In-hospital Opioid Consumption Research Articles

Adoption of Enhanced Surgical Recovery (ESR) Protocol for Lumbar Fusion Decreases In-Hospital Postoperative Opioid Consumption.

Retrospective observational cohort. We sought to evaluate the impact of ESR on in-hospital and 90-day postoperative opioid consumption, length of stay, urinary catheter removal and postoperative ambulation after lumbar fusion for degenerative conditions. We evaluated patients undergoing lumbar fusion surgery at a single, multi-surgeon center in the transition period prior to (N = 174) and after (N = 116) adoption of ESR, comparing in-hospital and 90-day postoperative opioid consumption. Regression analysis was used to control for confounders. Secondary analysis was preformed to evaluate the association between ESR and length of stay, urinary catheter removal and ambulation after surgery. Mean age study participants was 52.6 years with 62 (47%) females. Demographic characteristics were similar between the Pre-ESR and ESR groups. ESR patients had better 3-month pain scores, ambulated earlier, had urinary catheters removed earlier and decreased in-hospital opioid consumption compared to Pre-ESR patients. There was no difference in 90-day opioid consumption between the 2 groups. Regression analysis showed that ESR was strongly associated with in-hospital opioid consumption, accounting for 30% of the variability in Morphine Milligram Equivalents (MME). In-hospital opioid consumption was also associated with preoperative pain scores, number of surgical levels, and insurance type (private vs government). Pre-op pain sores were associated with 90-day opioid consumption. Secondary analysis showed that ESR was associated with a shorter length of stay and earlier ambulation. This study showed ESR has the potential to improve recovery after lumbar fusion for degenerative conditions with reduced in-hospital opioid consumption and improved postoperative pain scores.

Effectiveness of Liposomal Bupivacaine Compared With Standard-of-Care Measures in Pediatric Cardiothoracic Surgery: A Retrospective Cohort Study

Effective postsurgical pain management is important for pediatric patients to improve outcomes while reducing resource use and waste. The authors examined opioid consumption and economic outcomes associated with liposomal bupivacaine (LB) or non-LB analgesia use in pediatric patients undergoing cardiothoracic surgery. The authors retrospectively analyzed Premier Healthcare Database records. The data extracted from the database included patient records from hospitals across the United States in both rural and urban locations. The records included data from patients aged 12-to-<18 years. The records belonged to patients undergoing video-assisted thoracoscopic procedures (VATS) who received LB or non-LB analgesia after surgery. Outcomes included in-hospital postsurgical opioid consumption in morphine milligram equivalents (MMEs), hospital length of stay (LOS), and total hospital costs; the LB and non-LB cohorts were compared using a generalized linear model with inverse probability of treatment weighting to balance the cohorts. For VATS procedures, pediatric patients receiving LB had significant reductions in in-hospital opioid consumption (632 v 991 MMEs; p < 0.0001), shorter LOS (5.1 v 5.6 days; p = 0.0023), and lower total hospital costs ($18,084 v $21,962; p < 0.0001) compared with those receiving non-LB analgesia. These results support use of LB in multimodal analgesia regimens for managing pain in pediatric patients after cardiothoracic surgery.

52 Impact of National Marijuana Legalization on Delirium Rates and Opioid Use in Acute Burns

Abstract Introduction Cannabis use has been associated with larger total burn size areas, longer hospital stays, and an increased number of operations. Legalization of marijuana in Colorado has led to marked increases in burn injuries. Tetahydrocannabinol (‘THC’) use has been shown to increase psychosis, anxiety, and depression, however, it is unknown how this has impacted rates of ICU related delirium in the burn context. Further, observational studies have shown that marijuana use has decreased opioid-related overdoses, but it is unknown how chronic marijuana use affects opioid consumption in the ICU. Thus, it is unknown how national marijuana legalization has impacted ICU rates of delirium and opioid use. As such, the objectives of this study are to describe trends of marijuana legalization on burns and determine if the amount of delirium and opioid use while in hospital has increased after national marijuana legalization. Methods We conducted a retrospective cohort study of 514 patients admitted to an ABA-verified centre one year prior to national marijuana legalization and one-year afterwards. Inclusion criteria consisted of an acute burn injury admission. Data included demographics, toxicology screening information, hospital rates of delirium, and pain medication use. Statistical analysis consisted of student’s t-test, one-way ANOVA, Kruskal-Wallis, Mann-Whitney U, Fisher’s exact, and χ2 test. P value of &amp;lt; 0.05 was considered statistically significant. Results Out of 514 patients, 422 were included; 203 prior to legalization (‘PL’) and 219 afterwards (‘AL’). Cohorts were similar regarding age, gender, inhalation injury, and smoking history. TBSA, length of stay, police custody, major psychiatric illness, alcoholism, and drug dependence were significantly higher in the AL cohort. Positive cannabinoid screens were similar in each cohort (13.3 versus 13.7%), however in both cohorts a large proportion of admissions did not have a toxicology screen completed (58.4–63.5%). Delirium rates (PL=0.5%, AL=4.1%; p=0.02) and opioid use (PL=48%; AL=52%;X2(1, N=422)=5.7, p=0.02) were significantly higher in the AL cohort. Conclusions National legalization of marijuana is associated with increased in-hospital delirium rates and opioid consumption in the acute burn context. Every effort should be made to ensure toxicology screens are completed on admission with the appropriate use of both opioid and adjunct pain medication regimens. In addition, for those not eligible for a toxicology screen due to delayed arrival time to the burn centre, an in-depth discussion should be completed to elicit drug history.

Drivers of in-hospital opioid consumption in patients undergoing lumbar fusion surgery

With the current opioid crisis, as many as 38% of patients are still on opioids one year after elective spine surgery. Identifying drivers of in-hospital opioid consumption may decrease subsequent opioid dependence. We aimed to identify the drivers of in-hospital opioid consumption in patients undergoing 1-2-level instrumented lumbar fusions. This is a retrospective cohort study. Electronic medical record analysts identified consecutive patients undergoing 1-2 level instrumented lumbar fusions for degenerative lumbar conditions from 2016 to 2018 from a single-center hospital administrative database. Oral, intravenous, and transdermal opioid dose administrations were converted to morphine milligram equivalents (MME). Linear regression analysis was used to determine associations between postoperative day (POD) 4 cumulative in-hospital MMEs and the patients' baseline characteristics including body mass index (BMI), race, American Society of Anesthesiologists (ASA) grade, smoking status, marital status, insurance type, zip code, number of fused levels, approach and preoperative opioid use. A total of 1,502 patients were included. The mean cumulative MMEs at POD 4 was 251.5. Linear regression analysis yielded four drivers including younger age, preoperative opioid use, current smokers and more levels fused. There were no associations with surgical approach, zip code, ASA grade, marital status, BMI, race or insurance type. Use of preoperative opioids and smoking are modifiable risk factors for higher in-hospital opioid consumption and can be targets for intervention prior to surgery in order to decrease in-hospital opioid use.

608 Predictors of post discharge opioid use after cesarean section

To determine characteristics associated with post-cesarean outpatient opioid use. We conducted a prospective cohort analysis of women who underwent cesarean section at a single urban academic center from September 22, 2019 to March 11, 2020. Opioid use data was obtained via standardized phone surveys on post-discharge days three, seven, and fourteen. Demographic, hospital and surgery data was obtained from electronic medical records. Primary outcomes were post-discharge quantitative opioid use, and factors associated with increased use. Opioids were mathematically converted into morphine milligram equivalents (MME). Both Spearman’s correlation and Wilcoxon test examined association between total amount of outpatient opioid used, and patient and hospital factors. Secondary outcomes were length of post-discharge opioid use and use of non-opioid pain medications. Of 205 eligible patients who answered the phone, 190 (91%) agreed to participate and 173 (84%) participated in all three surveys. Median amount of opioid prescribed was 75 MME. 46.2% of patients (80/173) did not use opioids post-discharge. Median amount of total opioid used post-discharge was 15 MME, stratified to a median of 7.5 MME day 0-3, 0 MME day 4-7, and 0 MME day 8-14. Increased outpatient opioid use moderately correlated with increased in-hospital opioid consumption (r=0.3, p<0.0001), and weakly correlated with age (r=0.15, p=0.04), gravida (r=0.22, p=0.003), parity (r=0.21, p=0.005), number of previous cesarean (r=0.16, r=0.003) and amount of opioid prescribed (r=0.22, p=0.003). Patients used opioids for a median of two days post discharge. Patient use of non-opioid pain medication was not associated with narcotic use. Consistent with prior post-cesarean literature, opioids were prescribed in excess of consumption. A strategy to reduce overprescribing includes an algorithm for outpatient opioid prescriptions incorporating factors predictive of opioid use, including amount of opioid consumed in the hospital, age, gravida, parity and number of prior cesareans.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Multi-modal pain control regimen for anterior lumbar fusion drastically reduces in-hospital opioid consumption.

The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF). This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs). In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 vs. 66.9, P=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs. 314.8, P<0.001). There was no difference in postoperative ileus, length of stay, and hospital costs. The use of a MMPC protocol in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on the first day after surgery, resulting in a cumulative reduction of 62%.

P54. Multimodal pain control regimen for anterior lumbar fusion drastically reduces in-hospital opioid consumption

BACKGROUND CONTEXT Recent studies suggest as much as 25% of patients undergoing spine surgery are still on opioids two years later. In response, we developed protocols to minimize opioid consumption following elective spine surgery. Our goal was to evaluate patients undergoing single-level Anterior Lumbar Interbody Fusions (ALIF ± posterior fixation) on MMPC compared to patients who were not (nonMMPC). PURPOSE To determine if the combination of an oral preoperative pain cocktail with transverse abdominis plane (TAP) block (multi-modal pain control: MMPC) will reduce length of stay (LOS), ileus, and in-hospital opioid consumption. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE Consecutive patients undergoing single-level ALIF for degenerative lumbar conditions by a single-surgeon. OUTCOME MEASURES Length of stay (LOS), incidence of ileus and in-hospital opioid consumption. METHODS A retrospective review of a prospective, single-surgeon, surgical database was utilized for consistency in technique. Consecutive patients undergoing single-level ALIF for degenerative lumbar conditions were identified before and after initiation of the MMPC. The MMPC consisted of a preop oral regimen of cyclobenzaprine (10mg), gabapentin (600mg), acetaminophen (1g) and methadone (10mg). Postoperatively they received a bilateral transverse abdominis plane (TAP) block with 0.5% Ropivicaine. Our primary outcome was total, in-hospital opioid consumption (morphine milligram equivalents: MME). RESULTS There were 68 patients in the MMPC cohort and 39 in the nonMMPC cohort. There was no difference in baseline demographics such as sex, BMI, smoking, or preoperative opioid use between the two groups. The MMPC cohort was older (56.7 vs 51.1 years, p=0.026). Similar rates of ileus (4 vs 6, p=0.102), no difference in LOS (3.8 vs 4.5, p=0.246) and no difference in index hospital costs was found. Although there was no difference in day of surgery MMEs (58.5 vs 68.9, p=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs 314.8, p CONCLUSIONS The use of a MMPC regimen in patients undergoing single-level ALIF for degenerative conditions reduced opioid consumption starting on POD 1, resulting in a cumulative reduction of 62%. Further research should strive to minimize opioid use and the downstream effects. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

139. Adoption of enhanced recovery after surgery (ERAS) protocol for lumbar fusion decreases in-hospital postoperative opioid consumption

BACKGROUND CONTEXT ERAS is a multimodal and multidisciplinary evidence-based perioperative approach for surgery intended to reduce surgical morbidity and improve recovery. PURPOSE We sought to evaluate the impact of ERAS implementation on in-hospital and 90-day postop opioid consumption, length of stay, urinary catheter removal and postop ambulation after lumbar fusion for degenerative conditions STUDY DESIGN/SETTING Prospective observational cohort study. PATIENT SAMPLE Patients undergoing lumbar fusion for degenerative spine conditions in the transition period prior to (N=29) and after (N=56) adoption of ERAS. OUTCOME MEASURES In-hospital and 90-day postop opioid consumption measured in morphine milligram equivalents (MMEs), postop day mobilization and urinary catheter removal. METHODS From a multisurgeon, single center, we evaluated patients undergoing lumbar fusion surgery in the transition period prior to (N=63) and after (N=70) adoption of ERAS, comparing in-hospital and 90-day postop opioid consumption. Regression analysis was used to control for confounders including age, number of surgical levels, surgical approach, revision, staged vs same-day surgery, insurance type and preop opioid use. Secondary analysis evaluating the association of ERAS and length of stay, urinary catheter removal and ambulation after surgery was also performed. RESULTS Mean age of the cohort was 52.6 years with 62 (47%) females. Demographic characteristics were similar between the pre-ERAS and ERAS groups. ERAS patients had a shorter operative time, less blood loss, shorter length of stay, ambulated earlier and had less in-hospital opioid consumption compared to pre-ERAS patients. There was no difference in day of urinary catheter removal or 90-day opioid consumption between the two groups. Regression analysis showed that ERAS was strongly associated with in-hospital opioid consumption, accounting for 26% of the variability in MMEs consumed in-hospital. Other factors associated with in-hospital opioid consumption was age and operative time. Age and revision surgery, but not ERAS was associated with 90-day opioid consumption. Secondary analysis showed that ERAS was associated with a shorter length of stay and earlier ambulation but not early urinary catheter removal after surgery. CONCLUSIONS ERAS was associated with decreased in-hospital postop opioid consumption, shorter length of stay and earlier ambulation but not 90-day postop opioid consumption or early urinary catheter removal after lumbar fusion for degenerative conditions. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery

Background and objectivesAt our institution, we developed an individualized discharge opioid prescribing and tapering protocol for joint replacement patients and implemented the same protocol for neurosurgical spine patients. We then...

A Multidisciplinary Patient-Specific Opioid Prescribing and Tapering Protocol Is Associated with a Decrease in Total Opioid Dose Prescribed for Six Weeks After Total Hip Arthroplasty.

This retrospective cohort study tested the hypothesis that implementing a multidisciplinary patient-specific discharge protocol for prescribing and tapering opioids after total hip arthroplasty (THA) will decrease the morphine milligram equivalent (MME) dose of opioids prescribed. With institutional review board approval, we analyzed a Perioperative Surgical Home database and prescription data for all primary THA patients three months before (PRE) and three months after (POST) implementation of this new discharge opioid protocol based on patients' prior 24-hour inpatient opioid consumption. The primary outcome was total opioid dosage in MME prescribed and opioid refills for six weeks after surgery. Secondary outcomes included the number of tablets and MME prescribed at discharge, in-hospital opioid consumption, length of stay, and postoperative complications. Forty-nine cases (25 PRE and 24 POST) were included. Total median (10th-90th percentiles) MME for six weeks postoperatively was 900 (57-2082) MME PRE vs 295 (69-741) MME POST (mean difference = 721, 95% confidence interval [CI] = 127-1316, P = 0.007, Mann-Whitney U test). Refill rates did not differ. The median (10th-90th percentiles) initial discharge prescription in MME was 675 (57-1035) PRE vs 180 (18-534) POST (mean difference = 387, 95% CI = 156-618, P = 0.003, Mann-Whitney U test) MME. There were no differences in other outcomes. Implementation of a patient-specific prescribing and tapering protocol decreases the mean six-week dosage of opioid prescribed by 63% after THA without increasing the refill rate.

Pediatric Chronic Postsurgical Pain And Functional Disability: A Prospective Study Of Risk Factors Up To One Year After Major Surgery.

BackgroundChronic postsurgical pain (CPSP) is a surgical complication associated with increased functional disability, psychological distress, and economic costs. The aims of this paper were to prospectively: (1) examine the incidence of CPSP 6 and 12 months after pediatric major surgery; (2) identify pain intensity and pain unpleasantness trajectories before, and up to 12 months after, surgery; (3) identify pre-operative factors that predict pain trajectory group membership; and (4) identify predictors of 12-month functional disability.MethodsThis study followed 265 children aged 8–17 years at four time points (pre-surgical [T0], in-hospital [T1], 6 [T2] and 12 [T3] months after surgery). Children and parents completed pain and psychological questionnaires. In-hospital physical activity was monitored using actigraphy.Results and discussionThe incidence of moderate-to-severe CPSP at 6 and 12 months was 35% (95% CI 29.1% to 41.9%) and 38% (95% CI 32.4% to 45.1%), respectively. Three percent (95% CI 1.17% to 6.23%) and 4% (95% CI 1.45% to 6.55%) of children reported using opioids to manage pain at 6 and 12 months, respectively. Growth mixture modeling revealed a two-class trajectory model with a quadratic slope best fit the data for both pain intensity (Bayesian information criterion [BIC] = 3977.03) and pain unpleasantness (BIC = 3644.45) over the 12 months. Preoperative functional disability and cumulative in-hospital opioid consumption predicted pain intensity trajectories. Preoperative functional disability predicted pain unpleasantness trajectories. Preoperative functional disability (OR: 1.05, 95% CI: 1.01 to 1.09) and pain unpleasantness trajectories (OR: 2.59, 95% CI: 1.05 to 6.37) predicted 12-month moderate-to-severe functional disability.ConclusionPre-surgical functional disability is the only factor that predicts both 12-month functional disability and the course of pain intensity and pain unpleasantness ratings over the 12-month period.

P64. Initiation of a standardized escalation pain protocol after 1-2 level lumbar fusion reduces in-hospital opioid consumption

BACKGROUND CONTEXT Our previous study showed that prescribing patterns, more than surgery invasiveness or patient factors, affect post-operative opioid consumption. Since then we have instituted a Standard Escalation Pain Protocol (SEPP): patients receive 0-60 Morphine Milligram Equivalents (MME) above their baseline pre-op MME after surgery. PURPOSE The purpose of this study is to evaluate how prescribing patterns affect immediate postoperative opioid consumption in patients undergoing 1- to 2-level posterior lumbar interbody fusion with a navigated or robotic-assisted, midline exposure (MIDLIF). STUDY DESIGN/SETTING Single surgeon consecutive series. PATIENT SAMPLE Patients with degenerative lumbar pathology who had a MIDLIF from 2017 to 2018 were identified. OUTCOME MEASURES In-hospital opioid consumption. METHODS Patients with degenerative lumbar pathology who had a MIDLIF from 2017 to 2018 were identified and divided into two cohorts: patients who had surgery before the institution of SEPP (PreSEPP) and those who had surgery after (PostSEPP). Length of stay and daily opioid consumption were extracted by EMR data analysts unaware of the purpose of the study. RESULTS The PreSEPP (N=34) and PostSEPP (N=27) patients were similar at baseline in age, sex distribution, ASA grade, BMI and smoking status. Pre-Op (2.2 vs 3.6, p=0.630) and Post-op Day-0 (POD-0, 52.5 vs 38.8, p=0.192) MME consumption was similar between the two groups. At POD-1, cumulative MME consumption was higher in the Pre-SEPP (131.7) compared to the PostSEPP group (76.0, p=0.004) and this was maintained up to discharge (54% total MME reduction). Length of stay was also longer in the PreSEPP (1.97 days) compared to the PostSEPP group (1.37 days, p=0.004). CONCLUSIONS The use of a standard escalation pain protocol decreases in-hospital opioid consumption by 54% and shortens length of stay after 1-2 level lumbar spinal fusion. Similar to our previous study, prescribing pattern is an important factor affecting post-op opioid consumption. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

286. Early adoption of enhanced recovery after surgery protocol following adult spinal deformity surgery is not associated with decreased in-hospital opioid use

BACKGROUND CONTEXT The United States is facing an opioid crisis. Opioid use is common and widespread in the adult spinal deformity (ASD) population. Enhanced Recovery After Surgery (ERAS) is a multimodal and multidisciplinary evidence-based, perioperative approach for surgery intended to reduce surgical morbidity and improve recovery. We sought to evaluate the effects of ERAS implementation on postoperative opiate consumption, length of stay (LOS), and postoperative day of ambulation (PDA) following ASD surgery. PURPOSE The purpose of this study is to test if the implementation of ERAS protocol will help reduce in-hospital opioid use, length of stay and postoperative day of ambulation following ASD surgery. STUDY DESIGN/SETTING Single site, multisurgeon, retrospective longitudinal cohort study. PATIENT SAMPLE We sampled a total of 50 patients, 6 months pre- (n=20) and post- (n=30) ERAS implementation. METHODS A single center, multisurgeon, retrospective review identified patients with adult deformity who underwent ASD surgery 6 months pre- (n=20) and post- (n=30) ERAS implementation. The 2 cohorts were statistically similar in age, sex, BMI, diagnosis, ASA grade and levels fused. Total morphine equivalent doses (MED) in-hospital as well as 90-day postoperative prescriptions were calculated. LOS and PDA were also evaluated. Preoperative opiate prescriptions were recorded to determine baseline opioid use. RESULTS We found no difference in hospital postoperative mean total MED between the 2 cohorts (preERAS=263, postERAS=211, p=0.44). The 90-day mean total MED was also not significantly different between the cohorts (preERAS= 572, postERAS=326, p=0.12). 25 (50%) patients were taking opiates prior to surgery. Opiate naive patients required significantly less in-hospital mean total MED compared to nonopiate naive patients (124 vs 629, p=0.02, respectively). However, 90-day mean total MED was not significantly different between the 2 cohorts (naive=197 vs non-opiate naive=311, p=0.18). LOS for ERAS cohort (5.20.±73) was less when compared to preERAS cohort (5.9±0.6, p=0.22), but this was not significant. PDA was significantly decreased after ERAS implementation (1.1 vs 0.43, p=0.006). CONCLUSIONS Early adoption of ERAS did not decrease in-hospital opioid consumption or total 90-day opioid prescription. In-hospital opioid consumption was correlated with preoperative opioid use. Decreasing presurgical opioid use has a significant effect on postoperative patient opioid consumption and should be implemented as part of ERAS protocol. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Predicting chronic pain after major traumatic injury.

Background and aims Chronic pain after traumatic injury and surgery is highly prevalent, and associated with substantial psychosocial co-morbidities and prolonged opioid use. It is currently unclear whether predicting chronic post-injury pain is possible. If so, it is unclear if predicting chronic post-injury pain requires a comprehensive set of variables or can be achieved only with data available from the electronic medical records. In this prospective study, we examined models to predict pain at the site of injury 3-6 months after hospital discharge among adult patients after major traumatic injury requiring surgery. Two models were developed: one with a comprehensive set of predictors and one based only on variables available in the electronic medical records. Methods We examined pre-injury and post-injury clinical variables, and clinical management of pain. Patients were interviewed to assess chronic pain, defined as the presence of pain at the site of injury. Prediction models were developed using forward stepwise regression, using follow-up surveys at 3-6 months. Potential predictors identified a priori were: age; sex; presence of pre-existing chronic pain; intensity of post-operative pain at 6 h; in-hospital opioid consumption; injury severity score (ISS); location of trauma, defined as body region; use of regional analgesia intra- and/or post-operatively; pre-trauma PROMIS Depression, Physical Function, and Anxiety scores; in-hospital Widespread Pain Index and Symptom Severity Score; and number of post-operative non-opioid medications. After the final model was developed, a reduced model, based only on variables available in the electronic medical record was run to understand the "value add" of variables taken from study-specific instruments. Results Of 173 patients who completed the baseline interview, 112 completed the follow-up within 3-6 months. The prevalence of chronic pain was 66%. Opioid use increased from 16% pre-injury to 28% at 3-6 months. The final model included six variables, from an initial set of 24 potential predictors. The apparent area under the ROC curve (AUROC) of 0.78 for predicting pain 3-6 months was optimism-corrected to 0.73. The reduced final model, using only data available from the electronic health records, included post-surgical pain score at 6 h, presence of a head injury, use of regional analgesia, and the number of post-operative non-opioid medications used for pain relief. This reduced model had an apparent AUROC of 0.76, optimism-corrected to 0.72. Conclusions Pain 3-6 months after trauma and surgery is highly prevalent and associated with an increase in opioid use. Chronic pain at the site of injury at 3-6 months after trauma and surgery may be predicted during hospitalization by using routinely collected clinical data. Implications If our model is validated in other populations, it would provide a tool that can be easily implemented by any provider with access to medical records. Patients at risk of developing chronic pain could be selected for studies on preventive strategies, thereby concentrating the interventions to patients who are most likely to transition to chronic pain.

Implementation of an Enhanced Recovery After Spine Surgery program at a large cancer center: a preliminary analysis.

This study describes the implementation of a multimodal, multidisciplinary, evidence-based ERAS program in oncologic spine surgery, identifies and measures several relevant postoperative recovery outcomes, and demonstrates the feasibility and potential benefit of the program in improving analgesia and decreasing opioid consumption. The study underscores the importance of defining and capturing meaningful, patient-specific, and patient-reported outcomes, and constant evaluation and monitoring of a group's compliance with the program. The study represents the steppingstone for evaluation and improvement of a young ERAS program for spine surgery and serves as a roadmap for further initiatives and larger-scale studies.

Tourniquetless Total Knee Arthroplasty With Modern Perioperative Protocols Decreases Pain and Opioid Consumption in Women

BackgroundThis study examined whether a modern total knee arthroplasty (TKA) protocol without a tourniquet results in less patient-reported pain and in-hospital opioid consumption compared to TKA with a tourniquet. MethodsA retrospective study of 203 primary unilateral cemented TKAs consecutively performed with or without tourniquet was performed. Identical perioperative pain and blood loss protocols were used in all cases. In tourniquetless TKAs, the tourniquet was not inflated at any time, and sterile CO2 gas compression maximized cement interdigitation. ResultsAfter exclusions for scientific confounds, 184 TKAs (93 with tourniquet; 91 tourniquetless) were analyzed. Controlling for multiple covariates, females with a tourniquet reported significantly more pain (P = .002) and opioid consumption (P < .001) the first 24 hours after surgery compared to females without a tourniquet. There were no differences in pain (P = .192) or amount of opioids consumed (P = .203) among males with and without a tourniquet. Tourniquet use resulted in a significant reduction in blood loss for both females (P ≤ .040) and males (P ≤ .020), although the total blood savings of approximately 200 mL is of unknown clinical significance. ConclusionAvoiding tourniquet use during TKA for females may be a relatively risk-free adjunct to minimize opioid consumption during hospitalization. Further study is warranted to elucidate the factors accounting for different outcomes in females and males.

Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery.

OBJECTIVE Perception of perioperative pain is influenced by various psychological factors. The aim of this study was to determine the impact of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain scores, and quality of recovery in adults who underwent spine surgery. METHODS Patients undergoing spine surgery were enrolled in this study, and the preoperatively completed questionnaires included the verbal rating scale (VRS), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), and Oswestry Disability Index (ODI). Quality of recovery was assessed using the 40-item Quality of Recovery questionnaire (QoR40). Opioid consumption and pain scores according to the VRS were recorded daily until discharge. RESULTS One hundred thirty-nine patients were recruited for the study, and 101 completed the QoR40 assessment postoperatively. Patients with higher catastrophizing scores were more likely to have higher maximum pain scores postoperatively (estimate: 0.03, SE: 0.01, p = 0.02), without increased opioid use (estimate: 0.44, SE: 0.27, p = 0.11). Preoperative anxiety (estimate: 1.18, SE: 0.65, p = 0.07) and depression scores (estimate: 1.06, SE: 0.71, p = 0.14) did not correlate with increased postoperative opioid use; however, patients with higher preoperative depression scores had lower quality of recovery after surgery (estimate: -1.9, SE: 0.56, p < 0.001). CONCLUSIONS Catastrophizing, anxiety, and depression play important roles in modulating postoperative pain. Preoperative evaluation of these factors, utilizing a validated tool, helps to identify patients at risk. This might allow for earlier psychological intervention that could reduce pain severity and improve the quality of recovery.

Pectoralis and Serratus Fascial Plane Blocks Each Provide Early Analgesic Benefits Following Ambulatory Breast Cancer Surgery: A Retrospective Propensity-Matched Cohort Study.

Pectoralis and serratus blocks have been described recently for use in breast surgery, but evidence supporting their analgesic benefits is limited. This cohort study evaluates the benefits of adding a pectoralis or serratus block to conventional opioid-based analgesia (control) in patients who underwent ambulatory breast cancer surgery at Women's College Hospital between July 2013 and May 2015. We tested the joint hypothesis that adding a pectoralis or serratus block reduced postoperative in-hospital (predischarge) opioid consumption and nausea and vomiting (PONV). We also examined the 2 block types for noninferiority. A total of 225 patients were propensity matched on 5 potential confounders among 3 study groups (75 per group): (1) pectoralis; (2) serratus; and (3) control. The propensity-matched cohort was used to evaluate the effect of the study group on postoperative in-hospital oral morphine equivalent consumption and PONV. We considered pectoralis noninferior to serratus block if it was noninferior for both outcomes, within 10 mg morphine and 17.5% in PONV incidence margins. Other outcomes included intraoperative fentanyl requirements, pain scores, time to first analgesic request, and duration of recovery room stay. Both pectoralis and serratus blocks were each associated with reduced postoperative in-hospital opioid consumption and PONV compared with control. Pectoralis was noninferior to serratus block for these 2 outcomes. Pectoralis and serratus blocks were each associated with reduced intraoperative fentanyl requirements, prolonged time to first analgesic request, and expedited recovery room discharge compared with control; there were no differences for the remaining outcomes. Pectoralis and serratus blocks were each associated with a reduction in postoperative in-hospital opioid consumption and PONV compared with conventional opioid-based analgesia after ambulatory breast cancer surgery.

A High Preoperative Pain and Symptom Profile Predicts Worse Pain Outcomes for Children After Spine Fusion Surgery.

Preoperative pain predicts persistent pain after spine fusion, yet little is understood about the nature of that pain, related symptoms, and how these symptoms relate to postoperative pain outcomes. This prospective study examined children's baseline pain and symptom profiles and the association between a high symptom profile and postoperative outcomes. Seventy children (aged 10-17 years) scheduled for correction of idiopathic scoliosis completed pain and symptom surveys during their preoperative visit (ie, pain intensity [0-10 numeric rating scores], a pediatric version of the 2011 fibromyalgia survey criteria [including pain locations and symptom severity scale], neuropathic pain symptoms [painDETECT], and Patient-Reported Outcome Measurement System measures of fatigue, depression, function, pain interference, and pain catastrophizing). Pain intensity and total analgesic use were recorded daily postoperatively and for 2 weeks after discharge. A 2-step cluster analysis differentiated a high and low pain and symptom profile at baseline, and a multivariate main effects regression model examined the association between pain profile and posthospital discharge pain and analgesic outcomes. The cluster analysis differentiated 2 groups of children well characterized by their baseline symptom reporting. Thirty percent (95% confidence interval [CI], 20.2%-41.8%) had a high symptom profile with higher depression, fatigue, pain interference, a pediatric version of the fibromyalgia survey criteria symptoms, neuropathic pain, and catastrophizing. Girls were more likely than boys to be clustered in the high symptom profile (odds ratio [OR], 5.76 [95% CI, 1.20-27.58]; P = .022) as were those with preoperative pain lasting >3 months (OR, 3.42 [95% CI, 1.21-9.70]; P = .018). Adjusting for sex, age, and total in-hospital opioid consumption, high cluster membership was independently associated with higher self-reported pain after discharge (mean difference +1.13 point [97.5% CI, 0.09-2.17]; P = .015). Children in the high symptom cluster were more likely to report ongoing opioid use at 2 weeks compared with the low symptom group (87% vs 50%; OR, 6.5 [95% CI, 1.30-33.03]; P = .015). At 6 months, high symptom cluster membership was associated with higher pain intensity, higher pain interference, and ongoing analgesic use (P ≤ .018). A behavioral pain vulnerable profile was present preoperatively in 30% of children with idiopathic scoliosis and was independently associated with poorer and potentially long-lasting pain outcomes after spine fusion in this setting. This high symptom profile is similar to that described in children and adults with chronic and centralized pain disorders and was more prevalent in girls and those with long-standing pain. Further study is needed to elucidate the potential mechanisms behind our observations.