Pain Regimen Research Articles

817: EFFECT OF GABAPENTIN AND METHOCARBAMOL ON LENGTH OF STAY IN PATIENTS WITH TRAUMATIC RIB FRACTURES

Introduction: Use of opioid-sparing agents in patients with traumatic rib fractures is associated with positive outcomes such as reduced intensive care unit (ICU) length of stay (LOS) and opioid exposure. While multiple studies have aimed to evaluate analgesic interventions for rib fractures, no specific bundled combination of analgesia has demonstrated superiority. The objective of this study was to characterize the effect of non-opioid analgesic agents (methocarbamol and gabapentin) as part of a multimodal pain regimen including acetaminophen and lidocaine patches on ICU LOS, hospital LOS, and opioid utilization in patients with traumatic rib fractures. Methods: This was a retrospective cohort study of patients admitted to a surgical ICU at a level I trauma center. Of these, patients with at least one rib fracture were eligible for inclusion. Patients were divided between APAP-lidocaine-methocarbamol and APAP-lidocaine-gabapentin groups. The primary endpoint, ICU LOS, and secondary endpoint of hospital LOS were analyzed by log-rank test. Average cumulative oral morphine equivalents (OME) was analyzed by t-test. Results: 129 patients were included in study analysis: 98 in the APAP-lidocaine-gabapentin group and 31 in the APAP-lidocaine-methocarbamol group. There were no differences in age, sex, race, type of injury, mechanism of injury, and injury severity. The median ICU LOS was similar between APAP-lidocaine-gabapentin (2 +/- 3.2 days) and APAP-lidocaine-methocarbamol (1.8 +/- 1 days) (p=0.23). There was no difference in median hospital LOS between APAP-lidocaine-gabapentin (3.7 +/- 3.8 days) and APAP-lidocaine-methocarbamol (3.8 +/- 1.9 days) (p=0.72). There was also no difference in average cumulative opioid exposure between APAP-lidocaine-gabapentin (85.1 +/- 40.5 mg) and APAP-lidocaine-methocarbamol (84.4 +/- 46.2 mg) (p=0.98). Conclusions: The addition of gabapentin or methocarbamol to acetaminophen plus topical lidocaine patches did not appear to affect the LOS or opioid exposure in this cohort of patients with traumatic rib fractures.

Perioperative use of NSAIDs and the risk of short-term endoscopic recurrence in Crohn's disease patients: A retrospective cohort study

BackgroundMore evidence is needed on the use of NSAID based postoperative pain regimens for Crohn's disease (CD) and its association with recurrence. Our goal is to assess the impact of perioperative use of NSAIDs on endoscopic disease recurrence in patients with CD. MethodsA retrospective cohort study was conducted. The primary outcome measured was endoscopic disease recurrence within 24 months of surgery, defined as a Rutgeerts score ≥ i2. ResultsWe identified 107 patients with CD that underwent index ileocolectomy with primary anastomosis between January 2009 and July 2019. Endoscopic disease recurrence was identified in 28 (26.2%) and clinical recurrence in 18 (16.8%) patients. Exposure to NSAIDs did not increase 24-month endoscopic recurrence risk (22.2% vs. 38.5% patients, p = 0.12). ConclusionIn patients with CD undergoing elective ileocolic resection and primary ileocolic anastomosis, NSAID use in the perioperative period did not impact endoscopic or clinical disease recurrence rate.

Multimodal Analgesia for Accelerated Rehabilitation after Total Knee Arthroplasty: A Randomized, Double-Blind, Controlled Trial on the Effect of the Co-Application of Local Infiltration Analgesia and Femoral Nerve Block Combined with Dexmedetomidine.

Multimodal postoperative pain regimens are widely used following total knee arthroplasty (TKA). However, there are few studies on the rehabilitation of the co-application of local infiltration analgesia (LIA) and femoral nerve block (FNB) combined with dexmedetomidine (DEX) for patients undergoing TKA. This study aimed to investigate the effect of LIA plus FNB and co-application of perioperative DEX on TKA outcomes. 95 patients were randomized into two groups. Patients in group B (n = 48) received a single preoperative FNB and LIA. Patients in group A (n = 47) received FNB and LIA, as well as continuous intravenous injection of DEX starting from the induction of anesthesia to postoperative day 2. All patients were allowed patient-controlled analgesia postoperatively. Visual analog scale (VAS) scores, knee range of motion (ROM) degrees, narcotic consumption, length of hospital stay (LOS), complications, Hospital for Special Surgery (HSS) scores and Montreal Cognitive Assessment-Basic (MoCA-B) Scores were recorded. In group A, the mean VAS scores at rest and during movement were lower, the amount of rescue analgesia was decreased, first time of ambulation was reduced, ROM was improved, MoCA-B Scores were increased, LOS was shorter, HSS scores were higher postoperatively compared with group B (all p < 0.05). Our study indicated multimodal analgesia involving a single FNB and LIA combined with DEX accelerates rehabilitation for patients undergoing TKA.

Mu-opioid receptor and receptor tyrosine kinase crosstalk: Implications in mechanisms of opioid tolerance, reduced analgesia to neuropathic pain, dependence, and reward.

Despite the prevalence of opioid misuse, opioids remain the frontline treatment regimen for severe pain. However, opioid safety is hampered by side-effects such as analgesic tolerance, reduced analgesia to neuropathic pain, physical dependence, or reward. These side effects promote development of opioid use disorders and ultimately cause overdose deaths due to opioid-induced respiratory depression. The intertwined nature of signaling via μ-opioid receptors (MOR), the primary target of prescription opioids, with signaling pathways responsible for opioid side-effects presents important challenges. Therefore, a critical objective is to uncouple cellular and molecular mechanisms that selectively modulate analgesia from those that mediate side-effects. One such mechanism could be the transactivation of receptor tyrosine kinases (RTKs) via MOR. Notably, MOR-mediated side-effects can be uncoupled from analgesia signaling via targeting RTK family receptors, highlighting physiological relevance of MOR-RTKs crosstalk. This review focuses on the current state of knowledge surrounding the basic pharmacology of RTKs and bidirectional regulation of MOR signaling, as well as how MOR-RTK signaling may modulate undesirable effects of chronic opioid use, including opioid analgesic tolerance, reduced analgesia to neuropathic pain, physical dependence, and reward. Further research is needed to better understand RTK-MOR transactivation signaling pathways, and to determine if RTKs are a plausible therapeutic target for mitigating opioid side effects.

Dexamethasone as analgesic in different types of gynecologic surgery – A literature review

Background: Dexamethasone is a glucocorticoid and is widely used for postoperative nausea and vomiting (PONV). Recent studies and subsequent guidelines also suggest a role as an analgesic. Dexamethasone as an analgesic has been studied with varying degrees of success in different types of surgery with intravenous doses ranging from 4 mg to 80 mg. The procedure specific postoperative pain management (PROSPECT) guidelines for elective cesarean sections, laparoscopic hysterectomy and oncologic breast surgery all recommend the use of dexamethasone as an analgesic in a multimodal pain regimen, however a particular dose is not mentioned. Objective: To provide a literature review of the use of dexamethasone as an analgesic and at what dosage it has been studied in elective cesarean sections, gynecological laparoscopy and oncologic breast surgery. Methods: The Embase, PubMed, and Cochrane databases were searched for randomized controlled trials published between 2000 and 2021. Results: A total of thirty-four articles were found. Fourteen about elective cesarean section, Thirteen concerning gynecologic laparoscopy and seven regarding oncologic breast surgery. Literature review demonstrated that during elective cesarean section the intravenous (IV) doses ranged from 4 mg to 16 mg. The most investigated IV dose was 8 mg, but overall studies showed conflicting results concerning pain scores and analgesic use. In gynecologic laparoscopy the IV dose ranged from 4 mg to 15mg and again 8 mg was the most frequently studied dose. The IV dose of dexamethasone in oncologic breast surgery ranged from 8 mg to 24 mg. Also in these studies the results were conflicting. In addition, dexamethasone was used as an adjunct to locoregional blocks (perineural use): the transversus abdominis block (TAP) in cesarean section, the serratus anterior plane block (SAP) and the paravertebral block (PVB) in oncologic breast surgery. Conclusion: This literature review provides an overview of the use of dexamethasone in elective cesarean section, gynecologic laparoscopic surgery and oncological breast surgery. Three routes of administration were examined: intravenous, perineural and intraperitoneal. IV 8 mg dexamethasone was the most studied dosage but there were mixed results. Based on this literature review we cannot draw any conclusions regarding the analgesic dose. Further research, with more qualitative RCT’s and systematic reviews with meta-analysis are needed.

Intercostal Nerve Cryoablation is Associated with Reduced Opioid Use in Pediatric Oncology Patients

IntroductionIntercostal nerve cryoablation reduces postoperative pain in adults undergoing thoracotomy and children undergoing pectus excavatum repair. We hypothesize that cryoablation is associated with decreased post-thoracotomy pain and opioid use in pediatric oncology patients. MethodsA single-center retrospective cohort study was performed for oncology patients who underwent thoracotomy from January 1, 2017 to May 31, 2021. Outcomes included postoperative opioid use measured in morphine milligram equivalents per kilogram (MME/kg), pain scores (scale 0-10), and opioid prescription at discharge. Univariable analysis compared patients who received cryoablation to patients who did not receive cryoablation. Multivariable regression analysis controlling for age and prior thoracotomy evaluated associations between cryoablation and postoperative pain. ResultsOverall, 32 patients (19 males:13 females) underwent thoracotomy with 16 who underwent >1 thoracotomy resulting in 53 thoracotomies included for analysis. Cryoablation was used in 14 of 53 (26.4%) thoracotomies. Throughout the postoperative hospitalization, patients receiving cryoablation during thoracotomy consumed less opioids compared to patients who did not receive cryoablation (median 0.38 MME/kg, interquartile range [IQR] 0.20-1.15 versus median 1.47 MME/kg, IQR 0.71-4.02, P < 0.01). Maximum pain scores were lower in cryoablation patients (median 6, IQR 5-8) than noncryoablation patients (median 8, IQR 6-10), with a significant difference observed on postoperative day 4 (P = 0.01). Cryoablation patients were also less frequently prescribed opioids at discharge (21.4% versus 58.97%, P = 0.02). Multivariable regression demonstrated that cryoablation was associated with 2.59 MME/kg less opioid use (95% confidence interval −4.56 to −0.63) and decreased likelihood of opioid prescription at discharge (adjusted odds ratio 0.14, 95% confidence interval 0.03-0.67). ConclusionsCryoablation is significantly associated with decreased post-thoracotomy pain and opioid use in pediatric cancer patients and should be considered in postoperative pain regimens.

Ultrasound-Guided Nerve Blocks: Suggested Procedural Guidelines for Emergency Physicians.

Acute pain is one of the most frequent, and yet one of the most challenging, complaints physicians encounter in the emergency department (ED). Currently, opioids are one of several pain medications given for acute pain, but given the long-term side effects and potential for abuse, alternative pain regimens are sought. Ultrasound-guided nerve blocks (UGNB) can provide quick and sufficient pain control and therefore can be considered a component of a physician's multimodal pain plan in the ED. As UGNB are more widely implemented at the point of care, guidelines are needed to assist emergency providers to acquire the skill necessary to incorporate them into their acute pain management.

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

7547 Opioid-Sparing Versus Standard Postoperative Pain Regimen for Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

<h3>Study Objective</h3> This study investigated whether ICE-T, a multimodal opioid-sparing pain regimen using ice packs, acetaminophen (Tylenol), and ketorolac (Toradol) provided effective postoperative pain management compared with a standard pain regimen for total laparoscopic hysterectomy (TLH). <h3>Design</h3> This randomized controlled trial was designed to achieve over 90% power. Patients who underwent TLH were randomized to the ICE-T or standard pain regimen and outcomes were followed until postoperative day 4. <h3>Setting</h3> Intra-operatively patients were in dorsal lithotomy and Trendelenburg position. <h3>Patients or Participants</h3> Patients undergoing TLH for benign indications at the academic center from August 2019 until June 2021 were assessed for eligibility. Sixty-seven patients were enrolled preoperatively; 36 were randomized to the ICE-T regimen and 31 to the standard regimen. <h3>Interventions</h3> The ICE-T regimen prescribed around-the-clock ice-packs, acetaminophen and ketorolac. The standard protocol prescribed as needed ibuprofen and acetaminophen/oxycodone based on pain score. Both regimens included hydromorphone for breakthrough pain. These regimens were used inpatient and outpatient from post-anesthesia care unit discharge onwards. <h3>Measurements and Main Results</h3> Postoperative day 1 and 4 outcomes were evaluated using visual analog scales, validated Quality of Recovery Questionnaires, patient satisfaction scores, inpatient narcotic consumption and outpatient pain medication consumption. Patient and surgical demographics were evenly distributed. The median visual analog score and quality of recovery scores on postoperative day 1 were not significantly different; p=0.44 and p=0.85 respectively. However, the ICE-T arm median narcotic consumption on postoperative day 1 was significantly lower; 480.6 morphine milligram equivalents (MME) versus 619.2 MME, p=0.02. ICE-T arm postoperative day 4 median visual analog scores were also significantly lower in the per-protocol analysis (p=0.014). There were no significant differences in the postoperative day 4 median quality of recovery or satisfaction scores. <h3>Conclusion</h3> The ICE-T regimen is an effective multimodal opioid-sparing postoperative pain regimen for TLH. ICE-T has comparable pain control and patient satisfaction to the standard regimen while significantly decreasing narcotic consumption.

Benefits of Implementing an Enhanced Recovery After Surgery Protocol in Ambulatory Surgery.

Enhanced recovery after surgery (ERAS) protocols in orthopaedic surgery have garnered significant focus due to their ability to control pain adequately in the immediate postoperative window, allowing for earlier mobilization, shorter hospital stays, and fewer complications. Virginia Commonwealth University created a multimodal pain management approach in which patients receive a preoperative femoral nerve block followed by periarticular intraoperative local injection anesthesia consisting of bupivacaine, ketamine, and ketorolac. We hypothesized that implementation of the ERAS protocol will decrease postoperative pain scores, decrease recovery time in the postanesthesia care unit (PACU), and decrease opioid use in anterior cruciate ligament (ACL) reconstruction. Cohort study; Level of evidence, 3. Two patient cohorts were involved: before ERAS implementation (pre-ERAS) and after (post-ERAS). Patients with ACL reconstruction only and patients with ACL reconstruction with meniscal repair were analyzed separately. Post-ERAS patients received an intraoperative periarticular injection of bupivacaine, ketamine, and ketorolac and a postoperative multimodal pain regimen. Outcomes included time spent in the PACU, short-term and long-term opioid consumption, and pain score at discharge from the PACU. Compared with pre-ERAS patients, post-ERAS patients had decreased pain (2.1 vs 0.84 out of 10, respectively), spent less time in the PACU (79.4 vs 62.8 minutes, respectively), and had less opioid consumption in the immediate postoperative period (4.55 vs 2.26 total morphine milligram equivalents [MMEs], respectively) (P < .001 for all). After ERAS implementation, long-term MME use decreased from 410 to 321 between 0 and 2 weeks postoperatively, 92.6 to 1.69 between 2 and 6 weeks, and 494.5 to 323 between 0 and 6 weeks (P < .001 for all). All domains showed significant improvements for both the ACL and the ACL plus meniscal repair cohorts, with the exception of pain at discharge in the ACL plus meniscal repair group. The study findings suggest that an enhanced recovery pathways protocol that includes a standardized intraoperative periarticular bupivacaine, ketamine, and ketorolac injection improves pain scores in the immediate postoperative window, decreases opioid consumption, and reduces recovery time in the PACU for patients undergoing ACL reconstruction.

Multimodal Pain Management in Orthopedic Surgery.

Orthopedic surgery typically results in moderate to severe pain in a majority of patients. Opioids were traditionally the primary medication to target mechanisms of pain transmission. Multimodal analgesia has become a preferred method of pain management in orthopedic practice. Utilizing more than one mode to address post-surgical pain by recruiting multiple receptors through different medications accelerates the recovery process and decreases the need for opioids. By implementing effective analgesic techniques and interventions, this practice, in turn, decreases the usage of perioperative opioids, and in the long term, prevents addiction to pain medications and risk of opioid overdose. In orthopedic surgeries, previous studies have found that multimodal analgesia has reduced early opioid usage in the postoperative course. Pain is the result of direct injury to the nervous system, with a wide variety of chemicals directly stimulating or sensitizing the peripheral nociceptors. The pathophysiology behind the mechanism of post-surgical pain, along with the importance of preoperative, perioperative, and postoperative pain regimens are emphasized. A brief overview of pain medications and their properties is provided. These medications are further categorized, with information on special considerations and typical dosage requirements. Pain management should address both neuropathic and subjective types of pain. Effective pain control requires constant reassessment with individualized strategies. By focusing on multimodal analgesia, anesthesiologists can now utilize newer techniques for postoperative pain relief from orthopedic surgery, with better short-term and long-term outcomes for the patient.

Multidisciplinary Review Committee Oversight Improves Adherence to Newly Implemented Thoracic Enhanced Recovery after Surgery Protocol

INTRODUCTION: Benefits of thoracic Enhanced Recovery After Surgery (ERAS) programs have been well described in the literature. After implementing a thoracic ERAS program, we sought to determine if compliance review during quality improvement meetings improved protocol adherence. METHODS: A multidisciplinary committee developed and implemented a thoracic ERAS protocol for anatomic lung resections across 6 hospitals within our health system. Adherence data was tracked for 3 months after initiation of the ERAS protocol, a quality review committee meeting was held to review compliance barriers, and 2 additional months of compliance data were recorded. We examined compliance changes to 5 key protocol elements. Pathway elements deferred due to mindful deviation were excluded. Chi-square and Fisher’s exact tests were used to compare categorical data where appropriate. RESULTS: We included 81 patients, 53 patients before the quality review committee meeting and 28 after. There were 405 compliance opportunities; 68 (17%) were excluded for mindful deviation, leaving 337 (83%) for inclusion. Overall adherence improved after the quality review committee meeting (Table; 53% vs 84%, p < 0.001). Compliance to avoiding intraoperative urinary catheters, placing chest tubes to water seal in post-anesthesia recovery unit, early chest tube removal, and postoperative multimodal pain regimen use improved after the quality review committee meeting (all p < 0.05). Use of preoperative pain bundles improved, but this did not reach statistical significance (87% vs 96%, p = 0.25). CONCLUSION: Conducting a thoracic ERAS quality review meeting to identify compliance barriers significantly improved protocol adherence. This experience can be extrapolated to other institutions implementing ERAS protocols. Table. - Adherence to Targeted Enhanced Recovery After Surgery (ERAS) Elements Before and after the First Quality Review Committee Meeting Adherence item Pre-meeting cohort adherence Post-meeting cohort adherence p Value Preoperative pain bundle given 45/52 (87%) 26/27 (96%) 0.25 Intraoperative indwelling urinary catheter avoided 5/33 (15%) 22/27 (81%) <0.001 Chest tube placed to water seal in PACU 4/29 (14%) 9/16 (56%) 0.005 Early chest tube removal 21/52 (40%) 15/21 (71%) 0.02 Use of opioid sparing multimodal pain regimen 39/52 (75%) 28/28 (100%) 0.002 Overall 114/218 (53%) 100/119 (84%) <0.001

Interscalene block with liposomal bupivacaine versus continuous interscalene catheter in primary total shoulder arthroplasty.

Multimodal pain regimens in total shoulder arthroplasty (TSA) now include regional anesthetic techniques. Historically, regional anesthesia for extended postoperative pain control in TSA was administered using a continuous interscalene catheter (CIC). Liposomal bupivacaine (LB) is used for its potential for similar pain control and fewer complications compared with indwelling catheters. We evaluated the efficacy of interscalene LB compared with a CIC in postoperative pain control for patients undergoing TSA. This was a retrospective cohort study at a tertiary-care academic medical center including consecutive patients undergoing primary anatomic or reverse TSA from 2016 to 2020 who received either single-shot LB or a CIC for perioperative pain control. Perioperative and outcome variables were collected. The primary outcome was postoperative pain control, whereas the secondary outcome was health care utilization. The study included 565 patients, with 242 in the CIC cohort and 323 in the LB cohort. Demographic characteristics including sex (P=.99) and race (P=.81) were similar between the cohorts. The LB cohort had significantly lower mean pain scores at 24 hours (3 vs. 2, P<.001) and 36 hours (3 vs. 2, P<.001) postoperatively. The CIC cohort showed a higher percentage of patients experiencing a pain score of 9 or 10 postoperatively (29% vs. 17%, P=.001), whereas the LB cohort had a significantly greater proportion of opioid-free patients (32% vs. 10%, P<.001). Additionally, a greater proportion of CIC patients required opioid escalation to patient-controlled analgesia (7% vs. 2%, P=.002). The CIC cohort experienced a greater length of stay (2.3 days vs. 2.1 days, P=.01) and more 30-day emergency department visits (5% vs. 2%, P=.038). LB demonstrated lower mean pain scores at 24 and 36 hours postoperatively and lower rates of severe postoperative pain. Additionally, LB patients showed significantly higher rates of opioid-free pain regimens. These results suggest that as part of a multimodal pain regimen in primary shoulder arthroplasty, LB may provide greater reductions in pain and opioid use when compared with CICs.

S1665 Hypertriglyceridemia Independent Propofol-Induced Acute Pancreatitis—A Rare and Unusual Complication

Introduction: Propofol is a widely utilized lipophilic sedative anesthetic. Common side effects include hypotension, apnea, and rash. While rare, acute pancreatitis (AP) is a documented complication of propofol administration. Though the exact mechanism has yet to be established, current theories include propofol-induced hypertriglyceridemia (HTG) or idiosyncratic hypersensitivity reaction. We present a rare case of HTG-independent propofol-induced AP after an elective rhytidectomy. Case Description/Methods: A 75-year-old woman with hypertension and hypothyroidism, presented with 4 days of worsening mentation, abdominal distention and pain after an outpatient rhytidectomy. She was a former smoker, but denied alcohol or illicit drug use. On arrival, vital signs were significant for fever of 100.4F and tachycardia to 106 beats/min. Physical exam was significant for abdominal distension and epigastric tenderness. Laboratory studies revealed leukocytosis of 12,200 mm3 with 10.4% bandemia, alkaline phosphatase of 143 U/L, serum calcium of 8.9 mg/dL, lipase of 222 U/L, and triglycerides of 111 mg/dL. Abdominal ultrasound was unremarkable without evidence of gallstones or biliary dilatation. A computed tomography of the abdomen revealed extensive peripancreatic fat stranding and fluid with homogenous parenchymal enhancement consistent with severe interstitial edematous AP. An infectious workup was unremarkable for a concomitant source. Medication reconciliation revealed no confounding medications known to cause pancreatitis. She received intravenous fluids, proton pump inhibitor and pain regimen. Her diet was gradually advanced and she clinically improved over the next 48 hours with mentation returning to baseline. She was subsequently discharged home. Discussion: AP is responsible for over 230,000 hospitalizations annually in the US, with drug-induced AP comprising 0.5-2% of all cases. Propofol-induced AP has been sparsely reported in the setting of HTG, though exceedingly rare without this lab abnormality. The Badalov classification system differentiates association and causality of drug-induced AP by evaluating latency, rechallenge, and published evidence (Figure). Within this system, propofol has traditionally been characterized as a class II drug. However, recent published evidence has shown recurrence of AP upon propofol rechallenge, suggesting a more causal relation and a reclassification to class Ib. We present this case to raise awareness of the possible complications of propofol administration.Figure 1.: The Badalov Classification System of Drug-Induced Acute Pancreatitis.

A Large Database Evaluation of Infection and Nonunion Following Ankle Arthrodesis: Does Pain Regimen Matter?

Category: Ankle Arthritis; Ankle Introduction/Purpose: Multimodal therapies are critical for limiting use of opioids for postoperative pain control after orthopaedic procedures. Though NSAIDs and COX-2 inhibitors are effective non-opioid adjuncts for postoperative pain, animal models have demonstrated increased rates of nonunion or delayed union in the presence of NSAIDs. Nonunion or delayed union results in a protracted postoperative course that may warrant longer duration of surveillance or revision procedures. Retrospective studies and meta-analyses investigating NSAID use and bone healing have conflicting findings. Additionally, there are few studies investigating NSAID use and other adverse events such as postoperative infection. Improved understanding of the impact of NSAID use on union rates and infection after ankle arthrodesis will allow practitioners to optimize safe, effective pain control while limiting risk of nonunion. Methods: This large retrospective database study queried a national insurance claims database (PearlDiver Technologies) for patients undergoing ankle arthrodesis from 2015 through 2019 as identified by ICD-10 codes. Patients prescribed NSAIDs or COX-2 inhibitors within six weeks following ankle arthrodesis were identified. Patients with any operation one year prior to or following ankle arthrodesis were excluded from analysis to prevent attributing complications to another operation. Association between NSAID or COX-2 inhibitor use and infection or nonunion following ankle arthrodesis were analyzed using multivariable logistic regression analyses. To adjust for comorbid conditions, multivariable models included age at time of operation, sex, obesity, tobacco use, and diabetes. Results: Our query yielded 2,355 patients in the five-year period who underwent ankle arthrodesis. 257 (11%) patients were prescribed NSAIDs following surgery and 56 (2.4%) patients were prescribed COX-2 inhibitors. Infection risk was similar between patients not prescribed either medication (n=92, 4.5%) and those treated with NSAIDs (n=14, 5.4%; P=0.60) or COX-2 inhibitors (n=2, 3.5%; P=0.99). The nonunion rate between patients not prescribed either medication (n=232, 11%) was similar to those treated with COX-2 inhibitors (n=8, 14%; P=0.64), but increased in patients treated with NSAIDs (n=45, 18%; P=0.006). On multivariable analysis, tobacco use (OR, 1.46; 95% CI, 1.09-1.94), obesity (OR, 2.08; 95% CI, 1.57-2.76), and NSAID use (OR, 1.53; 95% CI, 1.06-2.17) were associated with increased odds of nonunion after ankle arthrodesis (all P&lt;0.02) (Table). Conclusion: Analysis of the PearlDiver database, the largest available administrative claims database, for 2,355 patients undergoing ankle arthrodesis demonstrated an 11% risk of nonunion and 4.5% risk of infection. The risk of nonunion is increased in patients prescribed NSAIDs within six weeks postoperatively (18%). After adjusting for comorbid conditions associated with nonunion, such as tobacco use and obesity, NSAID use increased risk of nonunion whereas COX-2 inhibitor use did not. Prospective investigation is necessary to better understand these relationships, however, our analysis suggests practitioners should judiciously utilize NSAIDs and consider use of COX-2 inhibitors for pain control after ankle arthrodesis surgery.

Recurrent triamcinolone injections for the treatment of Hunner’s lesions in bladder pain syndrome

Objective: To determine if periodic triamcinolone injections into Hunner’s lesion in patients with bladder pain syndrome (BPS) reduces the need for opioids and other pain treatments. Methods: This is a retrospective analysis of 28 patients receiving endoscopic injections of 0.5–1.0 cc of triamcinolone acetate into Hunner’s lesions between 2010 and 2018. Wilcoxon signed-rank test was used to compare pain regimens before and after injections. Results: Median age at first triamcinolone injection was 63 (IQR 54–73). Median number of injections/patient was 3 (IQR 2–5.5), at a mean of 8-month intervals (2–80). The median number of pain treatments prior to triamcinolone was 4 (0–13), and 25% of patients were using opioids. With one or more injections, 92.9% had improvement in pain symptoms. There was a significant decrease in number of pain treatments following triamcinolone injections (4.1 vs 0.8, p = 0.006). Fifty-seven percent managed with triamcinolone injections alone, with no other pain treatments. Of the seven patients using opioids, four discontinued opioids altogether. Conclusions: Repeat triamcinolone injections into Hunner’s lesions are associated with a significant reduction in the number of pain treatments used for BPS, with an associated decrease in opioid use. Level of evidence: 4

The Ramifications of Opioid Utilization and Outcomes of Alternative Pain Control Strategies for Total Knee Arthroplasties.

Morbidity and mortality related to opioid use has generated a public health crisis in the United States. Total knee arthroplasty (TKA) is an increasingly common procedure and is often accompanied by post-operative opioid utilization. Unfortunately, post-operative opioid usage after TKA has been shown to lead to higher rates of complications, longer hospital stays, increased costs, and more frequent need for revision surgery. Pre-operative opioid utilization has been shown to be one of the most important predictors of post-operative opioid usage. Additional risk factors for continued post-operative opioid utilization after TKA include pre-operative substance and tobacco use as well as higher post-operative prescription dosages, younger age, female gender, and Medicaid insurance. One method for mitigating excessive post-operative opioid utilization are Enhanced Recovery After Surgery (ERAS) protocols, which include a multidisciplinary approach that focuses on perioperative factors to optimize patient recovery and function after surgery. Additional strategies include multimodal pain regimens with epidural anesthetics, extended duration local anesthetics and adjuvants, and ultrasound guided peripheral nerve blocks. In recent years, opioid prescribing duration limitations have also been put into place by state and federal government, hospital systems, and ambulatory surgery centers making effective acute pain management imperative for all stakeholders. In this regard, as rates of TKA continue to increase across the United States, multidisciplinary efforts by all stakeholders are needed to ensure adequate pain control while preventing the negative sequalae of opioid medications.

Impact of Clinical Pharmacist Practitioner-Driven High Opioid Dose Reevaluation in Veterans with Chronic Non-Cancer Pain

Veterans Health Administration implemented the Opioid Safety Initiative (OSI) in 2013 to promote safe/rational opioid prescribing. West Palm Beach VA Healthcare System (WPBVAHCS) has been an outlier for the percentage of Veterans with chronic non-cancer pain receiving ≥90 mg Morphine Equivalent Daily Dosing (MEDD) in Veterans Integrated Service Networks (VISN) 8 since the 2016 fiscal year. The purpose was to determine the utility of a Pain Clinical Pharmacist Practitioner (CPP) identifying, reviewing, and approaching Veterans utilizing high-dose opioids for dose reevaluation and the impact on OSI metric post-opioid reevaluation. Pain CPP opioid education resulted in 28% (11/39) of Veterans undergoing an average 17.7 mg MEDD opioid dose reduction. For Veterans evaluated by Pain CPP, 83% (15/18) reported no change or improvement in average pain and PEG score. Pain CPP’s implemented 48 interventions outside of opioid dose reduction, the most common related to naloxone. No documented opioid overdose events, hospitalizations for uncontrolled pain or mental health, suicide attempts or pain-related crisis interventions were reported. Pain CPP’s are equipped to provide opioid education, address risk mitigation strategies, reassess pain regimens, and refer for non-pharmacologic modalities. Utilization of Pain CPP resources helps improve OSI metrics while providing safe comprehensive medication management (CMM) for chronic pain.

Pain management after microtia repair with costal cartilage: De-escalation and opioid use reduction

ObjectiveComplex and invasive postoperative pain regimens for microtia reconstruction with costal cartilage are often utilized. These generate added costs and invasiveness. We evaluated the effectiveness of a de-escalated pain regimen without use of invasive interventions. MethodsCase series of patients who underwent stage 1 microtia reconstruction with a modified Nagata/Firmin technique from 2017 to 2020 at a pediatric tertiary care hospital. Patients received intraoperative bupivacaine intercostal blocks and scheduled acetaminophen. Adjunct medications administered and pain scores (Wong-Baker FACES and FLACC-Face, Legs, Activity, Cry, Consolability) at intervals 2–72 h postoperatively were recorded. Narcotic use, peak and median pain scores, and length of stay were compared with published values. ResultsTwenty patients were included. Mean age of 12 and length of stay of 2.8 days. Average postoperative FACES scores between 0 and 72 h ranged between 0.7 and 4.0. The average peak pain score was 6.1 (±2.0). FLACC scores were low. Narcotics (0.59 ±0 .35 Morphine Milligram Equivalents/kg) were given to 17 patients. Compared to Shaffer et al. (paravertebral catheter-based infusion), total narcotics use (p = 0.03), peak pain (p = 0.0001), and length of stay (p = 0.001) were less. Compared to Woo et al. (intercostal catheter-based infusion), median pain scores at identical time intervals were lower (p = 0.04). ConclusionIntraoperative intercostal nerve blocks followed by scheduled, weight-based acetaminophen, adjunctive medications (ibuprofen and lidocaine patches), and rescue narcotics are effective in managing pain following microtia repair with autologous costal cartilage. It results in decreased narcotic usage, shorter length of stay, and lower pain scores compared to more complex regimens.

Implementation of a standardized multimodal pain regimen significantly reduces postoperative inpatient opioid utilization in patients undergoing bariatric surgery.

Routine opioid use in surgical patients has received attention given the opioid epidemic and a renewed focus on the dangers and drawbacks of opioids in the postoperative setting. Little is known about opioid use in bariatric surgery, especially in the inpatient setting. We hypothesize that a standardized opioid-sparing protocol reduces postoperative inpatient opioid use in bariatric surgery patients. A retrospective cohort study was conducted of bariatric surgery patients at a single institution. From March to September 2019, a standardized intraoperative and postoperative opioid-sparing protocol was designed and implemented along with an educational program for patients regarding safe pain management. Inpatient opioid utilization in patients undergoing surgery in the preintervention phase between April and March 2019 was compared to patients from a postintervention phase of October 2019 to December 2020. Opioid utilization was measured in morphine milliequivalents (MME). A total of 359 patients were included; 192 preintervention and 167 postintervention. Patients were similar demographically. For all patients, mean age was 44.1years, mean BMI 49.2kg/m2, and 80% were female. Laparoscopic sleeve gastrectomy was performed in 48%, laparoscopic gastric bypass in 34%, robotic sleeve gastrectomy in 17%, and robotic gastric bypass in 1%. In the postintervention phase inpatient opioid utilization was significantly lower [median 134.8 [79.0-240.8] MME preintervention vs. 61.5 [35.5-150.0] MME postintervention (p < 0.001)]. MME prescribed at discharge decreased from a median of 300 MME preintervention to 75 MME postintervention (p < 0.001). In the postintervention phase, 16% of patients did not receive an opioid prescription at discharge compared to 0% preintervention (p < 0.001). When examining by procedure, statistically significant reductions in opioid utilization were seen for each operation. Implementation of a standardized intraoperative and postoperative multimodal pain regimen and educational program significantly reduces inpatient opioid utilization in patients undergoing bariatric surgery.