Narcotic Usage Research Articles

The effect of an early mobilization rehabilitation protocol on outcomes after reverse shoulder arthroplasty

BackgroundGiven the continued growth of reverse shoulder arthroplasty (RSA), it is important to optimize factors that contribute to successful outcomes. Rehabilitation after RSA is critical to achieve successful outcomes including patient function and satisfaction; however, the ideal rehabilitation program has not been established. The purpose of this study was to evaluate the effect of early mobilization (EM) compared with delayed mobilization (DM) on outcomes and function after RSA. MethodsA retrospective study of prospectively collected data was performed comparing 67 patients who underwent RSA in two groups: the EM group began a rehabilitation program immediately after surgery, and the DM group began after 4-6 weeks postoperatively. Preoperative and postoperative Constant shoulder score, American Shoulder and Elbow Surgeons (ASES) score, Penn Shoulder Score (PSS), shoulder satisfaction value as well as demographics, opioid usage, range of motion, 90-day complications, reoperation, and readmission rates were collected. Statistical analysis was performed between each group’s outcomes and for the change (delta) of outcomes from baseline to each postoperative time point. ResultsAt 6 weeks postoperatively, the EM group showed significantly higher scores in ASES function, PSS, active forward elevation, passive forward elevation, active external rotation, and passive external rotation. There was significantly lower narcotic usage in the EM group at 6 weeks. At 3 months postoperatively, the EM group showed a lower numerical rating score for pain and higher active forward elevation. At the last follow-up, there was a lower numerical rating score and greater degree for all ranges of motion for the EM group than that for the DM group. A greater change from baseline to 6 weeks postoperatively was seen for the EM group in shoulder satisfaction value, ASES function, PSS, active forward elevation, passive forward elevation, and internal rotation. From baseline to 3 months postoperatively, ASES pain, PSS, active forward elevation, and passive forward elevation improved significantly in the EM group. At the final follow-up, active forward elevation increased greater for the EM group. There were 3 complications (2 hematomas and 1 infection) in the DM group and none in the EM group. ConclusionThe EM rehabilitation protocol after RSA achieved lower opioid usage at 6 weeks, lower pain scores at each time point, and better range of motion during the final follow-up than DM protocol. There were no complications reported with the EM protocol, suggesting it is a safe alternative for postoperative recovery. Orthopedic surgeons should consider the EM rehabilitation protocol after RSA.

Next day discharge after the Nuss procedure using intercostal nerve cryoablation, intercostal nerve blocks, and a perioperative ERAS pain protocol

BackgroundThe Nuss procedure for pectus excavatum has historically been associated with significant postoperative pain, which has been the major factor contributing to hospital length of stay (LOS). MethodsA single-institution, prospective study of 40 consecutive patients undergoing Nuss bar placement for pectus excavatum between November 2019 and January 2021 was conducted to assess the effectiveness of a multimodality pain management protocol. All patients received T3-T8 intercostal nerve cryoablation (INC), T3-T8 bupivacaine intercostal nerve blocks, Exparel at the skin incisions, and management with a perioperative analgesia regimen that minimized narcotic usage. The primary outcome was LOS. Secondary outcomes included opioid use, pain scores, and time to sensory recovery. Results37/40 patients (92.5%) were discharged home on postoperative day (POD) 1, and 3/40 (7.5%) were discharged on POD 2 (mean LOS = 1.1 days). The median average postoperative pain score was 2/10. After eliminating IVPCA from our protocol, total oral morphine equivalent (OME) decreased by 73% (55.5 mg to 15 mg) with no change in pain scores or discharge timing. ConclusionsINC combined with bupivacaine intercostal nerve blocks and a pre- and post-hospital analgesia protocol facilitated discharge one day after the Nuss procedure, achieved excellent pain control, and eliminated the need for intravenous opioids.

Is ERAS for Everyone?: A Comparison of Pain Control Outcomes across Veau Classifications following Primary Palatoplasty

BACKGROUND: Patients undergoing primary palatoplasty generally rely on narcotic medication for pain control. However, there are concerns with over-medication, sedation, respiratory depression, sensitization to pain, and physical dependency with the use of narcotics. Enhanced Recovery after Surgery (ERAS) protocols using multi-modal therapy for pain control have seen adoption in numerous surgical sub-specialties since their inception in the 1990s. Recent publications have demonstrated decreased narcotic usage and hospital length of stay after palatoplasty with the use of ERAS protocols. This study aims to assess clinical outcomes before and after ERAS implementation to evaluate for a differential effect among Veau Classifications and identify significant predictors of narcotic medication prescription at discharge. METHODS: A single center study of patients undergoing primary palatoplasty examined two cohorts: a retrospective review (2014–2016) of patients treated prior to ERAS implementation and a prospective trial (2016–2018) in which palatoplasty patients were managed with an ERAS protocol. Data regarding postoperative pain scores, oral intake, morphine milligram equivalents (MMEs) administered, narcotic medication prescription at discharge, and length of stay for retrospective and prospective cohorts were compiled (Excel, Microsoft Corporation). Pain scores were measured using the Faces, Legs, Activity, Cry, and Consolability scale. All data were analyzed using R Software (R Foundation for Statistical Computing, Vienna, Austria). RESULTS: A total of 113 patients (56 Pre-ERAS, 57 ERAS) were included in this study. ERAS patients were found to have significantly longer operative times when compared with Pre-ERAS [167min (121–191) versus 131min (114.75–157)] as well as a significantly higher rate of Furlow repair (63.2% versus 33.9%, P = 0.002). The ERAS group was found to have a significant decrease in total MMEs administered when compared with Pre-ERAS (5.29 ± 4.61 versus 11.83 ± 7.13, P < 0.001). Comparison of clinical outcomes within Veau classifications by their respective cohorts yielded no significant differences. Comparison of clinical outcomes among Veau classification between cohorts revealed significant decreases in the ERAS group for total MMEs administered in Veau class II (8.87 ± 5.97 versus 4.38 ± 3.43, p =0.015), III (12.42 ± 7.05 versus 6.25 ± 5.39, P = 0.001), and IV (16.54 ± 6.39 versus 4.54 ± 4.45, P = 0.003). A multivariate generalized linear model using significant univariate variables as well as Cohort and Veau Classification data demonstrated that total MMEs administered was a significant predictor with a P value of 0.041 and an odds ratio of 1.10 (CI 1.01–1.21). CONCLUSIONS: Our ERAS protocol for primary palatoplasty led to decreased pain scores and improved oral intake. Significant reductions in total MMEs administered to patients with Veau II–IV cleft palates were observed, which was associated with 10% increased odds for discharge narcotics per MME administered. There was variability in outcomes based on Veau classification, though larger studies may demonstrate a more reproducible effect. Our results illustrate the potential benefit that standardized ERAS protocols may have in this patient population, and merit further study.

S20 Common Bile Duct Dilation After Roux-en-Y Gastric Bypass Surgery

Introduction: As the obesity epidemic continues, surgical interventions to address this issue have become more prevalent. One of the most widely used methods for bariatric surgery is Roux-en-Y gastric bypass (RYGB). A unique problem that has been identified in the post-bariatric surgery population is biliary duct dilation without specific pancreatobiliary pathology. This study aims to evaluate the change in common bile duct (CBD) diameter following RGYB. Methods: This was a single center retrospective study that evaluated patients who had undergone RYGB between 1/1/2010 and 12/31/2020. Adults (>18 years of age) who had CT imaging for non-pancreatobiliary reasons before and after their RYGB were included. Patients with known pancreatobiliary pathology were excluded from analysis. An abdominal radiologist measured the diameters of the CBD in all images at the porta hepatis. Linear regression modeling and t-tests in SPSS were used to analyze data. Results: 46 patients met the inclusion criteria. The average age and BMI at time of RYGB was 48.4 years and 46.4. The average age and BMI at time of post-operative CBD measurement was 49 years and 38.1. The mean CBD diameter of all included patients pre-RYGB was 5.93 mm (SD 1.5) and the mean diameter post-RYGB was 7.0 mm (SD 3.3). Mean diameter change between pre and post RYGB was 1.31 mm (SD 2.8, P < 0.05). Controlling for prior cholecystectomy as well as narcotic use at the time of post-operative imaging, the change in CBD diameter was 1.15 mm (SD 0.6, P value 0.06). Prior cholecystectomy and narcotic usage did not affect in person change of CBD diameter (P 0.9, P 0.6). Conclusion: There are many known causes of non-pathological biliary duct dilation, including age, history of cholecystectomy and narcotic use. Our data shows that biliary dilation can occur after bariatric surgery. This finding is important because endoscopic biliary evaluation with EUS and ERCP in RYGB anatomy is challenging and associated with high failure rates. Other biliary interventions like laparoscopic assisted, percutaneous and trans-gastric procedures are associated with higher risk of complications. Given these issues, it is crucial for patients to have a strong indication for biliary intervention. As physicians treat an increasing number of patients with RYGB anatomy, they must consider that incidentally found biliary dilation might not necessarily indicate the presence of biliary pathology in order to prevent avoidable imaging and interventions.

Monitored Anesthesia Care and Soft-Tissue Infiltration With Local Anesthesia: An Anesthetic Option for High-Risk Patients With Hip Fractures.

To examine the feasibility of a novel anesthetic option for hip fracture fixation with short cephalomedullary nails. Retrospective cohort study. The study setting involved an urban, academic Level 1 trauma center, a tertiary care academic medical center, and an orthopaedic specialty hospital. Twenty recent and 40 risk-matched (1:1:1 by anesthesia type) historical hip fracture patients were included in the study. All patients with an OTA/AO 31.A1-3 intertrochanteric hip fracture presenting from October 1, 2019 to March 31, 2020 treated with a short cephalomedullary nail underwent a new intraoperative anesthesia protocol using monitored anesthesia care (MAC) and soft-tissue infiltration with local anesthesia (STILA). Intraoperative measures, postoperative pain scores, narcotic and acetaminophen use, hospital quality measures, and inpatient cost. A total of 60 patients (20 each: MAC, general, and spinal) were identified. There were differences among the groups regarding mean minimum and maximum intraoperative heart rate with MAC-STILA protocol demonstrating the best maintenance of normal heart rate parameters (60-100 beats per minute). For the first 3 hours postoperatively, MAC-STILA patients reported consistently lower pain scores (visual analog scale <1) than spinal or general patients (visual analog scale > 1). Through 48 hours postoperatively, MAC-STILA narcotic usage was similar to that of the spinal cohort and approximately 5 times less than the general cohort. There were no differences in procedural time, length of stay, minor or major complications, inpatient and 30-day mortality, or 30-day readmissions, or postoperative ambulatory distance. There was no difference in inpatient cost among cohorts. This feasibility study demonstrates safety for the MAC-STILA protocol with comparison to spinal and general anesthesia. The MAC-STILA protocol is a viable option for treatment of OTA/AO 13.A1-3 intertrochanteric fractures with a short cephalomedullary nail and may be the preferred method for patients with severe medical comorbidities or relative contraindications to general and/or spinal anesthesia. Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Postoperative Use of Ketorolac Improves Pain Management and Decreases Narcotic Use Following Primary Cleft Palate Surgery.

To study the efficacy and safety profile of ketorolac in cleft palate surgery. Retrospective analysis of patients who underwent primary cleft palate surgery and received either postoperative ketorolac or opioids. Tertiary care children's hospital. Eighty-nine patients enrolled who were all younger than 36 months of age, not dependent on a gastrostomy tube, with no history of bleeding disorders, and had undergone their primary cleft palate procedure by one specific surgeon between January 2010 and June 2019. n/a. Morphine equivalent dose (MED), Face, Legs, Activity, Cry, Consolability (FLACC) score, length of stay (LOS), total oral intake (mL), total oral intake/LOS, and postoperative adverse events between ketorolac and no ketorolac groups. MED, FLACC score, and LOS were significantly lower in the ketorolac group compared to the no ketorolac group. One patient in the ketorolac group had a bleeding event. Use of ketorolac significantly decreased narcotic usage and pain scores as reported by the FLACC score. Moreover, postoperative bleeding was rare in both ketorolac and no ketorolac groups.

Dexmedetomidine as an Anesthetic Adjunct in Off-Pump Coronary Artery Bypass Grafting: A Case Report

Abstract Introduction: This case report describes the implementation of a dexmedetomidine (Precedex) infusion in a patient undergoing off-pump coronary artery bypass grafting (OPCABG). The focus of this case report is to analyze the impact dexmedetomidine has on perioperative opioid consumption, postoperative recovery, and hemodynamic effects that result. This case is important to analyze because OPCABG is a surgery encountered globally and advances in medicine have made this procedure more accessible to patients. The addition of dexmedetomidine in the anesthetic plan of care resulted in positive outcomes for this patient. Case Presentation: An OPCABG was performed on a 52-year-old male who had a history of hypertension, multivessel coronary artery disease, NSTEMI, congestive heart failure, end stage renal disease on hemodialysis, and type 2 diabetes mellitus. The patient had a 20-pack year history of smoking and previous surgeries showed no anesthetic complications. Invasive monitoring for the procedure included the use of an arterial line and pulmonary artery catheter. A multimodal anesthetic approach was used which incorporated the use of volatile anesthetics, neuromuscular blockers, opioids, benzodiazepines, and a dexmedetomidine infusion. The dexmedetomidine infusion was started at 0.2 mcg/kg/hr intraoperatively and was continued over into the cardiovascular ICU (CVICU). The patient was able to emerge from anesthesia comfortably and was extubated before leaving the operating room without any complications. The patient’s narcotic usage during the first 48 hours post procedure was recorded. The patient remained hemodynamically stable and required no vasopressor support on emergence and during the entire stay in the CVICU. The patient was transferred out of the CVICU on post op day 2 without any complications. Discussion: The addition of a dexmedetomidine infusion to the anesthetic plan of care in patients undergoing OPCABG is supported by current literature. Dexmedetomidine has many advantageous effects including analgesia, improvement in hemodynamic stability, and offers cardiac protection.1 The end result may lead to decreased narcotic requirements which may enable earlier extubation times and an overall decreased length of stay in the ICU.1,2,3 Intraoperative hemodynamic instability resulting from fluctuations in plasma levels of norepinephrine and epinephrine due to surgical stimulation are attenuated by dexmedetomidine due to the reduction in sympathetic output as a result of alpha-2 agonism.4 Heart rate, mean arterial pressure, and systemic vascular resistance will be lower intraoperatively and postoperatively as a result.4,5 Incidence rates of arrythmias occurring perioperatively such as atrial fibrillation, premature atrial contractions, premature ventricular contractions, and heart blocks are decreased with the use of dexmedetomidine.4,6 Dexmedetomidine is shown to be a safe and useful anesthetic adjunct in patients undergoing OPCABG. Keywords Precedex, dexmedetomidine, off-pump coronary artery bypass grafting, alpha-2 agonist, cardiac surgery

Comparison of Cranioplasty Techniques Following Translabyrinthine Surgery: Implications for Postoperative Pain and Opioid Usage.

To assess differences in postoperative pain, opioid usage, and surgical outcomes between cranioplasty using abdominal fat graft (AFG) versus hydroxyapatite cement (HAC) following translabyrinthine surgery. Retrospective case control. Tertiary referral center. Sixty translabyrinthine procedures were evaluated, including 30 consecutive HAC patients and 30 matched AFG patients. Patients were matched by age, gender, body mass index, and tumor size. Cranioplasty using HAC or AFG following translabyrinthine resection of vestibular schwannoma. Postoperative patient pain ratings, narcotic usage, inpatient length of stay, and complication rates. Patients who underwent HAC cranioplasty had lower postoperative pain scores on several measures (p < 0.05) and less postoperative narcotic usage (mean difference of 36.7 morphine equivalents, p = 0.0025) when compared to those that underwent AFG closure. HAC cranioplasty patients had shorter average length of hospital stay (2.2 vs 3.4 days, p = 0.0441). Postoperative cerebrospinal fluid leaks (one in HAC group, two in AFG group) and skin reactions in AFG closure patients (n = 1) were infrequent. HAC cranioplasty is a safe technique comparable to AFG closure following translabyrinthine surgery which can decrease postoperative pain, narcotic usage, and hospital length of stay.

269. Two-year clinical and radiographic outcomes after minimally invasive sacroiliac joint fusion with decortication and none grafting utilizing a threaded implant

269. Two-year clinical and radiographic outcomes after minimally invasive sacroiliac joint fusion with decortication and none grafting utilizing a threaded implant

Comparative Analysis of Prepectoral versus Subpectoral Implant-based Breast Reconstruction.

Background:Recent advances in mastectomy and reconstruction have allowed for an evolution in implant-based breast reconstruction to a muscle-sparing, prepectoral approach. Advantages of this technique may include reductions in postoperative pain, shorter hospitalization, less narcotic usage, and improved aesthetic outcomes. Postoperative complication rates are described as comparable to subpectoral techniques; however, little comparative data exist to adequately assess prepectoral versus subpectoral implant placement.Methods:To address this knowledge gap, we performed a single institution retrospective review of 186 (83 prepectoral, 103 subpectoral) consecutive immediate breast reconstructions. All cases were tracked for a minimum of 2 years between 2016 and 2021.Results:Prepectoral patients demonstrated an overall higher seroma rate (P = 0.001), with all other postoperative complications being comparable. Prepectoral patients tolerated higher intraoperative tissue expander fill volumes (P < 0.001), shorter hospital stays (P = 0.007), fewer clinic visits for tissue expansion (P < 0.001), and experienced less animation deformity (P = 0.005). Both groups demonstrated similar pain scores (P = 0.65) and needs for narcotics (P = 0.8) as well as comparable scores of capsular contracture (P = 0.791).Conclusions:Our comparative analysis of consecutive immediate implant-based breast reconstructions finds prepectoral reconstruction to be safe and effective. Compared with subpectoral reconstruction, the prepectoral approach may offer quicker tissue expansion, less postoperative office visits, less need for muscle relaxants, and a shorter hospital stay with a comparable complication profile.

Examination of Adult Spinal Deformity Patients Undergoing Surgery with Implanted Spinal Cord Stimulators and Intrathecal Pumps.

Retrospective cohort study of a prospectively collected multi-center database of adult spinal deformity (ASD) patients. We hypothesized that patients undergoing ASD surgery with and without previous spinal cord stimulators (SCS)/ intrathecal medication pumps (ITP) would exhibit increased complication rates but comparable improvement in health-related quality of life. ASD patients sometimes seek pain management with SCS or ITP before spinal deformity correction. Few studies have examined outcomes in this patient population. Patients undergoing ASD surgery and eligible for 2-year follow-up were included. Preoperative radiographs were reviewed for the presence of SCS/ITP. Outcomes included complications, Oswestry Disability Index (ODI), Short Form-36 Mental Component Score, and SRS-22r. Propensity score matching was utilized. In total, of 1034 eligible ASD patients, a propensity score-matched cohort of 60 patients (30 with SCS/ITP, 30 controls) was developed. SCS/ITP were removed intraoperatively in most patients (56.7%, n = 17). The overall complication rate was 80.0% versus 76.7% for SCS/ITP versus control (P > 0.2), with similarly nonsignificant differences for intraoperative and infection complications (all P > 0.2). ODI was significantly higher among patients with SCS/ITP at baseline (59.2 vs. 47.6, P = 0.0057) and at 2-year follow-up (44.4 vs. 27.7, P = 0.0295). The magnitude of improvement, however, did not significantly differ (P = 0.45). Similar results were observed for SRS-22r pain domain. Satisfaction did not differ between groups at either baseline or follow-up (P > 0.2). No significant difference was observed in the proportion of patients with SCS/ITP versus control reaching minimal clinically important difference in ODI (47.6% vs. 60.9%, P = 0.38). Narcotic usage was more common among patients with SCS/ITP at both baseline and follow-up (P < 0.05). ASD patients undergoing surgery with SCS/ITP exhibited worse preoperative and postoperative ODI and SRS-22r pain domain; however, the mean improvement in outcome scores was not significantly different from patients without stimulators or pumps. No significant differences in complications were observed between patients with versus without SCS/ITP.Level of Evidence: 3.

Minimally Invasive Stabilization with or without Ablation for Metastatic Periacetabular Tumors.

Metastatic bone disease in the periacetabular region represents a potentially devastating problem for patients. Surgical treatment can offer pain relief and restore function. We describe a series of patients treated with minimally invasive osteoplasty and screw fixation with or without ablation. Thirty-eight patients with 16 different metastatic tumor subtypes were managed with osteoplasty and screw fixation with or without ablation at a single institution. A retrospective review was performed to determine functional outcomes with use of the 1993 Musculoskeletal Tumor Society (MSTS) score as well as changes in narcotic usage. MSTS scores improved for all patients following surgery. Narcotic usage decreased in >80% of patients. Approximately half of the operations were outpatient procedures. Complications were minimal, there were no delays in chemotherapy or radiation due to surgical wound concerns, and there were no surgery-related deaths. The mean duration of follow-up was 9 months, with a 39% survival rate at the time of writing. Six of the 12 patients who survived for >1 year required additional procedures at a mean of 12 months (range, 4 to 23 months). Treatment of periacetabular metastatic disease with minimally invasive stabilization with or without ablation provides pain relief and functional improvement with lower complication rates than previously reported open reconstruction techniques. The minimally invasive approach allows for rapid initiation of chemotherapy and radiation. Patients with particularly aggressive cancers that are poorly responsive to systemic therapies and radiation may have progression of disease and may require additional procedures. Conversion to total hip arthroplasty was uncomplicated, and the cement and screw constructs were retained, providing a stable base for the arthroplasty reconstruction. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Implementation of an enhanced recovery protocol in gynecologic oncology

Enhanced Recovery after Surgery (ERAS) is an evidence-based approach that aims to reduce narcotic use and maintain anabolic balance to enable full functional recovery. Our primary aim was to determine the effect of ERAS on narcotic usage among patients who underwent exploratory laparotomy by gynecologic oncologists. We characterized its effect on length of stay, intraoperative blood transfusions, bowel function, 30-day readmissions, and postoperative complications. A retrospective cohort study was performed at Abington Hospital-Jefferson Health in gynecologic oncology. Women who underwent an exploratory laparotomy from 2011 to 2016 for both benign and malignant etiologies were included before and after implementation of our ERAS protocol. Patients who underwent a bowel resection were excluded. A total of 724 patients were included: 360 in the non-ERAS and 364 in the ERAS cohort. An overall reduction in narcotic usage, measured as oral morphine milliequivalents (MMEs) was observed in the ERAS relative to the non-ERAS group, during the entire hospital stay (MME 34 versus 68, p < 0.001 and within 72 h postoperatively (MME 34 versus 60, p < 0.005). A shorter length of stay and earlier return of bowel function were also observed in the ERAS group. No differences in 30-day readmissions (p = 0.967) or postoperative complications (p = 0.328) were observed. This study demonstrated the benefits of ERAS in Gynecologic Oncology. A significant reduction of postoperative narcotic use, earlier return of bowel function and a shorter postoperative hospital stay was seen in the ERAS compared to traditional perioperative care.

Abstract No. 132 Same-day discharge versus overnight stay after uterine artery embolization for symptomatic fibroids: an assessment of patient safety and satisfaction

Purpose: To compare the safety of and patient satisfaction with same-day discharge versus overnight stay after uterine artery embolization (UAE) for patients with symptomatic uterine fibroids Materials and Methods: A prospective observational study of patients who underwent UAE for symptomatic fibroids from January 2018 to June 2020 was performed. Chart review was performed for outcomes of interest including complication rates, readmission rates, emergency department visits, and inpatient narcotic usage. During post-procedure follow-up, patients completed an optional survey to measure self-reported post-procedural pain scores and satisfaction with pain regimen, length of hospital stay, and overall satisfaction. Results: Of 49 UAEs performed during the study period, 29% (n = 14) of patients were discharged home the same day and 71% (n = 35) were admitted for an overnight stay. When comparing the same-day discharge to overnight stay groups, no significant difference was found in complication rates (7% vs 26%, P = 0.24), emergency department visits (0% vs 14%, P = 0.30), re-hospitalization (0% vs 6%, P = 1), or opioid use (mean of 17 vs 26 morphine equivalents, P = 0.85). The survey received 18 responses, of which 33% (n = 6) were discharged home the same day and 67% (n = 12) were admitted overnight. When comparing the same-day discharge to overnight stay groups, no significant difference was found between self-reported pain the night of the procedure (on a scale from 0 to 10, mean 7 vs 5.5, P = 0.31), self-reported pain the week after the procedure (mean 4.9 vs 3.2, P = 0.23), satisfaction with the pain regimen (P = 0.7), satisfaction with the outpatient pain regimen (P = 0.28), satisfaction with length of hospital stay (P = 0.17), and overall satisfaction (P = 0.89). Conclusions: Same-day discharge after UAE when compared to overnight stay was found to have no significant difference in rates of readmission, emergency room visits, narcotic usage, patient-reported post-procedural pain, satisfaction with inpatient and outpatient pain regimen, satisfaction with length of hospital stay, and overall patient satisfaction. Same-day discharge is a safe and feasible option for patients undergoing UAE which may provide improved cost-effectiveness and resource utilization benefits for both the patient and the healthcare system. In light of the ongoing COVID-19 pandemic, prioritization of resource allocation without compromise of patient safety will be of utmost importance.

P29: TRANSVERSUS ABDOMINIS PLANE BLOCK IN LAPAROSCOPIC BARIATRIC SURGERY- A SYSTEMATIC REVIEW AND META ANALYSIS OF RANDOMISED CONTROLLED TRIALS

Abstract Introduction Effective postoperative analgesia is paramount in the management of patients undergoing bariatric surgery, given their increased predisposition to systemic narcotic-induced respiratory depression. Transversus abdominis plane (TAP) block has shown promise in the enhanced recovery pathway for several abdominal procedures. We performed a systematic review and meta-analysis to compare the effectiveness of TAP block in laparoscopic bariatric surgery. Method PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until November 2019. All trials that compared TAP blocks versus none in laparoscopic bariatric procedures were included. The primary outcome measure was narcotic consumption at 24 hours postoperatively, while secondary outcomes included pain scores, time to ambulation, postoperative nausea and vomiting (PONV) and complication rates. Random effects models were used to calculate pooled effect size estimates. Result Seven randomised controlled trials were included capturing 617 patients. There was high statistical heterogeneity across studies. On random effects analysis, there were no significant differences in narcotic consumption (Mean difference –18.4 mg, 95% CI=-38.7 to 1.91, p=0.08), pain scores (Mean difference -0.71, 95% CI=-1.93 to 0.50, p=0.25) or complications (OR=0.67, 95% CI=0.11 to 4.23, p=0.67) between TAP and no TAP groups. However, TAP was associated with significantly less time to ambulation (Mean difference -2.22 hours, 95% CI=-3.89 to -0.56, p=0.009), and PONV (OR=0.13, 95% CI=0.05 to 0.35, p&amp;lt;0.0001) rates. Conclusion TAP in laparoscopic bariatric surgery is associated with significantly less PONV and time to ambulation but similar narcotic usage, postoperative pain and complication rates, compared to no TAP. Take-home message TAP in laparoscopic bariatric surgery is associated with a shorter time to ambulation and less PONV but similar postoperative pain and narcotic usage, compared to no TAP.

P28: LAPAROSCOPIC VERSUS ULTRASOUND-GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCK IN LAPAROSCOPIC COLORECTAL SURGERY - A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Introduction A multimodal approach to peri-operative analgesia represents a cornerstone of enhanced recovery programmes in minimally invasive colorectal surgery. Transversus abdominis plane (TAP) block is an emerging anaesthetic technique that may reduce postoperative opiod analgesic requirements. It can be performed laparoscopically or percutaneously. We performed a systematic review and meta-analysis to compare the effectiveness of laparoscopic versus ultrasound-guided TAP block in laparoscopic colorectal surgery. Method PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until November 2019. All studies that compared laparoscopic (LTB) versus ultrasound-guided (UTB) TAP blocks in laparoscopic colorectal resections were included. The primary outcome measure was narcotic consumption at 24 hours postoperatively, while secondary outcomes included pain scores, operative time, postoperative nausea and vomitting (PONV) and complication rates. Random effects models were used to calculate pooled effect size estimates. Result Three randomised controlled trials and one retrospective study were included capturing 309 patients. On random effects analysis, there were no significant differences in narcotic consumption between LTB and UTB (Mean difference -8.12 mg, 95% CI=-22.13 to 5.89, p=0.26). LTB was associated with significantly lower pain scores (Mean difference -0.49, 95% CI=-0.96 to -0.02, p=0.04). There were no differences in operative time (Mean difference -6.67 mins, 95% CI=-29.4 to 16.06, p=0.57), PONV (OR=0.97, 95% CI=0.36 to 2.65, p=0.96) or complication (OR=1.30, 95% CI=0.64 to 2.64, p=0.47) rates. Conclusion LTB is associated with significantly less pain at 24 hours postoperatively but similar narcotic usage, PONV, operative time and complication rates, compared to UTB. Take-home message Laparoscopic transversus abdominis plane block is shown to leave patients with less pain at 24 hours post-op compared to ultrasound guided methods in colorectal patients.

Average narcotic usage in a group of TKA patients following a modern TKA protocol

IntroductionThe optimal dosing of post-operative total knee arthroplasty (TKA) narcotics is unclear. We report on the average narcotic usage in a group of patients treated with an identical multimodal pain protocol following TKA. Materials and methods49 patients undergoing TKA participated in the survey. Patients with pre-op narcotic use, recent prior total joint arthroplasty or study refusal were excluded. All patients received a spinal anesthetic. No pre-surgery narcotics were given. All received an identical local infiltrative anesthetic combination along with a multimodal pain protocol. Patients were placed into an identical rapid rehab program. Narcotic usage during hospitalization was recorded in morphine equivalent doses (MED). Patients were given a journal to record their daily narcotic utilization. ResultsPre-operative pain scores of the excluded groups had slightly higher but clinically insignificant differences compared to the study group. In the hospital, POD1 study group daily MED averaged 28 (range 0–110). POD2 had an average of 33.6 and POD 3 daily usages averaged 28.6 (range 0–100). By the end of week two, the average daily use was 19.2 and 24% patients were off all narcotics. By the end of week four, the average daily usage was 7.5 and 63% of patients were off all narcotics. By 8 weeks, there were no patients still taking narcotics. KSS averaged 76.9 (range 51–97) at the 6 week visit, and 94.2 at the 3-month visit (range 72–100). SummaryThis study documents the average needs of an average TKA patient treated with modern pain protocols. The majority of these patients were off narcotics by week four.

Prescribing Trends in Post-operative Pain Management After Urologic Surgery: A Quality Care Investigation for Healthcare Providers

To assess prescribing and refilling trends of narcotics in postoperative urology patients at our institution. Although the opioid epidemic remains a public health threat, no series has assessed prescribing patterns across urologic surgery disciplines following discharge. All urologic surgeries were retrospectively reviewed from May 2017-April 2018. Demographics, comorbidities, and postoperative pain management strategies were analyzed. Narcotics usage following surgery were reported in total morphine equivalents (TME). Opioid refill rate was characterized by medical specialty and stratified by urologic discipline. 817 cases were reviewed. Mean age and TME at discharge was 57±15.6 years and 35.43±19.5 mg, respectively. 13.6% (mean age 55±15.9) received a narcotic refill following discharge (mean TME/refill 37.7±28.9 mg). A higher proportion of patients with a pre-operative opioid prescription received a refill compared to opioid naïve patients (38.2% vs 21.6%, P < .01). Refill rate did not differ between urologic subspecialties (P = .3). Urologists were only responsible for 20.4% of all refills filled, despite all patients continuing follow-up with their surgeon. Procedures with the highest rates of post-operative refills were in oncology, male reconstruction/trauma and endourology. Patients with a history of chronic pain (OR 1.9, CI 1.1-3.3) preoperative narcotic prescription (OR 1.6, CI 1.0-2.6), and higher ASA score (OR 1.8, CI 1.6-2.8) were more likely to obtain a postoperative opioid prescription refill. Approximately 1 in 7 postoperative urology patients receive a postoperative narcotics refill; however, nearly two-thirds receive refills exclusively from non-urologic providers. Attempts to avoid overprescribing of postoperative narcotics need to account for both surgeon and nonsurgeon sources of opioid refills.

Contemporaneous evaluation of patient experience, surgical strategy, and seizure outcomes in patients undergoing stereoelectroencephalography or subdural electrode monitoring.

Intracranial electrographic localization of the seizure onset zone (SOZ) can guide surgical approaches for medically refractory epilepsy patients, especially when the presurgical workup is discordant or functional cortical mapping is required. Minimally invasive stereotactic placement of depth electrodes, stereoelectroencephalography (SEEG), has garnered increasing use, but limited data exist to evaluate its postoperative outcomes in the context of the contemporaneous availability of both SEEG and subdural electrode (SDE) monitoring. We aimed to assess the patient experience, surgical intervention, and seizure outcomes associated with these two epileptic focus mapping techniques during a period of rapid adoption of neuromodulatory and ablative epilepsy treatments. We retrospectively reviewed 66 consecutive adult intracranial electrode monitoring cases at our institution between 2014 and 2017. Monitoring was performed with either SEEG (n=47) or SDEs (n=19). Both groups had high rates of SOZ identification (SEEG 91.5%, SDE 88.2%, P=.69). The majority of patients achieved Engel class I (SEEG 29.3%, SDE 35.3%) or II outcomes (SEEG 31.7%, SDE 29.4%) after epilepsy surgery, with no significant difference between groups (P=.79). SEEG patients reported lower median pain scores (P=.03) and required less narcotic pain medication (median = 94.5 vs 594.6 milligram morphine equivalents, P=.0003). Both groups had low rates of symptomatic hemorrhage (SEEG 0%, SDE 5.3%, P=.11). On multivariate logistic regression, undergoing resection or ablation (vs responsive neurostimulation/vagus nerve stimulation) was the only significant independent predictor of a favorable outcome (adjusted odds ratio = 25.4, 95% confidence interval = 3.48-185.7, P=.001). Although both SEEG and SDE monitoring result in favorable seizure control, SEEG has the advantage of superior pain control, decreased narcotic usage, and lack of routine need for intensive care unit stay. Despite a heterogenous collection of epileptic semiologies, seizure outcome was associated with the therapeutic surgical modality and not the intracranial monitoring technique. The potential for an improved postoperative experience makes SEEG a promising method for intracranial electrode monitoring.

Do Thoracic Spinal Deformities Affect Outcomes of Spinal Cord Stimulators: A Retrospective Chart Review.

Retrospective chart review. The aim of this study was to ascertain whether the presence of structural thoracic deformities affects outcomes of permanent SCS placement. Neural modulation via spinal cord stimulators (SCSs) has become an accepted treatment option for various chronic pain syndromes. In most cases, the surgeon desires accurate midline positioning of the paddle lead, allowing for flexibility of unilateral or bilateral coverage of pain patterns. Structural spinal deformities (scoliosis or kyphosis) often result from coronal, sagittal, and rotatory deformity that can make midline placement more difficult. Between 2013 and 2017, two-hundred forty-one charts of patients who underwent permanent SCS placement at our suburban hospital were reviewed. Demographic information, numerical rating system (NRS) pain scores, Oswestry Disability Index (ODI) scores, and opioid medication usage were recorded at baseline and after permanent stimulator placement. Thoracic scoliosis and kyphosis angles were measured using spinal radiographs. The effect of each structural deformity on NRS, ODI, and narcotic medication usage changes from baseline was analyzed. Overall, 100 patients were included in our cohort. Fifty-six patients had measured thoracic spinal deformities (38% with scoliosis, 31% with kyphosis). There was no significant difference in NRS scores, ODI scores, or narcotic usage change between patients with scoliosis and those without (P = 0.66, P = 0.57, P = 0.75) or patients with kyphosis and those without (P = 0.51, P = 0.31, P = 0.63). Bivariate linear regression analysis showed that scoliotic and kyphotic angles were not significant predictors of NRS (P = 0.39, P = 0.13), ODI (P = 0.45, P = 0.07), and opioid usage (P = 0.70, P = 0.90) change, with multivariate regression analyses confirming these findings. SCSs can be effective options for treating lumbar back pain and radiculopathy. Our study suggests that the presence of mild structural deformities does not adversely affect outcomes of permanent SCS placement and as such should not preclude this population from benefiting from such therapies.Level of Evidence: 4.