Opioid-related Complications Research Articles

Systemic Complications and Radiographic Findings of Opioid Use and Misuse: An Overview for Orthopedic Surgeons.

Amid growing concern about the misuse of prescribed opioids, the rising rates of opioid use disorder, and the use of illicit opioids, clinicians in ambulatory, inpatient, and operative environments are encountering opioid-related complications in their patients. These complications can affect multiple organ systems including cardiovascular, pulmonary, gastrointestinal, and neurologic and are related to excess opioid levels in the body or contamination from non-sterile injection. It is important for the orthopedic surgeon to have a general understanding of the pathologies associated with opioid use disorder and their appearance on diagnostic imaging. This article reviews image findings of several complications, organized in a systems-based approach, for the orthopedic surgeon.

Prevalence and Risk Factors for Opioid-Related Complications in Patients with Myeloproliferative Neoplasms: An International Survey of 502 Patients By the MPN Quality of Life Study Group

Introduction:Myeloproliferative Neoplasm (MPN) patients encounter debilitating pain syndromes as a result of their disorder. Opioids are frequently employed in cancer-related pain but have been increasingly recognized for their risk profiles including accidental overdose, addiction and death. With many MPN patients facing near-normal life expectancies, chronicity of opioid use may increase the risk of adverse events. In this survey, we evaluated the prevalence of MPN opioid use, risk factors for negative outcomes and compared the features of this population to MPN patients not receiving opioid therapy.Methods:This study was performed by the MPN Quality of Life Study Group. A survey was designed by a team of MPN investigators experienced with MPN symptomatology. Patients completed the MPN-10, a 10 item survey of MPN symptoms completed on a 0 (absent) to 10 (worst imaginable) scale (Blood. 2011 Jul 14;118(2):401-8). Other surveyed tools included the Opioid Risk Tool (ORT) as well as DSMV criteria for Opioid Use Disorder (OUD). The survey was posted on high-traffic MPN-related webpages focused on patient education and advocacy (MPN Forum, MPN Net, MPN Research Foundation, MPN Voice)for a total of 28 days. Patients currently receiving opioids were compared to patients not receiving opioids and statistical significance was defined as p<0.05.ResultsDemographicsA total of 416 patients completed the survey and were compared by active opioids use (n=69) vs. no active opioid use (n=347). Patients described a history of myelofibrosis (MF, 28.8%), polycythemia vera (PV, 44.2%) and essential thrombocythemia (ET, 26.9%). Most MPNs were diagnosed between 1-3 years ago (22.2%), 3-10 years ago (35.0%) or >10 years ago (30.4%). Patients were furthermore of expected mean age (60.7), primarily female (75.0%) and from the United States (66.6%). Few patients had a history of transformation to acute leukemia (0.5%), severe bleeding (12.3%) or blood clot (26.5%). Mean individual symptom scores and prevalences were 3.0 and 65.6% for abdominal discomfort and 3.3 and 59.4% for bone pain, respectively, indicating a low to moderate symptom burden.Patients Receiving Opioid TherapyPatients on opioid therapy (n=69) displayed a number of high risk features for adverse outcomes including a personal history of substance abuse (20.2%), respiratory disease (33%) and mental health disorders (60.1%). By DSMV criteria, 5.9% of opioid patients scored ‘mild’ and 2.9% scored ‘moderate’ for OUD (total 8.8%), consistent with prevalence in the general population. Approximately 24.6% of opioid-using patients scored moderate to high risk on the ORT but despite this, did not appear more likely to meet criteria for OUD (p=0.81). Palliative care and pain management were involved in only 34.3% of patients and side effects of opioids were discussed in only 70.1% of all cases.Opioid vs. Non-Opioid PatientsCompared to patients not receiving opioid therapy, patients currently on opioid treatment were more likely to describe more frequent and/or more severe abdominal discomfort (88.4% vs. 61.0%, p<0.001; mean 5.0 vs. 2.6, p<0.001), bone pain (87.0% vs. 53.9%, p<0.001; mean 5.6 vs. 2.4, p<0.001), unintentional weight loss (41.2% vs. 21.4%, p=0.001), inactivity (94.2% vs. 71.5%, p<0.001), early satiety (84.1% vs. 58.2%, p<0.001), and impaired quality of life (mean 4.9 vs. 6.6, p<0.001). They were also more likely to describe regularly taking pain medications (85.5% vs. 34.5%, p<0.001) as well as attempt non-pharmacological treatments to manage symptoms (Figure 1). Despite more aggressive pain treatment approaches, only 42% of opioid patients reported satisfaction with their current pain plan vs. 62.2% of patients not receiving opioid therapy.Conclusions:MPN patients face significant symptom burden despite often limited reduction in life expectancy. Patients furthermore demonstrate a high prevalence of risk factors for opioid-related complications including overdose and substance misuse. Despite aggressive pain regimens, opioid patients are less likely to voice adequate symptom control or satisfaction with their pain treatment plans. Providers should be cognizant of opioid-related complications and consider subspecialty pain management referrals or adaptation of the JCO Clinical Practice Guidelines for Management of Chronic Pain in Survivors of Adult Cancers (J Clin Oncol. 2016 Sep 20;34(27):3325-45). [Display omitted] DisclosuresScherber:Orphan Pharmaceuticals: Honoraria; Incyte: Consultancy. Palmer:Novartis: Research Funding. Dueck:Phytogine: Employment; Pfizer: Honoraria; Bayer: Employment. Mesa:Gilead: Research Funding; Novartis: Consultancy; CTI: Research Funding; Galena: Consultancy; Incyte: Research Funding; Promedior: Research Funding; Ariad: Consultancy; Celgene: Research Funding.

Effectiveness of intravenous acetaminophen for postoperative pain management in shoulder arthroplasties: A population-based study

BackgroundIntravenous acetaminophen (IV APAP) is an option in multimodal postoperative analgesia. Prior trials focus on hip and knee arthroplasties, whereas large-scale data on utilization and effectiveness in shoulder arthroplasties are lacking. MethodsData on 67,494 (452 hospitals) partial/total shoulder arthroplasties were extracted from the Premier claims database (2011–2016). Patients were categorized by receipt and dosage of IV APAP. Multilevel models measured associations between IV APAP and opioid utilization (in oral morphine equivalents), length/cost of stay and opioid-related complications. Effect estimates (adjusted % change) with 95% confidence intervals (CIs) are reported. ResultsIV APAP was used in 17.7% (n = 11,949) of patients with an increasing utilization trend. Most patients received only one dose on the day of surgery (69.5%; n = 8308). When adjusting for relevant covariates, IV APAP was not associated with meaningful effects on outcomes. Specifically, its use (versus no use) was not associated with decreased (but rather somewhat increased) opioid utilization: + 5.4% (CI 3.6–7.1%; P < 0.05). ConclusionIn this first large-scale study that assesses IV APAP in shoulder arthroplasties, IV APAP use was not associated with decreased opioid utilization or the length/cost of stay. These results do not support routine use of IV APAP in this cohort, especially given its high cost. The translational potential for this articleMultimodal pain control to assist in reducing the opioid pain medications are seen as a route to improved postoperative patient outcomes, better pain control and expedited hospital discharge. Acetaminophen plays a significant role in these protocols in many institutions, but it is not established if this expensive IV formulation is superior to the oral formulation. This study evaluates the use and effectiveness of IV acetaminophen following shoulder arthroplasty at a large number of institutions.

Liposomal Bupivacaine Does Not Reduce Inpatient Opioid Prescription or Related Complications after Knee Arthroplasty: A Database Analysis.

WHAT THIS MANUSCRIPT TELLS US THAT IS NEW: BACKGROUND:: Although some trials suggest benefits of liposomal bupivacaine, data on real-world use and effectiveness is lacking. This study analyzed the impact of liposomal bupivacaine use (regardless of administration route) on inpatient opioid prescription, resource utilization, and opioid-related complications among patients undergoing total knee arthroplasties with a peripheral nerve block. It was hypothesized that liposomal bupivacaine has limited clinical influence on the studied outcomes. The study included data on 88,830 total knee arthroplasties performed with a peripheral nerve block (Premier Healthcare Database 2013 to 2016). Multilevel multivariable regressions measured associations between use of liposomal bupivacaine and (1) inpatient opioid prescription (extracted from billing) and (2) length of stay, cost of hospitalization, as well as opioid-related complications. To reflect the difference between statistical and clinical significance, a relative change of -15% in outcomes was assumed to be clinically important. Overall, liposomal bupivacaine was used in 21.2% (n = 18,817) of patients that underwent a total knee arthroplasty with a peripheral nerve block. Liposomal bupivacaine use was not associated with a clinically meaningful reduction in inpatient opioid prescription (group median, 253 mg of oral morphine equivalents, adjusted effect -9.3% CI -11.1%, -7.5%; P < 0.0001) and length of stay (group median, 3 days, adjusted effect -8.8% CI -10.1%, -7.5%; P < 0.0001) with no effect on cost of hospitalization. Most importantly, liposomal bupivacaine use was not associated with decreased odds for opioid-related complications. Liposomal bupivacaine was not associated with a clinically relevant improvement in inpatient opioid prescription, resource utilization, or opioid-related complications in patients who received modern pain management including a peripheral nerve block.

Critical Care Pain Management in Patients Affected by the Opioid Epidemic: A Review

The rapid rise in the opioid epidemic has had a deleterious impact across the United States. This increase has drawn the attention of the critical care community not only because of the surge in acute opioid overdose-related admissions, but also due to the increase in the number of opioid-dependent and opioid-tolerant patients being treated in the intensive care unit (ICU). Opioid-related issues relevant to the critical care physician include direct care of patients with opioid overdoses, the provision of sufficient analgesia to patients with opioid dependence and tolerance, and the task of preventing long-term opioid dependence in patients who survive ICU care. This review identifies the challenges facing the ICU physician working with patients presenting with opioid-related complications, discusses current solutions, and suggests future areas of research and heightened ICU clinician attention.

Multi-modal Analgesic Strategies for Trauma (MAST): protocol for a pragmatic randomized trial

BackgroundPain management after injury is critically important for functional recovery. Although opioids have been a mainstay for treatment of pain, they are associated with adverse events and may contribute to...

Opioid Analgesics and Adverse Outcomes among Hemodialysis Patients.

Patients on hemodialysis frequently experience pain and may be particularly vulnerable to opioid-related complications. However, data evaluating the risks of opioid use in patients on hemodialysis are limited. Using the US Renal Data System, we conducted a cohort study evaluating the association between opioid use (modeled as a time-varying exposure and expressed in standardized oral morphine equivalents) and time to first emergency room visit or hospitalization for altered mental status, fall, and fracture among 140,899 Medicare-covered adults receiving hemodialysis in 2011. We evaluated risk according to average daily total opioid dose (>60 mg, ≤60 mg, and per 60-mg dose increment) and specific agents (per 60-mg dose increment). The median age was 61 years old, 52% were men, and 50% were white. Sixty-four percent received opioids, and 17% had an episode of altered mental status (15,658 events), fall (7646 events), or fracture (4151 events) in 2011. Opioid use was associated with risk for all outcomes in a dose-dependent manner: altered mental status (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.23 to 1.34; higher dose: hazard ratio, 1.67; 95% confidence interval, 1.56 to 1.78; hazard ratio, 1.29 per 60 mg; 95% confidence interval, 1.26 to 1.33), fall (lower dose: hazard ratio, 1.28; 95% confidence interval, 1.21 to 1.36; higher dose: hazard ratio, 1.45; 95% confidence interval, 1.31 to 1.61; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.03 to 1.05), and fracture (lower dose: hazard ratio, 1.44; 95% confidence interval, 1.33 to 1.56; higher dose: hazard ratio, 1.65; 95% confidence interval, 1.44 to 1.89; hazard ratio, 1.04 per 60 mg; 95% confidence interval, 1.04 to 1.05). All agents were associated with a significantly higher hazard of altered mental status, and several agents were associated with a significantly higher hazard of fall and fracture. Opioids were associated with adverse outcomes in patients on hemodialysis, and this risk was present even at lower dosing and for agents that guidelines have recommended for use.

Acute Radiologic Manifestations of America's Opioid Epidemic.

The United States is in the midst of an opioid use epidemic, which has severe medical, social, and economic consequences. Addictions to and abuse of prescription and illicit opioids are increasing, and emergency department radiologists are increasingly being faced with the task of examining patients who present with opioid-related complications. These complications may be the result of direct drug toxicity or nonsterile injection of the drugs. Neurologic, musculoskeletal, cardiopulmonary, genitourinary, and gastrointestinal complications may be evident at diagnostic imaging in emergent settings. Heroin-induced leukoencephalopathy, cerebral septic emboli, mycotic arterial aneurysms, soft-tissue infections, and infective endocarditis are some of the conditions that patients may be found to have after they present to the emergency department. In this article, the above topics, including clinical features, pathophysiology, imaging findings, and treatment options, are reviewed. Recognizing the limitations of diagnostic imaging modalities that are available to radiologists is equally important, as some conditions can be successfully diagnosed after the initial triage-for example, transesophageal echocardiography can be performed to diagnose infective endocarditis. The emergency department radiologist may be responsible for identifying acute conditions, which can be life threatening. Some of the more common emergent opioid-related conditions and complications are reviewed, with specific emphasis on cases in which emergency department radiologists encounter conditions for which additional expertise is required. Becoming familiar with the conditions directly related to the current opioid epidemic will enable the diagnosis of these entities in a timely and accurate manner. ©RSNA, 2018.

Periarticular Injection Versus Femoral Nerve Block for Pain Relief After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

To compare the effectiveness and safety of periarticular injection (PI) with those of femoral nerve block (FNB) after anterior cruciate ligament (ACL) reconstruction. A total of 129 patients scheduled for ACL reconstruction were randomly assigned to receive PI or FNB. Other perioperative interventions were identical for all patients. The primary outcome was the postoperative pain score 24hours after surgery, which was measured using a 100-mm visual analog scale (VAS). The pain scores were also assessed to determine whether the VAS score would reach the threshold values reported for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS). The PI group had significantly lower VAS scores 24hours after ACL reconstruction than the FNB group (21mm vs 39mm; P < .0001). Consequently, the primary outcome reached the level of clinical significance as indicated by the threshold values of an MCID of 9.9 and a PASS of 33. The PI group also had a significantly lower VAS score at rest at 4hours, 8hours, and 2days after surgery (30mm vs 39mm [P= .025], 25mm vs 33mm [P= .022], and 22mm vs 32mm [P= .0022], respectively). The opioid consumption during the initial 24hours was significantly lower in the PI group (354μg vs 503μg; P= .0003). The complication rate, including opioid-related complications, was not significantly different between groups. The patients treated with PI had significantly better pain scores and lower opioid consumption than those treated with FNB without elevating the complication rate. Level I, randomized controlled trial.

Pain Management After Hip Arthroscopy: Systematic Review of Randomized Controlled Trials and Cohort Studies

Background: Hip arthroscopy is often associated with significant postoperative pain and opioid-associated side effects. Effective pain management after hip arthroscopy improves patient recovery and satisfaction and decreases opioid-related complications. Purpose: To collect, examine, and provide a comprehensive review of the available evidence from randomized controlled trials and comparative studies on pain control after hip arthroscopy. Study Design: Systematic review. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the literature for postoperative pain control after hip arthroscopy was performed using electronic databases. Only comparative clinical studies with level 1 to 3 evidence comparing a method of postoperative pain control with other modalities or placebo were included in this review. Case series and studies without a comparative cohort were excluded. Results: Several methods of pain management have been described for hip arthroscopy. A total of 14 studies met our inclusion criteria: 3 on femoral nerve block, 3 on lumbar plexus block, 3 on fascia iliaca block, 4 on intra-articular injections, 2 on soft tissue surrounding surgical site injection, and 2 on celecoxib (4 studies compared 2 or more methods of analgesia). The heterogeneity of the studies did not allow for pooling of data. Single-injection femoral nerve blocks and lumbar plexus blocks provided improved analgesia, but increased fall rates were observed. Fascia iliaca blocks do not provide adequate pain relief when compared with surgical site infiltration with local anesthetic and are associated with increased risk of cutaneous nerve deficits. Patients receiving lumbar plexus block experienced significantly decreased pain compared with fascia iliaca block. Portal site and periacetabular injections provide superior analgesia compared with intra-articular injections alone. Preoperative oral celecoxib, compared with placebo, resulted in earlier time to discharge and provided significant pain relief up to 24 hours. Conclusion: Perioperative nerve blocks provide effective pain management after hip arthroscopy but must be used with caution to decrease risk of falls. Intra-articular and portal site injections with local anesthetics and preoperative celecoxib can decrease opioid consumption. There is a lack of high-quality evidence on this topic, and further research is needed to determine the best approach to manage postoperative pain and optimize patient satisfaction.

Intrathecal morphine for postoperative pain control following robot-assisted prostatectomy: a prospective randomized trial.

Robot-assisted laparoscopic prostatectomy (RALP) is minimally invasive surgery, but also causes moderate to severe pain during the immediate postoperative period. We evaluated the efficacy and safety of intrathecal morphine (ITM) for postoperative pain control in patients undergoing RALP. Thirty patients scheduled for RALP were randomly assigned into one of two groups. In the ITM group (n=15), postoperative pain was managed using 300µg intrathecal morphine with intravenous patient-controlled analgesia (IV-PCA). In the IV-PCA group (n=15), only intravenous patient-controlled analgesia was used. The numerical pain score (NPS; 0=no pain, 100=worst pain imaginable), postoperative IV-PCA requirements and opioid-related complications including nausea, vomiting, dizziness, headache and pruritus were compared between the two groups. The NPSs on coughing were 20 (IQR 10-50) in the ITM group and 60 (IQR 40-80) in the IV-PCA group at postoperative 24h (p=0.001). The NPSs were significantly lower in the ITM group up to postoperative 24h. The ITM group showed less morphine consumption at postoperative 24h in the ITM group than in the IV-PCA group [5 (IQR 3-15) mg vs 17 (IQR 11-24) mg, p=0.001]. Complications associated with morphine were comparable between the two groups and respiratory depression was not reported in either group. Intrathecal morphine provided more satisfactory analgesia without serious complications during the early postoperative period in patients undergoing RALP.

Retrospective case-control non-inferiority analysis of intravenous lidocaine in a colorectal surgery enhanced recovery program

BackgroundEnhanced recovery after surgery (ERAS) programs typically utilizes multi-modal analgesia to reduce perioperative opioid consumption. Systemic lidocaine is used in several of these ERAS algorithms and has been shown to reduce opioid use after colorectal surgery. However it is unclear how much the other components of an ERAS protocol contribute to the final outcome. Using a noninferiority analysis we sought to assess the role of perioperative lidocaine in an ERAS program for colorectal surgery, using pain and opioid consumption as outcomes.MethodsWe conducted a retrospective review of patients who had received intravenous lidocaine perioperatively during colorectal surgery. We matched them with patients who were managed using a multi-component ERAS protocol, which included perioperative lidocaine. We tested a joint hypothesis of noninferiority of lidocaine infusion to ERAS protocol in postoperative pain scores and opioid consumption. We assigned a noninferiority margin of 1 point (on an 11-point numerical rating scale) difference in pain and a ratio [mean (lidocaine) / mean (ERAS)] of 1.2 in opioid consumption, respectively.ResultsFifty-two patients in the lidocaine group were matched with patients in the ERAS group. With regards to opioid consumption, in the overall [1.68 (1.43–1.98)] [odds ratio (95% confidence interval)] analysis and on postoperative day (POD) 1 [2.38 (1.74–3.31)] lidocaine alone was inferior to multi-modal analgesia. On POD 2 and beyond, although the mean odds ratio for opioid consumption was 1.43 [1.43 (1.17–1.73)], the lower limit extended beyond the pre-defined cut-off of 1.2, rendering the outcome inconclusive. For pain scores lidocaine is non-inferior to ERAS [-0.17 (-1.08–0.74)] on POD 2 and beyond. Pain scores on POD 1 and in the overall cohort were inconclusive based on the noninferiority analysis.ConclusionsThe addition of a multi-component ERAS protocol to intravenous lidocaine incrementally reduces opioid consumption, most evident on POD 1. For pain scores the data is inconclusive on POD 1, however on POD 2 and beyond lidocaine alone is non-inferior to an ERAS program with lidocaine. Opioid-related complications, including return of bowel function, were not different between the groups despite reduced opioid use in the ERAS group.

The Effect of Dexmedetomidine on Postoperative Opioid Consumption and Pain After Major Spine Surgery

(Abstracted from Anesth Analg, 122:1646–1653, 2016) Patients undergoing multilevel deformity-correction spine surgery may experience substantial inflammatory, muscular, neuropathic, and postsurgical pain, which increases chronic opioid use and incidence of opioid-related complications. Previous studies have shown α2 agonists to have an opioid-sparing effect in certain types of spine surgery.

Estimating the Effect of Intravenous Acetaminophen for Postoperative Pain Management on Length of Stay and Inpatient Hospital Costs.

IntroductionThe provision of safe, effective, cost-efficient perioperative inpatient acute pain management is an important concern among clinicians and administrators within healthcare institutions. Overreliance on opioid monotherapy in this setting continues to present health risks for patients and increase healthcare costs resulting from preventable adverse events. The goal of this study was to model length of stay (LOS), potential opioid-related complications, and costs for patients reducing opioid use and adding intravenous acetaminophen (IV APAP) for management of postoperative pain.MethodsData for this study were de-identified inpatient encounters from The Advisory Board Company across 297 hospitals from 2012–2014, containing 2,238,433 encounters (IV APAP used in 12.1%). Encounters for adults ≥18 years of age admitted for cardiovascular, colorectal, general, obstetrics and gynecology, orthopedics, or spine surgery were included. The effects of reducing opioids and adding IV APAP were estimated using hierarchical statistical models. Costs were estimated by multiplying modeled reductions in LOS or complication rates by observed average volumes for medium-sized facilities, and by average cost per day or per complication (LOS: US$2383/day; complications: derived from observed charges).ResultsAcross all surgery types, LOS showed an average reduction of 18.5% (10.7–32.0%) for the modeled scenario of reducing opioids by one level (high to medium, medium to low, or low to none) and adding IV APAP, with an associated total LOS-related cost savings of $4.5 M. Modeled opioid-related complication rates showed similar improvements, averaging a reduction of 28.7% (5.4–44.0%) with associated cost savings of $0.2 M. In aggregate, costs decreased by an estimated $4.7 M for a medium-sized hospital. The study design demonstrates associations only and cannot establish causal relationships. The cost impact of LOS is modeled based on observed data.ConclusionsThis investigation indicates that reducing opioid use and including IV APAP for postoperative pain management has the potential to decrease LOS, opioid-related complication rates, and costs from a hospital perspective.FundingMallinckrodt Pharmaceuticals.

A Rapid Recovery Pathway for Adolescent Idiopathic Scoliosis That Improves Pain Control and Reduces Time to Inpatient Recovery After Posterior Spinal Fusion

Study DesignRetrospective comparative cohort. ObjectivesTo determine if a standardized multimodal analgesic and rehabilitation protocol (rapid recovery pathway [RRP]) in adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) could improve pain control, reduce opioid-related complications, and expedite early mobilization. BackgroundSeveral reports have described postoperative recovery pathways for AIS patients undergoing PSF that shorten length of stay (LOS) without reporting the impact such pathways might have on patients' pain or quality of recovery. MethodsWe compared two high-volume surgeons' patients managed on our conventional pathway (CP) or our RRP. The CP analgesia consisted of intraoperative methadone and postoperative patient-controlled analgesia (PCA) until tolerating oral analgesics, with adjunctive diazepam. Analgesia on the RRP includes intraoperative methadone and postoperative PCA; patients also receive preoperative gabapentin and acetaminophen, intraoperative intravenous acetaminophen, and postoperative diazepam, gabapentin, acetaminophen, and ketorolac. Ambulation and full diet are permitted beginning postoperative day 1. The primary outcome was mean daily pain scores. Secondary outcomes were LOS, time to pathway milestone completions, and frequency of opioid-related side effects requiring treatment. ResultsThere were 58 patients in the RRP group and 80 patients in the CP group. Patients on RRP had improved mean daily pain scores on postoperative days 0 (p = .027), 1 (p < .001) and 2 (p = .004). RRP patients were discharged home 31% earlier, discontinued from PCA 34% earlier and had their urinary catheters removed 26% earlier. Total opioid consumption decreased on postoperative day 0 (p < .001), but not postoperative day 1 (p = .773) or 2 (p = .343). Fewer patients on the RRP required medication for opioid-induced pruritus (p = .001), but there was no difference in the frequency of odansetron administration (p = .566). There were no differences in 30-day rates of readmission (p = .407). ConclusionImplementation of standardized RRP resulted in reduced pain, faster mobilization, reduced frequency of opioid-related side-effects, and earlier discharge.

A prospective randomized comparative study of postoperative pain control using an epidural catheter in patients undergoing posterior lumbar interbody fusion.

To assess the efficacy of continuous epidural infusion analgesia (ED) with 0.2% Ropivacaine versus IV PCA (Fentanyl) in spinal fusion surgery patients. A prospective randomized comparative clinical trial. Patients were randomized into one of two groups-the epidural group (ED-51 patients) and the IV PCA group (IV-43 patients). The epidural catheter tip was placed one level cephalad to the level of the PLIF in patients in the ED group. Patients were assessed by determining the pain score, cumulative opioid requirement, adverse effects, and satisfaction. Pain score comparisons between the ED group and the IV group, respectively, were as follows: immediate postoperative status: 2.1±1.5 vs. 7.2±2.1, p=0.01; postoperative day 1: 2.3±1.9 vs. 6.8±2.3, p=0.02; postoperative day 2: 1.9±1.8 vs. 5.4±2.1, p=0.02; postoperative day 3: 1.5±1.6 vs. 3.9±1.9, p=0.03; postoperative day 4: 3.8±2.1 vs. 3.1±1.9, p=0.4. Lower levels of opioids were required in the ED group, and fewer opioid-related complications developed in the patients in this group. Complications related to the use of epidural catheters were comparable between the two groups. Patient satisfaction with postoperative pain control was higher in the ED group. In comparison with the use of IV PCA only, continuous epidural infusion of Ropivacaine resulted in lower pain scores and opioid consumption and higher patient satisfaction levels after posterior lumbar interbody fusion.

Effect of intravenous acetaminophen on post-operative opioid-related complications: study protocol for a randomized, placebo-controlled trial

Background: Unrelieved post-operative pain leads to physiological and psychological consequences which worsen outcomes. Patients still report a 31% incidence of severe pain and 47% incidence of moderate pain after surgery. Multimodal analgesia aims to improve satisfaction while reducing side effects. Opioids are the most common treatment for post-operative pain; however, acute tolerance and opioid-induced hyperalgesia increase opioid requirements and the risk of side effects. Previous studies with acetaminophen have shown consistent and clinically important opioid-sparing effects but were unable to demonstrate significant reductions in opioid-related adverse events (inadequate sample sizes, poorly monitored complications). Specifically, we propose to test the primary hypothesis that total duration of hypoxia (defined as saturation of peripheral oxygen (SpO 2 ) Methods/Design: A total of 528 patients undergoing elective open or laparoscopic abdominal surgery will be included in this prospective, randomized, double-blinded, placebo-controlled trial. Patients who have renal disease, liver disease, acetaminophen allergy, are on warfarin therapy, or are receiving regional blocks will be excluded. The incidence and duration of hypoxic events will be the primary outcome of the study. Secondary outcomes include opioid consumption, pain scores, post-operative nausea and vomiting, sedation, fatigue, respiratory rate, movement, and cost-benefit analysis. We will use a ViSi mobile device (Sotera Wireless, San Diego, CA, USA) that will provide continuous non-invasive pulseoximetry, blood pressure, skin temperature, and patient position. Respiratory function will be measured using an ExSpiron (Respiratory Motion Inc., Waltham, MA, USA) monitor which provides continuous non-invasive monitoring of tidal volume, respiratory rate, and minute ventilation. Discussion: The outcomes will reveal the effect of peri-operative IV acetaminophen use on post-operative opioid-related complications. Continuous non-invasive monitoring of vital signs is expected to accurately assess opioid-related complications after major abdominal surgery and provide reliable results correlated with opioid use. The use of novel technology in the post-operative setting permits the collection of a dense amount of data and eliminates gaps in post-operative vital sign measurements. Trial registration: ClinicalTrials.gov identifier: NCT02156154, registered on 3 June 2014. Ethics: The study protocol was approved by the Cleveland Clinic Institutional Review Board (IRB) on 28 April 2014, approval number 14-241. Informed consent: Written informed consent will be obtained from participants or their guardians.

Efficacy of intrathecal morphine for postoperative pain management following open nephrectomy.

ObjectiveTo evaluate the efficacy and safety of intrathecal morphine (ITM) for postoperative pain control in patients with renal cell carcinoma undergoing open nephrectomy.MethodsForty-five patients scheduled for open nephrectomy were randomised to receive 300 µg ITM and intravenous patient-controlled analgesia (IV-PCA) (n = 22) or IV-PCA alone (n = 23) for postoperative analgesia. The numeric pain score (NPS), postoperative IV-PCA requirements and opioid-related complications including nausea, vomiting, dizziness, headache, and pruritus were compared between groups.ResultsNPS was significantly lower in the ITM group up to 24 h postoperatively. Upon coughing, NPS at 24 h postoperatively was 50 (interquartile range (IQR) 30–60) in the ITM group and 60 (45–70) in the IV-PCA group. Cumulative morphine consumption at 72 h postoperatively was significantly lower in the ITM group compared with the IV-PCA group (20 (9–33) mg vs. 31 (21–49) mg, respectively). Opioid-related complications were similar in both groups with the exception of pruritus (ITM, 77% vs. IV-PCA, 26%).ConclusionsITM was associated with greater analgesia without serious complications in patients undergoing open nephrectomy.

Anesthesia‐ and opioids‐related malpractice claims following tonsillectomy in USA: LexisNexis claims database 1984–2012

Although commonly performed, tonsillectomy is not necessarily a low-risk procedure for litigation. We have reviewed malpractice claims involving fatal and nonfatal injuries following tonsillectomy with an emphasis on anesthesia- and opioid-related claims and their characteristics. Tonsillectomy-related malpractice claims and jury verdict reports from the United States (US) between 1984 and 2012 found in the LexisNexis MEGA™ Jury Verdicts and Settlements database were reviewed by two independent reviewers. LexisNexis database collects nationwide surgical, anesthesia, and other malpractice claims. Data including years of case and verdicts, surgical, anesthetic and postoperative opioid-related complications, details of injury, death, cause of death, litigation result, and judgment awarded were analyzed. When there were discrepancies between the two independent reviewers, a third reviewer (SS) was involved for resolution. Inflation adjusted monetary awards were based on 2013 US dollars. There were 242 tonsillectomy-related claim reports of which 98 were fatal claims (40.5%) and 144 nonfatal injury claims (59.5%). Verdict/settlement information was available in 72% of cases (n = 175). The median age group of patients was 8.5 years (range 9 months to 60 years). Primary causes for fatal claims were related to surgical factors (n = 39/98, 39.8%) followed by anesthesia-related (n = 36/98, 36.7%) and opioid-related factors (n = 16/98, 16.3%). Nonfatal injury claims were related to surgical (101/144, 70.1%), anesthesia (32/144, 22.2%)- and opioid-related factors (6/144, 4.2%). Sleep apnea was recorded in 17 fatal (17.4%) and 15 nonfatal claims (10.4%). Opioid-related claims had the largest median monetary awards for both fatal ($1 625 892) and nonfatal injury ($3 484 278) claims. Tonsillectomy carries a high risk from a medical malpractice standpoint for the anesthesiologists and otolaryngologists. Although surgery-related claims were more common, opioids- and anesthetic-related claims were associated with larger median monetary verdicts, especially those associated with anoxic, nonfatal injuries. Caution is necessary when opioids are prescribed post-tonsillectomy, especially in patients with sleep apnea.

L’analgésie multimodale est-elle aussi efficace que l’analgésie postopératoire contrôlée par le patient en chirurgie du membre supérieur ?

The present prospective study compared the clinical outcomes between a multimodal analgesia group and a patient-controlled analgesia (PCA) group for postoperative pain control in upper extremities surgery. Multimodal analgesia including pre-emptive analgesic can provide similar or superior analgesic effects and a lower incidence of adverse reactions than PCA following upper extremity surgery. Sixty-one patients undergoing upper extremity surgery were randomized to 2 perioperative analgesic groups (multimodal analgesia and PCA). We compared the clinical outcomes: use of additional pain rescue, opioid-related complication rate, and patient's satisfaction between the 2 groups. No significant differences on the resting and exercise pain scores between the two groups. Also, there were no differences regarding additional pain rescue during postoperative day (POD) 1, 2 and achievement of rehabilitation protocol in both groups. However, use of additional pain rescue in PCA group was increased significantly after PCA removal. Moreover, there was significant difference in the incidence of opioid-related complications on operation day and at POD 1. At discharge, multimodal analgesia group showed significantly greater satisfaction than PCA group. Perioperative pain management following upper extremity surgery through the multimodal analgesia could be an acceptable alternative method that can provide good results. Level II. Low-powered prospective randomized study.