Postoperative Narcotics Research Articles

Periarticular Injection With or Without Adductor Canal Block for Pain Control Following Total Knee Arthroplasty

Periarticular injections (PAIs) have become a critical part of multimodal anesthetic regimens for total knee arthroplasty (TKA). This study assessed the effect of adductor canal blocks (ACBs) alone, periarticular injections (PAIs) alone, and the combination of both ACBs and PAIs on postoperative pain management in patients undergoing primary TKA. We hypothesized that there would be no significant difference in postoperative outcomes, including pain scores and narcotic use. Patients who underwent primary TKA were retrospectively identified from February 2022 to February 2023. Patients were stratified based on perioperative local/regional anesthetic regimen (PAI only, PAI with an ACB, and ACB only) and matched in a 1:1:1 ratio. Patients were propensity score matched based on age, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and preoperative narcotic usage. Patient demographics, as well as intra- and postoperative variables including narcotic refills, postoperative morphine requirements, pain scores, and readmissions, were compared. After successful matching, there were 40 patients in each cohort. First post-anesthesia care unit (PACU) visual analog pain scale (VAS) scores after surgery were not significantly different across all groups (P = 0.082). Pair-wise comparisons of patients receiving either PAI alone or ACB alone showed that patients receiving PAIs had lower narcotic usage at six hours (P = 0.037). A PAI alone also demonstrated a shorter length of stay compared to ACB alone (P = 0.001). Postoperative narcotics refills were similar between ACB only and PAI only (P = 0.056); however, PAI with an ACB had lower postoperative narcotic refills (P = 0.017). The rate of same-day physical therapy (PT) clearance was lowest in the ACB only group (37.5% [15 of 40]) (P = 0.002). As hypothesized, there was no difference in pain scores immediately after surgery; however, postoperative morphine requirements at six hours, same-day physical therapy clearance, and length of stay were better in the PAI group. The use of PAIs may confer a benefit for both patients and healthcare systems as an adjunct to perioperative pain control.

Bilateral Erector Spinae Plane Block versus Oblique Subcostal Transversus Abdominal Plane Block for Postoperative Analgesia of Adults Patients Undergoing Laparoscopic Cholecystectomy

Abstract Background Nerve root or myofascial irritation at the abdominal wall is a common cause of pain following surgeries such as cholecystectomy, cesarean section, prostatectomy, hysterectomy and transplant surgery. Aim of the Work to test the efficacy of ultrasound guided bilateral erector spinae plane block versus ultrasound guided bilateral oblique subcostal tap block as regards its efficacy, hemodynamic stability, onset of post-operative pain, amount of post-operative narcotics used. Patients and Methods In the current study fifty eight patients scheduled for elective laparoscopic cholecystectomy received general anesthesia were included. Patients were divided randomly into two groups, each group consisted 29 patients. Group A: Patients in this group received bilateral US guided ESP block at the end of surgery. Group B: Patients in this group received bilateral US guided OSTAP block at the end of surgery. Results As regard the analgesic parameters recorded; in the current study, the VAS was significantly lower in group A (ESP block) when compared with that of group B (OSTAP block) and showed significant difference between both groups at 6,8 and 10hrs postoperatively. Also, time to rescue analgesia, there was clinically and statistically highly significant longer time to 1st rescue analgesic in group A (ESP block) was 15.25±1.50 hours compared to that of group B (OSTAP) was 9.86±2.01 hours These findings were in an array with a case series done by Luis-Navarro and his colleagues who reported that the first rescue analgesic was required only at 16 hours after ESP block. In the current study, total morphine consumption “mg” with the mean total consumption in each of Group was 4.45±0.42 mg in the ESP group compared with 5.44±0.37 mg in the OSTAP group there was highly statistically significant higher mean of total analgesic consumption in group B compared to Group A. Conclusion bilateral ultrasound-guided ESP block provides more potent and longer postoperative analgesia with less morphine consumption than OSTAP block after laparoscopic cholecystectomy

Comparison of epidural infusion versus intrathecal morphine block as part of enhanced recovery after open pancreatoduodenectomy.

The accepted approach to pain management following open pancreatoduodenectomy (PD) remains controversial, with the most recent enhanced recovery after surgery (ERAS) protocols recommending epidural anesthesia (EA). Few studies have investigated intrathecal (IT) morphine, combined with transversus abdominis plane (TAP) blocks. We aim to compare the different approaches to pain management for open PD. Patients who underwent open PD at our institution from 2020 to 2022 were included in the study. Patient characteristics, pain management, and postoperative outcomes between EA, IT morphine with TAP blocks, and TAP blocks only were compared using univariate analysis. Fiftypatients were included in the study (58% male, median age 66 years [interquartile range,IQR: 58-73]). Most patients received IT morphine (N = 24, 48%) or EA (N = 18, 36%). The TAP block-only group required higher doses of postoperative narcotics while hospitalized (p = 0.004) and at discharge (p = 0.017). The IT morphine patients had a shorter median time to Foley removal (p = 0.007). Postoperative pain scores, non-opioid administration, postoperative bolus requirements, postoperative outcomes, and length of stay were similar between pain modalities. IT morphine and EA showed comparable efficacy with superior results compared to TAP blocks alone. Integration of IT morphine into PD ERAS protocols should be considered.

Complication rates and efficacy of single-injection vs. continuous interscalene nerve block: a prospective evaluation following arthroscopic primary rotator cuff repair without a concomitant open procedure

To compare the complications and efficacy of pain relief of the interscalene anesthetic block using either a single-injection (SI) vs. a continuous, indwelling catheter (CIC) for arthroscopic rotator cuff repair surgery. Patients undergoing primary, arthroscopic rotator cuff repair without concomitant open procedure or biceps tenodesis were prospectively enrolled by 4 fellowship-trained sports medicine and shoulder surgeons. Patients received either a SI or CIC preoperatively based on surgeon preference. Patients were contacted by phone to complete a standard questionnaire on postoperative days (PODs) 1, 3, 7, 14, and 28. Patients were asked to rate the efficacy of their subjective pain relief (scale of 0-10), document issues with the catheter, describe analgesic usage, and report pharmacological and medical complications. The primary outcome was measured as complication rate. Postoperative narcotic use, patient satisfaction, and visual analog scale pain scores were measured as secondary outcomes. Seventy patients were enrolled, 33 CIC patients (13 male, 20 female, mean age 61±8 years) and 37 SI patients (20 male, 17 female, mean age 59±10 years). There were significantly more injection/insertion site complications in the CIC group (48%) vs. the SI group (11%, P=.001). The incidence of motor weakness was higher in the CIC group on POD 1 (P=.034), but not at any subsequent time points. On POD 1, CIC patients had a clinically significantly lower pain score compared to SI (3.2 vs. 5.4; P=.020). Similar scores were observed at subsequent time points until POD 28, when CIC again had a lower pain score (0.8 vs. 2.7; P=.005). However, this did not reach clinical significance. All patients in both groups rated a satisfaction of 9 or 10 (scale 0-10) with the anesthesia provided by their nerve block. CIC interscalene nerve blocks had an increased risk for injection site complications and minor complications in the immediate postoperative period when using the CIC for arthroscopic rotator cuff repair without any concomitant open procedures. CIC blocks demonstrated clinically significant superior pain relief on POD 1 but were equal to SI blocks at every time point thereafter. Superior pain relief of CIC at POD 28 was not clinically significant. CIC catheters do not appear to markedly decrease the use of postoperative narcotics. Despite this trend in complication rates and pain scores, all patients in both groups were satisfied with their nerve block.

Improved perioperative narcotic usage patterns in patients undergoing robotic-assisted compared to manual total hip arthroplasty

BackgroundRobot-assisted total hip arthroplasty (RA-THA) improves accuracy in achieving the planned acetabular cup positioning compared to conventional manual THA (mTHA), but optimal dosage for peri-RA-THA and mTHA pain relief remains unclear. This study aimed to compare pain control with opioids between patients undergoing direct anterior approach THA with the use of a novel, fluoroscopic-assisted RA-THA system compared to opioid consumption associated with fluoroscopic-assisted, manual technique.MethodsRetrospective cohort analysis was performed on a consecutive series of patients who received mTHA and fluoroscopy-based RA-THA. The average amount of postoperative narcotics in morphine milligram equivalents (MME) given to each cohort was compared, including during the in-hospital and post-discharge periods. Analyses were performed on the overall cohort, as well as stratified by opioid-naïve and opioid-tolerant patients.ResultsThe RA-THA cohort had significantly lower total postoperative narcotic use compared to the mTHA cohort (103.7 vs. 127.8 MME; P < 0.05). This difference was similarly seen amongst opioid-tolerant patients (123.6 vs. 181.3 MME; P < 0.05). The RA-THA cohort had lower total in-hospital narcotics use compared to the mTHA cohort (42.3 vs. 66.4 MME; P < 0.05), consistent across opioid-naïve and opioid-tolerant patients. No differences were seen in post-discharge opioid use between groups.ConclusionsFluoroscopy-based RA-THA is associated with lower postoperative opioid use, including during the immediate perioperative period, when compared to manual techniques. This may have importance in rapid recovery protocols and mitigating episode burden of care.

Evaluation of surgical complications after herniated spinal lumbar disc surgery

ObjectiveOne of the important and common complications of spinal surgery is Failed Back Surgery Syndrome (FBSS). The most significant symptom of this syndrome is prolonged pain after the surgery, which comes with many complications.Due to the importance of chronic pain after spinal surgeries and its complications, we have decided to investigate the prevalence of acute and chronic pain and other consequences after lumbar disc herniation surgery. MethodsIn this descriptive retrospective cohort study, 236 patients were selected using the available sampling method. Then, these patients were evaluated for complications such as worsening pain, the need for repeat surgery, mortality rate, and the level of symptom improvement.The checklist includes demographic information about the patient and information during and after surgery, which can be extracted from the patient's medical record. Additionally, the patient's preoperative pain severity and the occurrence and severity of acute and chronic pain after surgery, sensory and motor disability after surgery, and the need for repeat surgery are extracted through telephone contact with the patient, using the VAS scale as a criterion. ResultsIn this study, out of 236 patients who underwent discectomy surgery, 115 female patients (48.7 %) and 121 male patients (51.3 %). The mean age of this study was 51.81 years, with the minimum age being 36 and the maximum age being 60 years.70 patients (66.29%), experienced postoperative complications in this study. Of these, 15 patients (3.6%) experienced only acute pain, 16 patients (7.6%) experienced only chronic pain, and 39 patients (5.16%) experienced both acute and chronic pain. In addition, 42 patients (8.17%) experienced sensory-motor deficits after the operation, and 24 patients (2.10%) required further surgery after the first operation. ConclusionAge and smoking are among the influential factors in the surgical outcome for the patient. In addition, a history of underlying disease, especially diabetes, can have an impact on the occurrence of pain and sensory-motor disability after the operation. Among the effective therapeutic factors in the surgical outcome, the length of surgery and the use of postoperative narcotics can be mentioned. Additionally, the type of surgical technique and anesthesia can also be influential factors in the surgery, which require further study with a larger population and a variety of surgical techniques and anesthesia.

Ultrasound-Guided Rectus Sheath Block versus Transversus Abdominus Plane Block for Post-Operative Analgesia in Elective Cesarean Section

Abstract Background Nerve root or myofascial irritation at the abdominal wall is a common cause of pain following surgeries such as cesarean section, cholecystectomy, prostatectomy, hysterectomy and transplant surgery. Aim of the Work The aim of this study is to test the efficacy of ultrasound guided TAP block versus ultrasound guided rectus sheath block as regards its efficacy, hemodynamic stability, onset of post-operative pain, amount of post-operative narcotics used. Patients and Methods In the current study eighty patients who received spinal anesthesia were included. Patients were divided randomly into two groups, each group consisted of 40 patients. Group A: Patients in this group received bilateral US guided TAP block at the end of surgery. Group B: Patients in this group received bilateral US guided rectus sheath block at the end of surgery. Results These result met with another study, Ayman Saleh et al which shows the time for first analgesic request (minutes) was significantly increased in TAP when compared to RS block groups (332.50±42.93 vs 220.10±21.51 minutes, respectively). Also, the total analgesic consumption (mg) was significantly reduced in TAP when compared to RS block groups respectively (90.40±27.02 vs 157.00±37.80 mg, respectively). Conclusion Ultrasound-guided TAP block was more effective than ultrasound-guided RS block in patients undergoing cesarean delivery with prolonged postoperative analgesia, less analgesics consumption and less postoperative nausea and vomiting.

Virtual reality for the treatment of postoperative pain after laparoscopic hysterectomy for benign Indications: A randomized controlled trial

ObjectiveThe primary objective of this study was to determine if immediate post-operative use of virtual reality impacts pain scores or opioid consumption following hysterectomy. Study DesignA randomized controlled trial was performed at a university associated tertiary referral hospital in the United States among patients undergoing laparoscopic hysterectomy for benign indications. Prior to surgery, participants were randomized to use a VR program versus routine care postoperatively in the post anesthesia care unit. Postoperative pain was measured using visual analogue scale, and morphine milligram equivalent to quantify narcotic usage. Patient satisfaction was assessed with a survey. A total of 15 patients were randomized to the virtual reality intervention and 15 to the standard care group. The test statistic was a one-sided T-test, with a significance level targeted of 0.05. Categorical variables were analyzed using chi-square analysis and t-test for continuous variables. Pain score differences between the virtual reality and standard care groups at each time assessment were compared using the Wilcoxon Rank Sum test. ResultsThe use of virtual reality did not significantly affect pain scores or postoperative narcotics required; however, it did have a positive impact on the subject’s perception of their postoperative course. No adverse events were reported. ConclusionAlthough virtual reality use following hysterectomy did not improve pain scores or decrease narcotic usage, it was well received by patients.

The impact of intraoperative intravenous lidocaine infusion on early postoperative pain after complex spine surgeries

BackgroundThis study aimed to assess the effect of intravenous lidocaine infusion affected on early postoperative pain control after complex spin surgeries.Ninety patients who were scheduled for complex spine surgery were included in this prospective double-blinded controlled trial. They were randomly assigned to one of two groups: L and P. Patients in group L received a loading dose of lidocaine 1 mg/kg then followed by 1.5 mg/kg/h infusion till the end of the surgery, while in group P, lidocaine was replaced with normal saline.ResultsThe pain score assessed by VAS at rest showed statistically significant lower values in group L at 30 min, 8, 12, and 24 h postoperatively. VAS during movement was significantly higher in group P only after 24 h postoperatively. The entire dose of intraoperative fentanyl consumed was significantly lower in group L. The time elapsed to ask for the first dose of rescue analgesia was significantly longer in group L. The first rescue dose of nalbuphine was significantly lower in group L. In group P, the overall dose of narcotics consumed in the first postsurgical day was significantly higher.ConclusionsWhen compared to placebo, lidocaine infusion significantly reduced the postoperative pain scores, as well as the entire dose of intraoperative and postoperative narcotics used.

The I-STOP Program and Narcotic Prescriptions Following Facial Reconstructive Plastic Surgeries.

To explore the effect of e-prescribing requirements on narcotic dispersion in New York State. Slicer Dicer was used to identify patient records based on CPT codes. We investigated the influence of New York State e-prescribing requirements on narcotic dispersion following five common facial plastics procedures. Slicer Dicer was used to identify patient records based on CPT codes.We then looked at narcotic prescription rates following those surgeries between March 2014 and March 2018 at an academic institution. Overall, between March 2014 and March 2018, 76.1% of the sample received a narcotic prescription following a facial reconstructive plastic surgery. Patients who underwent rhinoplasty were most likely to receive a prescription for postoperative narcotics. The implementation of ISTOP, CPT code, use of non-narcotic adjuvant, and insurance type were each significantly associated with prescription of postoperative narcotics. Surgery time and age in years were significantly associated with prescription of postoperative narcotics. Ultimately, when controlling for the aforementioned clinical and sociodemographic variables included in the study, those who underwent surgery after the implementation of ISTOP were 42.8% less likely to receive a prescription for postoperative narcotics, aOR = 0.572, 95% CI 0.356, 0.919, p = 0.021. New York State's ISTOP program has succeeded in reducing the number of postoperative narcotic prescriptions following facial plastic reconstructive surgeries at this academic institution. However, opioid medications can still be utilized for postoperative analgesia when clinically appropriate. 3 Laryngoscope, 134:1208-1213, 2024.

MP62-20 EFFECTS OF ADJUVANT DEXMEDETOMIDINE IN DORSAL PENILE BLOCK FOR PENILE PROSTHESIS IMPLANTATION

You have accessJournal of UrologyCME1 Apr 2023MP62-20 EFFECTS OF ADJUVANT DEXMEDETOMIDINE IN DORSAL PENILE BLOCK FOR PENILE PROSTHESIS IMPLANTATION Kikuye Sugiyama, Amanda Swanton, Tejash Shah, and Ricardo Munarriz Kikuye SugiyamaKikuye Sugiyama More articles by this author , Amanda SwantonAmanda Swanton More articles by this author , Tejash ShahTejash Shah More articles by this author , and Ricardo MunarrizRicardo Munarriz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) surgery is the gold standard treatment for medication-refractory erectile dysfunction. While highly satisfactory, post-operative pain and narcotic requirement remains a concern. Use of intraoperative dorsal penile nerve block with long acting local anesthetic can improve postoperative analgesia. Recent studies in non-urologic fields have demonstrated prolonged analgesia with minimal adverse effects with local nerve blocks containing long acting local anesthetic with either dexamethasone or dexmedetomidine. This study aims to evaluate the analgesic efficacy of these adjuvants in bupivacaine penile nerve block as compared to a bupivacaine-only block during primary IPP surgery. METHODS: This is a retrospective single institution IRB-approved comparative study of patients undergoing primary IPP placement receiving intraoperative dorsal penile nerve block with either 0.25% bupivacaine (2019) versus combination block with 0.25% bupivacaine+70 µg dexmedetomidine+4 mg dexamethasone (2020 - 2021). The primary outcome was pain during the first 24 hours post-operatively (0, 2, 6, 12, 18, and 24 hrs) while secondary outcomes were intra- and postoperative narcotic use, intraoperative hypotension defined here as MAP<60 for more than 5 minutes or requiring intervention, and intraoperative bradycardia defined here as HR<50 for more than a minute. RESULTS: Of 98 the patients included, 32 received bupivacaine only and 66 received the combination block. Mean PACU pain in the first 24 hours at all times (0, 2, 6, 12, 18, 24 hrs) were significantly lower in the combination block group (1.1 vs 3.8, 1.6 vs 3.9, 3.1 vs 4.9, 2.4 vs 4.3, 2.9 vs 5.3, 2.3 vs 4.4; p<0.05). Mean total postoperative narcotics was lower for the combination block (46 vs 65, p<0.05). There was no significant difference in intraoperative narcotics between groups (111 vs 132; p=0.133). Of patients who received the combination block, 4 had intraoperative hypotension of MAP<60 for more than 5 minutes and 114 had bradycardia below 50 but did not require intervention. CONCLUSIONS: Intraoperative dorsal penile nerve block consisting of long acting local anesthetic mixed with dexmedetomidine and dexamethasone can safely enhance immediate post-operative analgesia and decrease opioid consumption in the first 24 hours after surgery. A prospective randomized study is underway to further evaluate outcomes. This type of combination penile nerve block may also be a useful tool for other penile and scrotal surgeries. Source of Funding: Unfunded © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e870 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kikuye Sugiyama More articles by this author Amanda Swanton More articles by this author Tejash Shah More articles by this author Ricardo Munarriz More articles by this author Expand All Advertisement PDF downloadLoading ...

The characteristics of opioid use in patients with proximal humerus fractures.

Orthopaedic surgeons prescribe more opioid narcotics than any other surgical specialty. Proximal humerus fractures (PHF) often occur in the high-risk elderly population. The opioid epidemic has led to public policy aimed at reductions in opioid prescription. This study aimed to evaluate the impact that new legislation has had on opioid prescription patterns in patients who sustained proximal humerus fractures. A retrospective review of all patients who sustained PHF at a single academic institution from 1/1/2015-12/31/2019 was performed. A total of 762 proximal humerus fractures were identified and final analysis included 383 patients. Collected data included basic demographics and opioid prescriptions obtained through review of the electronic medical record. The North Carolina Strengthen Opioid Misuse Prevention act legislation that went into effect on July 1, 2017. There was no difference in the number of pre- or postoperative opioid prescriptions provided with the new legislation. Our data showed a significant reduction in MeQs prescribed preoperatively pre-STOP act (188.1 MeQs) and post-STOP act (99.4 MeQs). There was also a significant difference in the amount of postoperative narcotics prescribed in the pre-STOP (972.6 MeQs) and post-STOP act (508.6 MeQs) groups (p < 0.01). With the enactment of the STOP act in North Carolina, we have seen a significant reduction in the amount of narcotic prescribed after sustaining a proximal humerus fracture preoperatively and postoperatively. This data demonstrates the impact that implementation of state-wide regulatory changes in opioid prescribing policy has had for a common orthopedic condition.

40 Pre-operative non-narcotic analgesia decreases the use of postoperative narcotics

40 Pre-operative non-narcotic analgesia decreases the use of postoperative narcotics

Elimination of Postoperative Narcotics in Infant Robotic Pyeloplasty Using Caudal Anesthesia and a Non-Narcotic Pain Pathway.

Introduction: Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary for postoperative pain control in most infants undergoing robotic pyeloplasty. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of eliminating postoperative narcotics after infant robotic pyeloplasty. Methods: We reviewed 24 consecutive patients who underwent robotic pyeloplasty by a single surgeon treated with an end-procedure caudal block followed by a non-narcotic postoperative pain pathway treated between May 2017 and May 2021. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating intravenous acetaminophen and ketorolac. We reviewed demographics, outcomes, and unscheduled health care encounters within 30 postoperative days. Results: Sixty-three percent (15/24) of patients were male and average age was 12.1 months (range 4-34 months). Fifty-eight percent (9/15) underwent surgery on the left, and 16.7% (4/24) of patients received a single postoperative dose of narcotics in the postanesthesia care unit. No patient required narcotic prescriptions at discharge or anytime thereafter. The average length of stay was 1.13 days. There was no pain-related unscheduled visits or phone calls after discharge. Conclusions: This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. Postprocedure caudal block is a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use.

Evaluating the Efficacy of Employing Local Anesthetic Prostatic Blocks During Rezum Procedure.

Introduction Rezum is a minimally invasive, outpatient procedure using convective water vapor to relieve outlet obstruction from benign prostatic hyperplasia (BPH). Evidence on the technical approach of Rezum therapy, particularly pain control, is lacking. The purpose of this study was to evaluate the efficacy of utilizing a local anesthetic prostate block for postoperative pain control during Rezum therapy for BPH. A multimodal approach is typically utilized for pain control during and after Rezum. However, little is known about which elements are most critical. Methods This is a single-center retrospective study of 109 patients who underwent Rezum for BPH. Patients were then divided into two groups: Local anesthetic prostatic block verse no local anesthetic prostatic block for the procedure. A phone survey was performed to assess the patients' subjective pain scores and postoperative analgesics usage. A comparison of reported pain scores on a 0-10 Likert scale as well as usage of prescription and non-prescription analgesics medications was performed. Results There were 109 patients who underwent Rezum therapy, and 86 (79%) of patients responded to phone surveys. There was no significant difference in postoperative pain scores between patients who received local anesthetic prostatic block vs those who did not (2.10 vs 3.03). Similarly, there were no significant differences in postoperative narcotics or non-prescription analgesic medications usage. Conclusion Our data suggest that when performing Rezum using conscious sedation in the operating room or cystoscopy suite, it is unnecessary to perform a local anesthetic prostate block as it has no significant effect on patient-reported pain or the use of analgesics in the postoperative period.

Opioid Use After Laparoscopic Surgery for Endometriosis and Pelvic Pain

The primary objective was to quantify postoperative opioid use after laparoscopic surgery for endometriosis or pelvic pain. The secondary objective was to identify patient characteristics associated with greater postoperative opioid requirements. Prospective, survey-based study in which subjects completed 1 preoperative and 7 postoperative surveys within 28 days of surgery regarding medication usage and pain control. Tertiary care, academic center. A total of 100 women with endometriosis or pelvic pain. Laparoscopic same-day discharge surgery by fellowship-trained minimally invasive gynecologists. A total of 100 patients were recruited and 8 excluded, for a final sample size of 92 patients. All patients completed the preoperative survey. Postoperative response rates ranged from 70.7% to 80%. The mean number of pills (5 mg oxycodone tablets) taken by day 28 was 6.8. The average number of pills prescribed was 10.2, with a minimum of 4 (n=1) and maximum of 20 (n=3). Previous laparoscopy for pelvic pain was associated with a significant increase in postoperative narcotic use (8.2 vs 5.6; p=.044). Hysterectomy was the only surgical procedure associated with a significant increase in postoperative narcotic use (9.7 vs 5.4; p=.013). There were no difference in number of pills taken by presence of deep endometriosis or pathology-confirmed endometriosis (all p >.36). There was a trend of greater opioid use in patients with diagnoses of self-reported chronic pelvic pain, anxiety, and depression (7.9 vs 5.7, p=.051; 7.7 vs 5.2, p=.155; 8.1 vs 5.6, p=.118). Most patients undergoing laparoscopic surgery for endometriosis and pelvic pain had a lower postoperative opioid requirement than prescribed, suggesting surgeons can prescribe fewer postoperative narcotics in this population. Patients with a previous surgery for pelvic pain, self-reported chronic pelvic pain syndrome, anxiety, and depression may represent a subset of patients with increased postoperative opioid requirements.

Pediatric Outcomes following Cranial Vault Remodeling with Restricted Use of Postoperative Narcotics: A Retrospective Review.

The appropriate use of narcotics for postoperative pain control is controversial because of potential medication-induced complications. The authors sought to determine the effects of narcotics in the pediatric population following cranial vault remodeling operations. A retrospective review was performed on 160 consecutive patients who underwent cranial vault remodeling for craniosynostosis. There was a statistically significant difference in total morphine equivalents in the group that experienced no emesis and those with at least one episode of emesis (0.97 morphine equivalents/kg versus 1.44 morphine equivalents/kg; p = 0.05). There was a statistically significant difference in hospital morphine equivalents in the group with documented respiratory events (average, 2.3 morphine equivalents/kg versus 1.3 morphine equivalents/kg in the nonevent group; p = 0.006). The patients who received dexmedetomidine had a trend toward a decrease in hospital narcotic administration with equivalent pain control (1.2 morphine equivalents/kg versus 1.9 morphine equivalents/kg; p = 0.09). There was a statistically significant positive correlation between total morphine equivalents for the hospitalization and hospital stay ( r = 0.27, p = 0.001). The amount of morphine equivalents used in the first 24 hours was also found to be an independent predictor of a respiratory event ( p = 0.002 by multivariate logistic regression). Independent positive predictors of hospital stay were age ( p < 0.001), intensive care unit time ( p < 0.001), and total morphine equivalents for the hospitalization ( p = 0.001) by multivariate analysis with linear regression. The authors' study demonstrates improvement in outcomes with decreased use of narcotics, which establishes that there is a need to further explore postsurgical recovery outcomes with multimodal pain control. Therapeutic, III.

Auricular Framework Construction Using Cadaveric Costal Cartilage in Type III Microtia: Preliminary Results.

Non/minimally irradiated Cadaveric Costal Cartilage (NCCC) is commonly used for grafts in nasal reconstruction; however, no information exists on its use in total ear reconstruction for type III microtia. In this case series we describe preliminary results from the novel use of NCCC for auricular framework construction in 7 ear reconstructions. Patients requiring total ear reconstruction from August 2020 to October 2021 were eligible and underwent ear reconstruction using NCCC from MTF Biologics (Edison, NJ). Patients were evaluated for surgical site infection, skin necrosis, cartilage exposure, warping, and resorption during regular follow up visits. Seven ears were reconstructed using NCCC across 5 patients with type III microtia. Patients ranged from 5 to 51 years old at the time of surgery. Follow up time ranged from 12 to 78 weeks (mean: 46wk). No patients experienced surgical site infections or significant cartilage resorption. All procedures were done outpatient, total time under anesthesia was <90 minutes in 5/7 cases and postoperative narcotics for pain management were not needed in 5/7 cases. Complications included minor skin necrosis that was repaired via primary closure, construct exposure in the immediate postoperative period, which was successfully salvaged with a local flap, and explantation of one construct after reconstruction for a complicated revision surgery involving a previous temporoparietal fascial flap. NCCC serves as an immediately available alternative to alloplastic and autologous materials for construction of auricular frameworks during ear reconstruction. Longer follow up times and a larger sample size will further elucidate long-term efficacy.

Enhanced recovery after surgery protocol is associated with a lower postoperative opioid use and a reduced postoperative office burden (470)

<b>Objectives:</b> Patients receiving postoperative opioids have a dosedependent risk of misuse and addiction. While the introduction of the enhanced recovery after surgery (ERAS) protocol has been shown to decrease hospital narcotic use, less attention has been directed towards the impact of ERAS on the clinic burden with respect to postoperative care. The objective of our study was to determine the impact of an ERAS protocol on narcotic prescription patterns after laparoscopic gynecologic surgery measured as the number of prescription pain medication refill requests, clinic phone calls, and unscheduled visits in the 30-day postoperative period. <b>Methods:</b> This retrospective study compared postoperative narcotic prescriptions and clinic burden ten months prior to and ten months following the implementation of a standard ERAS protocol after laparoscopic gynecologic surgery. The study included patients who underwent surgeries between January 2018, and July 2019, with the ERAS implementation in November 2018. The total oral morphine milligram equivalents (MMEs) prescribed postoperatively, and the number of unscheduled clinic visits and phone calls were compared before and after the implementation of the ERAS protocol. Postoperative prescribing practices were not standardized during the study period. <b>Results:</b> A total of 791 patients were identified with clinic follow-up; 445 before and 346 after ERAS implementation. All patients underwent laparoscopic or robotic-assisted surgery alone or in combination with mini-laparotomy. Baseline characteristics, including procedure, diagnosis, smoking, and alcohol use did not differ between groups. Use of ERAS was associated with higher rates of same-day discharge (49% vs 39%, p=0.003) and lower readmission rates (2.0% vs 5.6%, p=0.011). Postoperatively, patients who received the ERAS protocol were prescribed significantly less narcotics (197.8 vs 223.5 MMEs, p=0.0087) even though the postop narcotic doses were not specified. The number of refill requests was lower with ERAS (1.7% vs 3.6%, p=0.11). ERAS was associated with a lower chance of postoperative clinic phone calls (38% vs 46%, p=0.023), including calls for pain (10% vs 16%, p=0.021). There was a decrease in unscheduled visits related to pain (1.5% vs 5.8%, p=0.001), and a trend towards a decrease in the number of overall unscheduled visits (14% vs 18%; p=0.08) after ERAS implementation. <b>Conclusions:</b> Implementation of the ERAS protocol after laparoscopic gynecologic surgery resulted in a decrease in postoperative opioid prescribing and a lower incidence of unplanned interactions with the clinic staff, despite the lower amount of prescribed postoperative narcotics.

Eliminating postoperative opioid prescriptions is associated with lower long term opioid use (523)

<b>Objectives:</b> Since postoperative narcotics have been associated with the risk of long-term opioid use, they are no longer prescribed at our institution for patients undergoing robotic surgery for endometrial hyperplasia or endometrial carcinoma. This study compared postoperative narcotic use in the current cohort with a historical cohort who were prescribed postoperative opioids to assess the effect of the change in practice. <b>Methods:</b> We performed a retrospective chart review of 123 patients who underwent a robotic hysterectomy for endometrial hyperplasia or carcinoma. Group 1 patients underwent surgery between August 2017 and February 2018 and received opioid prescriptions. Group 2 underwent surgery between January and June 2020 and did not receive postoperative opioid prescriptions. We reviewed medical records and the New York State Internet System for Tracking Over-Prescribing (I-STOP), which reports all narcotic prescriptions filled in the state in the past 12 months. Narcotic use was assessed in one- month intervals for a total of 12 months after surgery. Demographic information, including diagnosis, histology, adjuvant therapy, insurance, median income based on zip code, and medical comorbid conditions, were collected. Results were analyzed using a hierarchical Bayesian ordinal regression model to determine whether Group 2 had a lower risk of opioid use and to evaluate other possible factors. The variable of interest was the time (months) from surgery to the patient filling an opiate prescription. <b>Results:</b> Group 1 had 57 patients, and Group 2 had 66 patients. There was no significant difference in age, median income, cancer stage, grade, histology, or adjuvant therapy between the groups. Group 1 had significantly more patients with private insurance (93% vs 53% p <0.0001) and fewer patients with favorable CCI scores of 1-4 (70% with vs 50%, p 0.02) compared to Group 2; however, only private insurance remained significant after Bonferroni correction. Prescriptions for opioids were filled more often by patients in Group 1 than Group 2 at immediate postop 0-1 months (79% vs 7%), 1-6 months (14% vs 6%) and 6-12 months (17% vs 6%). Opioid use was significantly higher across all measured time frames in patients who were prescribed postoperative opioids with a mean effect size of -0.99 with a 95% credible interval of -1.93 to -0.11. Lower Grade endometrial cancer was also associated with reduced opioid use with a mean effect size of -2.66 with 95% credible interval of -4.7 to -0.45 for Grade 1 and mean effect size -2.18 with 95% credible interval -4.4 to -0.16 for Grade 2. Fig. 1 <b>Conclusions:</b> Eliminating postoperative opioid prescriptions was associated with a significant decrease in both short- and long-term opioid use. While insurance type varied between the two groups, this was not an independent risk factor. The clinical relevance of the association of grade with opioid use is unclear as there was no association with stage or adjuvant therapy. Limitations of our study are the small sample size and possible confounders, including increasing awareness of the opioid crisis and a change in prescribing practices by other providers over time. This study supports avoiding prescribing opioids in the postoperative period.