Amount Of Morphine Equivalents Research Articles

MP80-04 NON-NARCOTIC REGIMEN CENTERED ON PREOPERATIVE ERECTOR SPINAE PLANE (ESP) BLOCKS FOR ROBOT-ASSISTED RADICAL PROSTATECTOMY DRASTICALLY REDUCES ADMINISTERED POSTOP MORPHINE EQUIVALENTS

You have accessJournal of UrologyCME1 Apr 2023MP80-04 NON-NARCOTIC REGIMEN CENTERED ON PREOPERATIVE ERECTOR SPINAE PLANE (ESP) BLOCKS FOR ROBOT-ASSISTED RADICAL PROSTATECTOMY DRASTICALLY REDUCES ADMINISTERED POSTOP MORPHINE EQUIVALENTS Aaron Saxton, Deaton Jones, Adam Visca, Kaitlyn Mitchell, Danielle Lindenmuth, Christopher Wanderling, Austin Lee, and Thomas P. Frye Aaron SaxtonAaron Saxton More articles by this author , Deaton JonesDeaton Jones More articles by this author , Adam ViscaAdam Visca More articles by this author , Kaitlyn MitchellKaitlyn Mitchell More articles by this author , Danielle LindenmuthDanielle Lindenmuth More articles by this author , Christopher WanderlingChristopher Wanderling More articles by this author , Austin LeeAustin Lee More articles by this author , and Thomas P. FryeThomas P. Frye More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003357.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robot-assisted radical prostatectomy (RARP) is associated with improved postoperative pain control and reduced opioid requirements compared with open surgery. Recent literature has shown a decreased need for narcotic use in the post-operative period. However, there is still question over the optimal pain regimen. Our study evaluates a non-narcotic regimen for patients undergoing RARP that centers on preoperative erector spinae plane (ESP) blocks. METHODS: In association with the Department of Anesthesiology, a non-narcotic analgesic pathway was created for patients undergoing RARPs. The pathway was centered on an ESP block and replacing narcotics with multi-modal analgesia post-operatively. After IRB approval, a retrospective cohort of patients who received narcotics post-operatively and no ESP block pre-operatively was compared to a prospective cohort of patients who underwent the non-narcotic pathway. Narcotics were available for patients in the non-narcotic group if their pain was not controlled. Patients were excluded from the non-narcotic group if NSAIDs were contraindicated, if they were taking narcotics, or if they underwent a concomitant procedure at the time of RARP. Nursing pain scores were recorded for each patient, as well as post-operative morphine equivalents received, if narcotic was prescribed for home, the amount of morphine equivalents prescribed for home, and the need for any narcotic refills. RESULTS: 163 patients were in the narcotic group compared to 131 in the non-narcotic group. There was a statistically significant difference in average post-operative pain scores between the narcotic and non-narcotic groups (3.5 vs. 2.4, p<0.001) and a statistically significant difference in postoperative morphine equivalents delivered (49.4 vs. 7.4, p<0.001). In addition, only 17 patients in the non-narcotic group were discharged with a narcotic prescription for home, compared to 161 in the narcotic cohort (13.0% vs, 98.8%, p<0.001). The average length of stay was lower in the non-narcotic group (1.1 vs 1.3, p<0.001). No adverse patient events resulted from the block. CONCLUSIONS: A non-narcotic analgesic pathway centered on pre-operative ESP blocks decreased both post-operative pain scores and post-operative morphine equivalents received in patients who underwent RARP, providing an additional modality to aid in optimal, non-narcotic analgesia. Source of Funding: N/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1152 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aaron Saxton More articles by this author Deaton Jones More articles by this author Adam Visca More articles by this author Kaitlyn Mitchell More articles by this author Danielle Lindenmuth More articles by this author Christopher Wanderling More articles by this author Austin Lee More articles by this author Thomas P. Frye More articles by this author Expand All Advertisement PDF downloadLoading ...

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

The Association between Early Opioids Prescribing and the Length of Disability in Acute Lower Back Pain: A Systematic Review and Narrative Synthesis.

Background: There is conflicting evidence with respect to whether early opioid prescribing (EOP) within the first two weeks of acute Low Back Pain (LBP) onset is associated with the length of disability (LOD). The aim of this systematic review was to examine the relationship between EOP and LOD in individuals with acute LBP. Methods: A systematic search of Medline, EMBASE, and CINAHL was conducted. The Newcastle–Ottawa scale was used to assess the methodological quality of included studies. A narrative synthesis of findings was used owing to between-study heterogeneity. Results: Six cohort studies using workers’ compensation administrative data on 178,130 adults with LBP were included. Most studies were of good methodological quality. One study reported that LBP cases with EOP had higher LOD by 4 days than cases without EOP. Two studies reported that each 100 mg morphine equivalent amount (MEA) was associated with an increase in mean LOD by 0.4 day (95% confidence interval (CI): 0.3, 0.5) and 0.4 day (95% CI: 0.3, 0.4). One study showed that LBP cases with EOP had a higher hazard of continuation of time loss benefits by 1.94 (95% CI 1.86, 2.02). One study reported a dose–response relationship between MEA of EOP and LOD ranging between 5.2 days (95% CI 14.6, 25.0) for 1–140 mg MEA and 69.1 (95% CI 49.3, 89.0) for 450+ mg MEA. One study reported that LBP cases with EOP had a higher mean LOD by 3.8 days, but there was no statistically significant relationship between EOP and LOD (Hazard ratio 1.02; 95% CI 0.91, 1.13). Conclusions: The use of early opioid in the management of acute uncomplicated LBP is associated with prolonged disability duration. Further research on factors influencing inadequate adherence to evidence-based guidelines and optimal strategies to modify such factors may improve disability outcomes among patients presenting with acute LBP.

Pediatric Outcomes following Cranial Vault Remodeling with Restricted Use of Postoperative Narcotics: A Retrospective Review.

The appropriate use of narcotics for postoperative pain control is controversial because of potential medication-induced complications. The authors sought to determine the effects of narcotics in the pediatric population following cranial vault remodeling operations. A retrospective review was performed on 160 consecutive patients who underwent cranial vault remodeling for craniosynostosis. There was a statistically significant difference in total morphine equivalents in the group that experienced no emesis and those with at least one episode of emesis (0.97 morphine equivalents/kg versus 1.44 morphine equivalents/kg; p = 0.05). There was a statistically significant difference in hospital morphine equivalents in the group with documented respiratory events (average, 2.3 morphine equivalents/kg versus 1.3 morphine equivalents/kg in the nonevent group; p = 0.006). The patients who received dexmedetomidine had a trend toward a decrease in hospital narcotic administration with equivalent pain control (1.2 morphine equivalents/kg versus 1.9 morphine equivalents/kg; p = 0.09). There was a statistically significant positive correlation between total morphine equivalents for the hospitalization and hospital stay ( r = 0.27, p = 0.001). The amount of morphine equivalents used in the first 24 hours was also found to be an independent predictor of a respiratory event ( p = 0.002 by multivariate logistic regression). Independent positive predictors of hospital stay were age ( p < 0.001), intensive care unit time ( p < 0.001), and total morphine equivalents for the hospitalization ( p = 0.001) by multivariate analysis with linear regression. The authors' study demonstrates improvement in outcomes with decreased use of narcotics, which establishes that there is a need to further explore postsurgical recovery outcomes with multimodal pain control. Therapeutic, III.

Sublingual Sufentanil vs. Intravenous Fentanyl for the Treatment of Acute Postoperative Pain in the Ambulatory Surgery Center: A Randomized Clinical Trial.

Objectives Sublingual sufentanil is a novel opioid medication to treat moderate to severe pain postoperatively. This study's aim was to determine if a single dose of a sublingual sufentanil tablet (SST) is as efficacious as a single dose of intravenous (IV) fentanyl in readiness to discharge from ambulatory surgery. Methods This was a two-arm, parallel group, randomized prospective outcomes study conducted at a single, free-standing ambulatory surgery center. Patients aged 18–80 undergoing general anesthesia who developed a postoperative pain score of ≥ 4 were enrolled and randomized to receive either 30 mcg SST or 50 mcg IV fentanyl. After their initial randomized dose, rescue IV fentanyl followed by oral oxycodone if needed. Recovery length of stay from arrival in the postanesthesia care unit until readiness to discharge criteria was met based on phase 2 discharge criteria. Results 75 patients were analyzed. Readiness to discharge from the recovery room was not significantly different between either group (IV fentanyl median 65 minutes; IQR 56–89; SST 73 min, IQR 58–89; p=0.903). There was no significant difference in the amount of morphine equivalents (MME) of rescue opioids needed (IV fentanyl median rescue MME of 22.5, IQR 13.1–23.4; SST median rescue MME of 15.0, IQR 7.5–30.0; p=0.742). The change in pain from PACU initially, and on discharge was not significantly different (IV fentanyl initial pain minus pain on discharge median 3, IQR 2–4; SST initial pain minus pain on discharge median 4, IQR 2–5.5; p=0.079). There was no difference in the six-item screener and the Overall Benefit of Analgesic Survey Score. Discussion. In conclusion, patients who received a sublingual sufentanil 30 mcg tablet had no significant differences in PACU length of stay or rescue analgesic usage when compared to intravenous fentanyl 50 mcg.

Fascia Iliaca Block in Hip and Femur Fractures to Reduce Opioid Use

BackgroundFascia iliaca compartment block (FICB) has become a keystone technique for acute pain management in patients with hip and proximal femur fractures. ObjectivesTo demonstrate that administering FICB preoperatively to patients with hip or proximal femur fractures in the emergency department (ED) is likely to reduce opioid use and related complications, and to decrease hospital length of stay (LOS). MethodsAn unblinded study of adult patients with hip and proximal femur fractures who consented to receive an FICB with 30 cc of bupivacaine with epinephrine administered in the ED. We compared this group with a contemporaneous group of controls who only received systemic opioids. Over the course of approximately 6 months, main outcome measured between the two groups was amount of morphine equivalents given from block administration until 8 h after. We also compared complications such as delirium, constipation, and bleeding rates (oozing from injection site or hematoma formation). ResultsA total of 166 patients with hip and proximal femur fractures from August 12, 2018 to April 25, 2021; 81 received FICB plus systemic opioids, and 85 received only systemic opioids. Among the FICB group, morphine equivalents were reduced by 0.6 mg/h with no significant difference in LOS. A statistically significant difference in opioid-related adverse outcomes was found between the anticoagulated group vs. the no anticoagulation group. ConclusionsFICB is a safe and effective preoperative technique for initial pain management in patients with hip and proximal femur fractures, as it can also be used with additional systemic opioids. FICB administration may reduce systemic opioid use preoperatively, thus reducing opioid-related adverse effects with no significant impact on hospital LOS.

A retrospective study evaluating the trend of opioid prescribing in low back pain at a UK teaching hospital.

Current data suggest that the chronic use of strong opioids in low back pain (LBP) is increasing. There is evidence for the use of opioids in the initial management of LBP, but the efficacy in the long term is unknown. This article intends to examine the use of opioids in patients with chronic LBP over a period of three doctor-led clinics. Single-center retrospective cohort study following 200 patients through the pain clinic at a UK teaching hospital for more than two clinic visits, up to a maximum of three. Data concerning demographics, pain scores, medication changes, and clinic outcome. Data collected showed that there was a significant correlation between baseline morphine equivalent amount (MEA) and final clinic MEA; initial pain scores and final clinic MEA; cause of LBP and final clinic LBP; and traumatic LBP and absolute change in MEA. There was no association between number of physical interventions and MEA. The sample also showed an average absolute change in MEA by 2.93 ± 57.86 mg. The proportion of patients with a MEA of >50 mg/d increased from 24 to 29 percent. The proportion of patients on opioids at least one opioid increased by 10 percent. Significant predictors of final clinic MEA were initial pain scores, baseline MEA, and the cause of LBP. Duration of pain was a poor predictor of MEA. There was no association between MEA and number of interventions. In this cohort, the trend seems to be increasing the number and dose of opioids in patients with LBP.

Analgesic effects of intravenous ketamine after spinal anaesthesia for non-elective caesarean delivery: a randomised controlled trial

ObjectivesThis study aimed to determine if low dose intravenous ketamine is effective in reducing opioid use and pain after non-elective caesarean delivery.DesignProspective, randomised, double-blind.SettingTertiary hospital, Bisheshwar Prasad Koirala Institute of...

Predictors of postoperative opioid use in NCAA Division 1 collegiate athletes

BackgroundWith the growing severity of the opioid epidemic in the United States, it is increasingly important for surgeons to understand the opioid requirements of their patients, especially in the population of collegiate athletes. The purpose of this study is to determine variables influencing the quantity of total morphine milligram equivalents (TMEs) and percent of prescribed TMEs used following surgery in Division 1 collegiate athletes. MethodsA consecutive cohort of 25 Division 1 collegiate athletes from one institution undergoing knee or shoulder surgery at a single hospital for sport-related injuries between December 2016 and December 2018 were retrospectively identified. A regional prescription drug monitoring program was used to verify discharge medications. Patients were instructed to bring their unused pills to a follow-up visit 2–4 days after surgery. The amount of opioids prescribed and used was standardized using morphine conversion factors to determine milligram morphine equivalents. TMEs Used was determined by summing the amount of morphine equivalents the patients used of their discharge opioids. The Percent of TMEs Used was determined by dividing the amount of TMEs used by the amount of TMEs prescribed at discharge. Demographic variables and other regulated prescriptions were also recorded. Bivariate and multivariate analyses were used to determine variables that influence and/or predict the amount of TMEs Used and Percent of TMEs Used. ResultsMultivariable regression found that a history of non-analgesic controlled substance use (p = 0.027) and the amount of TMEs prescribed at discharge (p < 0.001) were both independent predictors of the amount of TMEs Used. Operative site (p = 0.047) and number of prior orthopaedic surgeries (p = 0.016) were independent predictors of the Percent of TMEs Used. ConclusionsProviders for Division I collegiate athletes should carefully consider a patient’s nonanalgesic controlled substance history, comorbidities, and prescribed opioid burden when planning a postoperative pain management course.

189 Opioid Prescribing Habits in the Acute Emergency Department Visit: Before and After Implementation of Departmental Prescribing Guidelines

A rise in opioid-related overdoses, opioid-related deaths and possible association with recent decreases in life expectancy has captivated national attention. This has led to increased scrutiny of outpatient opioid prescribing by physicians. There have been multiple studies of emergency department (ED) populations which examine prescriptions that are provided for home use; however, we have not discovered studies that have evaluated intravenous (IV) opioid utilization for treatment of pain in the ED. At our tertiary care ED, a set of “opioid prescribing guidelines” (OPG) was created in September 2016. The OPG includes discussion of opioid risks, intention to maximize non-opioid analgesia, transparency about reviewing the Michigan Automated Prescriptions System (MAPS), and delineation of acute and chronic pain. It is not clear if such guidelines affect the prescribing patterns of clinicians or if they encourage more “appropriate” utilization of opioid medications. The primary objective is to determine if the overall number of IV opioids and total morphine equivalents (ME) changed after initiation of the OPG. A retrospective cohort study was conducted at a single-site tertiary care center with an annual census of 130,000 ED visits. We used ED pharmacy electronic medical records to compare opioid prescribing habits before and after the adoption of departmental OPG. We included patients aged 18 years and older who presented to the ED from 2015-2017. All prescriptions of fentanyl, morphine, and hydromorphone administered from November 2015 to July 2017 were tabulated to assess temporal trends in the number of prescriptions and ME of opioid medications. August through October of 2016 were excluded from data analysis to allow a washout period surrounding the adoption of the guidelines. Poisson and ordinary linear regression analyses were employed to evaluate any difference in prescribing habits before and after adoption of the guidelines. A total of 71,430 opioid-prescribing records were analyzed over the study period. The estimated mean of opioid prescriptions per 1,000 patients in the “pre” OPG period was 1797.5 (95% CI 1747.2 to 1847.8) and 1765.8 (95% CI 1715.7 to 1815.9) in the “post” period, resulting a decrease of 31.7 (95% CI 0 to 63.9, p-value = 0.05). Moreover, among patients who received opioids while in the ED, the estimated mean of ME per patient was 8.9 (95% CI 8.6 to 9.2) in the “pre” period and 8.4 (95% CI 8.1 to 8.7) in the “post” period, resulting a decrease of 0.5 (95% CI 0.3 to 0.7, p-value < 0.001). In our ED, after adoption of department-wide OPG, the number of opioids prescribed for pain during the ED encounter decreased but was not statistically significant, while the amount of ME statistically significantly decreased over the study period. Intradepartmental prescribing guidelines may be an effective tool to empower clinicians and may lead to more judicious prescribing of opioid medications.

Association of Celecoxib Use With Decreased Opioid Requirements After Head and Neck Cancer Surgery With Free Tissue Reconstruction

Head and neck cancer (HNC) surgery with free tissue reconstruction is associated with considerable postoperative pain. Opioids are typically used but can have adverse effects, including respiratory depression and high rates of dependence and addiction. Safe alternative analgesics that minimize opioid requirements are beneficial in HNC surgery. To investigate the association of celecoxib use with opioid requirements in the postoperative setting after HNC surgery with free tissue reconstruction. A retrospective, matched-cohort study of 147 patients who had undergone HNC surgery with free tissue reconstruction between June 2015 and Sept 2017 in an academic cancer hospital. Patients were separated into groups based on whether celecoxib had been used perioperatively or not. These groups were then matched by stage and site resulting in 102 included participants (51 celecoxib, 51 control). Oral, intravenous (IV), and total morphine equivalents used in the postoperative setting per patient per day. There were 51 patients in the celecoxib cohort (19 women and 32 men) and 51 patients in the control cohort (20 women and 31 men) who met inclusion criteria after clinicopathologic data were matched. The mean age of the celecoxib and control cohorts was 61.6 years and 66.1 years, respectively. Treatment with celecoxib in the postoperative setting was associated with decreased mean use of opioids in oral (mean difference, 9.9 mg/d; 95% CI, -1.2 to 21.1), IV (mean difference, 3.9 mg/d; 95% CI, 1.0-6.8), and total (mean difference, 14 mg/d; 95% CI, 2.6-25.4) amount of morphine equivalents per day. When patients were matched to surgical procedure, the effect was more significant. Patients who underwent composite oral resection and received celecoxib had decreased opioid use in oral (mean difference, 25 mg/d; 95% CI, 12.5-25.4), IV (mean difference, 3.4 mg/d; 95% CI, 1.5-5.5), and total (mean difference, 28.4 mg/d; 95% CI, 15.7-41.5) amounts compared with those in the control group. There was no significant difference in complication rates between the 2 cohorts. Use of celecoxib after head and neck cancer surgery and reconstruction with free tissue transfer was associated with a decrease in oral, IV, and total opioid requirements without increasing surgical or flap-related complications.

Intrathecal Baclofen Therapy Prior to Spinal Fusion for Patients With Gross Motor Function Classification System IV-V Cerebral Palsy.

Patients with Gross Motor Function Classification System (GMFCS) IV-V cerebral palsy (CP) have significant spasticity and frequently develop scoliosis. Intrathecal baclofen (ITB) pumps are effective in managing spasticity. The effect of ITB therapy on the postoperative course following spinal fusion in patients with GMFCS IV-V CP has not been described. This study sought to compare postoperative recovery, including complications, in patients using ITB therapy with those with no ITB therapy. Evaluate the effect of ITB on the postoperative recovery for patients with GMFCS IV-V CP who undergo spinal fusion for scoliosis. Health records for patients with GMFCS IV-V CP who underwent a spinal fusion for scoliosis at a major quaternary-care children's hospital from January 2009 to October 2015 were reviewed and relevant data were abstracted. Descriptive statistics and regression models were used to compare patients. Sixty-nine patients were included-19 ITB therapy and 50 no ITB therapy. Demographic and operative characteristics were similar across groups. The mean length of stay for patients in the ITB therapy group was 11.2 days and 14.3 days for the no ITB therapy group, with no difference between groups (p = .12). Pain scores in both groups decreased at the same rate, with scores in the ITB therapy group averaging one-half point lower (p = .32). The average amount of morphine equivalents (p = .71) and benzodiazepine equivalents (p = .53) used were similar between groups. Complication rates were significantly different between groups. Four (21%) of the ITB therapy patients had 1 or more complications whereas 28 (56%, p = .01) in the no ITB therapy group had 1 or more complications. The average number of complications per patient in the ITB therapy group was 0.3 (SD: 0.075, range: 0-3) and the no ITB therapy group was 1.1 (SD: 1.1, range: 0-6, p = .01). There was no significant difference in length of stay, pain scores, or pain/spasticity medication use between groups after spinal fusion, but there was a significantly lower incidence of complications in the ITB therapy group.

Effect of pre-injection opioid use on post-injection patient-reported outcomes following epidural steroid injections for radicular pain

Background ContextChronic opioid therapy is associated with worse patient-reported outcomes (PROs) following spine surgery. However, little literature exists on the relationship between opioid use and PROs following epidural steroid injections for radicular pain. PurposeWe evaluated the association between pre-injection opioid use and PROs following spine epidural steroid injection. Study DesignThis study is a retrospective analysis of a prospective longitudinal registry database. Patient SampleA total of 392 patients within our database who were undergoing epidural steroid injections (ESIs) at our institution for degenerative structural spine diagnoses and met our inclusion criteria were included in this study. Outcome MeasuresPatient-reported outcomes for disability (Oswestry Disability Index/Neck Disability Index [ODI/NDI)]), quality of life (EuroQol-5D [EQ-5D]), and pain (Numerical Rating Scale scores for back pain, neck pain, leg pain, and arm pain [NRS-BP/NP/LP/AP]) were assessed at baseline and at 3 and 12 months post-injection. MethodsMultivariable proportional odds logistic regression models were created to examine the relationship between pre-injection opioid use and post-injection PROs. A logistic regression with Bayesian Markov chain Monte Carlo parameter estimation was used to investigate a possible cutoff value of pre-injection opioid use above which the effectiveness of ESI (as measured by minimum clinically important difference [MCID] for ODI/NDI) decreases. ResultsA total of 276 patients with complete 12-month follow-up following ESI were analyzed. The mean pre-injection daily morphine equivalent amount (MEA) was 14.7 mg (95% confidence interval [CI] 12.4 mg–19.1 mg) for the cohort. Pre-injection opioid use was associated with slightly higher odds of worse disability (odds ratio [OR] 1.03, p=.03) and leg/arm pain (OR 1.01, p=.04) scores at 3 months post-injection only. No significant association between pre-injection opioid use and MCID for ODI/NDI was found, although a cutoff of 55.5 mg/day might serve as a significant threshold. ConclusionIncreased pre-injection opioid use does not impact long-term outcomes after ESIs for degenerative spine diseases. A pre-injection MEA around 50 mg/day may represent a threshold above which the 3-month effectiveness of ESI for back- and neck-related disability decreases. Epidural steroid injection is an effective treatment modality for pain in patients using opioids, and can be part of a multimodal strategy for opioid independence.

Preoperative opioid use and its association with perioperative opioid demand and postoperative opioid independence in patients undergoing spine surgery.

Prospective cohort. To assess whether preoperative opioid use is associated with increased perioperative opioid demand and postoperative opioid independence in patients undergoing spine surgery. Previous work has demonstrated increased opioid requirements during the intraoperative and immediate postoperative period in patients with high levels of preoperative opioid use. Despite this, they remain a common agent class used for the management of pain in patients prior to spine surgery. A total of 583 patients were included. Self-reported daily opioid consumption was obtained preoperatively and converted into morphine equivalent amounts and opioid use was recorded at the 12-month postoperative time. Intraoperative and immediate postoperative opioid demand was calculated. Linear regression analyses for intraoperative and immediate postoperative opioid demand while logistic regression analyses for opioid independence at 12 months including relevant covariates such as depression and anxiety were performed. The median preoperative morphine equivalent amount for the cohort was 8.75 mg, with 55% of patients reporting some degree of opioid use. Younger age, more invasive surgery, anxiety, and primary surgery were significantly associated with increased intraoperative opioid demand (P < 0.05). Younger age, anxiety, and greater preoperative opioid use were significantly associated with increased immediate postoperative opioid demand (P < 0.05). More invasive surgery, anxiety, revision surgery, and greater preoperative opioid use were significantly associated with a decreased incidence of opioid independence at 12 months postoperatively (P < 0.01). Greater preoperative opioid use prior to undergoing spine surgery predicts increased immediate postoperative opioid demand and decreased incidence of postoperative opioid independence. Psychiatric diagnoses in those using preoperative opioids were predictors of continued opioid use at 12 months. Patients may benefit from preoperative counseling that emphasizes minimizing opioid use prior to undergoing spine surgery. 2.

Continuous Regional Anesthesia Provides Effective Pain Management and Reduces Opioid Requirement Following Major Lower Limb Amputation

Postoperative stump pain after major lower limb amputation is a significant impediment to the recovery of amputees. The vast majority of patients require opioid analgesics after surgery, which are associated with opioid-related side effects. Here, we investigate whether intraoperative placement of a peripheral nerve stump catheter, followed by continuous infusion of local anesthetic, is as effective at pain control as current analgesic practices. If beneficial, this procedure could potentially reduce postamputation opioid consumption and opioid-related adverse effects. A retrospective record review was conducted of 198 patients over a 4-year period who had undergone a major lower limb amputation for indications related to peripheral vascular disease. Postoperatively, 102 patients who received a stump catheter were compared with 96 patients who did not. The primary outcomes of this study were the amount of morphine equivalents used in the first 72 hours postoperatively and postoperative pain intensity in the first 24 hours. A total of 198 lower-limb amputations were selected for analyses. Multiple regression analyses indicated that perineural catheter use was associated with a lower cumulative postoperative opioid consumption over the first 72 hours but not postoperative pain scores at 24 hours. Stump catheter use led to a 40% reduction in opioid use during the first 72 hours postoperatively. Mixed-model repeated-measures analysis demonstrated that this opioid reduction was consistent over time. Other variables related to total opioid use included age, presurgical chronic pain, presurgical opioid use, and patient controlled analgesia. Continuous stump infusions of local anesthetic are a safe and effective method for reducing postamputation opioid analgesic medications after major lower limp amputation.

Continuous Regional Anaesthesia Provides Effective Pain Management and Reduces Opioid Requirement Following Major Lower Limb Amputation

Postoperative stump pain after major lower limb amputation is a significant impediment to the recovery of amputees. The vast majority of patients require opioid analgesics following surgery, which are associated with opioid-related side-effects. Here, we investigate whether intraoperative placement of a peripheral nerve stump catheter followed by continuous infusion of local anesthetic is as effective at pain control as current analgesic practices. If beneficial, this procedure could potentially reduce post-amputation opioid consumption and opioid-related adverse effects. A retrospective chart review was conducted of 198 patients over a 4-year period who had undergone a major lower limb amputation for indications related to peripheral vascular disease. Postoperatively, 102 patients received a perineural catheter were compared to 96 patients who did not. The primary outcomes of this study were the amount of morphine equivalents used in the first 72 hours postoperatively and postoperative pain intensity in the first 24 hours. A total of 198 lower-limb amputations were selected for analyses. Multiple regression analyses indicated that perineural catheter use was associated with a lower cumulative postoperative opioid consumption over the first 72 hours but not postoperative pain scores at 24 hours. Perineural catheter use led to a 40% reduction in opioid use during the first 72 hours postoperatively. Mixed model repeated measures analysis demonstrated that this opioid reduction was consistent over time. Other variables related to total opioid use included age, pre-surgical chronic pain, pre-surgical opioid use, patient-controlled analgesia. Continuous perineural infusions of local anesthetic are a safe and effective method for reducing post-amputation opioid analgesic medications after major lower limp amputation.

Preoperative Opioid Use as a Predictor of Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery.

Opioids are commonly used for preoperative pain management in patients undergoing spine surgery. The objective of this investigation was to assess whether preoperative opioid use predicts worse self-reported outcomes in patients undergoing spine surgery. Five hundred and eighty-three patients undergoing lumbar, thoracolumbar, or cervical spine surgery to treat a structural lesion were included in this prospective cohort study. Self-reported preoperative opioid consumption data were obtained at the preoperative visit and were converted to the corresponding daily morphine equivalent amount. Patient-reported outcome measures were assessed at three and twelve months postoperatively via the 12-Item Short-Form Health Survey and the EuroQol-5D questionnaire, as well as, when appropriate, the Oswestry Disability Index and the Neck Disability Index. Separate multivariable linear regression analyses were then performed. At the preoperative evaluation, of the 583 patients, 56% (326 patients) reported some degree of opioid use. Multivariable analyses controlling for age, sex, diabetes, smoking, surgery invasiveness, revision surgery, preoperative Modified Somatic Perception Questionnaire score, preoperative Zung Depression Scale score, and baseline outcome score found that increased preoperative opioid use was a significant predictor (p < 0.05) of decreased 12-Item Short-Form Health Survey and EuroQol-5D scores, as well as of increased Oswestry Disability Index and Neck Disability Index scores at three and twelve months postoperatively. Every 10-mg increase in daily morphine equivalent amount taken preoperatively was associated with a 0.03 decrease in the 12-Item Short-Form Health Survey physical component summary and mental component summary scores, a 0.01 decrease in the EuroQol-5D score, and a 0.5 increase in the Oswestry Disability Index and Neck Disability Index score at twelve months postoperatively. Higher preoperative Modified Somatic Perception Questionnaire and Zung Depression Scale scores were also significant negative predictors (p < 0.05). Increased preoperative opioid consumption, Modified Somatic Perception Questionnaire score, and Zung Depression Scale score prior to undergoing spine surgery predicted worse patient-reported outcomes. This suggests the potential benefit of psychological and opioid screening with a multidisciplinary approach that includes weaning of opioid use in the preoperative period and close opioid monitoring postoperatively. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Paravertebral Blocks in Breast Cancer Surgery: Is There a Difference in Postoperative Pain, Nausea, and Vomiting?

The purpose of this study was to evaluate postoperative pain and postoperative nausea and vomiting (PONV) in patients with paravertebral blocks (PVB) undergoing breast cancer surgery with or without axillary staging. An Institutional Review Board approved, retrospective chart review from January 2007 to December 2009 was performed at a single institution. Charts were reviewed for type of breast cancer surgery, axillary staging, PVB, PONV, postoperative pain score, dosages of pain medication and antiemetic medication given in the Post Anesthesia Care Unit (PACU), and during the postoperative days (POD). The study population consisted of females with a diagnosis of breast cancer undergoing breast cancer surgery, with or without axillary staging. Patients were excluded if they: had simultaneous myocutaneous tissue flap breast reconstruction, had additional surgical procedures, used continuous delivery postoperative pain medications, had a history of chronic pain, or had a history of chronic antiemetics prior to surgery. All patients received standard perioperative medications per the anesthesia department. A total of 419 patients underwent breast cancer surgery during the given time period of which 337 patients were able to be included in the study. Of these patients, 241 of the 337 patients had PVB and 96 patients did not have PVB. The mean age was 59.5 years. The mean BMI was 28.7 kg/m(2). Also, 45.5% of the patients who had PVB (110) had a mastectomy, while 41.1% of patients in the non-PVB cohort (39) had a mastectomy. In addition, 45 patients with PVB had immediate tissue expander reconstruction and only 14 patients in the non-PVB group. Of patients with PVB, 53.3% (129) had a sentinel lymph node biopsy (SLN) and 33.5% (81) had full axillary dissections. Of patients in the non-PVB, 35.8% (34) had no axillary staging and 44.2% (42) underwent SLN. Also, 229 patients with PVB and 78 patients without PVB had a general anesthetic. Only 3.3% of patients with PVB and 4.2% of patients without PVB had postoperative nausea (P = 0.746). One patient with PVB and no patients without PVB reported emesis in the PACU (P = 1). There was no difference in morphine equivalents (P = 0.234) or in pain scores (P = 0.521) between the 2 groups in the PACU. There was no difference in amount of morphine equivalents given on POD0 (P = 0.8) or POD1 (P = 0.079). The reconstruction patients with PVB used less opioid analgesic on POD1 compared with the non-PVB reconstruction group (P = 0.02). Patients undergoing breast cancer surgery who have paravertebral blocks have similar postoperative nausea and vomiting and similar postoperative pain scores compared with patients without paravertebral blocks. PVB may have an important role in decreasing postoperative pain and opioid analgesic usage in patients electing to have immediate breast reconstruction with tissue expanders.

The Addition of Tramadol as a Second Opioid May Improve Pain Relief in Severe Osteoarthritis: A Prospective Study

Opioid combination has been shown to reduce the need for escalating doses for the treatment of cancer pain. A prospective study was planned to evaluate the addition of tramadol to a stronger opioid for the treatment of severe pain as a result of osteoarthritis, previously uncontrolled by non-opioid analgesics or weak opioids. All subjects received tramadol 200 mg and tizanidine 2 mg. At 2 weeks, tramadol was discontinued for patients still reporting poor pain relief (effectiveness ≤50%), and a stronger opioid was titrated to a morphine equivalent amount (MEA) of 40-60 mg orally. After two additional weeks, patients were then divided into two groups: the Strong Opioid Group (SO) and the Tramadol plus the Strong Opioid Group (TSO). The SO group was allowed to escalate opioid dose for lack of effectiveness; the TSO group received tramadol 150 mg daily, thereafter additional strong opioid titration was allowed. A total of 74 patients were studied: SO (n = 40) and TSOG (n = 34). All patients eventually achieved pain relief quality, with both groups reporting similar Karnofsky Performance Scale effectiveness. The SO group achieved satisfactory pain relief (>50%) at an average daily oral MEA of 120 mg. TSO subjects achieved satisfactory pain relief (>50%) at an average daily oral MEA of 95 mg. The addition of tramadol provided a synergistic effect resulting in a 30-mg decrease in necessary morphine equivalents with fewer opioid-related adverse effects.

Predictors of Pain Severity 3 Months after Serious Injury

Injury is a common initiating event for persistent pain. The presentation of injured patients to hospital represents an opportunity to identify patients at high risk of persistent pain and triage them to early intervention. Although a range of physical, psychological, and social risk factors have been implicated in the transition from acute to persistent pain, these factors have not been tested concurrently in a prospective study. This study aimed to determine the degree to which pain severity at 3 months can be predicted at the time of injury and which independent factors predicted pain severity. A large prospective cohort study was conducted recruiting patients from two trauma hospitals during their acute admission. Patients were assessed with a comprehensive battery of known and possible risk factors for persistent pain. Patients were assessed for pain severity on a visual analog scale over the past 24 hours at 3 months. Two hundred ninety patients were recruited, and 242 were followed up at 3 months. Older age, female gender, past alcohol dependence, lower physical role function, pain severity, amount of morphine equivalents administered on the day of assessment, and pain control attitudes predicted pain severity at 3 months. The variance attributed to these factors was 22%. Injured patients with a number of these factors may warrant increased monitoring and early triage to specialist pain services.