Perioperative Opioid Administration Research Articles

A comparison of efficacy of erector spinae plane block versus serratus anterior plane block plus subcostal transversus abdominus plane block for bariatric laparoscopic sleeve gastrectomy surgery: study protocol for a randomised clinical trial

BackgroundObesity is a rapidly growing global health concern. Limited long-term success of diet, behavioural modification and medical therapy have led to the increased performance of bariatric surgery. Laparoscopic sleeve gastrectomy, which permanently reduces the size of the stomach, has been shown to cause considerable weight loss, as well as improving or even eliminating obesity related medical comorbidities such as diabetes, obstructive sleep apnoea and hypertension. Unfortunately, this surgery can also result in significant postoperative pain which, when combined with the dangers of perioperative opioid administration for bariatric patients, can lead to a significantly reduced quality of recovery. Opioid-sparing analgesia has been widely recommended for perioperative bariatric patients, but research into the optimum regional analgesia approach for this surgery is lacking, with no trials to date comparing different regional analgesic techniques. This study protocol describes a randomised clinical trial aimed at answering this question, comparing the quality of recovery after laparoscopic sleeve gastrectomy for patients who receive erector spinae plane block, versus those who receive serratus anterior plane block plus subcostal TAP block.MethodsWe propose a prospective, randomised, blinded (investigator) clinical trial in a tertiary hospital in Ireland. Seventy patients presenting for laparoscopic sleeve gastrectomy will be randomised to two study groups—group A will receive bilateral erector spinae blockade; group B will receive left sided serratus anterior plane block plus subcostal TAP blocks. Both groups will receive the same dose of the same local anaesthetic and the different regional technique performed will be the only difference in their care. The primary outcome will be QoR-15 scores at 24 h postoperatively, a validated international tool for assessing a patient’s overall postoperative recovery.DiscussionRegional analgesia should be a mainstay of perioperative opioid-sparing analgesia where possible. This is especially important in the bariatric cohort who are particularly susceptible to the complications of perioperative opioid administration. To the best of our knowledge, this trial will be the first to compare efficacy of two different regional analgesia techniques for bariatric patients undergoing laparoscopic sleeve gastrectomy surgery.Trial registrationThis trial was pre-registered on clinicaltrials.gov, registration number NCT05839704, on March 5, 2023. All items from the World Health Organisation Trial Registration Data Set have been included.

Comparative retrospective review of perioperative analgesia using ultrasound-guided programmed intermittent erector spinae plane block for video-assisted thoracoscopic lobectomy

BackgroundThe retrospective cohort study was conducted to estimate the opioid-sparing anesthesia and limited side-effects with ultrasound (US)-guided ESPB using programmed intermittent bolus (PIB) or continuous infusion (CI) and standard opioid-based anesthesia in patients undergoing video-assisted thoracoscopic lobectomy (VATS).MethodsPatients underwent VATS were stratified into either control group or one of the two ESPB groups in a 1:2:2 ratio depending on whether PIB was implemented or not. The primary endpoint was intra- and post-operative opioids consumption over the first 48 h following surgery.ResultsA total of 180 cases were included in the analysis. Cumulative perioperative opioid administration was found to be significantly different between PIB, CI and control group (both p < 0.001), and between PIB and CI group (p = 0.028). More specifically, the mean was 305.30 ± 51.35 mg, 339.68 ± 56.07 mg and 468.91 ± 79.84 mg in PIB, CI and control group. NRS scores at rest across all postoperative times were comparable in two ESPB groups, while significantly lower than control group, however, scores during exercising at postoperative 3, 6, 12 h were significantly lower in PIB group as compared to CI group. A wider anesthetized dermatomes with PIB was observed at 6, 24 and 48 h as opposed to the CI. The mean of levobupivacaine plasma concentration was significantly lower for PIB at postoperative 0.5, 12, 24 and 48 h after initiation than CI. However, local anesthetic toxicity was not observed in any of the two ESPB groups.ConclusionsWhen US-guided ESPB using PIB was performed preoperatively, it contributed to the minimization of intra- and post-operative opioid consumption due to better analgesia with a wider anesthetic dermatome opposed to conventional CI, whereas, it was also associated with lower risk of local anesthetic toxicity because of lower plasma concentration of levobupivacaine.

The Efficacy of Ultrasound Guided Bilateral Pectoralis Nerve Block for Postoperative Pain Control in Cardiac Surgery, Randomized Control Trial

Abstract Background Cardiothoracic surgeries are associated with significant pain. Optimal analgesia is a vital part of enhanced recovery after surgery strategies intended to improve patients' perioperative experience and outcomes. Traditionally, analgesia in these types of surgeries has depended on large doses of I.V. opioids. This is particularly pertinent given the current focus on removing needless perioperative opioid administration, and thereby decreasing the potential for opioid side effects. Aim of the Work The aim of the study was to evaluate the effect of postoperative bilateral US guided Pecs block on postoperative pain control in patients undergoing cardiac surgery through mid-line sternotomy compared to systemic analgesia. Patients and Methods Approval was obtained from the research ethics committee of Faculty of Medicine; Ain Shams University and a written informed consent was taken from each patient to participate in the study, patients were randomly allocated into two groups with 15 patients in each group. Group 1 (control group) received systemic analgesics, whereas Group 2 (study group) received pecs block. Results Our study showed that when compared to general anesthesia with systemic opioids, PECs block is associated with significantly better postoperative pain control. Conclusion Pecs block is technically simple, safe and very effective technique and can be used as a part of multimodal analgesia in postoperative cardiac surgical patients for better patient comfort and satisfaction and also helps in superior pulmonary rehabilitation, thus assisting in better outcome and less unwanted side effects of systemic analgesics.

Erector spinae plane block for thoracoscopy in a paediatric patient

We present the case of a 9 year old patient with a clinical history of epilepsy and various hospitalizations due to aspirative broncopneumonia among others, who was admitted to our hospital because of septic shock secondary to pneumonia of the lower left lobule associated with a parapneumonic pleural effusion and a complicated clinical course. During her stay, the patient undergoes surgical debridement using video assisted thoracoscopic surgery (VATS) under general anaesthesia and the hydropneumothorax is drained. For the procedure an ecoguided erector spinae plane block is performed and combined with general anaesthesia. On one hand this block permitted reduction of perioperative opioid administration and improved the patient's respiration, on the other hand it permitted avoiding the use of drugs, which can lower seizure threshold and increase the risk of convulsions. This case illustrates the importance of locoregional anaesthesia, a technique on the rise in the field of paediatric anaesthesia.

The effect of anesthesia without opioid on perioperative opioid demand in children with severe obstructive sleep apnea (OSA) for adenotonsillectomies — single-center retrospective observational study

BackgroundChildren with severe obstructive sleep apnea (OSA) carry a higher risk of respiratory complications after adenotonsillectomy. Their altered sensitivity to opioids may be a significant contributor to respiratory morbidity. The purpose of this study was to identify how anesthesia without opioids affects perioperative opioid demand and postoperative course.MethodsA chart review of children with severe OSA (apnea hypoxia index; AHI ≥ 10) undergoing adenotonsillectomies was performed. Comorbidities and perioperative medications were documented. Perioperative opioid doses within 48 h of procedure were calculated as morphine equivalents (mcg/kg). Pain scores, rescue medications, and postoperative complications in PICU and non-PICU settings were also documented. Anesthesia without opioid and with opioid groups were compared.ResultsThe analysis included 225 children. A significantly higher percentage of children received no postoperative opioids in the anesthesia without opioid group compared to those with opioid (46 of 88 children vs. 43 of 137; P < 0.05). The incidence of severe postoperative pain between the two groups was not different in PICU (P = 0.88) or non-PICU setting (P = 0.84). Perioperative opioid administration was significantly lower in anesthesia without opioid (median, Q1, Q3: 0.0, 0.0, 83.0) compared to with opioid (144.4, 72.5, 222.2; P < 0.01). Anesthesia without opioid was one of the independent factors to achieve perioperative opioid avoidance (<50mcg/kg).ConclusionsAnesthesia without opioid for children with severe OSA for tonsillectomy significantly reduced perioperative demand for opioid and did not affect the occurrence of severe pain. Anesthesia without opioid is an effective strategy to minimalize opioid demand perioperatively for children with severe OSA for tonsillectomy.

Decreased Opioid Consumption in Bone Marrow Harvest Patients Using Quadratus Lumborum Blocks in a Standardized Protocol.

PurposeBone marrow harvesting is associated with significant postoperative pain that may have potential negative consequences for the patient and health care system. In the current absence of uniform guidelines, there exists considerable variability amongst providers with respect to perioperative analgesia, especially opioid administration. In this initiative, we explored the potential for preoperative bilateral quadratus lumborum blocks in combination with a standardized perioperative analgesic protocol to manage pain with the goal of reducing perioperative narcotic usage and thereby improving opioid stewardship.MethodsAdults who underwent bone marrow donation from 2018 to 2020 were included in this analysis (n = 32). The pre-implementation group (n = 19) was reviewed retrospectively while the implementation group (n = 13) was evaluated prospectively. Patient demographics, pain scores, and opioid consumption were evaluated.ResultsPatient characteristics were equivalent except for anesthesia type with an increased number of patients in the implementation group undergoing spinal anesthesia. The implementation group showed significantly reduced median intraoperative (20.0 mg vs. 0.0 mg; p < 0.001) and total opioid consumption (20.5 mg vs. 0.0 mg; p < 0.001). The number of patients who received any opioids decreased from 84.2% (16/19) before implementation to 23.1% (3/13) after implementation.ConclusionThis change in practice suggests that implementation of a standardized perioperative protocol, including bilateral quadratus lumborum blocks, for bone marrow harvest patients leads to reduced perioperative opioid administration without compromising immediate perioperative pain control.

This Month in Anesthesiology

This Month in Anesthesiology

The association of sex with pain scores and perioperative opioid administration following laparoscopic sleeve gastrectomy.

Aim: We investigated whether sex is associated with pain scores and opioid administration after laparoscopic sleeve gastrectomy. Materials & methods: We performed a single-center, retrospective analysis of laparoscopic sleeve gastrectomy patients from December2016-July2018. Multivariable linear regressions were performed to investigate the association of sex with pain scores and opioid administration. Results: Baseline pain scores were similar between women and men (n=266; 78% women). Men reported lower pain scores in all phases of care and received more opioids during their hospitalization (ß=25.48; 95% CI: 5.77-45.20;p=0.01), compared withwomen. Conclusion: Our data suggest that women self-report greater postoperative pain scores, while men received more opioids during their hospitalization. Further studies are needed to understand the reasons for such differences in postoperative pain management.

The Utilization of an Opioid-Free Anesthetic for Pediatric Circumcision in an Ambulatory Surgery Center.

Circumcision is one of the most common urologic procedures performed at pediatric ambulatory centers. Emerging data on the short- and long-term effects of perioperative opioid administration has highlighted the importance of an opioid-free anesthetic regimen. We sought to evaluate the effectiveness of an opioid-free anesthetic in pediatric circumcision and its correlation with ambulatory surgery center efficiency. Patients, 3 years of age and younger, who underwent circumcision or circumcision revision by two surgeons pre and post introduction of an opioid-free anesthetic fast-track regimen at an outpatient surgical center were included. There were 100 patients included in this analysis, with 50 patients in each cohort. On univariate analysis, fast-tracking was associated with a decrease in median combined in-room and post-anesthesia care unit times (102.5 vs. 129.0 min, p-value < 0.001). This difference continued after multivariable analysis with an adjusted median combined in-room and post-anesthesia care unit time difference of −15.6 min (95% CI −34.2 to −12.7 min, p-value 0.018). In addition, the fast-track cohort received less intraoperative morphine equivalents without an increase in post-operative analgesic administration or change in postoperative questionnaire score. This demonstrates that opioid-free anesthesia may be used effectively in pediatric circumcision while also allowing for significant time savings for surgical centers.

Perioperative Opioid Consumption is Not Reduced in Cyanotic Patients Presenting for the Fontan Procedure.

Adequate pain control is a critical component of the perioperative approach to children undergoing repair of congenital heart disease (CHD). The impact of specific anatomic and physiologic disturbances on the management of analgesia has been largely unexplored at the present time. Studies in other pediatric populations have found an association between chronic hypoxemia and an increased sensitivity to the effects of opioid medications. The purpose of this retrospective study was to examine perioperative opioid administration and opioid-associated adverse effects in children undergoing surgical repair of CHD, with a comparison between patients with and without chronic preoperative cyanosis. Patients between the ages of 2 and 5years whose tracheas were extubated in the operating room were included and were classified in the cyanotic group if they presented for the Fontan completion. The primary outcomes of interest were intraoperative and postoperative opioid administration. Secondary outcomes included pain scores and opioid-related side effects. The study cohort included 156 patients. Seventy-one underwent the Fontan procedure, twelve of which were fenestrated. Fontan patients received fewer opioids intraoperatively (11.33µg/kg fentanyl equivalents versus 12.56µg/kg, p = 0.03). However, there were no differences with regards to opioid consumption postoperatively and no correlation between preoperative oxygen saturation and total opioid administration. There were no differences between groups with regards to the respiratory rate nadir, postoperative pain scores, or the incidence of opioid-related side effects. In contrast to other populations with chronic hypoxemia exposure, children with cyanotic CHD did not appear to have increased sensitivity to the effects of opioid medications.

Influence of peri-incisional epaxial muscle infiltration with bupivacaine pre- or post-surgery on opioid administration in dogs undergoing thoraco-lumbar hemilaminectomy

This study investigated the influence of bupivacaine infiltration before or after hemilaminectomy on peri-operative opioid requirement in dogs. Thirty dogs undergoing T3-L3 hemilaminectomy were randomly assigned to receive peri-incisional infiltration of bupivacaine 2 mg/kg into the epaxial muscles before surgery (Group A), at wound closure (Group B), or no infiltration (Group C). Anaesthesia comprised dexmedetomidine 4 mcg/kg and methadone 0.3 mg/kg IV (premedication), alfaxalone IV (induction), and isoflurane in oxygen (maintenance). All dogs received meloxicam SC/PO prior to induction of general anaesthesia. Response to surgery, defined as a change in autonomic physiological variables >20% above baseline, was treated with fentanyl 2.5 mcg/kg boluses, followed by a continuous rate infusion of fentanyl at 5 mcg/kg/h. The Glasgow Composite Pain Score–Short Form (GCPS-SF) was performed before premedication and at regular intervals until 24 h postoperatively. Methadone 0.2 mg/kg analgesia was given IV if GCPS-SF was ≥5/20. Number of intraoperative, postoperative and total analgesic interventions were recorded. Analgesic interventions were analysed using a chi–squared test using a Pocock approach and statistical significance was set at P < 0.029.The number of intra-operative analgesic interventions in Group A (median, 0; range, 0–2), was significantly lower than in Group B (median, 3; range, 0–5) and Group C (median, 3; range, 0–5; P = 0.019). Regarding postoperative interventions, there were significantly fewer in Group A (median, 0; range, 0–1) and Group B (median, 0; range, 0–1) than in Group C (median, 1; range, 0–2; P = 0.047). Group A (median, 0; range, 0–3), had significantly fewer total analgesic interventions than Group B (median, 3; range, 0–6) and Group C (median, 4; range, 1–7; P = 0.014). Bupivacaine reduced peri-operative opioid administration and pre-surgical peri-incisional infiltration yielded the greatest benefit.

The effectiveness of Bilateral Erector Spinae Plane Block in reducing perioperative opioid administration in patients undergoing Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy (LC), is one of the most common surgeries performed in general surgery. Most of the times, LC is accompanied by moderate to severe postoperative pain. Erector Spinae Plane Block (ESPB) is an innovative trunk block which has been used as a method of postoperative analgesia in various clinical procedures. In this study we evaluated its effectiveness as a method of perioperative analgesia, seeking to investigate whether it is effective in reducing perioperative opioid administration in patients undergoing LC. Methods: This is a double-blind, randomized, controlled, prospective study. 60 patients were randomized into Group C (ESPB with N/S 0.9%), Group D (ESPB with ropivacaine 0.375%, dexmedetomidine 1 γ/kg) and Group R (ESPB with ropivacaine 0.375%). ESPB was performed bilaterally before induction of general anesthesia, with ultrasound guidance. Statistical analysis included ANOVA, two-way ANOVA for repeated measures, Kruskal-Wallis and Spearman tests. Results: All patients remained hemodynamically stable during their hospitalization, without major complications. Statistical significance was found to exist regarding total perioperative remifentanil consumption between all three Groups. Median morphine consumption, NRS pain scores and mobilization time of the patients was found to be significantly less in patients of Group D compared with patients of Group C and in patients of Group R compared with patients of Group C. However, there was no statistically important difference between Groups D and R. Satisfaction scores were found to be statistically higher in patients of Group D when compared with patients of Group C. Conclusion: ESPB performance with administration of ropivacaine or a combination of ropivacaine and dexmedetomidine in patients undergoing LC, is an innovative, safe and simple method which contributes to the amelioration of the quality of perioperative analgesia, avoiding the complications arising from opioid administration and thus, achieving multimodal analgesia.

Perioperative Opioid Administration

Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.

The Role of Opioids and Their Receptors in Urological Malignancy: A Review.

We reviewed the literature surrounding the role of opioids and their receptors in urological malignancy. Recent studies have suggested clinically significant effects of agonism or antagonism of opioid receptors on cancer related outcomes and tumorigenesis. The focus of these efforts has centered on nonurological malignancies. However, a compelling body of evidence is growing in the fields of prostate, bladder and kidney cancer. A systematic review of English language articles published through 2020 was conducted with key phrases related to kidney, bladder or prostate cancer, and opioids or narcotics. A total of 837 unique records were identified, of which 49 were selected for full text review and 33 were included in the qualitative analysis. Eight records were identified via citation review and 1 study was recently presented at a national meeting. Retrospective reviews suggest poorer disease specific and recurrence-free survival with increased perioperative opioid administration in patients undergoing prostate or bladder cancer surgery. However, the data are controversial. Kappa opioid receptors are implicated in both proliferation and inhibition of prostate cancer cell growth across in vitro studies, with a proposed interaction with the androgen cascade. Similarly opioid growth factor receptor is highly expressed in prostate cancer cells and repressed by androgens. Prostate cancer tissue stains more intensely for the mu opioid receptor, and patients with higher expression have poorer oncologic outcomes. Opioid agonism in vitro induces urothelial cell carcinoma proliferation, migration and invasion, with possible additional influence from interactions with the bradykinin b2 receptor. Agonism of the mu, kappa and delta opioid receptors induces renal cell carcinoma tumorigenesis, possibly via upregulation of survivin. Meanwhile, opioid growth factor receptor agonism has the opposite effect in renal cell carcinoma. Evidence surrounding the role of opioids and their receptors in urological malignancy is provocative and should serve as an impetus for further investigation.

54: Is hysterectomy a risk factor for urinary retention? A retrospective matched case control study

Urinary retention has been reported in up to 20% of outpatient minimally invasive hysterectomies. Studying the independent effect of hysterectomy on urinary retention is difficult because of the presence of multiple risk factors, which include menopause, perioperative opioid administration, and operative time. This is a retrospective chart review comparing patients who underwent minimally invasive hysterectomy to those who underwent non-hysterectomy minimally invasive gynecologic surgery between January 2013 and December 2018 at a single institution. The primary outcome was rate of urinary retention. A total of 200 hysterectomy cases were matched by operative time to non-hysterectomy gynecologic surgery controls in a 1:1 ratio. Differences in baseline and operative characteristics between the two groups (Table 1) included age (years, 48.6 vs. 45.7, p = 0.04), perioperative opioid administration (morphine mg equivalents, 11.6 vs. 7.6, p = 0.01) and estimated blood loss (EBL, mL, 64.1 vs. 31.8, p=0.001); menopausal status and body mass index (BMI) did not differ. Rate of urinary retention in the hysterectomy group was double that of the non-hysterectomy group (26.5% vs. 13%, p = 0.01). Overall, a 10.1% rate of urinary tract infection was observed in patients discharged home with indwelling catheter. Urinary retention was not associated with age (years, 47 vs. 47.2, p = 0.92), menopausal status (26.6% vs. 33.1%, p = 0.284), BMI (kg/m2, 26.8 vs. 27.8, p = 0.23), perioperative opioid administration (morphine milligram equivalent, 11.8 vs. 9, p = 0.53), or EBL (mL, 56 vs. 46, p = 0.42). Operative time was longer in the retention group (minutes, 104 vs 93.7, p = 0.01). Hysterectomy appears to be an independent and major factor contributing to postoperative urinary retention. When compared to non-hysterectomy gynecologic surgeries with similar operative times, the rate of urinary retention in hysterectomy patients was doubled. These results may be helpful to the gynecologic surgeon when selecting appropriate candidates for postoperative void trial.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Is Hysterectomy a Risk Factor for Urinary Retention? A Retrospective Matched Case Control Study

Compare the rates of urinary retention in patients undergoing endoscopic hysterectomy with those of patients undergoing nonhysterectomy endoscopic gynecologic surgery. Retrospective case control study matched by operative time. Academic medical center. All patients undergoing endoscopic gynecologic surgeries between January 2013 and December 2018. Outpatient endoscopic gynecologic surgery. A total of 200 endoscopic hysterectomy cases were matched to endoscopic nonhysterectomy gynecologic surgery controls in a 1:1 ratio. The differences in baseline and operative characteristics between the 2 groups included age (48.6 years vs 45.7 years, p = .04), perioperative opioid administration (morphine milligram equivalents, 11.6 mg vs 7.6 mg, p = .01), and estimated blood loss (64.1 mL vs 31.8 mL, p = .001). The rate of urinary retention in the hysterectomy group was double that in the nonhysterectomy group (26.5% vs 13%, p = .01). In the hysterectomy group, age, perioperative opioids, operative time, and estimated blood loss did not differ between those who failed and those who passed the void trial. In the nonhysterectomy group, only operative time was significantly longer in those who failed the void trial (108 minutes vs 94.3 minutes, p = .04). After adjusting for perioperative opioid use and operative time, the relative risk of urinary retention in the hysterectomy group was 2.3 (p = .002, 95% confidence interval, 1.38-3.98). Hysterectomy appears to be an independent and major factor contributing to postoperative urinary retention. When compared with nonhysterectomy gynecologic surgical controls with similar operative times, the rate of urinary retention in patients who underwent hysterectomy was doubled.

The Reducing Opioid Use in Children with Clefts Protocol: A Multidisciplinary Quality Improvement Effort to Reduce Perioperative Opioid Use in Patients Undergoing Cleft Surgery.

Cleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population. After identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores. The final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924). Perioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors' quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations. Therapeutic, III.

Advances in regional anaesthesia and acute pain management: a narrative review.

Regional anaesthesia has undergone several exciting advances in the past few decades. Ultrasound-guided techniques of peripheral nerve blockade have become the gold standard thanks to the associated improvements in efficacy, ease of performance and safety. This has increased the accessibility and utilisation of regional anaesthesia in the anaesthesia community at large and is timely given the mounting evidence for its potential benefits on various patient-centred outcomes, including major morbidity, cancer recurrence and persistent postoperative pain. Ultrasound guidance has also paved the way for refinement of the technical performance of existing blocks concerning simplicity and safety, as well as the development of new regional anaesthesia techniques. In particular, the emergence of fascial plane blocks has further broadened the application of regional anaesthesia in the management of painful conditions of the thorax and abdomen. The preliminary results of investigations into these fascial plane blocks are promising but require further research to establish their true value and role in clinical care. One of the challenges that remains is how best to prolong regional anaesthesia to maximise its benefits while avoiding undue harm. There is ongoing research into optimising continuous catheter techniques and their management, intravenous and perineural pharmacological adjuncts, and sustained-release local anaesthetic molecules. Finally, there is a growing appreciation for the critical role that regional anaesthesia can play in an overall multimodal anaesthetic strategy. This is especially pertinent given the current focus on eliminating unnecessary peri-operative opioid administration.

Implementation of an Enhanced Recovery Protocol (ERP) is associated with an increase in the perioperative use of non-opioid multimodal analgesia for non-ERP patients

Study objectiveIncorporation of multimodal, non-opioid analgesic medications into patient care pathways has become a common theme of enhanced recovery pathways (ERPs), which have been shown to improve patient outcomes such as complication rates and length of stay. With surgical care episodes, patients also incur a significant risk of persistent postoperative opioid use, whether the surgery is classified as major or minor surgery. One method that has been shown to reduce perioperative opioid administration is a structured non-opioid multimodal analgesic strategy, widely utilized in ERPs. Despite well-defined benefits, the time to translate evidence-based approaches into clinical practice can be prolonged. This study examines the effect of implementation of an Enhanced Recovery Protocol (ERP) on the adoption of intraoperative multimodal analgesia outside of the auspices of an ERP care pathway, describing factors influencing the clinical implementation of non-opioid multimodal analgesia (NOMA) in routine practice. DesignRetrospective cohort analysis. SettingWe identified all surgical cases between January 2013 and December 2016 at Vanderbilt University Medical Center (VUMC). InterventionsNone. MeasurementsUsing both segmented and logistic regression approaches, we compared non-ERP surgical cases before and after the initial ERP education and implementation in April 2014. Outcomes included provider, patient, and procedural factors associated with utilization of non-opioid multimodal analgesia (NOMA) in the immediate perioperative period. Main resultsWe studied 73,560 non-ERP cases. Cases utilizing any element of NOMA increased from 17.06% to 35.21% (X2 = 2358, df = 1, p < 0.01) before and after the initial ERP pathway implementation. Patient factors influencing this increased adoption of multimodal analgesia included lower American Society of Anesthesiologists Physical Status Class, younger age, and Caucasian race. Cases with in-room providers who were residents or trainees (as opposed to nurse anesthetists) or providers who had a greater number of prior ERP pathway cases were more likely to use multimodal. Procedure-specific factors favoring multimodal included use of laparoscopy. The gynecologic, neurosurgical, and orthopedic cases were more likely to utilize multimodal analgesics. ConclusionsFrom 2013 to 2016, NOMA usage in non-ERP patients increased significantly and in association with departmental education and concomitant implementation of an ERP pathway. Factors associated with increased uptake of multimodal analgesia included the presence of trainees, providers with a higher number of previous ERP pathway cases, patients who were younger, healthier, female, Caucasian race, and having specific types of surgery.

The Impact of Alvimopan on Return of Bowel Function After Major Spine Surgery - A Prospective, Randomized, Double-Blind Study.

Pain management following major spine surgery requires high doses of opioids and is associated with a risk of opioid-induced constipation. Peripheral mu-receptor antagonists decrease the gastrointestinal complications of perioperative systemic opioid administration without antagonizing the analgesic benefits of these drugs. To investigate the impact of alvimopan in opioid-naive patients undergoing major spine surgery. Patients undergoing>3 levels of thoracic and/or lumbar spine surgery were enrolled in this prospective, randomized, double-blind study to receive either alvimopan or placebo prior to and following surgery. Opioid consumption; pain scores; and time of first oral intake, flatus, and bowel movement were recorded. A total of 24 patients were assigned to the active group and 25 were assigned to the placebo group. There was no significant difference in demographics between the groups. Postoperatively, the alvimopan group reported earlier time to first solid intake [median (range): alvimopan: 15 h (3-25) vs placebo: 17 h (3-46), P<.001], passing of flatus [median (range): alvimopan: 22 h (7-63) vs placebo: 28 h (10-58), P<.001], and first bowel movement [median (range): alvimopan: 50 h (22-80) vs placebo: 64 h (40-114), P<.001]. The alvimopan group had higher pain scores (maximum, minimum, and median); however, there was no significant difference between the groups with postoperative opioid use. This study shows that the perioperative use of alvimopan significantly reduced the time to return of bowel function with no increase in postoperative opioid use despite a slight increase in pain scores.