Pain Regimen Research Articles

MP43-20 IMPACT OF SPECIFIC ANALGESIC INSTRUCTIONS FOR URETERAL STONE PATIENTS DISCHARGED FROM THE EMERGENCY DEPARTMENT

INTRODUCTION AND OBJECTIVE: While non-opioid analgesics are critical for pain management during a trial of ureteral stone passage, the deliberate instructed use of these adjuncts has not been well described. We aim to describe documented patient discharge instructions for specific analgesic use and assess its relation to unplanned healthcare utilization after discharge from the Emergency Department (ED). METHODS: A single-institution retrospective review of consecutive adults with ureteral calculi disease presenting to the ED from 1/1/2018-12/31/2018 was performed, excluding those requiring urologic intervention or hospital admission. A specific pain regimen was defined as instructions for acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) usage documented in the After Visit Summary. Telephone calls and ED return visits for stone related symptoms within 30-days were evaluated using univariable and multivariable logistic regression analysis, controlling for age, gender, psychiatric history, and stone size at ED discharge. RESULTS: A total of 155 patients (44 ± 17 years; 54% female) were included. The average ureteral stone size was 3.9 ± 2.0 mm (30% proximal; 7% mid; 63% distal). A history of chronic pain or psychiatric diagnosis was present in 28% and 20% of patients, respectively. Majority of patients were given an opioid prescription on discharge (84%). Specific analgesic instructions were given for NSAIDs (63%), acetaminophen (42%), both NSAIDs and acetaminophen (28%), or none at all (21%). Patients instructed on NSAID use were less likely to call for pain related symptoms (OR 0.3, CI 0.1-0.6), although no difference was observed for return rate to the ED. The rate of telephone calls and ED return visits did not differ with instructed acetaminophen use, both acetaminophen and NSAIDs, or none (figure). On multivariable analysis, instructed NSAID use demonstrated a lower likelihood of patient telephone calls related to symptoms (p<0.01). CONCLUSIONS: A considerable number of patients presenting to the ED for symptomatic urolithiasis did not receive advised pain regimens. When receiving specific NSAID use instructions, patients had a lower likelihood of calling for stone pain. Further studies evaluating standardized pain regimens may impact unplanned healthcare resource utilization.Source of Funding: n/a

Does Postoperative Gabapentin Administration Reduce Opioid Consumption after Foot and Ankle Surgery?

Category:Ankle; Hindfoot; Midfoot/ForefootIntroduction/Purpose:Prescription opioids are commonly used to control postoperative pain in foot and ankle surgery, but present potentially detrimental side effects including sedation, respiratory depression, and addiction. In foot and ankle surgery, pain is a common cause of delayed hospital discharge and decreased willingness to move, thereby slowing recovery. Gabapentin acts by decreasing lesion-induced hyperexcitability of posterior horn neurons and central sensitization, and has been explored as a potential addition to patients’ pain regimen. Although studies have previously assessed the effect of gabapentin on pain relief, to our knowledge none have evaluated whether gabapentin is effective in opioid consumption reduction beyond the immediate postoperative period. The purpose of this study is to assess whether gabapentin acts synergistically to improve postoperative pain among patients undergoing foot and ankle surgery.Methods:Patients from a single institution who underwent elective foot and ankle surgery were identified using CPT codes 27700, 27702, 27870, 28705, 28715, 28725, 28730, and 28740. All patients prescribed opioids postoperatively were included. A retrospective chart review was conducted for each patient to identify prescription dose, number of pills, date in which prescription was filled, and dates of refills for oxycodone, hydrocodone, oxycodone-acetaminophen, hydrocodone-acetaminophen, tramadol, and gabapentin. Medication information was collected only for prescriptions by the operating surgeon, nurse practitioner, physician assistant, resident, or fellow which were pertinent to the foot/ankle surgery performed; prescriptions from other services or providers were not included in order to ensure that the medications prescribed were specific to postoperative pain. Opioid quantities were converted to morphine equivalents and compared at various time intervals between patients who were prescribed only opioids, and patients who were prescribed opioids and gabapentin.Results:Among patients not taking opioids or gabapentin preoperatively, total morphine equivalents prescribed was significantly less among patients prescribed postoperative gabapentin (177.3 OME) in comparison to those prescribed only opioids (442.2 OME) (p=0.0018) in the 3-6 week postoperative interval. When all patients were analyzed, including those taking preoperative opioids or gabapentin, patients who received postoperative gabapentin were also prescribed significantly fewer OME at weeks 1-2 (p= 0.0270), weeks 3-6 (p = 0.0006), and weeks 7 - 12 (p = 0.0149).Conclusion:Gabapentin may be effective in reducing postoperative opioid consumption beyond the immediate postoperative period among elective foot and ankle surgery patients. Prospective clinical trials are warranted to further validate these results.

Efficacy of Flurbiprofen for Postoperative Pain in Chinese Surgical Patients: A Meta-Analysis

BackgroundThe objective of this meta-analysis is to assess the analgesic effect of flurbiprofen on postoperative pain in Chinese surgical patients. MethodsThe primary outcome was acute postoperative pain scores; the secondary outcomes included total opiate consumption during surgery and adverse effects, such as nausea, vomiting, and dizziness. Results were expressed as weighted mean difference (WMD) or odds ratio with 95% confidence intervals (95% CIs). We evaluated heterogeneity by visually examining the forest plots and quantified it by using the I2 statistic. We used random-effects models to pool the data. ResultsOf 573 abstracts reviewed, 19 studies involving 1628 participants met the inclusion criteria. Pooled results showed that the intravenous administration of flurbiprofen had a beneficial effect in reducing pain scores at 2 (WMD, −0.78; 95% CI, −1.22 to −0.34; P = 0.001), 6 (WMD, −0.93; 95% CI, −1.40 to −0.46; P = 0.000), 12 (WMD, −1.09; 95% CI, −1.93 to −0.24; P = 0.011), 24 (WMD, −1.08; 95% CI, −1.48 to −0.68; P = 0.000), and 48 (WMD, −0.62; 95% CI, −1.19 to −0.05; P = 0.032) h after surgery. In addition, flurbiprofen administration significantly decreased the incidence of postoperative nausea and vomiting (odds ratio, 0.39; 95% CI, 0.26-0.58; P = 0.000) but had no effects on opiate consumption and dizziness. ConclusionsThe perioperative administration of flurbiprofen is effective in reducing postoperative pain, nausea, and vomiting in Chinese surgical patients. Future studies with adequate power should evaluate the ideal flurbiprofen regimen for postoperative pain.

PD05-12 SCHEDULED KETOROLAC REDUCES POST-OPERATIVE NARCOTIC NEEDS WITHOUT INCREASED RISK OF COMPLICATIONS IN PATIENTS UNDERGOING ROBOTIC ASSISTED SIMPLE PROSTATECTOMY

INTRODUCTION AND OBJECTIVE: Multimodal pain regimens have shown to decrease narcotic use and hospital stay after surgical procedures. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used, though some argue that use NSAIDs can increase the risk of post-operative bleeding complications. We sought to assess the use of scheduled ketorolac for patients undergoing robotic assisted simple prostatectomy (RASP) on post-operative narcotic utilization and complications. METHODS: Retrospective review of data from single institution of all RASPs (11/2017 to 7/2019) was performed. Prior opioid use was defined as any opioid use for 1 month or longer prior to surgery. Scheduled ketorolac post-operatively was given at surgeon discretion for maximum duration of five days per hospital protocol. The primary outcome was morphine equivalent use in the post-operative period on the floor until discharge. Secondary outcomes were blood transfusion rate and overall complication rate in ketorolac and standard analgesic groups. Multivariable linear regression modeling was used to evaluate the association of scheduled ketorolac use with post-operative narcotic use. RESULTS: There were 207 patients who met inclusion criteria. 143 (69%) patients received scheduled post-operative ketorolac. Fourteen patients were prior opioid users (7%). There was no significant difference in length of stay between groups (Table 1). Median morphine equivalent consumption was significantly lower in the in the ketorolac group, 5 mg (IQR 0-14), compared to 15 mg (IQR 5-23) in the standard group (p < 0.001). There was no significant difference in transfusion rate between groups, respectively (3.5% vs. 1.6%, p = 0.44). Based on findings from univariable analysis, on multivariable analysis, after adjusting for age, BMI, prior opioid use and length of stay, use of ketorolac remained independently associated with decreased narcotic use (β = -5.1, 95% CI: -8.4 to -1.8, p = 0.003) CONCLUSIONS: Scheduled ketorolac is effective in reducing peri-operative opioid utilization without increasing morbidity after robotic assisted simple prostatectomy.Source of Funding: None

Enhanced Recovery and Opioid-Sparing Pain Management Following Lung Transplantation

Adequate pain control is essential following lung transplantation to reduce patient stress and minimize perioperative complications. Enhanced recovery after surgery (ERAS) protocols have demonstrated improvements in patient experience and reduced length of stay. However, the implementation of these protocols has not yet extended to the lung transplant population. We retrospectively reviewed all lung transplant recipients (LTR) at our institution from February 2018 to August 2019. An opioid-sparing, multimodal pain regimen was implemented that included preemptive analgesia with gabapentin and acetaminophen (APAP) pre-transplant; liposomal bupivacaine intercostal nerve block (INB) in the operating room; and a combination of APAP, gabapentin, and methocarbamol post-op with opioids given as indicated. Serratus anterior plane block was used for refractory pain. In total, we reviewed 48 LTR. The mean LAS was 43.74 and 21% were on mechanical ventilation or ECMO pre-transplant. Frequency of protocol adherence for each agent was as follows: liposomal bupivacaine INB (71%), APAP (100%), gabapentin (98%), methocarbamol (27%), and ketorolac (33%). Seven patients (15%) required a serratus plane block for refractory pain. Pain scores peaked at a median of 5 on postoperative day (POD) 1 and declined to a median of 3 by POD 3. By POD 4 only 54% of patients were still receiving opioids at a median of 15 mg oral morphine equivalents per day (IQR, 0-59). Only 3 patients were discharged on opioids and they were all on opioids pre-transplant. The median duration of mechanical ventilation was 1 day (IQR, 0.64-1.69) and 81% were extubated before 48 hours. The median hospital length of stay was 8 days (IQR, 6-15) and 30-day mortality was 0%. Enhanced recovery and opioid-sparing pain protocols are feasible in LTR leading to minimal opioid use and acceptable pain scores. Outcomes with ERAS protocols should be compared to standard-of-care postoperative management.

Implementation of a Reduced Opioid Utilization Protocol for Radical Cystectomy

BACKGROUND: Radical cystectomy (RC) often requires a prolonged course of opioid medications for postoperative pain management. We implemented a Reduced Opioid Utilization (ROU) protocol to decrease exposure to opioid medications. OBJECTIVE: To determine the impact of the ROU protocol on opioid exposure, pain control, inpatient recovery, and complication rates among patients who underwent RC. METHODS: The ROU protocol includes standardized recovery pathways, a multimodal opioid-sparing pain regimen, and improved patient and provider education regarding non-opioid medications. Opioid exposure was calculated as morphine equivalent dose (MED), and was compared between RC patients following the ROU protocol and patients who previously followed our traditional pathway. Opioid-related adverse drug events (ORADEs), pain scores, length of stay, and 90-day complications, readmission, and mortality were also compared between cohorts. RESULTS: 104 patients underwent RC, 54 (52%) of whom followed the ROU protocol. ROU patients experienced a statistically significant decrease in opioid exposure in the post-anesthesia care unit (p = 0.003) and during their postoperative recovery (85.7±21.0 MED vs 352.6±34.4 MED, p &lt; 0.001). The ROU protocol was associated with a statistically significant decrease in ORADEs after surgery. There was no significant difference in average pain scores, length of stay, readmissions, or 90-day complication or mortality rates. CONCLUSIONS: The ROU protocol decreased opioid use by 77% without compromising pain control or increasing the rate of complications. This study demonstrates the efficacy of non-opioid medications in controlling postoperative pain, and highlights the role providers can play to decrease patient exposure to opioids after RC surgery.

Rib fracture displacement worsens over time.

PurposeRib fractures (RF) occur in 10% of trauma patients; associated with significant morbidity and mortality. Despite advancing technology of surgical stabilization of rib fractures (SSRF), treatment and indications remain controversial. Lack of displacement is often cited as a reason for non-operative management. The purpose was to examine RF patterns hypothesizing RF become more displaced over time.MethodsRetrospective review of all RF patients from 2016–2017 at our institution. Patients with initial chest CT (CT1) followed by repeat CT (CT2) within 84 days were included. Basic demographics were obtained. Primary outcomes included RF displacement in millimeters (mm) between CT1 and CT2 in three planes (AP = anterior/posterior, O = overlap/gap, and SI = superior/inferior). Displacement was calculated by subtracting CT1 fracture displacement from CT2 displacement for each rib. Given anatomic and clinical characteristics, ribs were grouped (1–2, 3–6, 7–10, 11–12), averaged, and analyzed for displacement. Secondary outcome included number of missed RF on CT1. Non-parametric sign test and paired t test were used for analysis. Significance was set at p < 0.002.Results78 of 477 patients with RF on CT1 had CT2 during the study period: primarily male (76%) and age 55.8 ± 20.1 with blunt mechanism of injury (99%). Median Injury Severity Score was 21 (IQR, 13–27) with Chest Abbreviated Injury Score of 3 (IQR, 3–4). Median time between CT1 and CT2 was 6 days (IQR, 3–12). Missed RF rate for CT1 was 10.1% (p = 0.11). Average fracture displacement was significantly increased for all rib groupings except 11–12 in all planes (p < 0.002).ConclusionRF become more displaced over time. Pain regimens and SSRF considerations should be adjusted accordingly.

Resilience as a Predictor of Patient Satisfaction With Nonopioid Pain Management and Patient-Reported Outcome Measures After Knee Arthroscopy

The purpose of this study was to evaluate the Brief Resilience Score (BRS) as a predictor for patient satisfaction with nonopioid pain management and patient-reported outcome measures (PROMs) after arthroscopic partial meniscectomy or chondroplasty. One hundred seventy-five patients undergoing arthroscopic partial meniscectomy and/or chondroplasty were recruited from a single clinic and were preoperatively stratified into low-to-normal resilience or high resilience groups as measured by the BRS. Satisfaction with nonopioid pain control was assessed at a 2-week follow-up visit using the Hospital Consumer Assessment of Healthcare Provider and Systems questionnaire, and various PROMs were measured at 3 and 6 months postoperatively. Statistical analysis was performed to assess for differences in satisfaction with pain control or PROMs between resilience groups. Analysis revealed no statistically significant differences between the low-to-normal resilience group and the high resilience group with regard to satisfaction with nonopioid pain control or PROMs assessed at 3- or 6-month follow-ups. Outcome measures [visual analog scale pain, Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain, KOOS Activities of Daily Living, KOOS Quality of Life, Single Assessment Numerical Evaluation (SANE) Knee, and Veterans Rand 12-Item Health Survey Physical and Mental Component Scores] all followed expected trajectories after surgery, without a statistically significant difference between resilience groups. This study provides evidence that preoperative resilience score, as measured by the BRS, does not correlate with postoperative patient-reported functional outcome or satisfaction with a nonopioid pain regimen after knee arthroscopy. II.

CANNABIS USE IN THE AGE OF LEGALIZATION: IMPLICATIONS FOR THE GERIATRIC POPULATION

The prevalence of cannabis use among older adults has significantly increased in recent years. This trend likely captures the attitudes of the aging Baby Boomer generation as well as the spread of laws legalizing cannabis across the United States. As cannabis usage becomes more common in older adults, physicians must remain up to date regarding how cannabis is accessed and consumed, the types of strains and products sold in dispensaries, the indications and efficacy of FDA approved forms, as well as the different effects of tetrahydrocannabinol (THC) and cannabidiol (CBD). Despite the significant increase in cannabis use, there remains a paucity of evidence on the efficacy and safety in older adults. From a harm reduction standpoint, data regarding the safety profile of cannabis is essential since aging is typically associated with changes in pharmacokinetics and pharmacodynamics, multimorbidity, increase in prescription medication utilization and declines in function. Of particular importance in the geriatric population are the associations between cannabis and cognition, falls and injury, drug interactions, pain modulation and treatment of dementia related agitation. In terms of cognition and memory, heavy cannabis use has been traditionally associated with negative neurocognitive consequences. Interestingly, new animal models have found that low dose THC may actually improve memory and cognition in old animals, although how this data will translate to humans remains unclear. Next, commonly experienced side effects of cannabis in the elderly include dizziness, hypotension, drowsiness and confusion, all of which may impact fall risk. The risk of side effects may be compounded when considering interactions with other prescribed medications. In terms of pain modulation, although physicians may seek non-opioid pain regimens for geriatric patients, there is low-strength evidence that cannabis alleviates neuropathic pain and insufficient evidence for other types of pain. Finally, data does not yet support the usage of cannabis to improve neuropsychiatric symptoms in dementia patients. While physician knowledge of legalities, usage trends, indications and adverse effects of cannabis is necessary to manage medically and socially complex aging patients, this remains challenging in the setting of a very limited evidence-base.

126 Multimodal Analgesia and Discharge Opioid Requirements in Burn Patients

Abstract Introduction Analgesia in burn patients is significantly challenging given the complexity of burn pain. Opioids are a mainstay of therapy, but studies demonstrate varying outcomes with respect to the efficacy of adjunctive non-opioid agents in the treatment of burn pain. The need for analgesia extends beyond hospital admission—given the known risks of opioids, the impact of multimodal analgesia on opioid requirements post-discharge needs to be further elucidated in this population. Methods In this retrospective, single-center cohort study, adult burn patients who were consecutively admitted to the burn ICU service and subsequently followed in the burn clinic between 2/2015 and 9/2018 were evaluated up to 6 months post-discharge. The subjects were divided into two cohorts based on discharge pain regimens: multimodal vs non-multimodal. Individuals taking long-acting opioids prior to admission were excluded. The primary outcome was the change in oral morphine equivalents (OME) between discharge and follow up occurring between 2 - 6 weeks post-discharge. Secondary outcomes included the number of multimodal agents utilized and a comparison of OME between the last 24 hours of admission and discharge. Results A total of 152 patients were included for analysis (n= 76 per cohort). The multimodal cohort demonstrated increased total body surface area burned (23.9% ± 15.4 vs 16.6% ± 7.1; p &amp;lt; 0.001) and prolonged number of days spent in the ICU (22.7 ± 23.1 vs 10.7 ± 8.9; p &amp;lt; 0.001). The change in OME from discharge to first follow up was -106.6 mg in the multimodal vs -75.4 mg in the non-multimodal cohort (p = 0.039; figure 1). In each cohort, discharge OME did not statistically differ from last 24 hour OME (multimodal: p = 0.067; non-multimodal: p = 0.537). The most common non-opioid agents utilized were acetaminophen and gabapentin. Conclusions Despite extended ICU length of stay and larger TBSA, burn patients discharged with multimodal pain regimens demonstrated a statistically significant reduction in oral morphine equivalents from discharge to first follow up compared to those discharged on opioid-only regimens. Applicability of Research to Practice This study demonstrates promising results with respect to lowering discharge opioid requirements by utilizing a multimodal analgesic approach in the management of burn pain.

866 Meeting the Challenge of Analgesia in a Pregnant Woman with Burn Injury Using Subanesthetic Ketamine: A Case Report

Abstract Introduction Burn injury is the fourth most common form of trauma worldwide, requiring unique management considerations and a collaborative approach to treatment. Thermal injuries sustained during pregnancy add considerably to case complexity. Overall, there is a low incidence of burns in gravid women living in developed countries, making management guidelines in this patient population scarce. Despite few data, it is recognized that early intervention and inter-disciplinary treatment are critical to optimize maternal and fetal outcomes. Thus, interventions including fluid resuscitation, excision and grafting, routine debridement and dressing changes, antibiotic administration, and early mobilization are the cornerstones of management. Effective pain management is crucial in allowing patients to tolerate these often-painful procedures, engage in rehabilitation, and to prevent pain-related morbidity. Methods The patient is a 34-year-old G5P3013 in her third trimester of pregnancy, who sustained partial and full thickness burns to 18% of total body surface area in a grease fire. She was brought to the ED approximately 2 hours post-injury by EMS. During her hospital stay, Acute Pain Management Service (APMS) was consulted for a comprehensive pain management plan. APMS recommendations included IV acetaminophen, hydromorphone PCA, gabapentin, and ketamine infusion with a reduced dose bolus for procedural analgesia. Risks and benefits of these medications were explained to patient and her family by the APMS, Maternal-Fetal Medicine, and the Burn team, stressing the importance of tolerating routine burn care to decrease morbidity. Although human data are limited, it was explained that low doses (as outlined in our regimen) present little fetal risk in animal models. Results The patient was discharged at hospital day 11 and seen for burn follow-up after 2 weeks post-discharge (35 weeks gestation) with returning color, no evidence of hypertrophy, and overall excellent wound healing. Patient reported no pain, and her pain regimen was discontinued. Patient demonstrated significant improvement in her injuries, and had a normal spontaneous vaginal delivery of a live born male 7 weeks post discharge, with APGAR scores of 8 and 9 at 1 and 5 minutes, respectively. Additionally, the patient brought her infant to the office visit and conveyed that the child was consistently reaching pediatric milestones. Conclusions Ketamine may be considered as an adjunct for procedural and background analgesia during the third trimester, as part of a multi-modal strategy in a short-term, monitored setting after a thorough and complete analysis of risks and benefits and careful patient selection. Applicability of Research to Practice Procedural pain management in a third-trimester burn patient.

4:12 PM Abstract No. 335 Safety and feasibility of transradial uterine fibroid embolization in an office-based lab

To assess the safety and feasibility of performing transradial uterine fibroid embolization (trUFE) in an office-based lab (OBL). A retrospective review was performed of all patients who underwent transradial uterine fibroid embolization (trUFE) at two office-based labs between June 2018 and July 2019. Data collected included demographic information, pertinent medical history, and procedural details (radiation exposure, length of procedure, time to discharge, complications). All procedures were performed under conscious sedation. Fluoroscopy and digital subtraction radiography were performed utilizing a portable C-arm (Philips Veradius). Ultrasound guidance for radial access was used in all cases. Bilateral Embolization was performed in all cases using embozene 500um and 700 μm particles. Approximately 8 mL of 1% lidocaine was administered to each uterine artery at the end of embolization. Postprocedural pain regimen consisted of fentanyl 25 mcg PRN and oxycodone/acetaminophen 5 mg/325 mg PRN. A total of 9 premenopausal women (mean age, 46.7 ± 4.9 years) underwent trUFE for symptomatic uterine fibroids. The mean procedure time was 68 minutes (range, 53-120) with the average fluoroscopy time of 22.1 minutes (range, 14.2-29.5). The average time to discharge was 4.4 hours. Median follow-up was 4 months. Clinical success measured by subjective relief in symptoms at 2-month follow-up was seen in 9/9 (100%) of the patients. There were no immediate or delayed postprocedural complications. One patient returned to the Emergency room 5 hours after discharge for pain management. Transradial uterine fibroid embolization can be safely performed in an office-based lab.

Plastic Surgery Patient Expectations for Postoperative Opioid Prescriptions.

The opioid epidemic is a healthcare crisis perpetuated by analgesic overprescribing. Despite public health attention on this issue, expectations for pain management and opioid use by plastic surgery patients are poorly understood. This study aimed to evaluate patient expectations of postoperative pain, concern for opioid dependence, and anticipated analgesic plan after plastic surgery. New patients presenting to an academic plastic surgery clinic were prospectively enrolled from November 2017 to September 2018. These patients completed a preconsultation survey regarding their pain history and anticipated postoperative pain and analgesics regimens. Responses between cohorts expecting and not expecting postoperative opioids were compared using descriptive and univariate analyses. A total of 168 patients (63.9% female, 36.1% male; mean ± SD age 46 ± 17 years) completed the survey before breast (21.9%), cosmetic (5.3%), craniofacial (3.0%), general reconstruction (13.0%), hand (3.0%), and skin and soft tissue (49.1%) surgeries. Twenty-eight percent of patients expected opioid prescriptions. On a standard visual analog scale, patients who expected opioids anticipated greater postoperative pain (6.9 vs 4.6, P < 0.05). They were more concerned about experiencing pain (5.8 vs 4.9, P < 0.05), expected a longer duration of opioid use (63.0% vs 37.0%, P < 0.05), and were less interested in nonnarcotic analgesic alternatives (57.9% vs 19.8%, P < 0.05). Less than one-third of plastic surgery patients in this study expect opioid pain medications after surgery. This supports broader use of nonopioid, multimodal pain regimens. Identification and management of patient pain expectations, especially among those anticipating a need for opioids, provide a critical opportunity for preoperative education on the benefits of nonopioid analgesics, thus minimizing opiate prescribing.

Effect of Over the Counter Ibuprofen Dosing after Sinus Surgery for Chronic Rhinosinusitis: A Prospective Cohort Pilot Study.

Management of pain following endoscopic sinus surgery (ESS) often involves intermittent use of opioid medications. Given the current opioid crisis, many surgeons aim to minimize opioid prescriptions. However, surgeons often avoid the use of NSAIDs following ESS out of concern for increased bleeding risk. We sought to evaluate the effectiveness and safety of over the counter dosing of ibuprofen on pain and bleeding rates following ESS. Prospective cohort pilot study of patients undergoing ESS. Patients self-selected either control arm (acetaminophen and PRN oxycodone) or intervention arm (alternating ibuprofen with acetaminophen, and PRN oxycodone). Outcome measures included pain (10-point visual analog scale [VAS]), bleeding rate (10-point VAS), and number of opiate pills consumed. Thirty-nine patients completed the study (15 control and 24 intervention). Overall, patients in the intervention arm reported decreased pain levels at days 1 (-0.9 [95%CI: -2.2, 0.5], 3 (-0.9 [95%CI: -2.3, 0.5]), and 7 (-0.6 [95%CI: -1.8, 0.6]), as well as decreased postoperative bleeding at those same days -0.9 [95%CI: -2.1, 0.4], -0.9 [95%CI: -2.1, 0.4], and -0.7 [95% CI: -1.2, -0.7], compared to controls. Opiate consumption was similar between groups with patients consuming on average four opiate pills (oxycodone 5 mg). Over the counter dosing of ibuprofen along with acetaminophen may yield better pain control after sinus surgery compared to acetaminophen alone. Additionally, there was no significant difference in epistaxis in the ibuprofen cohort compared to the cohort who did not take ibuprofen. Furthermore, this study showed very few opioid pills were consumed after routine ESS regardless of pain regimen prescribed. A larger trial is needed to make definitive statements on safety and efficacy. 2b.

Multimodal pain control in adolescent posterior spinal fusion patients: a double-blind, randomized controlled trial to validate the effect of gabapentin on postoperative pain control, opioid use, and patient satisfaction.

Prospective double-blind, randomized controlled trial. The objective of this study was to validate the efficacy of gabapentin as part of a multimodal pain regimen in a double-blind, randomized controlled trial for patients aged 10-19years with idiopathic scoliosis undergoing posterior spinal fusion. Perioperative pain management represents a challenge for patients undergoing surgical correction of adolescent spinal deformity. Gabapentin has been shown to decrease postoperative pain and opioid use after spine surgery, but it has not yet been investigated as part of a multimodal pain regimen intended to decrease the perioperative use of opioids. Fifty patients were randomized to receive gabapentin or placebo pre- and postoperatively in addition to a standardized medication regime including scheduled ketorolac and as-needed acetaminophen, hydromorphone, and oxycodone. Patients were monitored in the pre-, peri-, and postoperative periods for pain levels, medication dosing, side effects, adverse events, hospitalization length of stay, and parent satisfaction. There were statistically significant decreases in early postoperative pain scores and opioid use as well as total postoperative opioid use for the treatment group relative to controls. There were no statistically significant differences in adverse events, medication side effects, or hospitalization length. Parents of patients in both groups were very satisfied with the pain control provided to their children. This randomized controlled trial demonstrates that pre- and postoperative administration of gabapentin as part of a multimodal pain management protocol significantly decreases both opioid use and visual analog pain scales in the first two postoperative days after posterior spinal fusion for adolescent idiopathic scoliosis. Gabapentin should be considered as a standard medication for perioperative pain control in this patient population. Level I.

Analgesia in Total Knee Arthroplasty: Current Pain Control Modalities and Outcomes.

➢ Implementation of multimodal pain management regimens after total knee arthroplasty has increased patient satisfaction, decreased pain scores, and facilitated faster recovery.➢ A variety of oral and intravenous analgesics, including nonsteroidal anti-inflammatory drugs, gabapentinoids, acetaminophen, and opioids, can be employed preoperatively and postoperatively.➢ Neuraxial anesthesia, peripheral nerve blocks, and periarticular injections are effective pain modulators that should be implemented in concert with the anesthesia teams.➢ There is no consensus on the optimal multimodal pain regimen, and substantial variability exists between institutions and providers.➢ The goals of minimizing pain and improving functional recovery in the postoperative period must be considered in light of evidence-based practice as well as the risk profile of the proposed analgesic treatment.

Impact of Voluntary Opioid Taper Program in Cancer Survivors (FR460B)

•Identify the challenges and risks related to long-term opioid therapy in cancer patients.•Characterize a successful voluntary opioid taper program in an outpatient palliative care clinic. ASCO Clinical Practice Guidelines for the management of chronic pain in cancer survivors recommend reducing or discontinuing opioids when no longer warranted, although if and how this can be achieved in practice is unknown. We examined the feasibility, impact, and best practices of a voluntary outpatient opioid taper program in cancer survivors on long-term opioid therapy (LTOT) for chronic pain. Eligible patients were followed in an NCI-designated Comprehensive Cancer Center. A retrospective chart review using electronic medical records was conducted in patients whose opioid dose was tapered between October 1, 2013, and April 30, 2018. Demographics, clinical data, and detailed pain regimens were collected. Statistical analyses were conducted to characterize the time from taper initiation to the lowest achieved dose, and to explore the relationships between dose reduction and independent variables. Opioid dose reduction was achieved in 162 (82%) out of 196 patients offered a voluntary taper. 119 (74%) of patients who were tapered had equal or greater than a 50% dose reduction. The average pain scores at baseline and at the time of the lowest tapered dose were unchanged. Less than 10% of patients reported withdrawal symptoms. An initial opioid dose of > 500 oral morphine equivalents at baseline was an independent predictor of a smaller percentage of taper. The presence of a co-morbid psychiatric condition and adjuvant co-analgesics did not significantly affect the amount of the taper. A clinically meaningful and well-tolerated opioid taper is feasible in cancer survivors on LTOT.

Quality improvement in post-operative opioid and benzodiazepine regimen in adolescent patients after posterior spinal fusion.

Prospective, quality-improvement. To evaluate pain management following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and Scheuermann's Kyphosis (SK) determine the optimal opioid and benzodiazepine prescription amounts, and implement a multimodal post-operative pain regimen. The incidence of prescription opioid abuse is increasing in the United States. Orthopedic spine surgeons often prescribe large quantities of opioids post-operatively for pain control. Previous efforts on pain control have focused on in-patient post-operative regimens after PSF. Between 2/1/17 and 5/30/18 patients with AIS or SK were sent home with pain diaries after discharge to document daily narcotic, benzodiazepine, non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen and gabapentin use following PSF. Diaries were collected at the 4week post-operative visit. Data from two cohorts were reviewed: pre-intervention and post-intervention. Our prescription intervention went into effect 9/1/17. Twenty-four (30%) patients returned pain diaries. The pre-intervention cohort consisted of 12 patients (7 female; 5 males; 14.9years (range 12-19)). Patients were prescribed on average 80 × 5mg tabs (26-140) of oxycodone but used on average 45 tabs (12-129) over an average of 17.5days (9-33). They were prescribed an average of 30 × 2mg tabs (0-150) of diazepam, used on average 4.8 (0-105) tabs over 12.5 (5-25) days. The post-intervention cohort consists of 12 patients (9 female; 3 male; 14.8years (12-19)). They were prescribed on average 50 × 5mg tabs (35-80) of oxycodone, used 20.5 (0-39.5) tabs over 8.5days (3-16). They were prescribed on average 18 × 2mg tabs of diazepam (0-43), used 5.4 tabs (0-19) over 10days (5-14). This analysis has directly impacted clinical practice. Prescribed opioid and benzodiazepine doses have been decreased by over 50%, and more resources are being directed towards determining the disparity between the amount of medications prescribed and consumed in our post-operative patients.

Use of erector spinae fascial plane blocks in open pancreatic surgery

Presenter: Hannah Wilcox | University of New Mexico Health Sciences Center Background: Bilateral erector spinae fascial plane blocks (ESPB) are a novel method of regional analgesia. The use of ESPB in abdominal surgery has sparked interest as an adjunct to opioid-sparing post-operative pain regimens. In this study, we describe our initial experience of ESPB in open pancreatectomy procedures. Methods: A retrospective analysis of a prospectively-maintained database was performed of all patients from August 2018 to March 2019 who received bilateral-ESPB for post-operative pain control after open pancreatectomy. Ultrasound-guided ESPB at the T7 or T8 level was performed in a cranial to caudal direction with infiltration of liposomal bupivacaine. Patient demographics, intraoperative and postoperative factors, including quality end points and intravenous morphine milligram equivalent (MME) requirements, were examined. Results: Twenty-nine patients met inclusion criteria, including 21 pancreaticoduodenectomy and 8 distal pancreatectomy patients. All incisions were via midline laparotomy. Diagnosis in 15 patients (52%) was ductal adenocarcinoma. Mean patient age was 66 years, and 48% were male (n=14). Average patient BMI was 28.7. Mean anesthesia preparation time was 82 minutes. Return of bowel function was a mean of 3.5 days post-operatively and urinary catheter removal was 1.8 days. Median hospital length of stay was 6.5 days. Seven patients were readmitted within 30 days of surgery (24%) and there were no deaths. Ten patients (34%) had complications within 30 days of surgery which included 3 superficial site infections, 2 organ space infections, 1 patient with atrial fibrillation, 1 patient with bleeding and 3 other causes. There were no recorded adverse events related to the ESPB procedure. No patients required rescue thoracic epidural catheter placement or intravenous patient controlled analgesia (PCA). Mean MME for first 72 hours after surgery was 40 mEq and 82 mEq for the entire inpatient stay. Nine patients received a mean of 18 mEq of opioid medications in the first 24 hours after surgery, followed by no further opioids. Three patients did not require any opioids after surgery. Conclusion: ESPB presents an effective and safe mode of regional analgesia in patients undergoing open pancreatectomy and shows promise as a key element in opioid-sparing post-operative pain regimens. The expanded role of ESPB in major abdominal surgery warrants further investigation.

Discussion

Discussion