mas prolongado.Consulte Video Resumen en http://links.lww.com/DCR/B533.

Analgesic Efficacy of Nefopam as an Adjuvant in Patient-Controlled Analgesia for Acute Postoperative Pain After Laparoscopic Colorectal Cancer Surgery

Despite rapid advancements in laparoscopic surgical techniques and perioperative management, postoperative pain remains a significant clinical issue. We examined the analgesic efficacy of nefopam as an adjuvant in patient-controlled analgesia (PCA) for acute postoperative pain in patients undergoing laparoscopic colorectal cancer surgery. We retrospectively analyzed the medical records of 120 patients who did or did not receive 80 mg of nefopam as an adjuvant in fentanyl PCA; they were allocated to the nefopam (n = 60) or non-nefopam group (n = 60). The demographic, clinical, and anesthetic data, with data on pain severity and opioid administration at the postoperative anesthesia care unit (PACU) on postoperative days (PODs) 1, 3, and 5, were compared between the groups. The pain score and opioid administration did not differ at the PACU or on PODs 1, 3, or 5. The day of PCA discontinuation, time to pass flatus, length of the hospital stay, and incidence of nausea/vomiting, dizziness, and headache also did not differ between the groups. Fentanyl PCA with 80 mg of nefopam as an adjuvant did not have a superior analgesic effect after laparoscopic colorectal cancer surgery.

Impact of a multimodal analgesic protocol modification on opioid consumption after cesarean delivery: a retrospective cohort study

INTRODUCTION

Adequate pain control is a mainstay in enhanced recovery after surgery (ERAS) protocols. ERAS protocols are widely accepted in colorectal and gynecologic surgeries and are increasingly implemented in the obstetric setting. Multimodal analgesia incorporating non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen is a mainstay of ERAS protocols for cesarean delivery, but little research has focused on the choice of NSAIDs or timing of initiation in women undergoing cesarean delivery. At our institution, patients undergoing cesarean delivery receive a standardized multimodal analgesic regimen consisting of neuraxial morphine with NSAIDs and acetaminophen. Our initial protocol involved starting the oral analgesics in the recovery room. There was variability in whether these medications were given in a timely manner or withheld in the setting of postoperative nausea and vomiting. We modified this protocol and performed a retrospective analysis to assess the impact of this change on postoperative opioid rescue requirements in women undergoing cesarean delivery under neuraxial anesthesia.

METHODS

This retrospective analysis included patients who underwent cesarean deliveries from 1 July 2014 to 22 August 2017. With the initial analgesic protocol, patients received neuraxial morphine, followed by naproxen 500 mg PO Q12 hours and acetaminophen 650-975 mg PO Q6 hours initiated in the recovery room. After protocol revision in January 2016, the same neuraxial morphine dose was used in addition to acetaminophen 975 mg PR at the start of the case and ketorolac 15-30 mg IV at the end of the case. Postoperatively, patients received acetaminophen PO 975 mg Q6 hours, ketorolac IV 15 mg Q6 hours for 3 doses, transitioning to ibuprofen 600 mg Q6 hours. Fentanyl, oxycodone, and intravenous hydromorphone were given for breakthrough pain with both protocols. The primary outcome of the study is the need for rescue opioid analgesia. Secondary outcomes are total opioid usage, time to first rescue opioid, maximum reported pain scores, and need for rescue antiemetics. Univariate and multivariate analyses were performed controlling for variables significantly different between the two cohorts.

RESULTS

3250 patients were included in our analysis (1574 in the old protocol and 1676 in the new protocol). There was no significant difference in patient demographics or intraoperative characteristics between the two cohorts except for more primiparous women (25% vs. 17%), more Pfannenstiel incision (98% vs. 96%), and less repeat cesarean deliveries (40% vs. 44%) in the new protocol cohort. Need for rescue opioids was reduced with the new protocol at 2, 24, and 48 h [(36.46% vs. 75.73%, p < .0001), (74.28% vs 91.99%, p < .0001), (87.53% vs 95.49% p < .0001), respectively]. Among those who received opioids, opioid consumption over 48 h was reduced (median [IQR]: 55 [30, 95] vs. 40 [20, 70] mg oxycodone equivalents) after protocol revision (GMR 0.75, 95% CI 0.7, 0.80, p < .0001). The time to first rescue opioid medication was significantly longer in the new protocol compared to the old protocol (175 [79, 1057] min vs 51 [28, 104] min, p < .001).

CONCLUSION

There was a significant decrease in the need for and the dose of rescue opioid medications with the new protocol. This highlights the importance of optimizing the choice of agents, as well as route and timing of administration of the components of the postoperative multimodal analgesic regimen.

Opioid Avoidance in Liver Transplant Recipients: Reduction in Postoperative Opioid Use Through a Multidisciplinary Multimodal Approach

The prevalence of substance use disorder in the liver transplantation (LT) population makes postoperative pain management challenging. We report our initial experience with a novel, comprehensive, multidisciplinary opioid avoidance pathway in 13 LT recipients between January 2018 and September 2019. Patients received comprehensive pre-LT education on postoperative opioid avoidance by the surgeon, pharmacist, and psychologist at the time of listing. Immediately after LT, patients received a continuous incisional ropivacaine infusion, ketamine, acetaminophen, and gabapentin as standard nonopioid medications; rescue opioids were used as needed. We compared outcomes with a historical cohort of 27 LT recipients transplanted between August 2016 and January 2018 managed primarily with opioids. On average, opioid avoidance patients used 92% fewer median (interquartile range [IQR]) morphine milligram equivalents (MMEs) versus the historical cohort (7 [1-11] versus 87 [60-130] MME; P < 0.001) per postoperative day over a similar length of stay (8 [7-10] versus 6 [6-10] days; P = 0.14). Fewer outpatient MMEs were prescribed within the first 60 days after LT in the opioid avoidance group versus the historical cohort: 125 (25-150) versus 270 (0-463) MME (P = 0.05). This proof-of-concept study outlines the potential to profoundly reduce opioid utilization in the LT population using a comprehensive multidisciplinary approach.