Median Morphine Milligram Equivalents Research Articles

Hyperbaric bupivacaine versus prilocaine for spinal anesthesia combined with total intravenous anesthesia during oncological colon surgery in a 23-hour stay enhanced recovery protocol: A non-randomized study.

After the success of the enhanced recovery after surgery protocol, perioperative care has been further optimized in accelerated enhanced recovery pathways (ERPs), where optimal pain management is crucial. Spinal anesthesia was introduced as adjunct to general anesthesia to reduce postoperative pain and facilitate mobility. This study aimed to determine which spinal anesthetic agent provides best pain relief in accelerated ERP for colon carcinoma. This single center study was a secondary analysis conducted among patients included in the aCcelerated 23-Hour erAS care for colon surgEry study who underwent elective laparoscopic colon surgery. The first 30 patients included received total intravenous anesthesia combined with spinal anesthesia with prilocaine, the 30 patients subsequently included received spinal anesthesia with hyperbaric bupivacaine. Primary endpoint of this study was the total amount of morphine milligram equivalents (MMEs) administered during hospital stay. Secondary outcomes were amounts of MMEs administered in the recovery room and surgical ward, pain score using the numeric rating scale, complication rates and length of hospital stay. Compared to prilocaine, the total amount of MMEs administered was significantly lower in the bupivacaine group (n = 60, 16.3 vs 6.3, P = .049). Also, the amount of MMEs administered and median pain scores were significantly lower after intrathecal bupivacaine in the recovery room (MMEs 11.0 vs 0.0, P = .012 and numeric rating scale 2.0 vs 1.5, P = .004). On the surgical ward, median MMEs administered, and pain scores were comparable. Postoperative outcomes were similar in both groups. Spinal anesthesia with hyperbaric bupivacaine was associated with less opioid use and better pain reduction immediately after surgery compared to prilocaine within an accelerated ERP for elective, oncological colon surgery.

Robotic-assisted hysterectomy for benign gynecologic disease in the United States: in-hospital use of opioid and non-opioid analgesics.

To compare the in-hospital opioid and non-opioid analgesic use among women who underwent robotic-assisted hysterectomy (RH) vs. open (OH), vaginal (VH), or laparoscopic hysterectomy (LH). Records of women in the United States who underwent hysterectomy for benign gynecologic disease were extracted from the Premier Healthcare Database (2013-2019). Propensity score methods were used to create three 1:1 matched cohorts stratified in inpatients [RH vs. OH (N = 16,821 pairs), RH vs. VH (N = 6149), RH vs. LH (N = 11,250)] and outpatients [RH vs. OH (N = 3139), RH vs. VH (N = 29,954), RH vs. LH (N = 85,040)]. Opioid doses were converted to morphine milligram equivalents (MME). Within matched cohorts, opioid and non-opioid analgesic use was compared. On the day of surgery, the percentage of patients who received opioids differed only for outpatients who underwent RH vs. LH or VH (maximum difference=1%; p<0.001). RH was associated with lower total doses of opioids in all matched cohorts (each p<0.001), with the largest difference observed between RH and OH: median (IQR) of 47.5 (25.0-90.0) vs. 82.5 (36.0-137.0) MME among inpatients and 39.3 (19.5-66.0) vs. 60.0 (35.0-113.3) among outpatients. After the day of surgery, fewer inpatients who underwent RH received opioids vs. OH (78.7 vs. 87.5%; p<0.001) or LH (78.6 vs. 80.6%; p<0.001). The median MME was lower for RH (15.0; 7.5-33.5) versus OH (22.5; 15.0-55.0; p<0.001). Minor differences were observed for non-opioid analgesics. RH was associated with lower in-hospital opioid use than OH, whereas the same magnitude of difference was not observed for RH vs. LH or VH.

Time trends in opioid use for patients undergoing hip fracture surgery in 1997-2018: A Danish population-based cohort study.

Although opioids are a mainstay for perioperative pain management in hip fracture patients, no studies have described changes in opioid use over the last two decades. The aim of this study was to describe time trends in opioid use in a population-based cohort of patients undergoing a first-time hip fracture surgery during 1997-2018. Opioid-naïve hip fracture patients >55 years old were identified in Danish medical databases (n = 115,962). By 2-year calendar periods, we calculated prevalence rates (PR) of opioid use in the four quarters after surgery (Q1-Q4). Corresponding prevalence rate ratios (PRR) with 1997-1998 as a reference were estimated with 95% confidence intervals. Further, we calculated the median morphine milligram equivalents (MME) for each quarter. For Q1, the PR of opioid use increased from 29% in 1997-1998 to 78% in 2017-2018 corresponding to a PRR of 2.7 (2.6-2.8). For Q4, the PR was 15% in 1997-1998, peaked in 2003-2004 and then decreased, but stayed high at 13% in 2017-2018. The median MME did not increase when comparing 2017-2018 with 1997-1998, irrespective of the quarter. Tramadol was most frequently used in 1997-1998 shifting to oxycodone in 2017-2018. The PRs of opioid use in Q1 after surgery increased substantially from 1997 to 2018, but this did not translate into increased opioid use up to 1 year after hip fracture surgery or higher dosage. Our findings underline the importance of sustained focus on opioid tapering, dosage and use of opioids with the lowest potential for addiction and other adverse events. Overall, opioid use in Q1 after hip fracture surgery increased 2.7 times from 1997 to 2018, but the doses and opioid use up to 1 year after surgery remained stable. Compared to elderly, younger patients were more likely to use opioid in Q1, while the tendency was opposite in Q2-Q4. The most used opioid type changed from tramadol to oxycodone. Our findings underline the importance of personalized opioid tapering and doses, and use of opioids with the lowest potential for addiction and other adverse events.

Intravenous versus oral acetaminophen for pain and quality of recovery after ambulatory spine surgery: a randomized controlled trial

IntroductionAs ambulatory spine surgery increases, efficient recovery and discharge become essential. Multimodal analgesia is superior to opioids alone. Acetaminophen is a central component of multimodal protocols and both intravenous and...

Impact of pharmacogenomic profiles on post-surgical pain following laparotomy for gynecologic pathology

ObjectivesThe aim of this prospective study was to compare perioperative opioid use in women by status of CYP2D6, a highly polymorphic pharmacogene relevant to opioid metabolism. MethodsPatients undergoing laparotomy were prospectively recruited and provided a preoperative saliva swab for a pharmacogenomic (PGx) gene panel. Postoperative opioid usage and pain scores were evaluated via chart review and a phone survey. Pharmacogenes known to be relevant to opioid metabolism were genotyped, and opioid metabolizing activity predicted by CYP2D6 genotyping. Patient and procedural factors were compared using Fisher's exact and Kruskal-Wallis tests. ResultsThe 96 enrolled patients were classified as ultra-rapid (N = 3, 3%), normal (58, 60%), intermediate (27, 28%), and poor (8, 8%) opioid metabolizers. There was no difference in surgical complexity across CYP2D6 categories (p = 0.61). Morphine Milligram Equivalents (MME) consumed during the first 24 h after peri-operative suite exit were significantly different between groups: ultrarapid metabolizers had the highest median MME (75, IQR 45–88) compared to the other three groups (normal metabolizers 23 [8–45], intermediate metabolizers 48 [20–63], poor metabolizers 31 [12–53], p = 0.03). Opioid requirements were clinically greater in ultrarapid metabolizers during the second 24 h and last 24 h but were statistically similar (p = 0.07). There was no difference in MME prescribed at discharge (p = 0.22) or patient satisfaction with pain control (p = 0.64) between groups. ConclusionsA positive association existed between increased CYP2D6 activity and in-hospital opioid requirements, especially in the first 24 h after surgery. This provides important information to further individualize opioid prescriptions for patients undergoing laparotomy for gynecologic pathology.

Influence of Implementing an Opioid Stewardship Team in the Primary Care Setting.

Background: The Updated 2022 Centers for Disease Control (CDC) Clinical Practice Guideline for Prescribing Opioids for Pain highlights the importance of shared decision making and provider-patient relationships. Interprofessional teams may be helpful in supporting providers and patients. A large, multi-site primary care department created an interprofessional primary care opioid stewardship team to target high-risk opioid prescribing and improve practice alignment with CDC recommendations through dashboard reporting and education. Objective: The primary objective was to assess reduction in morphine milligram equivalents (MME) from baseline to 6 months in patients on opioid doses ≥90 MME daily. The secondary objective assessed change in number of naloxone prescriptions from baseline to 6 months after education. Methods: The study was conducted across 30 primary care sites of one health system within Michigan from 2021 to 2022. The opioid stewardship team included 2 physicians, 3 pharmacists, a project operations manager, and IT support. Interventions included creation of a dashboard, provider education, dissemination of policy, and chart audits. Using the electronic health record (EHR) dashboard, patients on chronic opioid doses ≥90 MME daily or missing an active naloxone prescription were identified. Primary care providers (PCP) were provided with an individual list of patients for whom to consider intervention. Support was provided for prescribers, but the team did not interact with patients directly. Results: Baseline analysis identified 290 patients on doses ≥ 90 MME daily. There was reduction in median daily MME from baseline to 6 months in the overall study population (140 [105 240] vs 120 [90 240], P < .001). At 6 months 181 (62.4%) of patients had been given a prescription for naloxone versus 108 (37.2%) who had one at baseline, P < .001. Conclusion: The initiatives implemented by the opioid stewardship team resulted in statistically significant reductions in MME and an increase in naloxone prescribing from baseline to 6 months post-education.

Interpectoral nerve blocks may lower postoperative narcotic use after mastectomy

BackgroundPain management following mastectomy is a significant challenge often requiring opioids. Nonopioid pain management utilizing nerve blocks has been shown in other fields to reduce postoperative opioid use and may be effective for postoperative pain in mastectomy patients. The primary purpose of this study was to compare postoperative opioid use, measured in morphine milligram equivalents (MME), between mastectomy patients who underwent interpectoral nerve block (IPNB) and a historical control group. Secondary outcomes included length of stay (LOS) and postoperative pain scores. MethodsThis is a single-center, retrospective cohort study. The charts of women who underwent mastectomy for cancer without immediate reconstruction from 10/2017–12/2019 were reviewed. Wilcoxon rank sum test was used for unadjusted analysis and multiple linear regression for adjusted analysis. ResultsThere were 105 patients included in this study, of which 37 (35%) underwent IPNB. In unadjusted analysis, median MME use was significantly lower in patients that received IPNB compared to the control group (IPNB = 5, controls = 17, p = 0.03). Patients that received IPNB had an observed reduction in LOS and postoperative pain, though these results failed to reach statistical significance. There were no IPNB-related complications. ConclusionsIPNB may be an effective strategy to decrease postoperative opioid use in mastectomy patients. Larger, prospective studies are needed to further investigate the effectiveness of IPNB.

Opioid prescribing practices in breast oncologic surgery-A retrospective cohort study.

In breast oncologic surgery, 75% of patients receive a postoperative opioid prescription at discharge, and 10%-20% will develop persistent opioid use. To inform future institutional guidelines, the objective of this study was to determine baseline opioid prescribing patterns in a single high-volume, referral-based breast center. We hypothesized that opioid prescribing practices varied between procedures and operating surgeons. A retrospective analysis of all women undergoing breast cancer surgery between January and December 2019. Opioid prescriptions at discharge were converted to morphine milligram equivalents (MME). The primary outcome of interest was MME prescribed at discharge. Multiple linear regression was used to identify factors independently associated with MME prescribed. 392 patients met inclusion criteria; 68.3% underwent partial mastectomy. Median age was 61 (interquartile range [IQR] 51-70). Median MME prescribed at discharge was 112.5 (IQR 75-150); 83.9% of patients were prescribed co-analgesia. The prescriber was a trainee in 37.7% of cases. 15 patients (3.8%) required opioid renewal. On multivariate analysis, axillary procedure was associated with increased MME (ß=17, 95% CI 5.5-28 and ß=32, 95% CI 17-47, for sentinel node and axillary dissection, respectively). However, the factor with the greatest impact on MME was operating surgeon (ß=72, 95% CI 58-87). Residents prescribed less MME compared to attending surgeons (ß=11, 95% CI -22; -0.06). In a tertiary care center, the operating surgeon had the greatest influence on opioid prescribing practices, and trainees tended to prescribe less MME. These findings support the need for a standardized approach to optimize prescribing and reduce opioid-related harms after oncologic breast surgery.

Effect of a Multidisciplinary Review Panel on Daily Morphine Milligram Equivalents for Patients With Chronic Pain.

Physicians and other health care professionals are challenged regularly to balance managing pain for patients with chronic pain receiving chronic opioid therapy (COT) with following the national guidelines and standards regarding daily morphine milligram equivalents (MME). This quality improvement project aimed to determine the effect of referral to a multidisciplinary review panel on daily MME for patients receiving COT for chronic pain. This quality improvement project included patients who had an established relationship with a primary care or community internal medicine clinician at a large health care organization and were referred to a newly created multidisciplinary review panel for their recommendations regarding treatment of pain. Criteria for patient referral were diagnosis of a chronic, painful condition, and use of chronic opioid medications. These patients were selected and referred at the discretion of their primary care clinician from January 2, 2019, through December 31, 2020. Data for this project were collected at the time of initial referral to the panel and 6 months after recommendations. The daily MME were assessed at the 2 time points. Thirteen patients were referred to the review panel during the project period. The median daily MME at the time of referral was 180. Daily MME decreased by a median of 14 MME after 6 months. The MME did not increase during the project period for any participants. Referral of patients receiving COT to a multidisciplinary review panel may reduce their daily opioid dose.

Impact of opioid law on prescriptions and satisfaction of pediatric burn and orthopedic patients: An epidemiologic study.

The objective of this study was to determine the reduction in prescribed opioid pain dosage units to pediatric patients experiencing acute pain and to assess patient satisfaction with pain control 90-day post discharge following the 2017 Ohio opioid prescribing cap law. The retrospective chart review included 960 pediatric (age 0-18 years) burn injury and knee arthroscopy patients treated between August 1, 2015-August 31, 2019. Prospectively, legal guardians completed a survey for a convenience sample of 50 patients. Opioid medications (days and morphine milligram equivalents (MMEs)/kg) prescribed at discharge before and after the Ohio law implementation were collected. Guardians reported experience and satisfaction with their child's opioid prescription at 90-days post discharge. From pre-law to post-law, there was a significant decrease (p<0.001) within the burn and knee cohorts in the median days (1.7 to 1.0 and 5.0 to 3.8, respectively) and median total MMEs prescribed (15.0 to 2.5 and 150.0 to 90.0, respectively). An interrupted time series analysis revealed a statistically significant decrease in MMEs/kg and days prescribed at discharge when the 2017 Ohio opioid prescription law went into effect, with an abrupt level change. Prospectively, more than half of participants were satisfied (72% burn and 68% knee) with their pain control and felt they received the right amount of medication (84% burn and 56% knee). Inpatient opioid use was not changed pre- and post-law. Discharge opioids prescribed for pediatric burn and knee arthroscopy procedures has decreased from 2015-2019. Caregivers varied greatly in their satisfaction with pain control and the amount of opioid prescribed.

Intrathoracic plates versus extrathoracic plates: a comparison of postoperative pain in surgical stabilization of rib fracture technique

BackgroundSurgical stabilization of rib fractures (SSRF) has been shown to improve outcomes, yet there is an absence of studies comparing SSRF techniques. An intrathoracic system that minimizes incision length has...

A Prescribing Guideline Decreases Postoperative Opioid Prescribing in Emergency General Surgery

IntroductionPatients prescribed higher opioid dosages have a higher risk of persistent opioid use, overdose, and death. There is a lack of standardization for opioid prescribing for acute surgical pain in emergency general surgery (EGS) patients. We hypothesized that implementing a guideline to standardize opioid prescribing would be associated with a decrease in prescribing at hospital discharge for EGS patients without increasing additional postdischarge refills. MethodsThis was a quasi-experimental study evaluating opioid prescribing by EGS providers before and after the implementation of a prescribing guideline. Patients were assigned to preguideline and postguideline groups based on admission date surrounding the implementation of the guideline. The primary outcome was the proportion of patients receiving an opioid prescription for ≥50 Morphine Milligram Equivalents (MME) per day on hospital discharge. ResultsThere were 227 patients in the preguideline group and 226 patients in the postguideline group. After guideline implementation, median total MME prescribed decreased from 113 (interquartile range = 75) to 75 (interquartile range = 75, P = 0.03). The proportion of patients receiving a prescription for daily MME ≥50 also decreased from 75% to 25% (P ≤0.01). There were no increases in requested refills (17% versus 16%, P = 0.72) or received refills (14% versus 14%, P = 0.98). Guideline compliance ranged from 75% in ventral hernia repair patients to 94% in laparoscopic cholecystectomy patients. ConclusionsA departmental guideline to standardize postoperative opioid prescriptions was associated with a decrease in the amount of MMEs prescribed to EGS patients without an increase in requested or received refills.

Effectiveness of Sublingual Buprenorphine for Pain Control in the ICU.

The objective of this study was to compare pain control and opioid consumption in critically ill patients who were treated with buprenorphine sublingual or oxycodone oral/enteral during ICU admission. This was a retrospective, parallel, cohort study. General medical or surgical ICUs of a quaternary, urban hospital in Sydney, NSW, Australia. Data were obtained for all patients admitted to two general medical or surgical ICU from January 2019 to January 2023. Patients were grouped as those who received buprenorphine sublingual versus oxycodone oral/enteral. None. Pain control was compared between a propensity score matched cohort of patients who received buprenorphine versus oxycodone. The primary outcome was the probability of significant pain. A significant pain score was defined as greater than or equal to 4 on the 0-10 Numeric Rating Scale or greater than or equal to 6 on the Behavioral Pain Scale. The study cohort included 1,070 patients (288 buprenorphine and 782 oxycodone). After propensity score matching, there were 288 patients in each group. The mean age of the matched cohort was 64 ± 16 years, 295 (51%) were male, and 359 (62%) had a surgical admission. The median probability of significant pain was 0.16 with buprenorphine and 0.17 with oxycodone (median difference, 0.01; 95% CI, -0.02 to 0.04; p = 0.50). Median opioid consumption in oral morphine milligram equivalents (MMEs) was 65 with buprenorphine and 70 with oxycodone (median difference, -1 mg; 95% CI, -10 to 10 mg; p = 0.73). Median MME per ICU day was 22 with buprenorphine and 22 with oxycodone (median difference, 1 mg; 95% CI, -2 to 5 mg; p = 0.38). Buprenorphine sublingual is as effective as oxycodone oral/enteral with regard to pain control and opioid consumption in the ICU. Buprenorphine sublingual is an appropriate option for patients in the ICU who are unable to take oral/enteral medications.

Early versus delayed postoperative adductor canal block in total knee arthroplasty.

We hypothesized that patients who received an adductor canal block (ACB) in the operating room following unilateral total knee arthroplasty would have a lower oral morphine milligram equivalent (MME) consumption during the postanesthesia care unit (PACU) phase 1 recovery period compared to patients who received an ACB in the PACU. This was a retrospective cohort study of patients who underwent robotic-assisted unilateral total knee arthroplasty under general anesthesia between March 1, 2020, and February 28, 2021, and received postoperative ACB either in the operating room or the PACU. A total of 36 and 178 patients received postoperative ACB in the operating room and PACU, respectively, and had median and interquartile range MME consumption in the PACU of 22.5 (20-40) mg and 30.0 (20-40) mg (P = 0.76), respectively. Patients who had an ACB performed in the operating room and PACU had median and interquartile ranges of time spent in the PACU of 101 (75-178) minutes and 186 (125-272) minutes (P < 0.01), respectively. Patients who received an ACB in the operating room did not have a lower OME consumption than patients who received an ACB in the PACU but did have a shorter PACU length of stay.

Standardizing Opioids Prescribed at Discharge in Trauma Surgery

IntroductionExcessive opioid use after sustaining trauma has contributed to the opioid epidemic. Standardizing the quantity of opioids prescribed at discharge can improve prescribing behavior. We hypothesized that adopting new electronic medical record order sets would be associated with decreased morphine milligram equivalents (MME) prescribed at discharge for trauma patients. MethodsThis was a quasi-experimental study examining opioid prescribing practices at a Level 1 Trauma Center. All patients ages 18-89 admitted to the Trauma Service from January 2017 through March 2021 and hospitalized for at least 2 d were included. In November 2020, new trauma admission and discharge order sets were implemented with recommended discharge opioid quantity based on inpatient opioid usage the day prior to discharge multiplied by five. Postintervention prescribing practices were compared to historical controls. The primary outcome was MME at discharge. ResultsBaseline characteristics between preintervention and postintervention cohorts were comparable. There was a significant reduction in median MME prescribed at discharge postintervention (112.5 versus 75.0, P < 0.0001). Median inpatient MME usage also significantly reduced postintervention (184.1 versus 160.5; P < 0.0001). There were trends toward increased ideal prescribing per order set recommendation and a reduction in overprescribing. Patients receiving the recommended opioid quantity at discharge had the lowest opioid refill prescription rate (under: 29.6%, ideal: 7.3%, over: 19.7%, P < 0.0001). ConclusionsFor trauma patients requiring inpatient opioid therapy, a pragmatic and individualized intervention was associated with a reduced quantity of discharge opioids without negative outcomes. Reduction in inpatient opioid use was also associated with standardizing prescribing practices of surgeons with electronic medical record order sets.

Prevalence and Predictors of Long-term Opioid Use After Pelvic Fractures.

Opioids are effective in short-term pain treatment; however, their long-term effectiveness is unconfirmed. Many patients are exposed to opioids after pelvic injuries with little known about persistent use afterward. We assessed the prevalence and predictors of long-term opioid use following pelvic fractures. This retrospective study enrolled 277 patients with acute pelvic fractures over five years. Daily and total morphine milligram equivalents (MME) were calculated. The primary outcome was long-term opioid use (LOU) defined as ongoing opioid use 60-90days post-discharge. The secondary outcome was intermediate-term opioid use (IOU) defined as ongoing opioid use 30-60days post-discharge. Univariable and logistic regression analyses were performed. Median (interquartile range) total inpatient opioid MME was 422 (157-1667) with a median daily MME of 69 (26-145). Long-term opioid use occurred in 16%, and IOU occurred in 29%. Univariable analysis found that total and daily inpatient opioid use were each significantly associated with LOU (median MME, 1241 vs 371; median MMEs, 127.7 vs 59.2, respectively) and IOU (median MME, 1140 vs 326; median MMEs, 111.8 vs 57.9, respectively). Logistic regression analysis found daily inpatient MME ≥50 (odds ratio [OR] 3.027, 95% confidence interval [CI] 1.059-8.652]) and pelvic fracture type (Tile B/C) (OR 2.992 [CI 1.324-6.763])were independent predictors of LOU. Total and daily inpatient opioid use were significantly associated with LOU and IOU. Patients who received ≥50 MME/inpatient day had a higher likelihood of LOU. This study seeks to inform clinical decisions for pain management to prevent adverse outcomes.

Rectus Sheath Block Improves Patient Recovery Following Open Aortic Surgery

Postoperative pain management remains a barrier to recovery following aortic surgery. Although epidural catheters help in adjunctive pain management, less is known about the use of rectus sheath blocks. We compared patient recovery following open abdominal aortic surgery (OAS) with and without adjunctive rectus block. Adult patients undergoing open abdominal aortic aneurysm repair and aortobifemoral or aortoiliac bypass for occlusive disease were identified and stratified by use of general anesthesia alone (GA) versus adjunctive use of a rectus sheath block (GA+RB). A small number of patients with GA and concomitant epidural analgesia, along with patients that had retroperitoneal repairs, were not included in further analysis. Outcomes included time to extubation, intraoperative and postoperative morphine milligram equivalents (MME) utilization, length of stay, discharge MME, and postoperative complications. Categorial data were compared with Person Chi-Square tests or Fisher's exact tests. Continuous data were tested with independent t-tests or Mann-Whitney U-tests. From January 2017 to April 2022, there were 106 patients who underwent open aortic surgery, 55 patients with GA alone, 39 with GA+RB, and 12 patients who had a GA with concomitant epidural analgesia. Between GA and GA+RB, patients were comparable in both groups in terms of age, BMI (body mass index), smoking history, hypertension, diabetes, CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease), and ASA (American Society of Anesthesiologists) class and prior opioid use. Patients with GA+RB were more likely to have scheduled elective procedures (80% GA cohort vs. 94.9% RB, P=0.040), and a lower incidence of retroperitoneal exposure (14.5% GA cohort vs. 0% RB, P=0.019). Patients with GA+RB had shorter time to extubation than GA (84.6%<12hr vs. 44.4%, P<0.001), greater rate of procedural ketamine usage (GA+RB: 61.5% vs. GA: 40.0%, P=0.049), lower MME at first postoperative day (median MME GA+RB: 25.0 vs. GA: 67.5, P=0.002), lower discharge MME (median MME GA+RB: 142.5 vs. GA: 225.0, P=0.036), and overall shorter length of stay (median stay GA+RB: 5 vs. GA: 6days, P=0.006). Postoperative complications were similar between groups. Similar findings were found in the comparison between elective-only GA and GA+RB patients and after exclusion of patients who only had a single shot of regional anesthesia. Patients that receive adjunctive rectus sheath blocks for pain control following OAS utilize fewer opioid medications during hospital stay and at discharge. Rectus sheath blocks represent an alternative option to other periprocedural analgesia following open aortic surgery.

Retrospective Study of the Safety and Efficacy of Intraoperative Methadone for Pain Management in Patients Undergoing Elective Intracranial Surgery

Patients undergoing intracranial surgery experience significant perioperative pain and are typically treated with short-acting opioids. Methadone, with its prolonged half-life and multimodal central nervous system effects, presents a promising option for managing post-craniotomy pain. Despite its demonstrated efficacy in other types of surgeries, the use of methadone in craniotomy patients has not yet been explored. A retrospective chart review was conducted for 60 adult patients ranging in age from 18 to 81, who received methadone during intracranial surgeries. The primary outcome of interest was the total opioid consumption in oral morphine milligram equivalents (MMEs) and patient-reported pain scores within 24 hours and up to 72 hours postoperatively. The methadone dosage varied from 5 to 20 mg. In the infratentorial group, the median total MME on postoperative day (POD) 1, 2, and 3 were 30.5, 17, and 0.8, respectively, with mean pain scores of 3.56, 3.91, and 2.71. In the supratentorial group, the median total MME on POD 1, 2, and 3 were 17.85, 15.4, and 1.2, with mean pain scores of 2.31, 1.68, and 2.21, respectively. Patients who were chronic opioid users had significantly higher pain scores and average opioid use (p<0.05) . None of the patients required administration of naloxone or airway interventions. Comparison with the historical control showed that our study patients had lower pain scores and MME. The single intraoperative dose of methadone is well-tolerated by adult patients undergoing various types of intracranial surgeries, with minimal side effects, including elderly patients aged 65 or older.

Outcomes Related to Cardiac Enhanced Recovery After Surgery Protocol

The objective of this study was to assess the quality of pain control and outcomes in patients who underwent coronary artery bypass graft (CABG) over a period of 96 hours preimplementation of a cardiac enhanced recovery after surgery (C-ERAS) protocol compared with postimplementation. Single-center, retrospective cohort study. Cleveland Clinic Akron General Hospital. Patients ≥18 years of age who underwent CABG surgery and received perioperative pain management pre- and post-C-ERAS protocol implementation at admission to Cleveland Clinic Akron General Hospital. A hospital C-ERAS protocol that included a multimodal analgesia approach to postoperative pain management. The primary outcome was the amount of opioid used measured in morphine milligram equivalents (MME) within 96 hours postoperatively. A total of 146 charts were reviewed, with 133 included (66 pre-C-ERAS and 67 post-C-ERAS). There was a significant reduction in median MMEs 96 hours postoperatively post-C-ERAS (98 [52-135] v 211 [130-290], p < 0.001). Additionally, a significant reduction in median MMEs was observed post-C-ERAS before (65 [43-100] v 129 [95-165], p < 0.001) and after (10 [0-40] v 68 [21-141], p < 0.001) chest tube removal and for the entire prescription at discharge (0 [0-109] v 90 [0-210], p=0.005). Implementing a C-ERAS protocol within a CABG surgery patient population reduced the amount of MME.

Opioid-Sparing Analgesic Effects from Interscalene Block Impact Anesthetic Management During Shoulder Arthroscopy: A Retrospective Observational Study.

Ultrasound-guided interscalene nerve block (UISB) is commonly used to alleviate postoperative pain during shoulder arthroscopy. This retrospective observational study aimed to evaluate the intraoperative advantages and analgesic effects of preoperative UISB. In this retrospective observational study, a total of 170 patients underwent shoulder arthroscopy at a tertiary medical center in southern Taiwan throughout 2019. After applying the exclusion criteria, 142 of these cases were included, with 74 and 68 in the UISB group and control groups, respectively. The primary outcome was the evaluation of intraoperative morphine milligram equivalent (MME) consumption. Secondary outcomes were sevoflurane consumption, the use of intraoperative antihypertensive drugs, and postoperative visual analog scale (VAS) scores in the post-anesthesia care unit (PACU) and in the ward at 24 h after surgery. Preoperative UISB effectively reduced opioids and volatile gases during surgery, supported by a 48.1% and 14.8% reduction in the median intraoperative MME and sevoflurane concentrations, respectively, and showed less need for antihypertensive drugs. The preoperative UISB group also showed significantly better performance on the VAS in both the PACU and ward. Taken together, the preoperative UISB reduced not only intraoperative MME and sevoflurane consumption but also had satisfactory VAS scores in both the PACU and ward without any symptomatic respiratory complications. In summary, preoperative UISB is a reliable adjuvant analgesic technique and a key factor in achieving opioid-sparing and sevoflurane-sparing anesthesia and multimodal analgesia during shoulder arthroscopy.