Perioperative Opioid Use Research Articles

Optimizing pediatric tonsillectomy outcomes with an opioid sparing anesthesia protocol: Learning and continuously improving with real-world data.

This quality improvement initiative is a continued pursuit to optimize outcomes by iteratively improving our opioid sparing anesthesia protocol for tonsillectomy with or without adenoidectomy at our pediatric ambulatory surgical center through data driven Plan-Do-Study-Act cycles. From 1/2015 through 12/2023, our standardized tonsillectomy protocol underwent nine procedure-specific perioperative Plan-Do-Study-Act cycles, three procedure-specific postoperative prescription Plan-Do-Study-Act cycles, and four general ambulatory surgical center enhanced recovery Plan-Do-Study-Act cycles. We analyzed data from the medical record using statistical process control charts. The primary outcome measure was the percent of patients requiring intravenous opioid in the post anesthesia care unit. Secondary outcomes included maximum post anesthesia care unit pain score, the percent of patients requiring treatment for nausea and/or vomiting in the post anesthesia care unit, and the number of postoperative opioid prescription dosages. Balancing measures were average post anesthesia care unit length of stay, percent of patients with prolonged Post Anesthesia Care Unit length of stay (>120 min), and 30-day reoperation rate. A total of 5654 tonsillectomy with or without adenoidectomy cases were performed at our ambulatory surgical center from 2015 to 2023. The incidence of intravenous opioid administered in the post anesthesia care unit initially rose with opioid free anesthesia launch, but subsequently decreased below the target of 10%. Maximum post anesthesia care unit pain scores rose from mean 3.6 to 4.5, but subsequently returned to the baseline of 3.5, while the incidence of postoperative nausea and/or vomiting improved. The average post anesthesia care unit length of stay increased by 10 min with opioid free anesthesia; however, prolonged post anesthesia care unit stay and 30-day reoperation rates were unchanged. The continued refinement of our opioid sparing anesthesia protocol has led to reduced perioperative and home opioid use, stable maximum post anesthesia care unit pain scores, and improved postoperative nausea and vomiting rates, with only a slight increase in mean post anesthesia care unit length of stay.

Comparison of Ultrasound-Guided Single-Injection Erector Spinae Plane Block, Retrolaminar Block and Paravertebral Block for Postoperative Analgesia in Single-Incision Video-Assisted Thoracoscopic Surgery: A Three-Arm, Double-Blind, Randomized Controlled Non-Inferiority Trial.

Effective postoperative analgesia is critical for thoracic surgery. This study compares the analgesic efficacy of the erector spinae plane block (ESPB), retrolaminar block (RLB), and paravertebral block (TPVB) in single-incision video-assisted thoracoscopic surgery (SITS). Seventy-six patients underwent general anesthesia followed by ultrasound-guided nerve blocks with 20mL of 0.5% ropivacaine. Primary outcomes included the area under the curve (AUC) of Numeric Rating Scale (NRS) scores during rest and coughing over 24 hours. Secondary outcomes included perioperative opioid use, plasma biomarkers, and postoperative recovery measures. The AUC for NRS was 107.8±10.53 in the ESPB group, 104.8±8.05 in the RLB group, and 103.6±10.42 in the TPVB group, demonstrating non-inferiority for ESPB (difference: 4.2±3.0, 95% CI -1.82 to 10.22) and RLB (difference: 1.2±2.6, 95% CI -3.97 to 6.37) compared to TPVB. No significant differences were observed in opioid use, plasma biomarkers, QoR-15 scores, or adverse events. ESPB and RLB provide non-inferior analgesia compared to TPVB in SITS patients and are effective alternatives that enhance safety.

Postoperative delirium among elderly elective orthopedic patients in Addis Ababa Ethiopia: a multicentere longitudinal study

BackgroundDelirium is a neurocognitive disorder characterized by an acute and relatively rapid decline in cognition, disturbance of consciousness, reduced ability to focus, and shift of attention. It mainly affects elderly patients with an incidence of about 8–23% after an operation. It frequently occurs between 24-hrs and 5 days after surgery. It results in serious medical management problems. Hence, identifying the incidence and associated factors may help prevent and manage its sequel in the elderly.ObjectiveAssessment of the incidence and associated factors of postoperative delirium(POD) among elderly elective orthopedic surgical patients in Addis Ababa public hospitals, Ethiopia, 2024.MethodsA multi-centered longitudinal study was conducted on 220 elderly (age ≥ 65 years) patients in four selected public hospitals of the study area from February 2024 to May 2024, and a systematic sampling technique was used to select the study units. Data was collected through chart review and interviews of patients, and postoperative delirium was assessed using the confusion assessment method (CAM). Both bivariable and multivariable logistic regression models were used for statistical analysis. The strength of association was determined with an adjusted odds ratio (AOR) with a 95% confidence interval(CI) at a p-value of < 0.05.ResultsA total of 220 patients were studied, and the incidence of POD among elderly elective orthopedic surgical patients was 33.7%. Age 65–75(AOR = 0.47, 95%CI (0.226–0.97)), Induction using ketamine (AOR = 1.32, 95%CI(1.109–3.87), p = 0.003)), perioperative opioid use (AOR = 2.20, 95%CI(1.073 4.5313)), intraoperative anticholinergic use(AOR = 2.24,95%CI(1.831–4.235)), recent hospitalization history (AOR = 2.24,95%CI(1.202–4.206)), and transfusion (AOR = 2.83,95%CI(1.295–6.193)) were significantly associated with POD (p < 0.05).Conclusion and recommendationsThe incidence of POD in the study area was high (33.7%); advanced age, hospitalization history, Anesthesia induction by Ketamine, perioperative anticholinergic uses, opioid use, and blood transfusion use were associated factors for postoperative delirium. We recommend giving due attention to elderly patients with advanced age, history of hospitalization, perioperative Ketamie use, perioperative anticholinergic uses, opioid use, and blood transfusion use undergoing elderly elective orthopedic surgery.

Gabapentin and Rapidity of Recovery Among Patients Undergoing Minimally Invasive Ambulatory Uro-Oncologic Surgeries.

Gabapentin has been used in enhanced recovery after surgery (ERAS) pathways for pain control for patients undergoing ambulatory uro-oncologic surgery; however, it may cause undesirable side effects. We studied the causal association between gabapentin and rapidity of recovery and perioperative pain management after minimally invasive uro-oncologic surgery. We identified 2397 patients ≤ 65 years undergoing prostatectomies or nephrectomies between 2018 and 2022; 131 (5.5%) did not receive gabapentin. We tested the effect of gabapentin use on time of discharge and perioperative opioid consumption, respectively, using multivariable linear regression adjusting for potential confounders including age, gender, BMI, American Society of Anesthesiologists score, and surgery type. On adjusted analysis, we found no evidence of a difference in discharge time among those who did vs did not receive gabapentin (adjusted difference 0.07 hours shorter on gabapentin; 95% CI -0.17, 0.31; P = .6). There was no evidence of a difference in intraoperative opioid consumption by gabapentin receipt (adjusted difference -1.5 morphine milligram equivalents; 95% CI -4.2, 1.1; P = .3) or probability of being in the top quartile of postoperative opioid consumption within 24 hours (adjusted difference 4.2%; 95% CI -4.8%, 13%; P = .4). We saw no important differences in confounders by gabapentin receipt suggesting causal conclusions are justified. Our confidence intervals did not include clinically meaningful benefits from gabapentin, when used with an ERAS protocol, in terms of length of stay or perioperative opioid use. These results support the omission of gabapentin from ERAS protocols for minimally invasive uro-oncologic surgeries.

Contemporary utilization of three-column osteotomy techniques in a prospective complex spinal deformity multicenter database: implications on full-body alignment and perioperative course.

Research has focused on the increased correction from a three-column osteotomy (3CO) during adult spinal deformity (ASD) surgery. However, an in-depth analysis on the performance of a 3CO in a cohort of complex spinal deformity cases has not been described. This is a retrospective study on a prospectively enrolled, complex ASD database. This study aimed to determine if three-column osteotomies demonstrate superior benefit in correction of complex sagittal deformity at the cost of increased perioperative complications. Surgical complex adult spinal deformity patients were included and grouped into thoracolumbar 3COs compared to those who did not have a 3CO (No 3CO) (remaining cohort). Rigid deformity was defined as ΔLL less than 33% from standing to supine. Severe deformity was defined as global (SVA > 70mm) or C7-PL > 70mm, or lumbopelvic (PI-LL > 30°). Means comparison tests assessed correction by 3CO grade/location. Multivariate analysis controlling for baseline deformity evaluated outcomes up to six weeks compared to No 3CO. 648 patients were included (Mean age 61 ± 14.6years, BMI 27.55 ± 5.8kg/m2, levels fused: 12.6 ± 3.8). 126 underwent 3CO, a 20% higher usage than historical cohorts. 3COs were older, frail, and more likely to undergo revision (OR 5.2, 95% CI [2.6-10.6]; p < .001). 3COs were more likely to present with both severe global/lumbopelvic deformity (OR 4), 62.4% being rigid. 3COs had greater use of secondary rods (OR 4st) and incurred 4 times greater risk for: massive blood loss (> 3500mL), longer LOS, SICU admission, perioperative wound and spine-related complications, and neurologic complications when performed below L3. 3COs had similar HRQL benefit, but higher perioperative opioid use. Mean segmental correction increased by grade (G3-21; G4-24; G5-27) and was 4 × greater than low-grade osteotomies, especially below L3 (OR 12). 3COs achieved 2 × greater spinopelvic correction. Higher grades properly distributed lordosis 50% of the time except L5. Pelvic compensation and non-response were relieved more often with increasing grade, with greater correction in all lower extremity parameters (p < .01). Due to the increased rate of complications, 3COs trended toward higher perioperative cost ($42,806 vs. $40,046, p = .086). Three-column osteotomy usage in contemporary complex spinal deformities is generally limited to more disabled individuals undergoing the most severe sagittal and coronal realignment procedures. While there is an increased perioperative cost and prolongation of length of stay with usage, these techniques represent the most powerful realignment techniques available with a dramatic impact on normalization at operative levels and reciprocal changes.

Effects of liposomal bupivacaine on opioid use and healthcare resource utilization after outpatient spine surgery: a real-world assessment

BACKGROUND CONTEXTPerioperative pain management affects cost and outcomes in elective spine surgery. PURPOSEThis study investigated the association between liposomal bupivacaine (LB) and outpatient spine surgery outcomes, including perioperative, postoperative, and postdischarge opioid use and healthcare resource utilization. STUDY DESIGNThis was a retrospective comparative study. PATIENT SAMPLEEligibility criteria included adults with ≥6 months of continuous data before and after outpatient spine procedures including discectomy, laminectomy, or lumbar fusion. Patients receiving LB were matched 1:3 to patients receiving non-LB analgesia by propensity scores. OUTCOME MEASURESOutcomes included (1) opioid use in morphine milligram equivalents (MMEs) during the perioperative and postdischarge periods and (2) postdischarge readmission and emergency department (ED) visits up to 3 months after surgery. Generalized linear mixed-effects modeling with appropriate distributions was used for analysis. METHODSDeidentified data from the IQVIA linkage claims databases (2016-2019) were used for the analysis. This study was funded by Pacira BioSciences, Inc. RESULTSIn total, 381 patients received LB and 1143 patients received non-LB analgesia. Baseline characteristics were well balanced after propensity score matching. The LB cohort used fewer MMEs versus the non-LB cohort before discharge (80 vs 132 MMEs [mean difference, −52 MMEs; p=.0041]). Following discharge, there was a nonsignificant reduction in opioid use in the LB cohort versus the non-LB cohort within 90 days (429 vs 480 MMEs [mean difference, −50 MMEs; p=.289]) and from >90 days to 180 days (349 vs 381 MMEs [mean difference, −31 MMEs; p=.507]). The LB cohort had significantly lower rates of ED visits at 2 months after discharge versus the non-LB cohort (3.9% vs 7.6% [odds ratio, 0.50; p=.015]). Postdischarge readmission rates did not differ between cohorts. CONCLUSIONSUse of LB for outpatient spine surgery was associated with reduced opioid use at the hospital and nonsignificant reduction in opioid use at all postoperative timepoints examined through 90 days after surgery versus non-LB analgesia. ED visit rates were significantly lower at 60 days after discharge. These findings support reduced cost and improved quality metrics in patients treated with LB versus non-LB analgesia for outpatient spine surgery.

Local Anesthetics, Local Anesthetic Systemic Toxicity (LAST), and Liposomal Bupivacaine.

Local anesthetics have played a vital role in the multimodal analgesia approach to patient care by decreasing the use of perioperative opioids, enhancing patient satisfaction, decreasing the incidence of postoperative nausea and vomiting, decreasing the length of hospital stay, and reducing the risk of chronic postsurgical pain. The opioid-reduced anesthetic management for perioperative analgesia has been largely successful with the use of local anesthetics during procedures such as peripheral nerve blocks and neuraxial analgesia. It is important that practitioners who use local anesthetics are aware of the risk factors, presentation, and management of local anesthetic systemic toxicity (LAST).

A transitional pain management program is associated with reduced opioid dependence after major shoulder surgery

BackgroundOver-prescription of opioids in the United States increases risks of opioid dependence, overdose, and death. Increased perioperative and postoperative opioid use during orthopedic shoulder surgery is a significant risk factor for long term opioid dependence. The authors hypothesized that a multidisciplinary perioperative pain management program (Transitional Pain Service or TPS) for major shoulder surgery would lead to a reduced amount of opioids required postoperatively. MethodsA TPS was implemented at a Veterans Affairs Medical Center focused on non-opioid pain management and cessation support. Opioid consumption during the implementation of the TPS was compared to a historical cohort. All patients undergoing shoulder arthroplasty or rotator cuff repair were included. The primary outcome was the proportion of patients continuing opioid use at 90 days postoperatively. Secondary outcomes included postoperative pain scores, time to opioid cessation, and median opioid tablets consumed at 90-days. A multivariable model was developed to predict total opioid use at 90-days postoperatively. Kaplan Meier curves were calculated for time to opioid cessation. ResultsThe TPS group demonstrated decreased persistent opioid use at 90 days post-discharge (12.6% vs. 28.6%; p=0.018). Independent predictors associated with increased total opioid tablet prescriptions at 90 days included length of stay (β=19.17), anxiety diagnosis (β=37.627), and number of tablets prescribed at discharge (β=1.353). Shoulder arthroplasty surgery (TSA) was associated with decreased 90-day opioid utilization (β= -32.535) when compared to cuff repair (RCR). Median time to cessation was shorter in TSA (6 days) when compared with RCR (8 days). Pain scores were reduced compared to population mean by post-discharge day 2 for TSA and by post-discharge day 7 for RCR. Median number of post-discharge opioid tablets (oxycodone 5 mg) consumed under TPS management was 25 in both RCR and TSA surgery groups (180 MME). Discussion and ConclusionsThis study demonstrates that a TPS reduces the amount of opioid use of patients undergoing shoulder arthroplasty or cuff repair at 90 days when compared with a historical control. Multivariable regression indicated that fewer opioid tablets at discharge was a modifiable factor that may aid in reducing opioid consumption and that anxiety diagnosis, increased length of stay, and cuff repair surgery were other factors independently associated with increased opioid consumption. This data will assist surgeons in counseling patients, setting narcotic use expectations, and minimizing overprescribing. Use of a similar multidisciplinary perioperative pain management program may greatly reduce opioid over prescriptions nationally.

Real-world assessment of longitudinal opioid use and healthcare resource utilization in patients undergoing colorectal resection

Liposomal bupivacaine (LB) has been used in multimodal pain management regimens to improve postsurgical analgesia. This retrospective cohort analysis assessed clinical and economic outcomes of LB vs non-LB analgesia in minimally invasive colorectal resection surgery using real-world patient data from the IQVIA linkage claims databases. Patients who received LB were 1:1 matched to patients who did not receive LB (non-LB) via propensity scores. Outcomes included opioid use during the perioperative (2 weeks before surgery to 2 weeks after discharge), continued (>2 weeks to 3 months after discharge), and persistent (>3 months to 6 months after discharge) periods and healthcare resource utilization (HRU) during the first 3 months after discharge. Mean opioid consumption was lower in the LB (n = 4397) versus non-LB (n = 4397) cohort perioperatively (483 vs 538 morphine milligram equivalents [MMEs]; P = 0.001) and after discharge within ∼3 months (222 vs 328 MMEs; P < 0.0001) and 3–6 months (245 vs 384 MMEs; P < 0.0001). The LB cohort had shorter mean length of stay (5.2 vs 5.7 days; P < 0.0001) and fewer inpatient readmissions (odds ratio [OR], 0.71; P < 0.0001), emergency department visits (OR, 0.78; P < 0.0001), and outpatient/office visits (OR, 0.91; P = 0.028) than the non-LB cohort 3 months after discharge. These data suggest use of LB in minimally invasive colorectal resection surgery may reduce perioperative and postdischarge opioid use as well as HRU. Although additional studies are needed to confirm these findings, this analysis provides valuable real-world data from large claims databases to evaluate clinical and economic outcomes that complement other types of retrospective and prospective studies.

Long-term Health Outcomes of New Persistent Opioid Use After Gastrointestinal Cancer Surgery

BackgroundNew persistent opioid use (NPOU) after surgery has been identified as a common complication. This study sought to assess the long-term health outcomes among patients who experienced NPOU after gastrointestinal (GI) cancer surgery.MethodsPatients who underwent surgery for hepato-pancreato-biliary and colorectal cancer between 2007 and 2019 were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Mixed-effect multivariable logistic regression and Cox proportional hazard models were used to estimate the risk of mortality and hospital visits related to falls, respiratory events, or pain symptoms.ResultsAmong 15,456 patients who underwent GI cancer surgery, 967(6.6%) experienced NPOU. Notably, the patients at risk for the development of NPOU were those with a history of substance abuse (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.14–1.84), moderate social vulnerability (OR, 1.26; 95% CI, 1.06–1.50), an advanced disease stage (OR, 4.42; 95% CI, 3.51–5.82), or perioperative opioid use (OR, 3.07; 95% CI, 2.59–3.63. After control for competing risk factors, patients who experienced NPOU were more likely to visit a hospital for falls, respiratory events, or pain symptoms (OR, 1.45, 95% CI 1.18–1.78). Moreover, patients who experienced NPOU had a greater risk of death at 1 year (hazard ratio [HR], 2.15; 95% CI, 1.74–2.66).ConclusionApproximately 1 in 15 patients experienced NPOU after GI cancer surgery. NPOU was associated with an increased risk of subsequent hospital visits and higher mortality. Targeted interventions for individuals at higher risk for NPOU after surgery should be used to help mitigate the harmful effects of NPOU.

Experiences and perspectives of adults on using opioids for pain management in the postoperative period: A scoping review.

Opioids play an important role in peri-operative pain management. However, opioid use is challenging for healthcare practitioners and patients because of concerns related to opioid crises, addiction and side effects. This review aimed to identify and synthesise the existing evidence related to adults' experiences of opioid use in postoperative pain management. Systematic scoping review of qualitative studies. Inductive content analysis and the Theoretical Domains Framework (TDF) were applied to analyse and report the findings and to identify unexplored gaps in the literature. Ovid MEDLINE, PsycInfo, Embase, CINAHL (EBSCO), Cochrane Library and Google Scholar. All qualitative and mixed-method studies, in English, that not only used a qualitative approach that explored adults' opinions or concerns about opioids and/or opioid reduction, and adults' experience related to opioid use for postoperative pain control, including satisfaction, but also aspects of overall quality of a person's life (physical, mental and social well being). Ten studies were included; nine were qualitative ( n = 9) and one used mixed methods. The studies were primarily conducted in Europe and North America. Concerns about opioid dependence, adverse effects, stigmatisation, gender roles, trust and shared decision-making between clinicians and patients appeared repeatedly throughout the studies. The TDF analysis showed that many peri-operative factors formed people's perceptions and experiences of opioids, driven by the following eight domains: Knowledge, Emotion, Beliefs about consequences, Beliefs about capabilities, Self-confidence, Environmental Context and Resources, Social influences and Decision Processes/Goals. Adults have diverse pain management goals, which can be categorised as proactive and positive goals, such as individualised pain management care, as well as avoidance goals, aimed at sidestepping issues such as addiction and opioid-related side effects. It is desirable to understand the complexity of adults' experiences of pain management especially with opioid use and to support adults in achieving their pain management goals by implementing an individualised approach, effective communication and patient-clinician relationships. However, there is a dearth of studies that examine patients' experiences of postoperative opioid use and their involvement in opioid usage decision-making. A summary is provided regarding adults' experiences of peri-operative opioid use, which may inform future researchers, healthcare providers and guideline development by considering these factors when improving patient care and experiences.

Predictors of Perioperative Opioid Use in Hysterectomy Patients: A Prospective Cohort Study

Predictors of Perioperative Opioid Use in Hysterectomy Patients: A Prospective Cohort Study

Exploring the relationship between language, postoperative pain, and opioid use

Racial and ethnic disparities in pain management are well documented. Differences in pain assessment and management by language have not been studied in the postoperative setting in gynecologic surgery. This study aimed to investigate the association between language and immediate postoperative pain management by comparing pain assessments and perioperative opioid use in non-English speakers and English speakers. This was a retrospective cohort study comparing perioperative outcomes between non-English-speaking patients and English-speaking patients who had undergone a gynecologic oncology open surgery between July 2012 and December 2020. The primary language was extracted from the electronic medical record. Opioid use is expressed in oral morphine equivalents. Proportions are compared using chi-square tests, and mean values are compared using 2-sample t tests. Although interpreter services are widely available in our institution, the use of interpreters for any given inpatient-provider interaction is not documented. Between 2012 and 2020, 1203 gynecologic oncology patients underwent open surgery, of whom 181 (15.1%) were non-English speakers and 1018 (84.9%) were English speakers. There was no difference between the 2 cohorts concerning body mass index, surgical risk score, or preoperative opioid use. Compared with the English-speaking group, the non-English-speaking group was younger (57 vs 54 years old, respectively; P<.01) and had lower rates of depression (26% vs 14%, respectively; P<.01) and chronic pain (13% vs 6%, respectively; P<.01). Although non-English-speaking patients had higher rates of hysterectomy than English-speaking patients (80% vs 72%, respectively; P=.03), there was no difference in the rates of bowel resections, adnexal surgeries, lengths of surgery, intraoperative oral morphine equivalents administered, blood loss, use of opioid-sparing modalities, lengths of hospital stay, or intensive care unit admissions. In the postoperative period, compared with English-speaking patients, non-English-speaking patients received fewer oral morphine equivalents per day (31.7 vs 43.9 oral morphine equivalents, respectively; P<.01) and had their pain assessed less frequently (7.7 vs 8.8 checks per day, respectively; P<.01) postoperatively. English-speaking patients received a median of 19.5 more units of oral morphine equivalents daily in the hospital and 205.1 more units of oral morphine equivalents at the time of discharge (P=.02 and P=.04, respectively) than non-English-speaking patients. When controlling for differences between groups and several factors that may influence oral morphine equivalent use, English-speaking patients received a median of 15.9 more units of oral morphine equivalents daily in the hospital cohort and similar oral morphine equivalents at the time of discharge compared with non-English-speaking patients. Patients who do not speak English may be at risk of undertreated pain in the immediate postoperative setting. Language barrier, frequency of pain assessments, and provider bias may perpetuate disparity in pain management. Based on this study's findings, we advocate for the use of regular verbal pain assessments with language-concordant staff or medical interpreters for all postoperative patients.

Perioperative pain optimization in the age of the opioid epidemic.

The opioid epidemic remains a constant and increasing threat to our society with overdoses and overdose deaths rising significantly during the COVID-19 pandemic. Growing evidence suggests a link between perioperative opioid use, postoperative opioid prescribing, and the development of opioid use disorder (OUD). As a result, strategies to better optimize pain management during the perioperative period are urgently needed. The purpose of this review is to summarize the most recent multimodal analgesia (MMA) recommendations, summarize evidence for efficacy surrounding the increased utilization of Enhanced Recovery After Surgery (ERAS) protocols, and discuss the implications for rising use of buprenorphine for OUD patients who present for surgery. In addition, this review will explore opportunities to expand our treatment of complex patients via transitional pain services. There is ample evidence to support the benefits of MMA. However, optimal drug combinations remain understudied, presenting a target area for future research. ERAS protocols provide a more systematic and targeted approach for implementing MMA. ERAS protocols also allow for a more comprehensive approach to perioperative pain management by necessitating the involvement of surgical specialists. Increasingly, OUD patients taking buprenorphine are presenting for surgery. Recent guidance from a multisociety OUD working group recommends that buprenorphine not be routinely discontinued or tapered perioperatively. Lastly, there is emerging evidence to justify the use of transitional pain services for more comprehensive treatment of complex patients, like those with chronic pain, preoperative opioid tolerance, or substance use disorder. Perioperative physicians must be aware of the impact of the opioid epidemic and explore methods like MMA techniques, ERAS protocols, and transitional pain services to improve the perioperative pain experience and decrease the risks of opioid-related harm.

Impact of pharmacogenomic profiles on post-surgical pain following laparotomy for gynecologic pathology

ObjectivesThe aim of this prospective study was to compare perioperative opioid use in women by status of CYP2D6, a highly polymorphic pharmacogene relevant to opioid metabolism. MethodsPatients undergoing laparotomy were prospectively recruited and provided a preoperative saliva swab for a pharmacogenomic (PGx) gene panel. Postoperative opioid usage and pain scores were evaluated via chart review and a phone survey. Pharmacogenes known to be relevant to opioid metabolism were genotyped, and opioid metabolizing activity predicted by CYP2D6 genotyping. Patient and procedural factors were compared using Fisher's exact and Kruskal-Wallis tests. ResultsThe 96 enrolled patients were classified as ultra-rapid (N = 3, 3%), normal (58, 60%), intermediate (27, 28%), and poor (8, 8%) opioid metabolizers. There was no difference in surgical complexity across CYP2D6 categories (p = 0.61). Morphine Milligram Equivalents (MME) consumed during the first 24 h after peri-operative suite exit were significantly different between groups: ultrarapid metabolizers had the highest median MME (75, IQR 45–88) compared to the other three groups (normal metabolizers 23 [8–45], intermediate metabolizers 48 [20–63], poor metabolizers 31 [12–53], p = 0.03). Opioid requirements were clinically greater in ultrarapid metabolizers during the second 24 h and last 24 h but were statistically similar (p = 0.07). There was no difference in MME prescribed at discharge (p = 0.22) or patient satisfaction with pain control (p = 0.64) between groups. ConclusionsA positive association existed between increased CYP2D6 activity and in-hospital opioid requirements, especially in the first 24 h after surgery. This provides important information to further individualize opioid prescriptions for patients undergoing laparotomy for gynecologic pathology.

Retrolaminar block for opioid-free anaesthesia and enhanced recovery after posterior lumbar discectomy: A randomised controlled study.

Intraoperative regional analgesia and enhanced recovery are standard care models aimed at reducing perioperative opioid use following spine surgeries. This study aimed to examine the analgesic effect of retrolaminar block in promoting recovery and pain relief after posterior lumbar discectomy. The patients undergoing elective posterior lumbar discectomy were randomised into the retrolaminar group (n = 36) (received an intra-operative bilateral retrolaminar block with 15 mL of bupivacaine 0.25%, 2 mL (8 mg) of dexamethasone, and 2 mL of magnesium sulphate 10% (200 mg) on each side) and control group (n = 36) (received standard general anaesthesia). Primary outcomes were recovery time (time from isoflurane discontinuation to the first response to verbal command) and time to discharge (time from admission to the post-anaesthesia care unit (PACU) to discharge from the PACU, when Aldrete score was ≥9). P values < 0.05 were considered statistically significant. The extubation, recovery, and discharge times were significantly shorter in the retrolaminar group compared to the control group (P < 0.001). Postoperative pain scores were significantly lower in the retrolaminar group for up to 8 h compared to only 2 h in the control group (P < 0.001). The time to first administration of ketorolac post-operatively was significantly longer in the retrolaminar group compared to the control group (P < 0.001). The total consumption of ketorolac post-operatively was significantly reduced in the retrolaminar group compared to the control group (P < 0.001). Intra-operative retrolaminar block is an easy and effective opioid-free regional anaesthesia technique that improves recovery after posterior lumbar discectomy.

Preventive analgesia with oral tramadol and pregabalin for post-operative pain in breast surgical patients

Background &amp; objective: Preventive analgesia is implied before the actual surgical insult occurs and it is aimed to reduce the neuro-humoral changes associated with surgical induced pain. Different methods have been used by the anesthesiologists for this purpose. We studied the effect of pre-emptive oral tramadol 50 mg and pregabalin 100 mg on post-operative pain, the requirement of rescue analgesics and the stay in post-anesthesia care unit (PACU) in breast cancer surgery patients. Methodology: A randomized double blinded, placebo-controlled trial, was conducted in the Department of Anesthesia, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore (Pakistan) after ethical approval by the hospital Scientific Review Committee and Institutional Review Board. Atotal of 30 patients, undergoing breast cancer surgery, were enrolled and randomly divided into two groups. Group A (study group) patients were given tramadol 50 mg and pregabalin 100 mg orally, and Group B (control group) received two soda mint tablets orally 30 min prior to induction of anesthesia. Standard monitoring was done and routine general anesthesia was administered with intubation. After recovery, Visual Analog Scale (VAS) scores and time to rescue analgesia, total morphine consumption, were recorded. Data was analyzed using SPSS v.20. P &lt; 0.05 was considered significant. Results: The mean ages in Group A and B were 36.67 ± 9.50 y and 41.80 ± 12.43 y (P = 0.236). The differences in intra-operative morphine and rescue morphine use in both groups were not significant (P = 0.139 and 0.293, The rescue analgesic use and VAS scores in PACU were significantly different in both groups (P = 0.005 and P = 0.022, respectively). Total PACU stay in Group A was 79.33 ± 26.31 min and in Group B was 96.67 ± 34.98 min (P = 0.281). Tramadol use in the ward was not statistically equivalent (P = 0.300). Mean post-operative rescue morphine was 0.2 ± 0.775 mg/kg in control group as compared to placebo group was 1.4 ± 1.682 mg/kg, which was statistically significant (P = 0.02). VAS scores in PACU in both groups showed statistically differences, e.g., 1.33 ± 1.1 vs 2.70 ± 1.60 (P = 0.01). PACU stay time was also higher in the control group. Conclusion: The use of pre-emptive analgesia with oral tramadol 50 mg and pregabalin 100 mg 30 min before the surgery can reduce the requirement of peri operative opioid use, achieve better pain control and early recovery. Abbreviations: BMI- Basal Metabolic Rate; PACU- Post-Anesthesia Care Unit; PONV- Postoperative Nausea and Vomiting; VAS- Visual Analog Scale Key words: Analgesia, Preventive; Cancer Surgery; Opioids; Post-Anesthesia Care Unit; Pregabalin; Tramadol Citation: Usman A, Mehdi SR, Khan AA. Preventive analgesia with oral tramadol and pregabalin for post-operative pain in breast surgical patients. Anaesth. pain intensive care 2024;28(1):81−84; DOI: 10.35975/apic.v28i1.2374 Received: November 17, 2021; Reviewed: September 24, 2022; Accepted: July 06, 2023

Operation-specific risk of postoperative nausea: a cross-sectional study comparing 72 procedures

ObjectivesDetermination of the procedure-specific, risk-adjusted probability of nausea.DesignCross-sectional analysis of clinical and patient-reported outcome data. We used a logistic regression model with type of operation, age, sex, preoperative opioids, antiemetic...

Intraoperative Opioid Waste and Association of Intraoperative Opioid Dose with Postoperative Adverse Outcomes: A Hospital Registry Study.

Perioperative opioid use has been associated with adverse clinical outcomes. Additionally, opioid disposal carries significant costs, due to the waste of pharmaceutical products and the time needed by skilled labor to report the waste. In this study, we aimed to estimate costs and predict factors of opioid-associated intraoperative product waste, as well as to evaluate whether higher intraoperative opioid doses are associated with increased risk of adverse postoperative outcomes. We included 170,607 patients undergoing general anesthesia and receiving intraoperative fentanyl, hydromorphone, or morphine at Beth Israel Deaconess Medical Center, Boston, MA, USA, between January 2010 and June 2020. We estimated product waste-associated costs based on various opioid syringe sizes and determined predictors of opioid waste. Further, we evaluated whether higher opioid doses were associated with postoperative adverse events according to the severity-indexed, incident report-based medication error-reporting program classification. The primary outcome included post-extubation desaturation, postoperative nausea or vomiting, or postoperative somnolence or sedation. The use of the smallest syringe sizes (50 mcg for fentanyl, 0.2mg for hydromorphone, and 2mg for morphine) resulted in the lowest product waste-associated costs. The main predictor of opioid waste was the administration of more than one intraoperative opioid (adjusted odds ratio [aOR] = 7.64, 95% CI 7.40-7.89, P < 0.001). Intraoperative doses of fentanyl > 50-100 mcg (aOR = 1.17 [1.10-1.25], P < 0.001, adjusted risk difference [ARD] 2%) and > 100 mcg (aOR = 1.24 [1.16-1.33], P < 0.001, ARD 3%), hydromorphone > 1mg (aOR = 1.13 [1.06-1.20], P < 0.001, ARD 2%), and morphine > 2-4mg (aOR = 1.26 [1.02-1.56], P = 0.04, ARD 3%) and > 4mg (aOR = 1.45 [1.18-1.77], P < 0.001, ARD 5%) were associated with higher risk of the primary outcome. Smaller syringe sizes of intraoperative opioids may help to reduce product waste and associated costs, as well postoperative adverse events through utilization of lower intraoperative opioid doses.

Twelfth thoracic vertebra erector spinae plane block for postoperative analgesia and early recovery after lumbar spine surgery in elderly patients: a single-blind randomized controlled trial

BackgroundSevere pain after lumbar spine surgery can delay recovery in elderly patients. We explored the efficacy of T12 erector spinal plane block (ESPB) in elderly patients who underwent lumbar spine surgery.MethodsA total of 230 patients undergoing lumbar spine surgery were divided and randomly allocated to ultrasound-guided ESPB (n = 115) and control (n = 115) groups. The ESPB group received 20 mL of 0.4% ropivacaine bilaterally at the T12 level after intubation, whereas the control group did not receive a block. The primary outcome was the numeric rating scale (NRS) score at 12 h after surgery. Secondary outcomes included the NRS score and tramadol use within 72 h postoperatively, intraoperative remifentanil use, incidence of postoperative delirium (POD), complications of ESPB, ambulation time, and length of hospitalization after surgery.ResultsThe12-hour NRS (median (IQR)) score was remarkably lower in the ESPB group than in the control group (2 (1–3) vs. 3 (2–4), p = 0.004), as well as NRS score within 48 h (P < 0.01). The ESPB group had less intraoperative remifentanil use (P < 0.001), and less tramadol use within 72 h postoperatively (P < 0.001). Seven patients (6.7%) developed POD in the ESPB group and ten patients (9.3%) in the control group, without any statistically significant difference (P > 0.05). The ambulation time and length of hospitalization after surgery were shorter in the ESPB group than in the control group (P < 0.05). No ESPB-related complications were observed.ConclusionsBilateral T12 ESPB lowered the NRS score within 48 h after lumbar spine surgery, decreased perioperative opioid use and resulted in faster recovery in elderly patients but did not significantly reduce the incidence of POD.Trial registrationThe study was retrospectively registered at www.chictr.org.cn (ChiCTR2100042037) on January 12, 2021.