An Analgesic Regimen for Opioid Reduction in Elective Plastic Surgery: A Randomized Prospective Study

Abstract

In the Plastic Surgery Focus section, researchers Newman and Davison1 presented a study that led to a decrease in opioid analgesics used in the postoperative period, with findings that could potentially contribute to significant improvements in the care of plastic surgery patients. Their study showed that patients who received gabapentin in the perioperative period and oral oxycodone as rescue had a significant reduction in opioid analgesic doses and time of use compared to those who received the “standard treatment.” Patients did not receive long-acting local anesthetics for regional blocks. We stress that perioperative gabapentin is not a universal recommendation for all surgical patients because of the associated cognitive impairment, visual disturbances, and dizziness, which impede recovery and hospital discharge, as well as the lack of a dose range based on controlled trials and systematic reviews.2 On the other hand, accelerated recovery protocols recommend an intervention (e.g., with gabapentin) when there is clear evidence for that procedure, rather than extrapolating evidence from other surgical procedures, as is the case with the lack of evidence (randomized controlled trials, systematic reviews) for gabapentin in plastic surgery.3 Second, the researchers excluded the use of regional blocks with long-acting local anesthetics, which goes precisely against the recommendations of the accelerated recovery protocols. Furthermore, they suggest using adjuvants to extend the effect of these local anesthetics and, as a result, reduce the use of opioid analgesics in the postoperative period.4 Including this intervention would bring the findings of the Newman and Davison study1 closer to contemporary multimodal analgesia, as regional anesthesia is an essential component of this pain management method. They also state that patients in the postanesthesia care unit received benzodiazepines and opioid analgesics based on pain scores. However, we believe that one of the key messages for the Journal’s readers is that nonsteroidal anti-inflammatory drugs or COX-2 selective inhibitors may be used as first-line analgesics, as they minimize the use of opioid analgesics and are not associated with increased postoperative bleeding or altered consciousness.3 Findings in the authors’ Table 5 encourage clinicians to choose analgesics with different mechanisms of action. Nonetheless, despite the statistically significant decrease in the number of days the patient required analgesics, it would have been preferable if the researchers had specified, in their Patients and Methods section, how much less time (how many days) they considered clinically significant. This timely study generates great motivation for the implementation of multimodal protocols and the search for the best evidence. Given the impact that this critical study can have on Plastic and Reconstructive Surgery readers, we hope that our comments can complement its messages. DISCLOSURE The authors have no conflicts of interest to disclose. Jairo R. Moyano Acevedo, M.D., Ph.D.Anesthesia DepartmentPain Service Ednna Matute, M.D., M.S.C.Anesthesia Department Carlos Triana S, M.D., M.S.C.Anesthesia DepartmentFundación Santa Fé de BogotáBogotá, Colombia