Postoperative Opioids Research Articles

Opioid Usage After Hallux Valgus Correction Surgery.

Given the lack of objective data on opioid use and the difficulty of addressing a patient's postoperative pain, we sought to quantify patient's narcotic use after hallux valgus surgery. The purpose of our study was to determine the average quantity and type of postoperative opioids consumed after hallux valgus surgery and to assess potential predictive factors for increased opioid consumption. At the preoperative visit, patients were consented and completed a demographical questionnaire. Data were collected from the operative record, 2, 6, and 12-week postoperative visits. Type and number of pills prescribed were recorded as well as number of pills consumed at each postoperative visit. A logistic regression was performed to determine the average quantity consumed postoperatively and any statistically significant correlations. The average number of opioid pills collectively consumed at the 2-week and 12-week postoperative visit was 20 and 23, respectively. At the 2-week postoperative visit, only patient body mass index (BMI) showed a correlation with increased opioid use. Patients consumed an average of 23 of 40 (57.5%) narcotic pain pills prescribed after hallux valgus reconstruction surgery through the 12-week postoperative period. Owing to the opioid epidemic and potential for narcotic diversion, surgeons should counsel their patients on proper nonopioid postoperative pain management. II Therapeutic.

MP54-15 ASSOCIATION BETWEEN PRE-OPERATIVE OPIOID EXPOSURE AND POST-OPERATIVE OPIOID PRESCRIBING PATTERNS FOLLOWING MAJOR CANCER SURGERY

You have accessJournal of UrologyCME1 Apr 2023MP54-15 ASSOCIATION BETWEEN PRE-OPERATIVE OPIOID EXPOSURE AND POST-OPERATIVE OPIOID PRESCRIBING PATTERNS FOLLOWING MAJOR CANCER SURGERY Emily Serrell, Jessica Schumacher, Manasa Venkatesh, Randi Cartmill, Robert Tyllo, Daniel Shapiro, Kyle Richards, E. Jason Abel, David Jarrard, and Tudor Borza Emily SerrellEmily Serrell More articles by this author , Jessica SchumacherJessica Schumacher More articles by this author , Manasa VenkateshManasa Venkatesh More articles by this author , Randi CartmillRandi Cartmill More articles by this author , Robert TylloRobert Tyllo More articles by this author , Daniel ShapiroDaniel Shapiro More articles by this author , Kyle RichardsKyle Richards More articles by this author , E. Jason AbelE. Jason Abel More articles by this author , David JarrardDavid Jarrard More articles by this author , and Tudor BorzaTudor Borza More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003307.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Most post-operative opioid prescribing guidelines are restricted to opioid naïve populations due to a dearth of data regarding pre-operative opioid use. We aim to quantify pre- and post-operative opioid prescribing patterns among patients undergoing a major cancer surgery and measure the association between pre-operative opioid exposure and post-operative prescribing. METHODS: We used the Wisconsin Health Information Organization database, which includes commercial-payer, Medicare Advantage and Medicaid claims and captures over 75% of Wisconsin’s population. We collected demographic data on adult patients undergoing radical prostatectomy and partial or radical nephrectomy between 1/1/2017 and 12/31/2021. We evaluated pre- and post-operative opioid prescriptions, quantified opioid exposure in morphine milligram equivalents (MME), and compared prescribing characteristics between opioid naïve and opioid exposed patients (defined as those with a filled prescription in 6 months before surgery). RESULTS: We identified 3,693 patients (2,306 prostatectomy; 1,387 partial or radical nephrectomy). 23% of patients were exposed to opioids prior to surgery (18% prostatectomy, 30% nephrectomy). The median pre-operative dose was 202 MME (IQR 100-600), and fills occurred at a median time of 42 days (IQR 18-91), with increasing frequency in the weeks prior to surgery (Figure 1). After surgery, 55% of patients filled an initial opioid prescription, with a median first dose of 171 MME (IQR 100-334), equivalent to 23 oxycodone 5mg tablets. Opioid exposed patients had a significantly higher two-week post-operative dose (238 vs 142 MME, p<0.001) and number of prescriptions filled (1.46 vs 1.23, p<0.001). CONCLUSIONS: Nearly one quarter of prostatectomy and partial or radical nephrectomy patients are exposed to opioids prior to surgery. Post-operative prescribing remains at levels twice the guideline recommendations for all patients, even higher in patients with prior exposure. Understanding the implications of prior opioid exposure on the management of postoperative pain and opioid use is imperative to inform real-world care and guideline recommendations. Source of Funding: AHRQ K08HS028474 award © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e759 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Emily Serrell More articles by this author Jessica Schumacher More articles by this author Manasa Venkatesh More articles by this author Randi Cartmill More articles by this author Robert Tyllo More articles by this author Daniel Shapiro More articles by this author Kyle Richards More articles by this author E. Jason Abel More articles by this author David Jarrard More articles by this author Tudor Borza More articles by this author Expand All Advertisement PDF downloadLoading ...

PD07-01 PRACTICE-LEVEL VARIATION IN OPIOID-FREE DISCHARGE FOLLOWING SURGERY FOR T1 RENAL MASSES: A MUSIC-KIDNEY ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023PD07-01 PRACTICE-LEVEL VARIATION IN OPIOID-FREE DISCHARGE FOLLOWING SURGERY FOR T1 RENAL MASSES: A MUSIC-KIDNEY ANALYSIS Samantha Wilder, Ji Qi, Mahin Mirza, Adam Gadzinski, Thomas Maatman, Brian Lane, Craig Rogers, and for the Michigan Urological Surgery Improvement Collaborative Samantha WilderSamantha Wilder More articles by this author , Ji QiJi Qi More articles by this author , Mahin MirzaMahin Mirza More articles by this author , Adam GadzinskiAdam Gadzinski More articles by this author , Thomas MaatmanThomas Maatman More articles by this author , Brian LaneBrian Lane More articles by this author , Craig RogersCraig Rogers More articles by this author , and for the Michigan Urological Surgery Improvement Collaborative for the Michigan Urological Surgery Improvement Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003231.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The prescription of opioids following surgery has played a role in the current opioid epidemic, both by increasing the risk of persistent opioid use and through diversion of unused pills into the community. We evaluated practice-level variation in opioid prescribing following surgery for cT1 renal masses (T1RM) and examined the relationships between opioid-free discharge and postoperative emergency department (ED) visits and readmissions. METHODS: We retrospectively examined all T1RM patients with data regarding prescription of postoperative opioids within the MUSIC-KIDNEY registry from April 2021 to August 2022. Patients were stratified into those who received opioids at discharge and those who had opioid-free discharge, and associations with patient, tumor, and surgical factors were evaluated. Practice-level variation was assessed. Rates of postoperative ED visits and readmissions within 30 days were compared between cohorts. RESULTS: Of 248 patients who underwent surgery for T1RM across 11 practices in MUSIC-KIDNEY, 24.2% underwent opioid-free discharge. Practice level variation in rates of opioid-free discharge ranged from 0% to 72.7% (Figure 1). For patients prescribed opioids, the median number of pills was 12 (IQR 8-12). Patients prescribed opioids at discharge had a higher median BMI than those with opioid-free discharge (31.7 vs 28.7, p=0.003). Other patient comorbidities, tumor factors, surgical approach (minimally invasive vs. open), and surgery type (partial vs. radical nephrectomy) did not differ between cohorts (p>0.05). The opioid-free group had at least comparable rates of 30 day ED visits (0% vs. 3.2%) and readmission (1.7% vs. 5.3%), although this did not reach statistical significance (P>0.05). CONCLUSIONS: MUSIC-KIDNEY data suggests that opioid-free discharge is not associated with increased rates of postoperative ED visits or readmissions. There exists wide practice-level variation in the prescription of opioids following surgery for T1RM in the state of Michigan. Further investigation into additional factors driving this variation is warranted. There is potential to learn from practices that are safely limiting the number of pills entering the community, and future QI initiatives may focus on this metric. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e161 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Samantha Wilder More articles by this author Ji Qi More articles by this author Mahin Mirza More articles by this author Adam Gadzinski More articles by this author Thomas Maatman More articles by this author Brian Lane More articles by this author Craig Rogers More articles by this author for the Michigan Urological Surgery Improvement Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

MP18-09 LIPOSOMAL BUPIVACAINE PLUS BUPIVACAINE VS. BUPIVACAINE ALONE IN PEDIATRIC PATIENTS UNDERGOING UROLOGIC SURGERY: PRELIMINARY REPORT FROM THE BABY ORIOLES TRIAL

You have accessJournal of UrologyCME1 Apr 2023MP18-09 LIPOSOMAL BUPIVACAINE PLUS BUPIVACAINE VS. BUPIVACAINE ALONE IN PEDIATRIC PATIENTS UNDERGOING UROLOGIC SURGERY: PRELIMINARY REPORT FROM THE BABY ORIOLES TRIAL Andrew Gabrielson, Tamir Sholklapper, Chad Crigger, Logan Galansky, Kelly Harris, Hiten PATEL, Nora Haney, Ming-Hsien Wang, Charlotte Wu, John Gearhart, and Heather Di Carlo Andrew GabrielsonAndrew Gabrielson More articles by this author , Tamir SholklapperTamir Sholklapper More articles by this author , Chad CriggerChad Crigger More articles by this author , Logan GalanskyLogan Galansky More articles by this author , Kelly HarrisKelly Harris More articles by this author , Hiten PATELHiten PATEL More articles by this author , Nora HaneyNora Haney More articles by this author , Ming-Hsien WangMing-Hsien Wang More articles by this author , Charlotte WuCharlotte Wu More articles by this author , John GearhartJohn Gearhart More articles by this author , and Heather Di CarloHeather Di Carlo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003238.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Long-acting liposomal bupivacaine (Exparel) was approved for children >6 years old however it has not been evaluated in children undergoing urologic surgery. We report preliminary safety and efficacy data of Exparel plus bupivacaine vs. bupivacaine alone for incisional infiltration or penile block in pediatric patients undergoing ambulatory urologic surgery as part of a randomized trial. METHODS: The study is an IRB-approved prospective, single-blinded trial randomizing patients 6-18 years old 1:1 to receive Exparel plus 0.25% bupivacaine (experimental) vs. 0.25% bupivacaine alone (control) during ambulatory urology procedures (NCT04826484). Patients received Tylenol and Ibuprofen prescriptions and a rescue prescription of 3-5 doses 0.1 mg/kg Oxycodone. Efficacy endpoints include percent requiring no opioids within 48hr and 10-14d, parents’ postoperative pain measure (PPPM) scores at 48hr and 10-14d, and oral morphine equivalents (OMEQ) per kg given through 10-14d. RESULTS: A total of 52 patients (29 control, 23 experimental) have been enrolled. Demographic, procedural, efficacy, and safety data are summarized in Table 1. There was no difference in percentage of patients requiring no post-operative opioids through 48hr (57% vs 55%, p=0.92). There was no difference in mean FLACC score in PACU (0.9 vs 1.2, p=0.64), PPPM score at 48hr (2.5 vs. 3.5, p=0.09) or PPPM score at 10-14d (0.55 vs. 0.6, p=0.67). The experimental arm had significantly reduced OMEQ/kg at 10-14d (0.06 vs. 0.2, p=0.02). However, OMEQ/kg utilization was low and limited to the 48hr post-op period in both arms. There were no intraoperative complications and similar use of perioperative Ketorlac between arms. Roughly 10% of patients in both arms had an unplanned phone call or message to the office (all related to swelling). No patients had unplanned presentation to the emergency department. CONCLUSIONS: This prospective, single-blinded randomized trial is the first to evaluate Exparel in pediatric patients undergoing urologic surgery. We demonstrate that albeit safe, the addition of Exparel to 0.25% bupivacaine did not improve validated pain scores or opioid-free rate at 48 hours. Formal assessment of efficacy and safety pending trial accrual. Source of Funding: Internally funded © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e226 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Gabrielson More articles by this author Tamir Sholklapper More articles by this author Chad Crigger More articles by this author Logan Galansky More articles by this author Kelly Harris More articles by this author Hiten PATEL More articles by this author Nora Haney More articles by this author Ming-Hsien Wang More articles by this author Charlotte Wu More articles by this author John Gearhart More articles by this author Heather Di Carlo More articles by this author Expand All Advertisement PDF downloadLoading ...

MP53-05 RISK OF ACUTE KIDNEY INJURY AFTER LOWER URINARY TRACT RECONSTRUCTION WITH EARLY NSAID THERAPY: A PROPENSITY MATCHED RETROSPECTIVE ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP53-05 RISK OF ACUTE KIDNEY INJURY AFTER LOWER URINARY TRACT RECONSTRUCTION WITH EARLY NSAID THERAPY: A PROPENSITY MATCHED RETROSPECTIVE ANALYSIS Darren Ha, Eliza D. Blanchette, Duncan T. Wilcox, Vijaya M. Vemulakonda, Daniel N. Wood, and Kyle O. Rove Darren HaDarren Ha More articles by this author , Eliza D. BlanchetteEliza D. Blanchette More articles by this author , Duncan T. WilcoxDuncan T. Wilcox More articles by this author , Vijaya M. VemulakondaVijaya M. Vemulakonda More articles by this author , Daniel N. WoodDaniel N. Wood More articles by this author , and Kyle O. RoveKyle O. Rove More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003301.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Response to the opioid epidemic led to increased use of postoperative, non-opioid analgesia. Some pediatric urologists do not routinely use NSAIDs for fear of causing acute kidney injury (AKI). While previous studies have demonstrated the safety and efficacy of NSAIDs in children, safety after lower urinary tract reconstruction has not been well characterized. Using the Kidney Disease Improving Global Outcomes (KDIGO) criteria for AKI (increase in creatinine ≥0.3 mg/dL or increase in creatinine ≥1.5× baseline or urine output <0.5 mL/kg/hr for 6 hours), we hypothesized there would be a difference in incidence of postoperative AKI between patients who did and did not receive NSAIDs after these operations. METHODS: Patients 2–18 years old who underwent lower urinary tract reconstruction (i.e., bladder augmentation and/or creation of a catheterizable channel) from 2009 to 2021 and had documented urine were reviewed. CKD and stage were calculated from creatinine and cystatin C within 6 months of surgery using the CKiD U25 equations. Patients who received NSAIDs were propensity matched on 19 characteristics in a 2:1 ratio with patients undergoing similar surgeries who did not receive NSAIDs in the operating room or in the first 6 hours postoperatively. The primary outcome was incidence of AKI during 48 hours after surgery. RESULTS: The unmatched cohorts included 260 patients. After propensity matching, there were no meaningful differences in most characteristics among 118 in the NSAID arm and 59 in the no NSAID arm. 54 CKD and 4 renal transplant patients were included. There was no difference in the incidence of postoperative AKI based on any KDIGO criteria (18.6% no NSAID vs 15.3% NSAID, p=0.71). Median postoperative opioids fell from 0.75 mg/kg in the no NSAID arm to 0.30 mg/kg morphine equivalents in the NSAID arm (p=0.02). Log-rank testing by Kaplan-Meier analysis demonstrated no difference in time to incidence of low urine output between the groups (p=0.38). In the whole population not stratified by NSAID use, no differences were seen in AKI between those with and without CKD (16.6% vs 16.4%). CONCLUSIONS: There was no difference in the incidence of postoperative AKI among patients who did and did not receive NSAIDs after lower urinary tract reconstruction. These results support that postoperative NSAIDs were an unlikely source of AKI and result in lower opioid usage, but also indicate a proportion of patients undergoing these operations may be susceptible to AKI, likely owing to underlying disease, longer operations, and fluid shifts. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e713 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Darren Ha More articles by this author Eliza D. Blanchette More articles by this author Duncan T. Wilcox More articles by this author Vijaya M. Vemulakonda More articles by this author Daniel N. Wood More articles by this author Kyle O. Rove More articles by this author Expand All Advertisement PDF downloadLoading ...

Higher Pain Catastrophizing and Preoperative Pain is Associated with Increased Risk for Prolonged Postoperative Opioid Use

BACKGROUND: Prolonged postoperative opioid use (PPOU) is considered an unfavorable post-surgical outcome. Demographic, clinical, and psychosocial factors have been associated with PPOU, but methods to prospectively identify patients at increased risk are lacking. OBJECTIVES: Our objective was to determine whether an individual or a combination of several psychological factors could identify a subset of patients at increased risk for PPOU. STUDY DESIGN: Observational cohort study with prospective baseline data collection and passive outcomes data collection. SETTING: A single VA medical center in the United States. METHODS: Patients were recruited from a preoperative anesthesia clinic where they were undergoing evaluation prior to elective surgery, and they completed a survey before surgery. The primary outcome was PPOU, defined as outpatient receipt of a prescribed opioid 31 to 90 days after surgery as determined from pharmacy records. Primary covariates of interest were pain catastrophizing, self-efficacy, and optimism. Additional covariates included social and demographic factors, pain severity, medication use, depression, anxiety, and surgical fear. RESULTS: Of 123 patients included in the final analyses, 30 (24.4%) had PPOU. In bivariate analyses, preoperative opioid use and preoperative nonsteroidal anti-inflammatory drug use were significantly associated with PPOU. The combination of high pain catastrophizing and high preoperative pain (OR 3.32, 95% CI 1.41 - 7.79) was associated with higher odds of PPOU than either alone, and the association remained significant after adjusting for preoperative opioid use (OR 2.56, 95% CI 1.04 - 6.29). LIMITATIONS: Patients were recruited from a single site, and the sample was not large enough to include potentially important variables such as procedure type. CONCLUSIONS: A combination of high pain catastrophizing and high preoperative pain has the potential to be a clinically useful means of identifying patients at elevated risk of PPOU. KEY WORDS: Postoperative pain, postoperative opioids, opioid prescribing, preoperative evaluation, pain catastrophizing

Multimodal evaluation of locoregional anaesthesia efficacy on postoperative pain after robotic pulmonary lobectomy for NSCLC: a pilot study.

The primary objectives of the study were to analyse the robotic approach and ultrasound-guided paravertebral block compared to thoracoscopic intercostal nerve block after robotic pulmonary lobectomy on postoperative pain and opioids use. The secondary objectives were to analyse and compare patients' necessity of additional antalgic drugs and patients' performance during respiratory therapy, following robotic surgery and in the two groups. Consecutively, 52 patients undergoing robotic pulmonary lobectomies were treated either with ropivacaine-based intercostal nerve block or paravertebral block from February 2022 to October 2022. When necessary, morphine was administered at day 1. Acetaminophen was administered as an additional antalgic drug on demand up to 3 g per day. Pain was measured 1 h after the end of the surgical procedure and daily through the pain numeric rating scale (NRS). Morphine administration rate and per day and total additional administrations of acetaminophen were recorded. Pain and opioids administration was measured 1 month after the procedure. Data were analysed in the overall population and in the intercostal nerve block group VS paravertebral block group. Overall, 34.6% of the patients required morphine administration and 51.7% of the patients required at least daily acetaminophen administration up to discharge. At 1 month postoperatively, four patients presented with chronic pain and one still was under opioid medication. At intergroup analysis, the paravertebral block group demonstrated lower NRS at fixed time points (p < 0.0001) and lower morphine consumption (45.7%VS11.8%; p = 0.02). Acetaminophen rescue administration at fixed time points was lower in the paravertebral block group (p < 0.0001) and mobility and dynamic pain resulted in better results (p = 0.03; p = 0.04). At 1 month, no differences were found between study groups. Similarly to other minimally invasive techniques, postoperative pain may arise after robotic pulmonary lobectomy. Paravertebral bloc can help to reduce postoperative pain as well as morphine and antalgic drugs administration and improve early mobilization.

Post-traumatic Stress Disorder as an Independent Risk Factor for Increased Opioid Use Following Carpal Tunnel Surgery.

Carpal tunnel release (CTR) is one of the most common hand surgeries. Studies have highlighted a mental-physical connection to hand pathologies and psychological connections to postoperative pain burden. Post-traumatic stress disorder (PTSD) has been identified as a medical-psychological comorbidity like other mental health disorders such as generalized anxiety disorder (GAD). There remains a gap in the literature regarding PTSD as a comorbidity for hand surgeries, where there is this mental-physical connection. We hypothesize PTSD will be associated with increased risk of postoperative pain, evidenced by greater prevalence of opioid usage. The authors performed a retrospective analysis using the TriNetX Research Database. Patients who underwent elective CTR were identified within the database. Two groups were created and compared against individual controls: the first was identified based on the diagnosis of PTSD, and the second was identified based on the diagnosis of GAD. Cohorts were matched and opioid usage was compared postoperatively. Patients with PTSD who underwent CTR were found to be at significantly increased risk of postoperative opioid use (P = .033) and more likely to present to the emergency department (ED) (P = .001). Patients with GAD were found to be significantly less likely to require postoperative opioids (P = .040). We found patients with PTSD to be at increased risk of opioid use and more likely to present to ED following CTR. Patients with GAD were found to be at decreased risk of opioid use after CTR. Owing to the independent significant risks not found in GAD, further research of postoperative pain in patients with PTSD is needed.

Implementation of an opioid reduction toolkit in pancreatectomy patients significantly increases patient awareness of safe practice and decreases amount prescribed and consumed

BackgroundPostoperative opioid abuse following surgery is a major concern. This study sought to create an opioid reduction toolkit to reduce the number of narcotics prescribed and consumed while increasing awareness of safe disposal in pancreatectomy patients. MethodsPrescription, consumption, and refill request data for postoperative opioids were collected from patients receiving an open pancreatectomy before and after the implementation of an opioid reduction toolkit. Outcomes included safe disposal practice awareness for unused medication. Results159 patients were included in the study: 24 in the pre-intervention and 135 in the post-intervention group. No significant demographic or clinical differences existed between groups. Median morphine milliequivalents (MMEs) prescribed were significantly reduced from 225 (225–310) to 75 (75–113) in the post-intervention group (p < 0.0001). Median MMEs consumed were significantly reduced from 109 (111–207) to 15 (0–75), p < 0.0001), as well. Refill request rates remained equivalent during the study (Pre: 17% v Post: 13%, p = 0.9) while patient awareness of safe disposal increased (Pre: 25% v Post: 62%, p < 0.0001). DiscussionAn opioid reduction toolkit significantly reduced the number of postoperative opioids prescribed and consumed after open pancreatectomy, while refill request rates remained the same and patients’ awareness of safe disposal increased.

Evaluation of the effect of dexmedetomidine versus magnesium sulphate as an adjuvant to bupivacaine in ultrasound guided erector spinae block; a prospective randomized trial

Background &amp; Objectives: Since the introduction of erector spinae plane block (ESPB) in 2016 it has been used with success in various thoracic, abdominal, and spine surgeries. Spine surgeries result in significant postoperative pain. Postoperative opioids provide adequate pain control in most of the cases, but some patients continue to suffer from uncontrolled pain. Patients receiving multiple doses of opioids suffer from various side effects including postoperative nausea and vomiting, constipation, and delayed ambulation. We aimed to compare effect of dexmedetomidine and magnesium sulfate given as adjuvants with bupivacaine 0.25% for ESPB.&#x0D; Methodology: It was a prospective randomized single-blinded study including 52 patients divided into 2 groups; one receiving ESPB with a combination of bupivacaine 0.25% plus magnesium sulfate and the other receiving the same block with a combination of bupivacaine 0.25% plus dexmedetomidine.&#x0D; Results: The group receiving bupivacaine and dexmedetomidine had a prolonged postoperative analgesia duration as well as a decreased total opioid consumption (P &lt; 0.05) compared to group receiving bupivacaine 0.25% plus magnesium sulfate, but had a significant decrease in intraoperative pulse rate and blood pressure compared to the group receiving bupivacaine 0.25% plus magnesium sulfate (P &lt; 0.05).&#x0D; Conclusion: Although dexmedetomidine results in prolonged postoperative analgesia duration compared to magnesium sulfate when combined with bupivacaine 0.25% in ESPB, its negative effects on hemodynamics should be considered.&#x0D; Trial registration: This trial was registered on clinicaltrials.gov registry (NCT05694897) on 23/1/2023.&#x0D; Abbreviations: ASA: American Society of Anesthesiologist; ESPB: Erector Spinae Block; ERAS: Enhanced recovery After Surgery; SPSS: Statistical Package for Social Sciences; VAS: Visual Analog Score&#x0D; Key words: Erector Spinae Plane Block; Dexmedetomidine; Bupivacaine; Visual Analog Scale&#x0D; Citation: Refaat SA, Abdelmageed WM, Alwedeny HM, Soliman EH, Fouly MA. A randomized comparative trial of ultrasound guided erector spinae block with bupivacaine-magnesium sulphate vs. bupivacaine-dexmedetomidine for lumbar spine surgeries. Anaesth. pain intensive care 2023;27(5):425−430; DOI: 10.35975/apic.v27i5.2292&#x0D; Received: July 15, 2023; Reviewed: August 16, 2023; Accepted: August 16, 2023

Decreased Length of Stay and Opioid Usage After Liver Cancer Surgery With Enhanced Recovery Pathway Implementation.

Enhanced recovery after surgery (ERAS) pathways are associated with better postoperative recovery; however, evidence is lacking in liver cancer surgery. This study aimed to evaluate the impact of an ERAS pathway in US veterans undergoing liver cancer surgery. We initiated an ERAS pathway for liver cancer surgery with preoperative, intraoperative, and postoperative interventions, which included a novel regional anesthesia technique, erector spinae plane block, for multimodal analgesia management. A retrospective quality improvement study was conducted with patients undergoing elective open hepatectomy or microwave ablation of liver tumors before and after ERAS pathway implementation. With 24 patients in the post-ERAS group and 23 patients in the pre-ERAS group, we found a significant decreased length of stay in the ERAS group (4.1 days ± 3.9) compared with traditional care (8.6 days ± 7.1, P = .01) and decreased perioperative opioid consumption including intraoperative opioids (post-ERAS 49.8 mg ± 28.5 vs pre-ERAS 98 mg ± 42.3, P = 4.1E-5), postoperative opioids (post-ERAS 65.3 mg ± 59.9 vs pre-ERAS 175.7 mg ± 210.6, P = .018), and patient-controlled analgesia requirements (post-ERAS 0% vs pre-ERAS 50%, P < .001). The implementation of ERAS for liver cancer surgery in our veteran population translates into decreased length of stay and perioperative opioid consumption. Although this study is limited as a quality improvement project implemented at one institution with a small sample size, our results are clinically and statistically significant and sufficient to warrant further investigation into the efficacy of ERAS as the surgical needs of the US veteran population increase.

The effect of ultrasound-guided erector spinae plane block combined with dexmedetomidine for postoperative pain management in lumbar spine surgery: A case-based discussion

BackgroundUltrasound-guided erector spinae plane blocks (US-ESPB) can be valid resources of simple and safe execution in a multimodal approach to postoperative pain management in lumbar spine surgery. It has been shown that the use of multimodal anesthesia reduces the use of intraoperative and postoperative opioids, and also improves analgesia. A growing body of evidence supports that the adjuvant use of dexmedetomidine in locoregional anesthesia significantly prolongs the analgesia and potentiates the effect of the block, without clinically significant side effects.Case presentationA series of six consecutive patients received bilateral ultrasound-guided erector spinae plane blocks with local anesthetics and dexmedetomidine as part of a multimodal analgesic therapy after lumbar spine surgery. Treatment adequacy was evaluated using numerical rating scale (NRS) and overall benefit of analgesic score (OBAS); overall the observed results were satisfactory for all patients.ConclusionBilateral US-ESPB appears to be helpful in providing adequate postoperative analgesia after lumbar spine surgery. It is simple and safe, and so it is unique when compared to other blockages. The addition of Dexmedetomidine as an adjuvant seems to improve analgesic effectiveness and durability.

Opioid prescriptions after knee replacement: a retrospective study of pathways and prognostic factors in the Swiss healthcare setting

ObjectivesThe optimal use of opioids after knee replacement (KR) remains to be determined, given the growing evidence that opioids are no more effective than other analgesics and that their adverse...

Ureteral Stent Placement Prior to Definitive Stone Treatment Is Associated With Higher Postoperative Emergency Department Visits and Opioid Prescriptions for Youth Having Ureteroscopy or Shock Wave Lithotripsy.

Little is known about the impact of ureteral stents on youth having stone surgery. We evaluated the association of ureteral stent placement before or concurrent with ureteroscopy and shock wave lithotripsy with emergency department visits and opioid prescriptions among pediatric patients. We conducted a retrospective cohort study of individuals aged 0-24 years who underwent ureteroscopy or shock wave lithotripsy from 2009-2021 at 6 hospitals in PEDSnet, a research network that aggregates electronic health record data from children's health systems in the United States. The exposure, primary ureteral stent placement, was defined as a stent placed concurrent with or within 60 days before ureteroscopy or shock wave lithotripsy. Associations between primary stent placement and stone-related ED visits and opioid prescriptions within 120 days of the index procedure were evaluated with mixed-effects Poisson regression. Two-thousand ninety-three patients (60% female; median age 15 years, IQR 11-17) had 2,477 surgical episodes; 2,144 were ureteroscopy and 333 were shock wave lithotripsy. Primary stents were placed in 1,698 (79%) ureteroscopy episodes and 33 (10%) shock wave lithotripsy episodes. Ureteral stents were associated with a 33% higher rate of emergency department visits (IRR 1.33; 95% CI 1.02-1.73) and a 30% higher rate of opioid prescriptions (IRR 1.30; 95% CI 1.10-1.53). The magnitudes of both associations were greater for shock wave lithotripsy. Results were similar for age <18 and were lost when restricted to concurrent stent placement. Primary ureteral stent placement was associated with more frequent emergency department visits and opioid prescriptions, driven by pre-stenting. These results support elucidating situations where stents are not necessary for youth with nephrolithiasis.

Bones, groans and sending patients home: Perioperative opioid-related harm reduction strategy utilisation in a regional New South Wales (NSW) hospital.

Perioperative initiation of opioids continues to be a major contributor to chronic use, misuse and diversion in regional areas. There is considerable effort to mitigate harm through avoiding excessive prescribing and reducing the risk of persistent postoperative opioid use. Improving perioperative documentation practices has been reported to ensure appropriate opioid initiation and de-escalation. It has not been established whether these strategies are utilised in regional hospitals. A retrospective observational study of perioperative opioid prescribing and documentation practices in Goulburn Base Hospital, a regional centre in the Southern New South Wales (NSW) Local Health District. Data were collected from 110 records and validated for adult patients undergoing elective total knee replacement (TKR) or total hip replacement (THR) from 12 January 2020 to 13 January 2021. To observe perioperative opioid prescribing and utilisation of harm reduction strategies in a regional hospital. 65% of patients were opioid naïve (ON). Preoperative pain assessments and patient education were completed in 23% and 15% of records, respectively. Postoperative opioids were prescribed for 99% of patients, with 74% prescribed a slow-release (SR) formulation. 50% of patients were discharged with an SR prescription. Inadequate postoperative pain control was reported in 21% of patients. Of the 103 patients prescribed opioids on discharge, only 20% included a de-escalation plan and only 35% of discharge summaries included dose and quantity of opioids supplies. This study has identified underutilisation of perioperative harm reduction strategies despite the potential to improve appropriate initiation and de-escalation of opioids. These findings highlight opportunities for improvement in regional hospitals.

Postoperative opioid prescription and patient-reported outcomes after elective spine surgery: a Michigan Spine Surgery Improvement Collaborative study.

This study was designed to assess how postoperative opioid prescription dosage could affect patient-reported outcomes after elective spine surgery. Patients enrolled in the Michigan Spine Surgery Improvement Collaborative (MSSIC) from January 2020 to September 2021 were included in this study. Opioid prescriptions at discharge were converted to total morphine milligram equivalents (MME). A reference value of 225 MME per week was used as a cutoff. Patients were divided into two cohorts based on prescribed total MME: ≤ 225 MME and > 225 MME. Primary outcomes included patient satisfaction, return to work status after surgery, and whether improvement of the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System 4-question short form for physical function (PROMIS PF) and EQ-5D was met. Generalized estimated equations were used for multivariate analysis. Regression analysis revealed that patients who had postoperative opioids prescribed with > 225 MME were less likely to be satisfied with surgery (adjusted OR [aOR] 0.81) and achieve PROMIS PF MCID (aOR 0.88). They were also more likely to be opioid dependent at 90 days after elective spine surgery (aOR 1.56). The opioid epidemic is a serious threat to national public health, and spine surgeons must practice conscientious postoperative opioid prescribing to achieve adequate pain control. The authors' analysis illustrates that a postoperative opioid prescription of 225 MME or less is associated with improved patient satisfaction, greater improvement in physical function, and decreased opioid dependence compared with those who had > 225 MME prescribed.

The pregabalin effect on opioid consumption and postoperative pain in spinal fusion surgery, a prospective, randomized, controlled study

ABSTRACT Background and Aim Surgical trauma is known to cause peripheral and central sensitization and hyperalgesia, which if untreated can cause chronic postoperative pain after surgery. The current work was conducted to evaluate the effect of preoperative pregabalin 150 mg orally on opioid consumption and acute postoperative pain in spinal fusion surgery. Methods Over one-year duration between 2020 and 2021, the current study was conducted. Ninety patients who were scheduled for spinal fusion surgeries (single and double levels) were recruited and randomly subdivided into two equal groups who received either pregabalin or placebo. The primary outcome was the overall amount of consumed morphine in the first 24 hours postoperatively. Secondary outcomes included VAS score at 1 hour, 2 hours, 4 hours and 24 hours postoperative, time to first rescue analgesia and vital signs including heart rate and mean arterial blood pressure intra- and postoperatively. Results The overall amount of morphine consumed in the first 24 hours postoperatively was significantly lower in the pregabalin group than the placebo group (P < 0.001). Pregabalin group had significantly longer time to rescue analgesia than placebo group (P < 0.001). Additionally, within the first postoperative 24 hours, VAS was significantly lower (P < 0.05) in the pregabalin group than in the placebo group. Conclusions A single dose of 150 mg of pregabalin preoperatively may have the ability to reduce the acute postoperative pain and opioids consumption after spinal fusion surgeries.

Does Intraoperative Multi-Drug Wound Infiltration Relieve Postoperative Pain Following Single-Level TLIF Surgery? A Randomized Controlled Trial

BACKGROUND: How to minimize postoperative pain following spinal surgery has been a great challenge for both surgeons and patients. We hypothesized that intraoperative multi-drug wound infiltration could relieve postoperative pain following single-level transforaminal lumbar interbody fusion (TLIF) surgery. OBJECTIVES: To evaluate the effect of intraoperative multi-drug wound infiltration for postoperative pain following single-level TLIF surgery. STUDY DESIGN: A randomized, double-blinded controlled trial (RCT). SETTING: Department of Orthopaedic Surgery, Qilu Hospital of Shandong University. METHODS: The RCT enrolled 50 patients with 25 cases in 2 groups. The study group received intraoperative wound infiltration of mixed solution with lidocaine, ropivacaine, and epinephrine before wound closure. The control group was infiltrated with an equal amount of normal saline. The primary outcome measure was the visual analog scale (VAS) of postoperative incision pain. The secondary outcome measures were the postoperative opioids dosage, the time of first analgesic demand, and the Oswestry Disability Index (ODI). RESULTS: The VAS of postoperative pain in the study group was significantly lower than the control group within postoperative 24 hours. The opioid dosage was significantly less and the time of first analgesic demand of patient-controlled analgesia (PCA) in the study group was significantly longer than the control group. None of the patients in the study group required analgesic supplementation. The side effects of opioids were significantly less in the study group. There was no significant difference in ODI, operation time, intraoperative blood loss, postoperative drainage, and postoperative incision complications between the 2 groups. LIMITATIONS: Single-center study for single-level TLIF surgery. CONCLUSIONS: Intraoperative multi-drug wound infiltration before closure could significantly relieve postoperative pain following single-level TLIF surgery. KEY WORDS: Transforaminal lumbar interbody fusion, postoperative pain, wound infiltration, multi-drug, randomized controlled trial

Multimodal Analgesia and Patient Education Reduce Postoperative Opioid Consumption in Otology.

This study sought to validate alternative pain management strategies that can reduce reliance on opioids for postoperative pain management in otology. Prospective cohort study. Single tertiary-care facility. Adult patients who underwent outpatient otologic surgery from September 2021 to July 2022 were randomized into treatment cohorts. The opioid monotherapy cohort received a standard opioid prescription. The multimodal analgesia cohort received the same opioid prescription, prescriptions for acetaminophen and naproxen, and additional pain management education with a flyer on discharge. All patients completed a questionnaire 1 week after surgery to evaluate opioid usage and pain scores. Eighty-six patients completed the study. The opioid monotherapy cohort (n = 42) and multimodal analgesia cohort (n = 44) were prescribed an average of 42.1 ± 20.4 morphine milligram equivalents (MME) and 38.4 ± 5.7 MME, respectively (p = 0.373). Four patients (9.52%) in the opioid monotherapy cohort required opioid refills compared to 1 patient (2.27%) in the multimodal analgesia cohort (p = 0.156). Multivariate analysis demonstrated that the multimodal analgesia cohort consumed significantly fewer opioids on average than the opioid monotherapy cohort (11.9 ± 15.9 MME vs 22.8 ± 28.0 MME, respectively). There were no significant differences in postoperative rehospitalizations (p = 0.317) or Emergency Department visits (p = 0.150). Pain scores on the day of surgery, postoperative day (POD) 1, POD3, and POD7 were not significantly different between cohorts (p = 0.395, 0.896, 0.844, 0.765, respectively). The addition of patient education, acetaminophen, and naproxen to postoperative opioid prescriptions significantly reduced opioid consumption without affecting pain scores, refill rates, or complication rates after otologic surgery.

Comparative Evaluation of Tramadol and Butorphanol as an Adjuvant to Bupivacaine for Supraclavicular Block: A Randomised Clinical Study

Introduction: Brachial plexus blocks have become useful alternatives to general anaesthesia for forearm surgeries. When used as a sole agent, Local Anaesthetics (LA) do not provide adequate pain relief. Tramadol and Butorphanol are synthetic opioid analogues that, when added to Bupivacaine, improve the quality of the block and reduce the need for supplementary postoperative opioids. Aim: To evaluate the effect of Tramadol and Butorphanol as adjuvants to Bupivacaine for supraclavicular brachial plexus block on sensory and motor block characteristics. Materials and Methods: This double-blinded randomised clinical study was conducted in the Department of Anaesthesiology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India, from January 2021 to June 2022. The patients were randomly allocated into two groups of 30 each: group T received 0.5% Bupivacaine 25 mL with 50 mg Tramadol, and group B received 0.5% Bupivacaine 25 mL with 1 mg Butorphanol. The primary objective was to study the onset and duration of sensory and motor blockade. The secondary objectives were to study the duration of postoperative analgesia, requirements of rescue analgesia, and drug-related adverse effects in supraclavicular brachial plexus block. Fisher’s exact test and the Chi-square tests were used to compare categorical variables. Results: Group T and group B was 38.30±13.75 years and 38.30±14.79 years, respectively. Demographic data were comparable in both groups. A faster onset of sensory block and motor block was seen with Tramadol than with Butorphanol (p-value &lt;0.001). The duration of sensory and motor block was longer with Butorphanol than with Tramadol (p-value &lt;0.001 and p-value=0.01, respectively). The time to first rescue analgesia was longer with Butorphanol (p-value &lt;0.001). Beyond six hours, the Visual Analog Scale (VAS) score was significantly lower in group B, except at the 12th hour. Very few incidents of adverse events were recorded in both groups. Conclusion: The authors concluded that adding Butorphanol in a dose of 1 mg to Bupivacaine showed a delayed onset for sensory and motor block but prolonged duration of sensory and motor block, as well as the duration of postoperative analgesia, compared to the addition of 50 mg Tramadol, without producing any significant adverse effects.