Postoperative Narcotic Requirements Research Articles

Effectiveness of Liposomal Bupivacaine Transversus Abdominis Plane Block in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial.

Transversus abdominis plane (TAP) blocks improve pain control and reduce narcotic medication requirements in various surgical procedures. Liposomal bupivacaine may provide more sustained analgesia. This study compared pain-related outcomes between standard bupivacaine and liposomal bupivacaine TAP blocks after autologous breast reconstruction. The authors conducted a single-center, single-blinded randomized controlled trial between March of 2021 and December of 2022. Patients undergoing deep inferior epigastric perforator flap breast reconstruction in a standardized enhanced recovery after surgery pathway were randomized to receive intraoperative TAP blocks with either bupivacaine and epinephrine (control group) or liposomal bupivacaine, bupivacaine, and epinephrine (experimental group). Primary outcome was postoperative narcotic medication requirements, with secondary outcomes of pain scores, length of stay, and narcotic medication refills. A total of 117 patients met inclusion criteria (59 control patients and 58 experimental patients). Demographic characteristics, comorbidities, breast pathologic variables, surgery laterality, and immediate versus delayed reconstruction status were equivalent between groups. The control group had significantly higher average pain scores postoperatively (4.3 versus 3.6; P = 0.004). However, there were no significant differences in mean narcotic use (66.9 morphine milligram equivalents versus 60.2 morphine milligram equivalents; P = 0.47). Both length of stay and postoperative narcotic prescription refills were equivalent between groups (2.1 days versus 2.2 days, P = 0.55; 22% versus 17.2%, P = 0.52). The addition of liposomal bupivacaine to the standard bupivacaine TAP block mixture in a standardized enhanced recovery after surgery protocol did not demonstrate a significant reduction in postoperative narcotic requirements after deep inferior epigastric perforator flap breast reconstruction compared with standard bupivacaine alone. Patient-reported pain scores, however, were lower among liposomal bupivacaine patients after the initial 24 hours postoperatively and consistent with a longer duration of analgesia. Therapeutic, II.

Percutaneous lumbar interbody fusion results in less perioperative opioid usage compared to minimally invasive transforaminal lumbar interbody fusion: a single institution, multi-surgeon retrospective study.

Ultra-minimally invasive percutaneous lumbar interbody fusion (percLIF) has been demonstrated to further minimize tissue trauma and has been associated with improved clinical outcomes including decreased blood loss, post-operative pain and length of stay when compared to minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery. A single-institution retrospective study was conducted to investigate whether 1-level percLIF is associated with decreased narcotic consumption compared to 1-level MIS-TLIF in the first 24-hour following surgery. A retrospective study of patients undergoing either single-level percLIF or MIS-TLIF from January 2018 to December 2021. Opioid consumption in the 24-hour following surgery was converted into total morphine milligram equivalents (MME). The primary outcome used univariate and multivariate regression analysis to compare MME consumption between the MIS-TLIF and percLIF groups. Secondary outcome variables included, estimated blood loss, total intraoperative MME, MME at discharge, MME at 30 days post-op, exiting nerve root injury, post-anesthesia care unit (PACU) visual analogue scale (VAS) score at handoff, time to first ambulation, distance ambulated post-operative day one and hospital length of stay. A total of 51 patients (21 percLIF vs. 30 MIS-TLIF) were included in the study. Univariate regression analysis revealed that on average patients who underwent percLIF had a 24-hour postoperative MME -50.8 mg (95% CI: -91.6, -10) lower than those who had MIS-TLIF (P=0.02). On multivariable analysis, after adjusting for sex and age, 24-hour postoperative MME closely failed to meet statistical significance (P=0.06) with an average of -40.8 mg (95% CI: -83.2, 1.6) MME in percLIF patients compared to MIS-TLIF. There was no statistically significant difference in MME between MIS-TLIF and percLIF at the time of discharge and at 30 days post-op. In the setting of the current opioid epidemic in the United States and increased numbers of patients undergoing lumbar interbody fusion, spine surgeons must continue to do their part helping reduce the need for opioid prescriptions for postoperative pain management. New "ultra-MIS" techniques such as percLIF allow surgeons to further decrease tissue trauma, which should lead to reduced need for post-operative narcotic requirements.

The Impact of Marijuana Use on Postoperative Outcomes in Abdominal-based Free Flap Breast Reconstruction.

There is an increasing prevalence of marijuana use in the general population yet clinical studies on marijuana's effect on surgical outcomes remain limited. Marijuana's effect on wound healing, venous thromboembolism (VTE) due to endothelial inflammation, and bleeding due to inhibited platelet function have been cited based on animal models but have not been evaluated clinically in patients undergoing microsurgical reconstruction. Retrospective chart review was performed on all patients who underwent abdominal-based free flap breast reconstruction in a single institute from August 2018 to December 2022. Patient self-reported marijuana use, demographics, total narcotic use during hospitalization converted to oral morphine milligram equivalent (MME), and 90-day complications were collected and compared. A total of 162 patients were included and 13 patients (8.5%) had reported marijuana use on presurgical history. Marijuana users are more likely to be younger and report concurrent nicotine smoking. Marijuana users were also at a significantly elevated risk of developing symptomatic VTE (15 vs. 1%; odds ratio (OR) 13.4 [95% confidence interval (CI) 1.71-104.2]; p = 0.01) and marijuana use remained a significant risk factor with multivariate analysis. On postoperative 90-day complications, there was no increased risk of flap loss, reoperation, postoperative transfusion, or hematoma associated with marijuana use, and no significantly increased risk for overall donor or recipient site complications. Marijuana users required significantly more narcotics for pain control during hospitalization (100 ± 77 vs. 49 ± 45 MME; p = 0.0003), although they had similar lengths of stay, achievement of mobilization on post operative day (POD)1, and maximal pain scores. Marijuana use increases the risks of postoperative VTE and increased postoperative narcotic requirements in patients who underwent abdominal-based free flap breast reconstruction. Future prospective cohort study is required to further understand marijuana-associated risks in microsurgical procedures.

Suprazygomatic Maxillary Nerve Block in Palatoplasty: A Retrospective Cohort Study of Perioperative Outcomes in Syndromic and Non-Syndromic Children.

This study compares the impact of surgical site infiltration of local anesthesia alone to surgical site infiltration plus suprazygomatic maxillary nerve block (SMB) in non-syndromic and syndromic children undergoing primary palatoplasty. Retrospective cohort study of intra- and post-operative outcomes and opioid utilization in children undergoing palatoplasty by a single surgeon. Urban, academic, tertiary care children's hospital. Children 24 months or younger undergoing primary palatoplasty were included (n = 102). Exclusion criteria were concurrent painful procedures, history of neonatal abstinence syndrome, and nurse-controlled analgesia (n = 30). All patients received epinephrine-containing local anesthetic infiltrated at the surgical site. Fifty-seven also underwent placement of ultrasound-guided SMB. Intra-operative opioid requirement, duration of anesthesia, time to wake up, post-operative opioid requirement, hypoxemic episodes, need for respiratory support, FLACC scores, and length of stay. When controlling for syndromic status and cleft phenotype, SMB was associated with a 57% reduction in intraoperative opioid requirements (95% CI = 15-81%, p = 0.024) but also with a 29% (∼5-min) increase in wake-up time post-surgery (95% CI = 3-50%, p = 0.048). Postoperatively, SMB was linked to a 18% reduction in hospital stay length (95% CI = 2-31%, p = 0.027) and a 88% reduction in opioid requirements within 24 h after surgery (p = 0.006). Desaturations and new respiratory support requirements were unaffected by SMB. Compared to surgical site infiltration of local anesthetic alone, adding SMB reduces intra- and postoperative narcotic requirements and decreases length of stay. These benefits apply to both syndromic and non-syndromic children. SMB does not meaningfully affect respiratory outcomes.

“The Utility of Preoperative Acetaminophen in Reducing Postoperative Pain and Narcotic Use in Patients Undergoing Cosmetic Breast Augmentations, During a National Opiate Crisis”

Background:Preoperative use of acetaminophen has become widely adopted across the surgical subspecialties in attempt to maximize analgesia and minimize postoperative narcotic requirements. Whether or not acetaminophen use has an influence on these outcomes in cosmetic breast augmentation needs to be studied. Objectives: The aim of this study was to compare the differences in reported pain and narcotic use between patients undergoing breast augmentations who received preoperative oral acetaminophen and those who did not. Methods: This was a prospective, single-center study including 59 patients undergoing primary breast augmentation which were divided into 2 groups: control group (did not receive acetaminophen) and a study group (received 1000 g PO acetaminophen), all medications were administered prior to surgery. A self-reported survey was received from all patients which included pain scores as well as number of narcotics taken. Results: Data analysis indicated that the only statistically significant difference in pain was on postoperative day 2 (POD2), with patients who did not receive PO tylenol reporting more pain. There was no significant difference in the number of narcotics required between either group. Conclusions: It appears that preoperative PO acetaminophen did not significantly influence the amount of postoperative narcotic use. The only difference in reported pain was on POD2 and was higher in those who did not receive preoperative acetaminophen. It seems that PO acetaminophen is an inexpensive way of improving postoperative pain in patients undergoing cosmetic breast augmentation; however, it does not reduce narcotic use.

Efficacy of Liposomal Bupivacaine in Managing Postoperative Pain in Foot and Ankle Surgeries: A Prospective Randomized Blinded Controlled Study

Category: Hindfoot; Midfoot/Forefoot Introduction/Purpose: Surgeons’ response to the nationwide opioid epidemic has included using alternatives to narcotic pain medications. Regional anesthesia has provided options to reduce narcotic consumption after surgery. Liposomal Bupivacaine (LB) is not FDA approved for use in nerve blocks in the lower extremity, though it is approved for more dangerous blocks (interscalene for example) in the upper extremity. The literature on LB in foot and ankle surgery has been limited to local infiltration and no major study has explored its efficacy when used in lower extremity peripheral nerve blocks. In this study, we compare local LB infiltration with LB used in peripheral nerve blocks in the lower extremity and compare both of these techniques with the current standard of care, a non-LB peripheral nerve block. Methods: All patients undergoing surgery in a single surgeon foot and ankle practice were enrolled in this IRB approved, prospective, randomized controlled study. Patients having surgery between January 2022 – January 2023 were randomized to one of three study arms: Group 1 Anesthesia administered ultrasound guided nerve block with local anesthetic only, Group 2 Anesthesia administered ultrasound guided nerve block with LB/local only mix, or Group 3 Surgeon administered infiltrative field block with LB/local mix. The primary outcomes collected included the amount of narcotic pain medication required in the PACU, oral morphine equivalents (OME) up to postoperative day 4 and after postoperative day 4, subjective duration of nerve block, and patient reported outcomes (PROMIS Pain Interference/Depression/Physical Function). Collection was obtained via chart review from hospital EMR, and phone calls made to patients during specific time intervals after surgery. Analysis was performed utilizing GraphPad Prism (Ver 9.0, GraphPad Software, San Diego CA USA). Results: After exclusion of 110 patients, 248 patients met inclusion criteria. Ninety-eight underwent perineural popliteal or popliteal adductor block with LB/local mix, 70 underwent popliteal or popliteal adductor block with local only (Group 2), 80 underwent surgeon administered local field block with LB/local mix (Group 3). Median PACU morphine equivalents required for pain control were significantly lower in Groups 1 and 2 (0 OME) compared to local field block (7.5 OME) (p < 0.05). Median OME utilized up to POD 4 and median OME utilized after POD 4 were both significantly lower in the LB/local mix perineural block group (p < 0.05) compared to Groups 2 and 3. Duration of block effect was significantly higher in the LB/local mix group compared to Groups 2 and 3 (p < 0.05). Conclusion: Preoperative perineural blocks containing a mix of LB and local anesthetic significantly reduce PACU, early postoperative, and mid postoperative narcotic use of patients undergoing outpatient foot and ankle surgery. The duration of effect of perineural block is significantly extended with addition of LB to the block mixture. Consideration should be given to the use of LB blocks in foot and ankle surgical procedures to reduce patient postoperative narcotic requirements.

Comparison between adenosine and magnesium sulfate as an adjuvant for ultrasound-guided rectus sheath block. A prospective randomized controlled study

ABSTRACT Background Rectus sheath block (RSB) is an effective nerve block. This study aimed to compare adenosine and magnesium sulfate as an adjuvant for ultrasound-guided RSB (UG-RSB). Methods This prospective controlled randomized trial was performed on 96 adult patients (ASA I and II) undergoing umbilical or epigastric hernia repair. The patients were assigned randomly to three equal groups and got bilateral UG-RSB. Adenosine group: using 20 ml bupivacaine hydrochloride 0.25% + 12 mg of adenosine (4 ml) +1 ml saline 0.9%. Magnesium group: using 20 ml bupivacaine hydrochloride 0.25% + 500 mg of magnesium sulfate (5 ml). Control group: using 20 ml bupivacaine hydrochloride 0.25% + 5 ml of saline 0.9%. Registration No.: 6/2018ANET17 Results A significant postoperative reduction of VAS up to 18 h was detected in the magnesium sulfate group and up to 12 h was detected in the adenosine group. A statistically significant prolongation of time to the first analgesia in magnesium and adenosine groups than control groups (483.44 ± 48.03 & 415.28 ± 29.81 than 325.31 ± 50.29, respectively), as well as the mean postoperative morphine consumption was 5.94 ± 1.61, 8.03 ± 1.0 and 16.69 ± 2.49 among magnesium, adenosine, and control groups, respectively. The postoperative complications were statistically significantly higher in the control group. Conclusion This study validates the effectiveness of adenosine versus magnesium sulfate as good adjuvants for improving the quality and duration of UG-RSB and reduction of postoperative narcotic requirements. However, the duration was relatively longer with magnesium sulfate.

(350) Narcotic Requirements and Operative Outcomes of a Pudendal Nerve Block Prior to Primary Inflatable Penile Prosthesis Implantation in a Multiethnic Population

Abstract Introduction There are various analgesic regimens for post-operative pain control following inflatable penile prosthesis (IPP) implantation. Specifically, post-operative pain control with opioids is a common practice, but efforts to minimize narcotic usage are vital given the current opioid epidemic in the United States. Pudendal nerve block (PNB) provides regional perineal and penile anesthesia and represents an attractive option to maximize pain control while minimizing post-operative narcotic use. However, there is a paucity of studies describing whether utilization of PNBs decreases intra- and post-operative narcotic requirements following IPP implantation. Objective To determine whether PNB utilization in a multiethnic population undergoing primary IPP implantation can decrease rates of post-operative opiate usage. Secondary objectives were to assess PNB utilization on intra-operative and 30-day safety outcomes. Methods A single institution retrospective study was conducted of patients who underwent primary IPP implantation between December 2015 and February 2022. Demographic data, intra-operative characteristics, and outcome measures were extracted from electronic medical records. Baseline characteristics of PNB (yes or no) were summarized and analyzed using a Student’s t-test, Chi-square test, or Mann-Whitney U for non-normally distributed variables. PNB usage and PACU opioid administration (yes or no) were analyzed using binary logistic regression for univariate and multivariate analysis. Results A total of 363 patients were included, 294 (81.0%) in the PNB group and 69 (19.0%) in the non-PNB group. The majority of patients were of Hispanic race (62.3%). History of chronic pain (17.7% vs. 7.2%, p=0.03) and hyperlipidemia (52.0% vs. 34.8%, p=0.01) were more prevalent in the PNB group. Significantly more IPPs in the PNB group had cylinders measuring 20 centimeters or greater (57.1% vs 41.2, p=0.017). Estimated blood loss of 50ml or greater (43.1% vs. 20.0%, p<0.001), PACU narcotic usage (61.6% vs. 75.4%, p=0.040) and time (minutes) spent in the PACU (144 [111-185] vs. 238 [162-307], p<0.001) were all significantly lower in the PNB group. There were no significant differences in postoperative and 30-day safety outcomes. On univariate analysis, both PNB (OR=0.52, p=0.043) and age above 65 (OR=0.53, p=0.004) were associated with a lower likelihood of receiving opiates in the PACU, while only age remained significant (OR=0.53, p=0.006) on multivariate analysis. Conclusions Pre-operative PNB decreases intra-operative estimated blood loss, post-operative opioid analgesic requirements and time spent in PACU in patients undergoing a primary IPP implantation. Thus, PBN represents a potentially attractive, non-opioid means of analgesia in patients undergoing primary IPP surgery. Disclosure No

MP26-14 SINGLE PORT ROBOTIC ASSISTED VERSUS LAPAROSCOPIC RADICAL AND PARTIAL NEPHRECTOMY: SINGLE SURGEON COMPARISON

You have accessJournal of UrologyCME1 Apr 2023MP26-14 SINGLE PORT ROBOTIC ASSISTED VERSUS LAPAROSCOPIC RADICAL AND PARTIAL NEPHRECTOMY: SINGLE SURGEON COMPARISON Alexa Meyer, Aaron Zhang, Adam Hass, Stephanie Banks, Ella Taubenfeld, Jared Winoker, Ridwan Alam, Lee Richstone, and Louis Kavoussi Alexa MeyerAlexa Meyer More articles by this author , Aaron ZhangAaron Zhang More articles by this author , Adam HassAdam Hass More articles by this author , Stephanie BanksStephanie Banks More articles by this author , Ella TaubenfeldElla Taubenfeld More articles by this author , Jared WinokerJared Winoker More articles by this author , Ridwan AlamRidwan Alam More articles by this author , Lee RichstoneLee Richstone More articles by this author , and Louis KavoussiLouis Kavoussi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003254.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Despite the availability of the da Vinci Single Port (SP) system, wide adoption and report of its use for single site surgery remain limited. For radical (RN) and partial nephrectomy (PN), few series report on the use of the SP system with minimal comparisons to current standard-of-care minimally invasive treatments. In this series, we describe a single surgeon’s initial experience with the da Vinci SP system for RN and PN and compare it to laparoscopic RN and PN performed during this time frame. METHODS: We retrospectively reviewed all patients who underwent RN and PN since the introduction of the SP system within the health system. Patients who underwent SP and laparoscopic surgery were compared based on pre-, peri-, and post-operative outcomes, including baseline demographics, tumor size, estimated blood loss (EBL), operating room (OR) time, length of hospital stay (LOS), and complications. RESULTS: Between March 8, 2021 and May 2, 2022, a total of 121 patients underwent PN or RN by a single surgeon (LRK). A total of 78 patients underwent laparoscopic surgery (49 PN and 29 RN) and 43 patients underwent SP surgery (31 PN and 12 RN). Patients were comparable with respect to age, race, and body mass index. Those who underwent laparoscopic surgery had larger tumors (4.0 versus 3.1, p=0.02) and higher ASA scores (p=0.04). There were no significant differences between the two groups in terms of length of surgery (p=0.10), rate of conversion (p=0.62), intraoperative and postoperative complications (p>0.99 and p=0.45, respectively), and length of stay (p=0.45). Patients who underwent SP-PN had significantly longer ischemia time than patients who underwent laparoscopic PN (median 20 minutes versus 0 minutes, p =0.02), and significantly lower EBL (median 200 cc versus 300 cc, p =0.003). The SP group was discharged with significantly less narcotic prescriptions (10 patients versus 59 in laparoscopic group, p <0.001). CONCLUSIONS: The SP system appears to be a safe and feasible approach to performing RN and PN. A potential benefit is lower postoperative narcotic requirements. This may be due to midline port placement for the SP system versus the addition of a lateral port in the traditional laparoscopic approach. Limitations of the study include the retrospective nature and inherent selection bias. Further studies are needed to better characterize the relative safety and indications for a SP approach in renal surgery, compared to traditional laparoscopic and open techniques, as well as to thoroughly evaluate both long-term oncological outcomes and potential pain-related advantages. Source of Funding: n/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e358 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexa Meyer More articles by this author Aaron Zhang More articles by this author Adam Hass More articles by this author Stephanie Banks More articles by this author Ella Taubenfeld More articles by this author Jared Winoker More articles by this author Ridwan Alam More articles by this author Lee Richstone More articles by this author Louis Kavoussi More articles by this author Expand All Advertisement PDF downloadLoading ...

Effects of Dexmedetomidine on Immunomodulation and Pain Control in Videolaparoscopic Cholecystectomies: A Randomized, Two-Arm, Double-Blinded, Placebo-Controlled Trial.

Digital and robotic technology applications in laparoscopic surgery have revolutionized routine cholecystectomy. Insufflation of the peritoneal space is vital for its safety but comes at the cost of ischemia-reperfusion-induced intraabdominal organ compromise before the return of physiologic functions. Dexmedetomidine in general anesthesia promotes controlling the response to trauma by altering the neuroinflammatory reflex. This strategy may improve clinical outcomes in the postoperative period by reducing postoperative narcotic use and lowering the risk of subsequent addiction. In this study, the authors aimed to evaluate dexmedetomidine's therapeutic and immunomodulatory potential on perioperative organ function. Fifty-two patients were randomized 1:1: group A-sevoflurane and dexmedetomidine (dexmedetomidine infusion [1 µg/kg loading, 0.2-0.5 µg/kg/h maintenance dose]), and group B-sevoflurane with saline 0.9% infusion as a placebo control. Three blood samples were collected: preoperatively (T0 h), 4-6 h after surgery (T4-6 h), and 24 h postoperatively (T24 h). The primary outcome was the level analysis of inflammatory and endocrine mediators. Secondary outcome measures were the time to return to normal preoperative hemodynamic parameters, spontaneous ventilation, and postoperative narcotic requirements to control surgical pain. A reduction of Interleukin 6 was found at 4-6 h after surgery in group A with a mean of 54.76 (27.15-82.37; CI 95%) vs. 97.43 (53.63-141.22); p = 0.0425) in group B patients. Systolic and diastolic blood pressure and heart rate were lower in group A patients, who also had a statistically significantly lower opioid consumption in the first postoperative hour when compared to group B patients (p < 0.0001). We noticed a similar return to spontaneous ventilation pattern in both groups. Dexmedetomidine decreased interleukin-6 4-6 h after surgery, likely by providing a sympatholytic effect. It provides good perioperative analgesia without respiratory depression. Implementing dexmedetomidine during laparoscopic cholecystectomy has a good safety profile and may lower healthcare expenditure due to faster postoperative recovery.

Respiratory Monitoring after Opioid-Sparing Bariatric Surgery in Patients with Obstructive Sleep Apnea (OSA)

Introduction with Aim: Postoperative respiratory depression can complicate a patient’s recovery after surgery. A predictive score (PRODIGY) was recently proposed to evaluate the risk of opioid-induced postoperative respiratory depression. For the first time, we applied this score to a cohort of patients receiving bariatric surgery, stratified by Obstructive Sleep Apnea (OSA) status. In addition, we recorded continuous postoperative capnography to evaluate respiratory depression and apnea episodes (Respiratory Events, RE). Materials and Methods: The present study was approved by our IRB and comprised continuous surveillance of respiratory variables during postoperative recovery (in PACU) after robotic bariatric surgery. We utilized continuous capnography and pulse oximetry (Capnostream 35, Medtronic Inc., and Profox Respiratory Oximetry software). Preoperative preparation included OSA evaluation for all bariatric patients, additional sleep studies for severe OSA grades, and evaluation of risk for respiratory depression (low, intermediate, or high) using the published PRODIGY score. In addition, we evaluated patients by OSA status. All patients received multimodal intraoperative non-opioid anesthesia from the same team. After surgery, all patients received continuous respiratory surveillance in PACU (average duration exceeding 140 min). Respiratory depression events were scored using a modified list of the five standard published categories. Events were measured according to analysis of continuously recorded tracing of the compiled respiratory variables by observers kept blind from the study patient’s group. Results: Of the 80 patients evaluated (18 male), 56 had obstructive sleep apnea and were using CPAP at home (OSA); 24 did not. OSA patients received CPAP via an oronasal mask or a nasal pillow pressure support immediately after arriving in PACU, utilizing their at-home settings. We encountered 115 respiratory depression events across 48 patients. The most frequent respiratory event recorded was a transient desaturation (as low as 85%), which usually lasted 20–30 sec and resolved spontaneously in 3 to 5 min; most episodes followed small boluses of IV opioid analgesia administered during recovery, on demand. All episodes resolved spontaneously without any nursing or medical intervention. OSA patients had significantly more events than non-OSA patients (1.84 (1.78–1.9) mean events vs. 0.50 (0.43–0.57) for non-OSA, p = 0.0002). The level of PRODIGY score (low, intermediate, or high), instead, was not predictive of the number of events when we treated this variable as continuous (p = 0.39) or categorical (high vs. low, p = 0.65, and intermediate vs. low, p = 0.17). Conclusions: We attribute these novel results, showing a lack of respiratory events requiring intervention, to opioid-free anesthesia, early CPAP utilization, and head-up positioning on admission to PACU. Furthermore, all these patients had light postoperative narcotic requirements. Finally, an elevated PRODIGY score in our patients did not sufficiently predict respiratory events, but OSA status alone did. Key Points Summary: We investigated the incidence of Respiratory Events (RE) in Obstructive Sleep Apnea patients after surgery (56 patients) and compared them to similar patients without OSA (24 patients). All patients received identical robotic-assisted surgery and low- or no-opiate anesthesia. Patients were pre-screened with the standard published PRODIGY scores and were monitored after PACU arrival with continuous oximetry and capnography (Capnostream 35 and Profox analysis). OSA patients showed more RE than non-OSA (1.8 vs. 0.5, p = −0.0002). However, patients with elevated PRODIGY scores did not develop more frequent RE compared to patients with low scores. We attribute these novel results to opioid-sparing anesthesia/analgesia and immediate CPAP utilization on admission to PACU.

Abdominal Wall Reconstruction with Retrorectus Self-Adhering Mesh: A Single-Center Long-Term Follow-Up.

Mesh repair has been demonstrated to be superior to suture alone in ventral hernia repair. In a previous short-term pilot study, the authors found lower postoperative narcotic requirements with self-adhering mesh. The aim of this study was to follow-up on that pilot study, using long-term data. This is a retrospective review of a prospectively collected database. All patients who underwent ventral hernia repair with retrorectus mesh and who had at least a 12-month follow-up were reviewed. Comparisons were performed between patients who received self-adhering mesh and those who received transfascially sutured mesh, using matched-pair analysis, examining perioperative outcomes, surgical-site occurrences, and hernia recurrence/bulge. Forty-two patients were included in the study, with 21 patients undergoing repair with transfascially sutured mesh and 21 patients receiving self-adhering mesh. Average length of follow-up was 1078 days. There were no significant differences between the two groups in baseline characteristics. Patients receiving self-adhering mesh had significantly shorter surgery, and a shorter hospital length of stay. They also had a tendency toward lower narcotic requirements. There were no significant differences in the rate of surgical-site occurrences, hernia recurrences, or bulge between the two groups. This long-term study shows that self-adhering mesh in ventral hernia repair results in similar long-term outcomes to transfascially sutured mesh, with shorter surgery, shorter length of stay, and a tendency toward improved pain control. These findings mirror the known advantages of self-adhering mesh in inguinal hernia repair. Further research is needed to study the incidence of chronic pain and the cost-effectiveness of self-adhering mesh. Therapeutic, III.

To block or not to block? That is the question (114)

Objectives: Quadratus Lumborum (QL) blocks have gained popularity due to their more favorable safety profile compared to neuraxial techniques (e.g., epidural) in dealing with postoperative pain. They have been studied in the gynecologic population undergoing laparoscopic surgery, where pain scores were found to decrease as patients progressed through their recovery process. Yet, very little data exists studying their use in open surgery for gynecologic indications. Therefore, we aimed to determine the effect of QL blocks on postoperative opioid consumption in patients undergoing laparotomy. Methods: A retrospective study of gynecologic oncology patients undergoing surgery via laparotomy from 2018 to 2020 was performed. Demographics, postoperative pain scores, frequency, and duration of narcotic use, amount of narcotic use using Morphine Milligram Equivalents (MME), length of hospital stay, and re-admission rates for pain management were compared. Primary outcome measures include postoperative pain scores and the amount of narcotic use in MME. Results: Thirty-eight patients who met the inclusion criteria with complete data were identified as receiving QL blocks, whereas 32 patients did not receive a block during this time frame. Eighty-six percent of the blocks were placed preoperatively. Approximately 25% of patients reported their pain score on arrival to the floor as 0 out of 10. The mean pain score for patients with and without QL blocks on arrival to the floor were 2.9/10 and 3.7/10, respectively (p=0.57). Patients who received QL blocks used a mean of 18.4 MME on postoperative day 1 compared to 31.1 MME in those without blocks (p=0.008). This trend continued throughout their hospital course as the mean total MME used on hospital days 1-3 in the QL group was 49.11 compared to 80.24 in the non-QL group (p=0.009). Conclusions: Our study suggests that the use of regional QL blocks decreases the amount of narcotic pain medication (MME) used in the immediate postoperative period in patients undergoing laparotomy for gynecologic oncology indications. This is an important finding which may help decrease overall postoperative narcotic requirements given the current opioid epidemic. Future studies will focus on the impact of QL blocks on narcotic need after discharge in this patient population. Objectives: Quadratus Lumborum (QL) blocks have gained popularity due to their more favorable safety profile compared to neuraxial techniques (e.g., epidural) in dealing with postoperative pain. They have been studied in the gynecologic population undergoing laparoscopic surgery, where pain scores were found to decrease as patients progressed through their recovery process. Yet, very little data exists studying their use in open surgery for gynecologic indications. Therefore, we aimed to determine the effect of QL blocks on postoperative opioid consumption in patients undergoing laparotomy. Methods: A retrospective study of gynecologic oncology patients undergoing surgery via laparotomy from 2018 to 2020 was performed. Demographics, postoperative pain scores, frequency, and duration of narcotic use, amount of narcotic use using Morphine Milligram Equivalents (MME), length of hospital stay, and re-admission rates for pain management were compared. Primary outcome measures include postoperative pain scores and the amount of narcotic use in MME. Results: Thirty-eight patients who met the inclusion criteria with complete data were identified as receiving QL blocks, whereas 32 patients did not receive a block during this time frame. Eighty-six percent of the blocks were placed preoperatively. Approximately 25% of patients reported their pain score on arrival to the floor as 0 out of 10. The mean pain score for patients with and without QL blocks on arrival to the floor were 2.9/10 and 3.7/10, respectively (p=0.57). Patients who received QL blocks used a mean of 18.4 MME on postoperative day 1 compared to 31.1 MME in those without blocks (p=0.008). This trend continued throughout their hospital course as the mean total MME used on hospital days 1-3 in the QL group was 49.11 compared to 80.24 in the non-QL group (p=0.009). Conclusions: Our study suggests that the use of regional QL blocks decreases the amount of narcotic pain medication (MME) used in the immediate postoperative period in patients undergoing laparotomy for gynecologic oncology indications. This is an important finding which may help decrease overall postoperative narcotic requirements given the current opioid epidemic. Future studies will focus on the impact of QL blocks on narcotic need after discharge in this patient population.

Development and Internal Validation of the Postoperative Analgesic Intake Needs Score: A Predictive Model for Post-Operative Narcotic Requirement after Spine Surgery.

Retrospective Cohort. The aim of this study was to develop a clinical tool to pre-operatively risk-stratify patients undergoing spine surgery based on their likelihood to have high postoperative analgesic requirements. A total of 1199 consecutive patients undergoing elective spine surgery over a 2-year period at a single center were included. Patients not requiring inpatient admission, those who received epidural analgesia, those who had two surgeries at separate sites under one anesthesia event, and those with a length of stay greater than 10 days were excluded. The remaining 860 patients were divided into a derivation and validation cohort. Pre-operative factors were collected by review of the electronic medical record. Total postoperative inpatient opioid intake requirements were converted into morphine milligram equivalents to standardize postoperative analgesic requirements. The postoperative analgesic intake needs (PAIN) score was developed after the following predictor variables were identified: age, race, history of depression/anxiety, smoking status, active pre-operative benzodiazepine use and pre-operative opioid use, and surgical type. Patients were risk-stratified based on their score with the high-risk group being more likely to have high opioid consumption postoperatively compared to the moderate and low-risk groups in both the derivation and validation cohorts. The PAIN Score is a pre-operative clinical tool for patients undergoing spine surgery to risk stratify them based on their likelihood for high analgesic requirements. The information can be used to individualize a multi-modal analgesic regimen rather than utilizing a "one-size fits all" approach.

The impact of fascia iliaca nerve blockade on early postoperative pain and recovery after hip arthroscopy for femoroacetabular impingement syndrome.

ABSTRACTFascia iliaca nerve blockade (FIB) has been previously described as an effective technique for reducing postoperative pain and opioid consumption after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). We hypothesize that an FIB will significantly reduce opioid consumption, pain scores and recovery time in our population. A retrospective observational study of 326 consecutive patients undergoing hip arthroscopy for FAIS at a single institution was performed. Patients were classified based on whether or not they received an FIB. Patient demographics, surgical details, medication details and 6-month postoperative outcomes were collected. The primary endpoint was the amount of narcotics required intraoperatively and in the postanesthesia care unit (PACU). Of the 326 patients included in the study, 37 received an FIB. No differences in sex, age or other surgical details were observed between groups. Patients receiving an FIB were more likely to receive celecoxib (P < 0.001), pregabalin (P = 0.001) and methocarbamol (P = 0.002). The FIB group received lower doses of narcotics intraoperatively (P = 0.001), postoperatively (P < 0.001) and in total (P < 0.001). The FIB group also self-reported lower first pain scores upon arrival to PACU (P = 0.001) and experienced shorter PACU recovery times (P < 0.001). After controlling for differences between groups, patients who received an FIB required significantly lower amounts of narcotics, had shorter PACU times and lower first PACU pain score than those who did not (P < 0.001). No differences in complication rates were noted between groups. The use of FIB resulted in lower pain scores, reduced recovery time and decreased early postoperative narcotic requirements for patients undergoing hip arthroscopy for femoroacetabular impingement. Further study is required to validate these findings and determine the optimal approach to regional analgesia in this patient population.

A reduced concentration femoral nerve block is effective for perioperative pain control following ACL reconstruction: a retrospective review

IntroductionFemoral nerve block (FNB) is a routinely used regional analgesic technique for anterior cruciate ligament (ACL) reconstruction. One method to balance the analgesic effect and functional impairment of FNBs may be to control the concentration of local anesthetics utilized for the block.Materials and methodsRetrospective chart review was performed on 390 consecutive patients who underwent ACL reconstruction between June 2014 and May 2017. Patients were divided into those who received a standard (0.5%-bupivacaine) or low (0.1–0.125%-bupivacaine) concentration single-shot FNB performed with ultrasound guidance. Maximum postoperative VAS, Post-Anaesthesia Care Unit (PACU) time prior to discharge, need for additional ‘rescue’ block, and intravenous postoperative narcotic requirements were recorded.ResultsA total of 268 patients (28.4 ± 11.9 years) were included for final analysis, with 72 patients in the low-concentration FNB group and 196 patients receiving the standard concentration. There were no differences in the maximum postoperative VAS between the low (6.4 ± 2.5) and standard (5.7 ± 2.9) concentration groups (P = 0.08). Similarly, the time from PACU arrival to discharge was not different between groups (P = 0.64). A sciatic rescue block was needed in 22% of patients with standard-dose FNB compared to 30% of patients receiving the low-concentration FNB (P = 0.20). Patients with a hamstring autograft harvest were more likely to undergo a postoperative sciatic rescue block compared to a bone-patellar tendon autograft (P = 0.005), regardless of preoperative block concentration. Quadriceps activation was preserved with low-concentration blocks.ConclusionsUsing 1/5th to 1/4th the standard local anesthetic concentration for preoperative femoral nerve block in ACL reconstruction did not significantly differ in peri-operative outcomes, PACU time, need for rescue blockade, or additional immediate opioid requirements.Level of EvidenceIII.

Postoperative outcomes of total knee arthroplasty across varying levels of multimodal pain management protocol adherence

We examined the effect of varying multimodal pain management (MMPM) combinations on oral morphine milligram equivalents (OMME) and length of stay (LOS) after total knee arthroplasty (TKA). Five groups were compared based on the combination of multimodal analgesics ranging from no MMPM to full MMPM with acetaminophen, gabapentinoids, and celecoxib. After risk adjustment, MMPM was associated with decreased odds of LOS ≥2 days and OMME ≥75th percentile. MMPM protocols are effective at reducing LOS and postoperative narcotic requirements post-TKA. Patients appear to derive similar benefit from receiving all three medications, as well as various combinations of these drugs.

The Effects of Dexmedetomidine on Anesthetic Outcomes following Maxillomandibular Advancement Surgery

Research supports that maxillomandibular advancement (MMA) surgery is an effective treatment modality for severe obstructive sleep apnea (OSA). In a systematic review, Ankichetty, et al, found that the use of alpha 2 agonists in OSA patients reduces the requirement of perioperative analgesics, but no randomized clinical trials with the use of dexmedetomidine (DEX) in OSA patients exist.1 Furthermore, while there are several studies evaluating peri-operative parameters in patients who have undergone Stanford Protocol's Phase I OSA surgeries, published studies regarding the usage of intra-operative DEX and anesthetic outcomes following MMA surgery are difficult to find. The authors seek to elucidate the effects that DEX, an alpha 2 agonist with analgesic, amnesic, and supposed anesthesia-sparing properties, has on patients immediately following MMA surgery.2A search through the sponsoring institution's electronic medical record system was conducted from January 1, 2017, through December 31, 2020, using Current Procedural Terminology codes for bilateral sagittal split ramus osteotomy (BSSRO), Le Fort I osteotomy with or without bone grafts (LFI), genioplasty, genioglossus advancement, and/or genial bone graft (GG). Two independent investigators (ADC and YJL) reviewed the resultant charts and selected adult patients aged 18 years and older with a diagnosis of OSA. Patients who remained intubated at the conclusion of MMA surgery and whose procedures included solely revision osteotomies were excluded from this study. The remaining 58 patient records underwent a detailed retrospective chart review. Postoperative opioid requirement was calculated as milligrams (mg) of morphine equivalent dosages (MEDs). Univariate analysis was conducted with Pearson's Chi-square to determine the presence of a statistically significant association between cumulative doses of intraoperative DEX and the opioid requirement within the first 8- and 24-hours postoperatively, as well as the time from "Surgery End to Extubation" (EXT). Multiple linear regression and multinomial logistic regression were utilized to evaluate relationships among different doses of medications received and to calculate odds ratios, respectively. Significance was defined as P < .05.There were 58 patients included in this study: 47 (81%) males and 11 (19%) females; 27 (46.6%) had received intraoperative DEX and 31 (53.4%) had not. While all patients underwent at least 2 osteotomies, 49 (84.5%) of patients underwent 4 (i.e., LF1, BSSRO, and GG osteotomies). There was no significant difference detected between cumulative dosage of intraoperative DEX and first 8-hour postoperative narcotic requirement (P = .30). However, a statistically significant association was detected between cumulative dosage of intraoperative DEX and first 24-hour postoperative narcotic requirement (P = .02). Furthermore, patients who received a cumulative DEX dose between 100.1 and 200 micrograms (mcg) received less opioids within the first 24-hour postoperative period than those patients who received > 200mcg of DEX. EXT in patients who received between 100.1 and 200mcg of DEX, as compared to those who did not receive and those who did receive lower amounts of intraoperative DEX, was statistically significantly higher (P = .01 and .02, respectively).In contrary to the conclusions of Ankichetty, et al, and Bamgbade, et al, less intraoperative DEX was found to be significantly associated with lower 24-hour postoperative opioid requirements. This study also suggests that EXT may decrease with lower doses of DEX administered intraoperatively. Well-designed prospective, randomized studies involving larger numbers of patients with OSA undergoing MMA surgery and receiving DEX are warranted.

MP49-06 A HELPFUL TOOL IN THE RENAL SURGERY ARMAMENTARIUM: DORSAL LUMBOTOMY NEPHRECTOMY FOR TUMOR IN PATIENTS WITH END-STAGE RENAL DISEASE

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy IV (MP49)1 Sep 2021MP49-06 A HELPFUL TOOL IN THE RENAL SURGERY ARMAMENTARIUM: DORSAL LUMBOTOMY NEPHRECTOMY FOR TUMOR IN PATIENTS WITH END-STAGE RENAL DISEASE Ian Cooke, Samiha Sadruddin, Dattatraya Patil, Satyen Tripathi, Reza Nabavizadeh, Kenneth Ogan, and Viraj Master Ian CookeIan Cooke More articles by this author , Samiha SadruddinSamiha Sadruddin More articles by this author , Dattatraya PatilDattatraya Patil More articles by this author , Satyen TripathiSatyen Tripathi More articles by this author , Reza NabavizadehReza Nabavizadeh More articles by this author , Kenneth OganKenneth Ogan More articles by this author , and Viraj MasterViraj Master More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002075.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The dorsolumbar (DL) approach to the kidney was first described in 1870 but remains an infrequently utilized approach today, with little data comparing it to contemporary approaches. The purpose of our study was to compare operative outcomes between the DL and laparoscopic (LN) approaches for patients with end stage renal disease (ESRD) undergoing nephrectomy. DL operative technique is also described. METHODS: We performed a retrospective review of patients undergoing DL nephrectomy at our institution from 2008-2020. Cases were matched with controls who had undergone LN. Outcome parameters included operative time, estimated blood loss (EBL), length of stay (LOS), postoperative narcotic requirements, and complication rates. Statistical analysis performed with SPSS. RESULTS: 43 DL patients and 86 LN patients were assessed. DL had shorter total OR time (173min vs 198min; p=0.001) and surgery time (101min vs 135min; p<0.001) compared to LN. There was a trend towards decreased mean LOS among the DL group (2.65d vs 3.14d; p=0.069) as well as narcotic requirement measured in oral morphine equivalents (54.8mg/day vs 73.6mg/day, p=0.051). There were no differences in EBL, complication rates, or 30-day readmissions. Limitations include retrospective design and sample size. CONCLUSIONS: Our study is the first to perform a matched comparison of DL and LN approaches to nephrectomy in patients with ESRD. We found DL to be safe and effective compared to LN, with shorter operative times, a trend towards decreased LOS and post-operative narcotic requirements, and similar complication rates. DL should be considered as an approach for nephrectomy in appropriately selected patients in this population. Source of Funding: John Robinson Family Foundation, Christopher Churchill Foundation © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e876-e877 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ian Cooke More articles by this author Samiha Sadruddin More articles by this author Dattatraya Patil More articles by this author Satyen Tripathi More articles by this author Reza Nabavizadeh More articles by this author Kenneth Ogan More articles by this author Viraj Master More articles by this author Expand All Advertisement Loading ...

MP03-19 SUPPORT FOR MINIMIZING NARCOTIC REQUIREMENT FOLLOWING URETHROPLASTY

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) I (MP03)1 Sep 2021MP03-19 SUPPORT FOR MINIMIZING NARCOTIC REQUIREMENT FOLLOWING URETHROPLASTY Chase Mallory, Alejandra Perez, Adam Nolte, Scott Jamieson, Jessica Boyer, Dhaval Jivanji, Spencer Liem, and Billy Cordon Chase MalloryChase Mallory More articles by this author , Alejandra PerezAlejandra Perez More articles by this author , Adam NolteAdam Nolte More articles by this author , Scott JamiesonScott Jamieson More articles by this author , Jessica BoyerJessica Boyer More articles by this author , Dhaval JivanjiDhaval Jivanji More articles by this author , Spencer LiemSpencer Liem More articles by this author , and Billy CordonBilly Cordon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001964.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The opioid epidemic has led to increased use of non-narcotic post-surgical pain management. While many studies have assessed preoperative adjunct measures to decrease postoperative narcotic requirements, few studies have looked directly at optimal postoperative pain management following urethroplasty both in the peri- and postoperative settings and upon discharge. In this study, we aim to characterize pain control for patients undergoing urethroplasty and provide alternative non-narcotic adjuncts. METHODS: We retrospectively reviewed clinical and procedural characteristics for all patients that underwent urethroplasty at our institution from August 2016 through February 2021. The primary outcome was milligram morphine equivalents (MME) which is the amount of morphine (mg) equal to the strength of opioid prescribed. We utilized peripheral nerve blocks intraoperatively including a pudendal block along with a long buccal nerve block prior to buccal mucosa harvest, performed by infiltrating the buccal sulcus just distal to the last molar tooth. This strategy was implemented on December 2018 in efforts to decrease perioperative morbidity associated with buccal harvest. RESULTS: We identified 77 patients that underwent urethroplasty: 58% augmented and 26% anastomotic. 60% of patients did not receive any narcotics in the immediate postoperative period while 32.5% received 0.1-5 MME, and only 6.5% received >5 MME. When comparing groups before and after implementation of buccal nerve block, patients received 3.7 vs 1.18 MME (p=0.021) in the immediate postop period and 15.8 and 8.9 ME (p= 0.22) during admission. When breaking down by surgery type, we also noted a trend for patients who had augmented urethroplasty to have higher MME requirements. CONCLUSIONS: Non-narcotic alternatives following urethroplasty, such as NSAIDs and anticholinergics are viable options for pain control in certain patient cohorts. Our preliminary analysis demonstrates decreased need for post-operative narcotic pain control with intra-operative nerve blocks. Further studies will focus on identifying patient factors predictive of narcotic requirement to build an algorithmic approach that would minimize narcotic use and ultimately addiction. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e28-e28 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chase Mallory More articles by this author Alejandra Perez More articles by this author Adam Nolte More articles by this author Scott Jamieson More articles by this author Jessica Boyer More articles by this author Dhaval Jivanji More articles by this author Spencer Liem More articles by this author Billy Cordon More articles by this author Expand All Advertisement Loading ...