Intraoperative Opioid Administration Research Articles

Association between intraoperative opioid administration and 30-day readmission: a pre-specified analysis of registry data from a healthcare network in New England

BackgroundThe use of intraoperative opioids may influence the rate of postoperative complications. This study evaluated the association between intraoperative opioid dose and the risk of 30-day hospital readmission. MethodsWe conducted a pre-specified analysis of existing registry data for 153 902 surgical cases performed under general anaesthesia at Massachusetts General Hospital and two affiliated medical centres. We examined the association between total intraoperative opioid dose (categorised in quintiles) and 30-day hospital readmission, controlling for several patient-, anaesthetist-, and case-specific factors. ResultsCompared with low intraoperative opioid dosing [quintile 1, median (inter-quartile range): 8 (4–9) mg morphine equivalents], exposure to high-dose opioids during surgery [quintile 5: 32 (27–41) equivalents] is an independent predictor of 30-day readmission [odds ratio (OR) 1.15 (95% confidence interval 1.07–1.24); P<0.001]. Ambulatory surgery patients receiving high opioid doses were found to have the greatest adjusted risk of readmission (OR 1.75; P<0.001) with a clear dose–response effect across quintiles (P for trend <0.05), and were more likely to be readmitted early (postoperative days 0–2 vs 3–30; P<0.001). Opioid class modified the association between total opioid dose and readmission, with longer-acting opioids demonstrating a stronger influence (P<0.001). We observed significant practice variability across individual anaesthetists in the utilisation of opioids that could not be explained by patient- and case-specific factors. ConclusionsHigh intraoperative opioid dose is a modifiable anaesthetic factor that varies in the practice of individual anaesthetists and affects postoperative outcomes. Conservative standards for intraoperative opioid dosing may reduce the risk of postoperative readmission, particularly in ambulatory surgery.

The effect of ampule size of fentanyl on perioperative intravenous opioid dosing.

Background and Aims:There are limited data on the effect of ampule size on drug dosing. The objective of this study is to determine the effect of ampule size on perioperative opioid dosing and post-anesthesia care unit (PACU) outcomes.Material and Methods:This was a retrospective review of patients undergoing robotically assisted laparoscopic radical prostatectomy before and after a 5-ml fentanyl ampule was discontinued. The primary outcome was intraoperative opioid administration divided into fentanyl at induction of anesthesia, total fentanyl, and total opioid. Secondary outcomes observed in PACU included the opioid administered, visual analog scale (VAS) pain scores, postoperative nausea and vomiting, and length of stay in PACU.Results:A total of 100 patients (50 PRE and 50 POST) were included. In the intraoperative opioid administration, mean (SD) of fentanyl at induction was 117.0 (49.3) in PRE group and 85.0 (35.4) μg in POST group (P < 0.01). The total fentanyl requirement was 247.0 (31.0) in PRE group and 158.5 (85.1) μg in POST group (P < 0.01). The total opioid in intravenous morphine equivalents (IVME) was 34.1 (5.8) in PRE group and 23.2 (6.8) mg in POST group (P < 0.01). Among the secondary outcomes, mean (SD) of IVME of opioid was 7.7 (8.2) in PRE group and 9.9 (8.1) mg in POST group (P = 0.18). The VAS pain score on arrival was 0.7 (1.4) in PRE group and 3.8 (3.3) in POST group (P < 0.01). The cumulative VAS pain score was 2.3 (2.0) in PRE group and 3.3 (2.2) in POST group (P < 0.01). The length of stay was significantly more in POST group, 193.8 (75.8) minutes, as compared with PRE group, 138.6 (61.0) minutes (P < 0.01).Conclusions:A change in the ampule size significantly affected intraoperative dosing, PACU pain scores, and PACU length of stay in patients undergoing robotically assisted laparoscopic radical prostatectomy under general anesthesia. This was explained by clinician's desire to conserve the drug and avoid the complex process of narcotic waste disposal.

Pain Management in Abdominal Wall Reconstruction.

Background:In abdominal wall reconstruction, adequate pain control and minimization of narcotic consumption are essential to improving patient outcomes and satisfaction. Previous studies have examined the role of individual strategies, such as neuraxial analgesia and multimodal analgesia. However, there has not been a study that examined all potential determinants of postoperative narcotic requirements, including intraoperative strategies.Methods:Consecutive patients who underwent abdominal wall reconstruction were reviewed. Preoperative factors (chronic preoperative narcotic usage, indication for abdominal wall reconstruction, administration of neuraxial analgesia), intraoperative factors (intraoperative narcotics administered, method of mesh fixation), and postoperative factors (multimodal analgesia, complications) were collected. The main outcomes were daily amount of opioids used and length of hospital stay.Results:Ninety-three patients were included in the study. Patients who had an epidural required lower doses of opioids postoperatively, while those on chronic preoperative opioids, those whose mesh was fixated using transfascial sutures, and those who received large doses of opioids intraoperatively required higher doses of postoperative opioids. Hospital length of stay was longer in patients who received transfascially sutured mesh and those on chronic opioids preoperatively.Conclusions:This study provides potential strategies to improve pain control and minimize narcotic consumption postoperatively in patients undergoing abdominal wall reconstruction. Intraoperative administration of opioids should be minimized to avoid the development of tolerance. Epidural analgesia reduces postoperative narcotic requirement and may be especially beneficial in patients at highest risk for postoperative pain, including those on chronic opioids, and those in whom transfascial sutures are used for mesh fixation.

Perioperative opioid administration in children with and without developmental delay undergoing outpatient dental surgery

Study objectivePrior research has indicated that children with developmental delay (DD) experience qualitative and quantitative differences in health care (Boulet et al., 2009). In the perioperative setting, there is concern that children with DD may be more likely to experience postoperative complications including agitation and nausea/vomiting than typically developing patients (TDP). Differences in the administration and dosage of perioperative opioids may contribute to this, however, empirical investigations are lacking. The purpose of this research was to compare the experience of postoperative nausea/vomiting and agitation, as well as to examine perioperative opioid administration, among children with DD as compared to TDP. DesignRetrospective original research. SettingOperating room, postanesthesia care unit. Patients1145 patients (1–20.9years, ASA I-III, 23.9% with a history of DD) who had undergone outpatient dental surgery involving extraction/restorations under general anesthesia. MeasurementsData was obtained and analyzed from the medical records of both DD and TDP across a five-year period. Data included the experience of agitation, nausea/vomiting, as well as perioperative medication administration. Main resultsPostoperative agitation and nausea/vomiting did not differ significantly between the DD and TDP groups. Children with DD were significantly less likely to receive opioids during both the intra and postoperative period (χ2=10.02, p=0.001 and χ2=8.08, p=0.003, respectively). Further, higher dosage of intraoperative opioids was predictive of reduced administration of postoperative opioids among TDP; however, no significant association was observed between the dosage of intraoperative opioids and administration of postoperative opioids in the DD group. ConclusionsChildren with DD experience similar rates of postoperative complications including nausea/vomiting and agitation as TDP. DD children were less likely to receive both intra and postoperative opioids than TDP. Importantly, while the dosage of intraoperative opioids was predictive of administration of postoperative opioids in the TDP group, this was not the case for the DD group. Clinical implications are discussed.

A targeted remifentanil administration protocol based on the analgesia nociception index during vascular surgery

BackgroundThe intraoperative modulation of opioids continues to be based on clinical signs. This may result in adverse events such as sympathetic reactivity or opioid-induced hyperalgesia. Recently, the Analgesia/Nociception Index (ANI), a non-invasive 0–100 index derived from heart rate variability analysis, has been proposed for nociception assessment. However, the ability of the ANI to adequately guide intraoperative opioid administration has never been demonstrated. We designed a prospective study to evaluate the ability of the ANI to guide remifentanil administration in vascular surgery. MethodsOne hundred and eighty adults presenting for elective surgery were included. All received total intravenous anaesthesia with propofol adjusted to entropy and remifentanil adjusted to the ANI. The primary endpoint was the number of patients without any episode of reactivity defined as a 20% increase in heart rate or arterial pressure or the occurrence of movement. Secondary endpoints included opioid use and maximal pain rate in the first postoperative day. ResultsAnaesthesia was achieved without any episode of reactivity in 160 (89%) patients. Twenty-five episodes of reactivity occurred in 20 (11%) patients. The median remifentanil dose was 0.042 [0.040–0.044]μg.kg−1.min−1. At 24hours, the maximal NRS pain score was 2 [2,3]. One hundred and fifty-five patients (86%) did not receive any postoperative opioids, whereas 25 (14%) received a median dose of 5[5–10] mg of oxycodone. ConclusionThis prospective study demonstrated that the ANI can be used to adequately guide intraoperative remifentanil administration during vascular surgery. Such guidance resulted in low remifentanil consumption, low postoperative pain rates and low opioid rescue analgesia.

Implementation of an Enhanced Surgical Recovery Programme (ESRP) gynaecologic oncology: How much did intra-operative opioid administration decrease in first year post implementation?

Implementation of an Enhanced Surgical Recovery Programme (ESRP) gynaecologic oncology: How much did intra-operative opioid administration decrease in first year post implementation?

Perioperative analgesic requirements in severely obese adolescents and young adults undergoing laparoscopic versus robotic-assisted gastric sleeve resection.

Purpose:One of the major advantages for patients undergoing minimally invasive surgery as compared to an open surgical procedure is the improved recovery profile and decreased opioid requirements in the perioperative period. There are no definitive studies comparing the analgesic requirements in patients undergoing two different types of minimally invasive procedure. This study retrospectively compares the perioperative analgesic requirements in severely obese adolescents and young adults undergoing laparoscopic versus robotic-assisted, laparoscopic gastric sleeve resection.Materials and Methods:With Institutional Review Board approval, the medication administration records of all severely obese patients who underwent gastric sleeve resection were retrospectively reviewed. Intra-operative analgesic and adjuvant medications administered, postoperative analgesic requirements, and visual analog pain scores were compared between those undergoing a laparoscopic procedure versus a robotic-assisted procedure.Results:This study cohort included a total of 28 patients who underwent gastric sleeve resection surgery with 14 patients in the laparoscopic group and 14 patients in the robotic-assisted group. Intra-operative adjuvant administration of both intravenous acetaminophen and ketorolac was similar in both groups. Patients in the robotic-assisted group required significantly less opioid during the intra-operative period as compared to patients in the laparoscopic group (0.15 ± 0.08 mg/kg vs. 0.19 ± 0.06 mg/kg morphine, P = 0.024). Cumulative opioid requirements for the first 72 postoperative h were similar in both the groups (0.64 ± 0.25 vs. 0.68 ± 0.27 mg/kg morphine, P = NS). No difference was noted in the postoperative pain scores.Conclusion:Although intraoperative opioid administration was lower in the robotic-assisted group, the postoperative opioid requirements, and the postoperative pain scores were similar in both groups.

Robotic Mitral Valve Repair: A Review of Anesthetic Management of the First 200 Patients

The aim of this study was to describe the evolution in anesthetic technique used for the first 200 patients undergoing robotic mitral valve surgery. A retrospective review. A single tertiary referral academic hospital. Two hundred consecutive patients undergoing robotic mitral valve surgery using the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) at Mayo Clinic Rochester. None. After obtaining institutional review board approval, surgical and anesthetic data were recorded. For analysis, patients were placed in 4 groups, each containing 50 consecutive patients, labeled Quartiles 1 to 4. Over time, there were statistically significant decreases in cardiopulmonary bypass and aortic cross-clamp times. Significant differences in the anesthetic management were shown, with a reduction of intraoperative fentanyl and midazolam doses, and the introduction of paravertebral blockade in Quartile 2. There was a reduction of time between incision closure and extubation, and nearly 90% of patients were extubated in the operating room in Quartiles 3 and 4. Despite changes to the intraoperative analgesic management, and focus on earlier extubation, there were no differences seen in visual analog scale (VAS) pain scores over the 4 quartiles. Reductions were seen in total intensive care unit and hospital length of stay during the study period. Changes to the practice, including efforts to limit intraoperative opioid administration and the addition of preoperative paravertebral blockade, helped facilitate earlier extubation. In the second half of the study period, close to 90% of patients were extubated in the operating room safely and without delaying patient transition to the intensive care unit.

Propofol-Infusion at the End of Neurosurgery Does Not Prevent Postoperative Nausea — a Randomized Controlled Trial

Background:Postoperative nausea and vomiting (PONV) and pain are common in neurosurgery patients' and may involve a potential risk of neurological damage. The purpose of this study was to investigate whether a propofol infusion at the end of anaesthesia might decrease patients' postoperative nausea (PON) and shortening time to extubation compared to pure isoflurane anaesthesia. Methods:Randomized controlled clinical trial. In total, 73 ASA class 1–2 patients were randomized to receive either isoflurane- (Group C) or propofol anaesthesia (Group P), who underwent surgery with intracranial procedures with an expected time of anaesthesia of at least 4 hours. The patients' demographic data, intraoperative and postoperative opioid administration, time to extubation, the rate of PON and pain and frequency of doses for PON and pain were recorded and analysed. Result:Overall time of anaesthesia (324 ± 73 vs 347 ± 11minuter) and time to extubation (16 ± 9 vs 18 ± 11minuter) did not differ significantly between the groups C and P, respectively. The results over time between the groups C and P of PON (VAS md 0, IQR 0–0 vs. md 0, IQR 0–0) and pain scores (md 0–2, IQR 0–4 vs. 0–2, IQR 0–4.25) was not significant. Conclusion:Propofol infusion at the end of neurosurgery does not seem to reduce PON or extubation times compared to pure isoflurane anaesthesia.

Chronic postsurgical pain

Chronic postsurgical pain (CPSP) is the consequence of acute postoperative pain. Unfortunately, despite many attempts of improvement, the treatment of acute postoperative pain remains unsatisfactory. In the present review, the probable reasons for this will be reviewed. Based on the demonstration of specific, patients-related 'pain risk', individual pain trajectories and the importance of secondary hyperalgesia in the development of CPSP, new methods have to be applied in order to determine the real efficacy of new analgesic adjuvants. The key importance of the early inflammatory reaction in the genesis of the 'postoperative syndrome' and its close interaction with the mechanisms elicited by intraoperative opioid administration must also be outlined. A single treatment approach is almost unlikely to solve the problem of CPSP. Consequently, the management of postoperative pain has to become more patients' specific and etiologies sensitive.

Pain Medicine

Pain Medicine

The Effect of an Anatomically Classified Procedure on Antiemetic Administration in the Postanesthesia Care Unit

The effect of the type of surgical procedure on postoperative nausea and vomiting (PONV) rate has been debated in the literature. Our goal in this retrospective database study was to investigate the effect the type of surgical procedure (categorized and compared anatomically) has on antiemetic therapy within 2 h of admission to the postanesthesia care unit (PACU). We retrospectively analyzed data for oncology surgeries (n = 18,109), from our automated anesthesia information system database. We classified the types of surgical procedures anatomically into seven categories, with the integumentary musculoskeletal and the superficial surgeries chosen as the referent group. Our analysis included nine other risk factors for each patient, such as gender, smoking status, history of PONV or motion sickness, duration of anesthesia, number of prophylactic antiemetics administered, intraoperative opioids, ketorolac, epidural use, and postoperative opioids. Multivariate logistic regression was used to assess the effect of the type of surgery on antiemetic administration within the first 2 h of PACU admission, while adjusting for the other risk factors. Compared with integumentary musculoskeletal and superficial surgeries, patients undergoing neurological (P < 0.0001), head or neck (P < 0.0001), and abdominal (P < 0.0001) surgeries were administered PACU antiemetic significantly more often, whereas patients undergoing thoracic surgeries were administered PACU antiemetic significantly less often (P = 0.02). Breast or axilla (P = 0.74) and endoscopic (P = 0.28) procedures did not differ from the referent category. Female, nonsmoker, history of PONV or motion sickness, anesthesia duration, and intraoperative and postoperative opioid administration were significantly associated with antiemetic administration during early PACU admission. Using our automated anesthesia information system database, we found that the type of surgery, when categorized anatomically, was associated with an increased frequency of early PACU antiemetic administration in our population.

Perioperative Management of Obstructive Sleep Apnea With Nasal Continuous Positive Airway Pressure

The high risks associated with general anesthesia in obstructive sleep apnea syndrome (OSAS) patients have been reported. Many authors have suggested that the intraoperative administration of opioids and sedatives should be limited or avoided because these drugs selectively impair muscle activity in the upper airway. We report the case of an OSAS patient who was managed with nasal continuous positive airway pressure (NCPAP) and treated safely in spite of the use of conventional anesthetic and analgesic agents typically used for patients without OSAS. She had little pain during the perioperative period. It is suggested that NCPAP is an effective treatment for not only preventing airway obstructive apnea but for allowing the administration of anesthetic and analgesic drugs without major complications.

Effects of continuous remifentanil administration on intra‐operative subcutaneous tissue oxygen tension

Surgical stress response markedly increases sympathetic nerve activity and catecholamine concentrations. This may contribute to peripheral vasoconstriction, reduced wound perfusion and subsequent tissue hypoxia. Opioids are known to depress the hypothalamic-adrenal response to surgery in a dose-dependent manner. We tested the hypothesis that continuous remifentanil administration produces improved subcutaneous tissue oxygen tension compared to fentanyl bolus administration. Forty-six patients undergoing major abdominal surgery were randomly assigned to receive either fentanyl bolus administration or continuous remifentanil infusion. Mean subcutaneous tissue oxygen values over the entire intra-operative period were significantly higher in the remifentanil group, when compared to the fentanyl group: 8 (2) kPa vs 6.7 (1.5) kPa, % CI difference: - 2.3 kPa to - 0.3 kPa, p = 0.013. Continuous intra-operative opioid administration may blunt vasoconstriction caused by surgical stress and adrenergic responses more than an equi-effective anaesthetic regimen based on smaller-dose bolus opioid administration.

Continuous intraoperative opioid administration increases subcutaneous tissue oxygen tension

Continuous intraoperative opioid administration increases subcutaneous tissue oxygen tension

A Large Trial Is Vital to Prove Perioperative β-blockade Effectiveness and Safety before Widespread Use

A Large Trial Is Vital to Prove Perioperative β-blockade Effectiveness and Safety before Widespread Use

Propofol and halothane versus sevoflurane in paediatric day-case surgery: induction and recovery characteristics†

The aim of this study was to compare the induction and recovery characteristics associated with propofol induction and halothane maintenance with sevoflurane anaesthesia in paediatric day surgery. In total, 322 children were assigned randomly to i.v. propofol induction and halothane/nitrous oxide maintenance or sevoflurane/nitrous oxide alone. The patients' age, sex, and type of surgery were recorded, as were the times required for anaesthetic induction, maintenance, recovery and time to discharge home. Postoperative nausea and vomiting, and the incidence of adverse events during induction and recovery were also noted. No significant differences were detected in age, sex, type of surgery performed or intraoperative opioid administration. Excitatory movement was more common during induction with sevoflurane. The mean time required for induction with propofol was 3.1 min compared with 5 min in the sevoflurane group (P<0.001). The recovery time was shorter in the sevoflurane group compared with propofol/halothane (23.2 vs 26.4 min, P<0.002). The incidence of delirium in recovery was greater in the sevoflurane group (P<0.001). There was no difference between groups in the time spent on the postoperative ward before discharge home. On the postoperative ward the incidence of both nausea and vomiting was significantly higher in the sevoflurane group (P=0.034). Five children were admitted to hospital overnight, none for anaesthetic reasons. The increased incidence of adverse events during induction, postoperative nausea and vomiting and postoperative delirium in the sevoflurane group suggests that sevoflurane is not ideal as a sole agent for paediatric day case anaesthesia.

A prospective observational study of post‐operative analgesic requirements for fundonlication

Introduction Laparoscopic surgical techniques have developed more slowly in children than adults. This is due to technical problems, a longer surgical learning curve and an underappreciation of post-operative pain and surgical stress in small children (1). Fundoplication is a well-established procedure that is commonly performed in children. The laparoscopic approach is becoming increasingly popular and it is claimed to result in a significantly lower or even no post-operative opioid requirement (2,3) Methods Over a one-year period all children undergoing elective Fundoplication were prospectively studied. The surgical technique (laparoscopy or laparotomy) and intra-operative analgesic requirements were recorded. Postoperatively the pain control service reviewed the analgesic requirements twice daily and any parenteral or epidural infusions weaned as appropriate to the pain scores. Results A total of 64 cases were studied, 40 performed via laparotomy, and 24 by laparoscopy. Post-operative pain was controlled with a morphine nurse controlled analgesia system (NCA) in all the laparoscopy patients and 18 of the laparotomy patients. The remaining 22 patients in the laparotorny group received epidural analgesia postoperatively. The mean weight was 12 kg for each group. Laparotomy took a mean of 103 min while laparoscopy a mean of 163 min. Mean time to first oral intake was 46 hours for laparotomy and 38 hours for laparoscopy. Discussion As the population studied included one whole years caseload selection bias was minimised so we feel that these results truly reflect the analgesic requirements for this operation. Suprisingly intra-operative opioid administration was greater during laparoscopy than laparotomy. This may just reflect the longer surgical time but could also be explained by the anaesthetists responding to the cardiovascular responses of hypertension and tachycardia elicited by pneumoperitoneum (2). Contrary to other studies (2,3) we found that even on days 3–4 post-laparoscopy a significant number of patients needed parenteral opioids augmented with simple analgesics. Patients who are discharged within 3 days of their operation are in danger of experiencing significant pain at home and must be followed up. The laparoscopy group had a shorter time to first oral intake and a better cosmetic outcome reflecting the reported advantages of this approach. Conclusions Laparoscopic fundoplication has a significant intra and post-operative analgesic requirement that has previously been underestimated. The laparoscopic approach leads to a quicker oral intake and a better cosmetic result.

Postoperative Tracheal Extubation

Postoperative Tracheal Extubation

Postoperative Tracheal Extubation

Postoperative Tracheal Extubation