Multimodal Perioperative Pain Management Research Articles

The Efficacy of Preoperative Video-Based Opioid Counseling on Postoperative Opioid Consumption After Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

BackgroundThere are myriad strategies to reduce opioid consumption after total knee arthroplasty (TKA). Recent studies have suggested that preoperative counseling may reduce opioid use after a variety of orthopedic procedures. The purpose of this study was to investigate whether preoperative video-based patient education regarding opioid use and abuse reduces opioid consumption after TKA. MethodsIn this prospective randomized controlled trial, patients were randomized before TKA to either receive preoperative video-based counseling or not. Counseling involved a pretaped 5-minute video that educated patients on statistics regarding the “opioid epidemic” and discussed safe use and alternatives to opioids after TKA. There were no significant differences in baseline patient demographics between groups. All patients received a similar multimodal perioperative pain management protocol and completed a daily diary for 2 weeks postoperatively. Diary records measured pain levels using a visual analog score, opioid consumption, side effects experienced, and patient opinion and satisfaction regarding their pain control. ResultsPatients in the counseling group consumed significantly less morphine milligram equivalents on postoperative days 0 to 3 (78.8 versus 106.1, P = .020) and in week one postoperatively (129.9 versus 180.7, P = .028), with a trend of less consumption over 2 weeks postoperatively (186.9 versus 239.1, P = .194). There were no significant differences in the number of patients requiring refills, side effects, or daily pain levels between the 2 groups. ConclusionsThis study found significantly decreased opioid consumption within the first week after TKA in patients who received preoperative video counseling.

Paracetamol add-on treatment for perioperative pain management in dogs undergoing single-site thoracolumbar hemilaminectomy: a prospective clinical study

In this prospective, double-blinded, randomized, clinical trial, it was evaluated whether paracetamol, as an adjunct to NSAID and opioid analgesia, might limit the requirements for intraoperative fentanyl and postoperative methadone administration in dogs undergoing a singlesite thoracolumbar hemilaminectomy for surgical treatment of an intervertebral disc extrusion. Twelve client-owned dogs were randomly assigned to two multimodal analgesia groups: NSAID + paracetamol group (group NP) and NSAID + placebo group (group N). Intraoperative analgesic assessment was based on the clinical evaluation of a nociceptive response, whereas postoperative analgesic assessment was determined by using the short form of the Glasgow Composite Pain Scale. No statistically significant difference was found in both groups for the intraoperative need for fentanyl (P = 0.18). The probability of having to administer rescue analgesia postoperatively was significantly higher in group N than in group NP (P = 0.01). For both groups, there were no serious side effects reported, nor was any significant difference found between both groups regarding the occurrence of side effects (P = 0.55). Despite multimodal perioperative pain management consisting of a full μ-agonist opioid, a NSAID and paracetamol, intraoperative rescue analgesia was still required, although the need for postoperative opioid based analgesia was significantly lower in group NP.

Caring for Our Patients With Opioid Use Disorder in the Perioperative Period: A Guide for the Anesthesiologist.

Opioid use disorder (OUD) is a rising public health crisis, impacting millions of individuals and families worldwide. Anesthesiologists can play a key role in improving morbidity and mortality around the time of surgery by informing perioperative teams and guiding evidence-based care and access to life-saving treatment for patients with active OUD or in recovery. This article serves as an educational resource for the anesthesiologist caring for patients with OUD and is the second in a series of articles published in Anesthesia & Analgesia on the anesthetic and analgesic management of patients with substance use disorders. The article is divided into 4 sections: (1) background to OUD, treatment principles, and the anesthesiologist; (2) perioperative considerations for patients prescribed medications for OUD (MOUD); (3) perioperative considerations for patients with active, untreated OUD; and (4) nonopioid and nonpharmacologic principles of multimodal perioperative pain management for patients with untreated, active OUD, or in recovery. The article concludes with a stepwise approach for the anesthesiologist to support OUD treatment and recovery. The anesthesiologist is an important leader of the perioperative team to promote these suggested best practices and help save lives.

Raising the Bar: Multimodal Analgesia with Transdermal Lidocaine for Nuss Repair of Pectus Excavatum Decreases Length of Stay and Opioid Use

IntroPain management for minimally invasive (Nuss) repair of pectus excavatum (PE) is challenging, particularly as the judicious use of opioids has become a patient safety priority. Multi-modal pain management protocols are increasingly used, but there is limited experience using transdermal lidocaine patches (TLP) in this patient population. MethodsPediatric anesthesiologists and surgeons in a children's hospital within a hospital designed a multi-modal perioperative pain management protocol for patients undergoing Nuss repair of PE (IRB00068901). The protocol included use of TLP in addition to other adjuncts such as methadone, gabapentin, and NSAIDS. Following initiation of the protocol charts were reviewed retrospectively, comparing outcomes before and after implementation of the protocol. ResultsForty-nine patients underwent a Nuss procedure between 2013 and 2022, 15 prior to initiation of the protocol and 34 after. Patient demographics and operative length were similar between the two groups. Average length of stay decreased from 4.7 to 3.3 days and reported opioid use at the time of the first outpatient post-op visit dropped from 60% to 24% (p < 0.05). Morphine milligram equivalents (MME) usage was decreased following implementation during hospital admission, at discharge, and at first post-operative visit (464 vs. 169, 1288 vs. 218, and 214 vs. 56, respectfully, p < 0.05). There were no ED visits or readmissions <30 days related to post-operative pain. ConclusionPost-operative opioid usage and hospital length of stay were decreased after initiation of the protocol. Transdermal lidocaine patches may be a helpful adjunct to minimize narcotic requirements after repair of pectus excavatum. Level of EvidenceLevel II.

Effectiveness of Bariatric Surgery Targeting Opioid Prescriptions (BSTOP) protocol on postoperative pain control.

BackgroundSurgical pain management is a critical component in the success of bariatric procedures. With the opioid epidemic, there have been increased efforts to decrease opioid use. In 2019, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program developed the BSTOP protocol, a multimodal perioperative pain management regimen to minimize opioid use. The objective of this study is to evaluate the effectiveness of the BSTOP protocol on patients’ need for opioid medications during their perioperative care.MethodsThis is a single-institution prospective cohort study on patients who underwent bariatric surgery from 10/2019 to 5/2021. Data was collected on morphine equivalent dose of opioids during different stages of inpatient and outpatient care. BSTOP was implemented on 7/2020. Primary outcomes were total inpatient and outpatient opioid use as well as hospital length of hospital stay (LOS). Gabapentin was removed from the protocol between 10/20/2020 and 12/31/2020 due to side effects; it was re-implemented on 1/1/2021 due to observed spikes in opioid use during its absence.Results1264 patients who had bariatric surgery between 10/2019 and 5/2021 were included in the study, with 409 patients before (pre-BSTOP) and 855 patients after BSTOP implementation. There was a 36% reduction in total inpatient opiate use and a 57% reduction in total outpatient opiate use. LOS also significantly decreased, from 1.53 to 1.28 days. 179 patients received BSTOP without gabapentin. These patients used more opioids in the post-anesthesia care unit and on the inpatient floors compared to pre-BSTOP and BSTOP with gabapentin patients. With total inpatient and outpatient opioid use, patients on BSTOP without gabapentin used fewer opioids than those pre-BSTOP. However, those on BSTOP without gabapentin used more opioids than those with gabapentin.ConclusionThe BSTOP protocol significantly reduced inpatient and outpatient opioid use as well as LOS. Gabapentin is a crucial component of the BSTOP protocol.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-022-09646-4.

Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation.

BackgroundAs enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay.MethodsMembers of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020–2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes.ResultsEarly experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing.ConclusionsThe SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.

Opioid-free shoulder arthroplasty is safe, effective, and predictable compared with a traditional perioperative opiate regimen: a randomized controlled trial of a new clinical care pathway.

Opiate-based regimens have been used as a foundation of postoperative analgesia in orthopedic surgery for decades, and the vast majority of orthopedic patients in the United States receive postoperative opioid prescriptions. Both the safety and efficacy of opioid use in orthopedic patients have been questioned because of mounting evidence that postoperative opioid use can be detrimental to outcomes and patient satisfaction. The purpose of this study is to compare a new, opioid-free pain management pathway with a traditional opioid-containing, multimodal pathway in patients undergoing shoulder arthroplasty. This is a single-center randomized clinical trial in which 67 patients who underwent shoulder arthroplasty were allocated into 2 treatment arms: either a completely opioid-free, multimodal perioperative pain management pathway (OF), or a traditional opioid-containing perioperative pain management pathway (OC). Pain was measured on a numeric rating scale from 0 to 10 at 6-, 12-, 24-hour, 2-week, and 6-week time points. Deviations from the OF pathway, morphine milligram equivalents, readmissions, and opioid-related side effects were analyzed. Pain levels were significantly lower in the OF group at 12 hours, 24 hours, and 2 weeks. At 12 hours, the median pain rating was 0 compared with a median pain rating of 3 in the OC group (P=.003). At 24 hours, the OF group reported a median pain rating of 1 and the OC group reported a median pain rating of 4 (P<.001). The median pain rating at the 2-week time point in the OF group was 2 compared with 4 in the OC group (P=.006). Median pain ratings were similar between the OF group and the OC group at the 6-week time point. The median pain rating in the OF group at 6 weeks was 1, compared with 1.5 in the OC group. Of the 35 patients in the OF pathway, 1 required a rescue opioid medication for left cervical radiculopathy that ultimately necessitated cervical spine fusion after recovery from right shoulder arthroplasty, and 1 was noted to have taken an opioid medication, diverted from a prior prescription, at the 2-week visit. The morphine milliequivalents received in the OF group was 20 compared with 4936.25 in the OC group. There were no readmissions in the OF pathway, and no differences between the groups with regard to constipation, falls, or delirium. A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively.

Clinical effect of rectus sheath block compared to intrathecal morphine injection for minimally invasive colorectal cancer surgery: a propensity score-matched study.

To evaluate the postoperative outcomes of a multimodal perioperative pain management protocol with rectus sheath blocks (RSBs) or intrathecal morphine (ITM) injection for minimally invasive colorectal cancer surgery. A total of 112 patients underwent minimally invasive colorectal surgery. Forty-one patients underwent RSB (group 1), whereas 71 patients underwent ITM (group 2) in addition to multimodal pain management using enhanced recovery after the surgery protocol. To adjust for the baseline differences and selection bias, baseline characteristics and postoperative outcomes were compared using propensity score matching. Forty patients were evaluated in each group. There was no significant difference in the length of hospital stay between the two groups. According to the Comprehensive Complication Index (CCI) score, the postoperative complication rate was significantly lower in the RSB group (3.0 ± 7.8) than in the ITM group (8.1 ± 10.9; p = 0.016). During the first 24h after surgery, the median postoperative visual analog scale score was significantly higher in the RSB group than in the ITM group (2.0 ± 1.1 vs. 1.5 ± 1.2; p = 0.048). Postoperative morphine use was also significantly higher in the RSB group than in the ITM group in the first 24h (23.7 ± 19.8 vs 11.6 ± 15.6%; p = 0.003) and 48h (16.9 ± 24.8 vs. 7.5 ± 11.9; p = 0.036) after surgery. Significant urinary retention occurred after the in the RSB and ITM groups (5% vs. 45%; p < 0.001). Although the RSB group had higher morphine use during the first 48h after surgery, the length of hospital stay remained the same and the complications were less in terms of the CCI score. Thus, transperitoneal RSB is a safe and feasible approach for postoperative pain management following minimally invasive procedures.

Implementation of a Standardized Perioperative Pain Management Protocol to Reduce Opioid Prescriptions in Otolaryngologic Surgery.

To evaluate the efficacy of implementing a standardized multimodal perioperative pain management protocol in reducing opioid prescriptions following otolaryngologic surgery. Retrospective cohort study. County hospital otolaryngology practice. A perioperative pain management protocol was implemented in adults undergoing otolaryngologic surgery. This protocol included preoperative patient education and a postoperative multimodal pain regimen stratified by pain level: mild, intermediate, and high. Opioid prescriptions were compared between patient cohorts before and after protocol implementation. Patients in the pain protocol were surveyed regarding pain levels and opioid use. We analyzed 210 patients (105 preprotocol and 105 postprotocol). Mean ± SD morphine milligram equivalents (MMEs) prescribed decreased from 132.5 ± 117.8 to 53.6 ± 63.9 (P < .05) following protocol implementation. Mean MMEs prescribed significantly decreased (P < .05) for each procedure pain tier: mild (107.4 to 40.5), intermediate (112.8 to 48.1), and high (240.4 to 105.0). Mean MMEs prescribed significantly decreased (P < .05) for each procedure type: endocrine (105.6 to 44.4), facial plastics (225.0 to 50.0), general (160.9 to 105.7), head and neck oncology (138.6 to 77.1), laryngology (53.8 to 12.5), otology (77.5 to 42.9), rhinology (142.2 to 44.4), and trauma (288.0 to 24.5). Protocol patients reported a mean 1-week postoperative pain score of 3.4, used opioids for a mean 3.1 days, and used only 39% of their prescribed opioids. Preoperative counseling and standardization of a multimodal perioperative pain regimen for otolaryngology procedures can effectively lower amount of opioid prescriptions while maintaining low levels of postoperative pain.

Quadratus lumborum block in pediatric patients - a case series

Introduction. The quadratus lumborum block (QLB) was the first interfascial plane block introduced to the Leskovac General Hospital thanks to the Kybele Inc. international teaching program in April 2017. Outlines of cases. During the period from April 2017 to December 2019, 22 pediatric patients underwent various surgical procedures and had the QLB type 1 block as a part of a multimodal perioperative pain management plan. Unilateral QLB was provided for unilateral inguinal hernia repair, orchidopexy, testicular torsion repair, and open appendectomy. Bilateral QLB was provided for laparoscopic appendectomy and cholecystectomy. Decreased use of fentanyl and sevoflurane was noticed in the cases when QLB was performed preoperatively. All the patients had well controlled pain. Conclusion. QLB is a simple and safe technique. Clear sonographic landmarks allow it to be easily performed. QLB has great potential to improve and facilitate postoperative pain management.

Clinical effect of multimodal perioperative pain management protocol for minimally invasive colorectal cancer surgery: Propensity score matching study

Reducing postoperative pain with less opioid is critical in postoperative care. Author developed our multimodal perioperative pain management protocol and it consists of preoperative medication, intraoperative ultrasound-guided laparoscopic transverse abdominis plane (LTAP) block and postoperative medication. This study aimed to evaluate the clinical effect of the multimodal perioperative pain management protocol for minimally invasive colorectal cancer surgery. Of 596 colorectal surgery cases for colorectal cancer, 133 patients managed with multimodal perioperative pain protocol (group 1) and 463 patients managed without multimodal perioperative pain protocol (group 2) were enrolled in this study. To adjust for baseline differences and selection bias, operative outcomes and complications were compared after propensity score matching (PSM). After 1:1 propensity score matching, well-matched 133 patients in each group were evaluated. The median VAS scores on post-operative day 1 (2.1±1.1 vs. 3.9±1.8, p<0.001) and day 2 (2.0±1.2 vs. 3.8±1.7, p<0.001) was significantly reduced in group 1. The length of postoperative hospital stays was also significantly shorter in Group 1 (4.4±3.0 vs. 5.8±5.6; p=0.014). Implementing multimodal perioperative pain protocols reduced postoperative pain and hospital stay of minimally invasive colorectal surgery.

Feasibility of Implementing Opioid Stewardship Recommendations for Sinonasal Surgery.

The objective of our study was to review the current literature pertaining to perioperative opioids in sinus surgery and to determine the effects of implementing opioid stewardship recommendations in the setting of endoscopic sinonasal surgery. Single-institution retrospective case-control study. Academic medical center outpatient area. This retrospective review comprised 163 patients who underwent routine functional endoscopic sinus surgery, septoplasty, and/or inferior turbinate reduction before and after implementation of a standardized pain control regimen based on published opioid stewardship recommendations. The regimen consisted of an oral dose of gabapentin (400 mg) and acetaminophen (1000 mg) at least 30 minutes prior to surgery, absorbable nasal packing soaked in 0.5% tetracaine intraoperatively, and a postoperative regimen of acetaminophen and nonsteroidal anti-inflammatory medications. Tramadol tablets (50 mg) were prescribed postoperatively for breakthrough pain. The primary outcome measure for the study was the average number of hydrocodone equivalents (5 mg) prescribed before and after the new protocol. The average number of opioid medications prescribed, measured as hydrocodone equivalents (5 mg), decreased from 24.59 preprotocol to 18.08 after the initiation of the new perioperative regimen (P < .001). There was no significant difference between the periods (P > .05) in number of postoperative phone calls regarding pain or in patient satisfaction scores. Opioid stewardship recommendations can be instituted for sinonasal surgery, including multimodal perioperative pain management and substitution of tramadol for breakthrough pain, as a method to decrease the volume of opioids prescribed, without increasing patient phone calls or affecting the likelihood of physician recommendation Press Ganey scores.

Multimodal perioperative pain management in a horse undergoing partial phallectomy

A well-balanced multimodal pain management including local anaesthetic techniques was used to provide perioperative analgesia in a horse undergoing partial phallectomy. This surgical intervention has been associated with moderate to severe pain and may present additional challenges to the veterinarian when providing pain relief postoperatively.In the present case, preoperative analgesia included morphine and flunixin meglumine, both intravenously. Throughout surgery, adaptable constant rate infusions (CRIs) with ketamine and xylazine were supplemented to address different receptors of the pain pathway. Additionally, a pudendal nerve block with ropivacaine was added intraoperatively to reduce nociception and decrease sensitisation of the central nervous system. An epidural injection of morphine and dexmedetomidine was performed after recovery from general anaesthesia. Postoperative pain treatment included morphine and flunixin meglumine that resulted in adequate pain relief, based on pain assessment every 6–12 hours. Neither side effects nor complications were observed during the hospital stay.

Is Benign Prostatic Hyperplasia a Perpetrator for Periprosthetic Joint Infection?: Commentary on an article by Hamidreza Yazdi, MD, et al.: "Symptomatic Benign Prostatic Hyperplasia. A Risk Factor for Periprosthetic Joint Infection in Male Patients".

Commentary In the current era, total joint arthroplasty (TJA) is considered to be safe and cost-effective and a successful procedure to improve quality of life. However, a periprosthetic joint infection (PJI) is a huge setback to the patient, family, and surgeon alike. Although the overall incidence of PJI following TJA is low, there is high morbidity (persistent pain, prolonged hospital stay, multiple surgical procedures, functional loss) and even mortality associated with PJI. Over the last couple of decades, several hundred studies have been done on the prevention, diagnosis, treatment, and outcomes of PJI. We are certainly making progress by lowering the incidence of infection, but the search for causes is relentless. In the current study, Yazdi et al. performed a retrospective study to explore another potential cause for PJI: benign prostatic hyperplasia (BPH) in male patients. Anecdotally, I have also observed BPH to be a potential cause for PJI, given that my current practice is dominated by male patients. Yazdi et al. reviewed 12,902 patients from their institution registry database and grouped them into symptomatic and non-symptomatic BPH groups. They further matched patients with symptomatic BPH (n = 250) with a non-symptomatic BPH control group in a 1:3 ratio. The PJI rate was 7.9% in the symptomatic group compared with 2.8% in the control group. Multivariate regression analysis in unmatched groups showed that symptomatic BPH was a strong independent risk factor for PJI. Symptomatic BPH remained a significant risk factor for PJI after matching for variables related to outcomes. Yazdi et al. concluded that symptomatic BPH might be a reason for the high incidence of PJI in male patients. Interestingly, in the current study, multivariate analysis also showed that symptomatic BPH carried a risk higher than even diabetes mellitus for PJI. Another interesting finding in the current study is that symptomatic BPH showed a higher trend toward acute PJI. However, there is no obvious pathomechanism as to why BPH could cause PJI. It is hypothesized that the collection of excess urine in the bladder in the perioperative period or high post-void residual urine in patients with symptomatic BPH increases the bacterial load, subsequently potentiating the spread of the infection to the newly implanted joint prosthesis. With the current trend of patients undergoing fast-track TJA under spinal anesthesia, the incidence of postoperative urinary retention is on the rise1. The incidence of postoperative urinary retention may even be higher with symptomatic BPH and may potentially increase the risk of PJI, especially if BPH is not treated before the surgical procedure. Similarly, the current trend of multimodal perioperative pain management for TJA includes a scopolamine (anticholinergic) patch, given its ease of use and successful avoidance of postoperative nausea and vomiting2. In patients with symptomatic BPH, scopolamine might further increase BPH-related urinary retention or post-void residual urine and subsequent risk of PJI. This preliminary study identifies BPH as a potential cause for PJI in male patients. The study had several limitations: it was a retrospective study, there were potential concerns with regard to the data collection method, the duration of follow-up was 1 year, and there were no explicit data on catheterization done in the perioperative period. There are several strengths to this study as well. The Rothman Institute has a reputation for good patient follow-up with low dropout rates, this is a single-institution study, and there was a matched-cohort study design to minimize the effect of confounding variables. For these reasons, I consider this a well-conducted outcome study. The total number of TJAs performed annually has been on an upward trend globally. It is expected to reach 4 million annually by 2030 in the United States3 alone, in contrast to about 1 million per year currently. Any and every step to reduce the incidence of PJI is worth taking into consideration considering the economic and individual patient burden of treating a PJI. Kee et al. demonstrated that nearly half of all patients undergoing early revision arthroplasties had at least 1 modifiable risk factor and emphasized proper patient selection and preoperative optimization of modifiable risk factors to minimize the risk of adverse outcomes following TJA4, but BPH was not a part of the study. It would be worthwhile to also include symptomatic BPH as a modifiable risk factor and to preoperatively optimize patients to reduce PJI. This study by Yazdi et al. will serve as a great precursor for further multicenter, larger population-based studies to assess any regional or geographical biases and confounding factors.

Enhanced recovery after cesarean delivery: a challenge for anesthesiologists.

Enhanced recovery after cesarean (ERAC) delivery is an evidence-based, multi-disciplinary approach throughout pre-, intra-, post-operative period. The ultimate goal of ERAC is to enhance recovery and improve the maternal and neonatal outcomes. This review highlights the role of anesthesiologist in ERAC protocols. This review provided a general introduction of ERAC including the purposes and the essential elements of ERAC protocols. The tool used for evaluating the quality of ERAC (ObsQoR-11) was discussed. The role of anesthesiologist in ERAC should cover the areas including management of peri-operative hypotension, prevention and treatment of intra- and post-operative nausea and vomiting, prevention of hypothermia and multi-modal peri-operative pain management, and active pre-operative management of unplanned conversion of labor analgesia to cesarean delivery anesthesia. Although some concerns still remain, ERAC implementation should not be delayed. Regular assessment and process improvement should be imbedded into the protocol. Further high-quality studies are warranted to demonstrate the effectiveness and efficacy of the ERAC protocol.

Multimodal Perioperative Pain Management: ComfortSafe Program

Multimodal Perioperative Pain Management: ComfortSafe Program

A retrospective analysis of the use of intravenous dexamethasone for postoperative nausea and vomiting in total joint replacement

BackgroundMultimodal perioperative pain-management protocols have contributed to the success of elective total joint replacement in orthopedic surgery. General or neuraxial anesthesia for arthroplasty is accompanied by complications such as pruritis, nausea, and vomiting. Dexamethasone has been demonstrated to be a safe perioperative antiemetic. This study evaluates the benefit of low-dose intravenous dexamethasone used in the perioperative period to prevent postoperative nausea and vomiting.MethodsTwo scheduled doses of 8 mg of dexamethasone 12 hours apart after total hip arthroplasty or total knee arthroplasty were given to a dexamethasone group (n = 492) and were retrospectively compared with a no-dexamethasone group (n = 364) based on the use of antiemetics in the postoperative period. Frequency of antiemetic use in both groups was compared using a zero-inflated fixed-model Poisson distribution. Additional analysis included need for opioid analgesic, administration of diphenhydramine, and postoperative infection rates at 30 and 90 days.ResultsThe dexamethasone group was found to have a significant reduction in need for the rescue antiemetic ondansetron (P = .00194). There was an associated reduction in length of stay for the treatment group (mean 1.83 days) relative to the control group (mean 2.17 days) (P < .001). There was no significant difference in postoperative infection rates at 30 or 90 days after arthroplasty.ConclusionsDexamethasone is a safe adjunct to perioperative protocol that may reduce nausea, thus improving patient satisfaction. There is an associated reduction in length of stay that may reduce cost of hospitalization.

Major lower limb amputation audit - introduction and implementation of a multimodal perioperative pain management guideline.

Major lower limb amputation audit - introduction and implementation of a multimodal perioperative pain management guideline.

Improved Quality of Recovery from Ambulatory Shoulder Surgery After Implementation of a Multimodal Perioperative Pain Management Protocol.

Pain control after shoulder arthroscopy can be challenging, often relying on opioids. The study aims to measure the quality of recovery (QoR) before and after implementation of a "Multimodal Perioperative Pain Protocol" (MP3) in patients undergoing ambulatory shoulder arthroscopy. Prospective cohort study. Free-standing ambulatory surgery facility of a tertiary care academic center. Patients undergoing ambulatory shoulder arthroscopy. The primary end point of the study was the QoR-9 score at 24 hours, 48 hours, and one week after surgery. Secondary end points included 1) measuring the quality of pain management using the Revised American Pain Society Patient Oriented Questionnaire (APS-POQ-R) and 2) postoperative opioid requirements. Data from132 patients in the control group (pre-intervention) and 120 patients in the MP3 group were analyzed. The QoR-9 scores were significantly higher for the MP3 group at all time points, but only met the minimal clinical important difference threshold at 24 hours (13.4 vs 14.9, P < 0.05) and 48 hours (14.0 vs 15.0, P < 0.05) postoperatively. Patients reported better quality of pain management after implementation of the MP3 in the domains of pain intensity, pain interference with activity, and sleep, and they reported the presence of negative emotions up to two days after ambulatory shoulder surgery. In addition, this protocol significantly reduced opioid consumption up to three days after surgery. Implementation of the MP3 improved the overall QoR and many aspects of postoperative pain relief while reducing total opioid consumption in patients undergoing ambulatory shoulder surgery.

Team Approach: Multimodal Perioperative Pain Management in Upper-Extremity Surgery: Combating the Opioid Epidemic.

* Rates of opioid use and abuse continue to rise in the United States, as do opioid-related deaths. Many patients who misuse opioids receive their first exposure in the perioperative setting.* Postoperative opioid use reduction in patients who have undergone an upper-extremity procedure can be difficult secondary to the often-painful nature of orthopaedic procedures. Postoperative pain can prevent timely discharge from hospitals and is a major cause for emergency medicine visits following outpatient upper-extremity surgical procedures.* Utilization of a multidisciplinary, multimodal, home-going continuous peripheral nerve block catheter protocol may be able to comfortably allow patients to recover in an outpatient setting after an upper-extremity surgical procedure, with a diminished opioid requirement.