Postoperative Narcotics Research Articles

Randomized comparison between interscalene and costoclavicular blocks for arthroscopic shoulder surgery

BackgroundThis randomized trial compared ultrasound-guided interscalene block (ISB) and costoclavicular brachial plexus block (CCB) for arthroscopic shoulder surgery. We hypothesized that CCB would provide equivalent analgesia to ISB 30 min...

Prepectoral Direct-to-Implant Breast Reconstruction: Early Outcomes and Analysis of Postoperative Pain.

BackgroundDirect-to-implant (DTI) breast reconstruction provides high-quality aesthetic results in appropriate candidates. Most commonly, implants are placed in the subpectoral space which can lead to pain and breast animation. Surgical and technological advances have allowed for successful prepectoral implant placement which may eliminate these trade-offs.ObjectivesHere we present early outcomes from 153 reconstructions in 94 patients who underwent prepectoral DTI. We sought to determine whether these patients have less postoperative pain and narcotic use than subpectoral implant or expander placement.MethodsA retrospective review was performed for all prepectoral DTI reconstructions at our institution from 2015 to 2016. Data were collected on postoperative pain and narcotic use while in hospital.ResultsThe average follow-up time was 8.5 months (range, 3–17 months) and the overall complication rate was 27% (n = 41) with the most common complications being skin necrosis (9%, n = 13) and infection (7%, n = 11). No statistically significant difference in complications was found in patients who underwent postmastectomy radiation therapy. Patients who underwent prepectoral DTI reconstruction did not have a statistically significant difference in postoperative pain and narcotic use while in-hospital compared with other techniques.ConclusionPrepectoral DTI reconstruction provides good results with similar complication rates to subpectoral techniques. Prepectoral DTI eliminates the problem of breast animation. Although our series did not reach statistical significance in pain scores or requirement for postoperative narcotics, we believe that it is an important preliminary result and with larger numbers we anticipate a more definitive conclusion.Level of Evidence: 4

04: Impact of statewide legislation on opioid prescribing following hysterectomy and hysteroscopy

To determine the oral morphine equivalents (OMEs) prescribed and refill rates following hysterectomy and hysteroscopy in the setting of statewide legal changes to opioid prescribing across two states. Patients undergoing hysterectomy (including concomitant procedures for oncology and urogynecology cases) and hysteroscopy (diagnostic and operative) from January 2011 through July 2018 were identified using Current Procedural Terminology (CPT) procedure codes in our institution’s databases in two affiliated hospitals (Arizona and Florida). Hysterectomy was chosen as the most invasive gynecologic procedure requiring the most postoperative narcotic medication, while hysteroscopy was chosen as the least invasive necessitating the fewest postoperative narcotics. Opioid prescriptions at time of discharge and refills within 30 days were identified and converted to OMEs. OMEs were calculated per quarter year. In Arizona, the Arizona Opioid Epidemic Act was passed in January 2018 and went into effect in April 2018; this limited prescriptions to 90 OMEs per day for five days. In Florida, House Bill 21 restricted prescribing of Schedule II medications to three days for acute pain or up to seven days when medically necessary. The law was signed in March 2018 and took effect in July 2018. Prior to these changes, there were a number of informal provider-led initiatives in both departments to reduce opioid prescribing given the media attention to the subject. Our study compares prescribed OMEs and refill rates before and after the first quarter in 2018. In Arizona, 2204 hysterectomies were performed during the study period; 1077 (49%) were vaginal, 1002 (45%) were laparoscopic/robotic, and 125 (6%) were abdominal. There were 1196 hysteroscopies. Median OMEs for all four procedure types were unchanged before and after 2018 (225). The overall opioid refill rate decreased, from 10% prior to 2018 versus 4% after 2018 (p value 0.0004). In Florida, there were 1459 hysterectomies; 380 (26%) vaginal, 936 (64%) laparoscopic/robotic, and 143 (10%) abdominal. There were 972 hysteroscopies. Overall median OMEs decreased from 245 prior to 2018 to 0 after 2018, p value <0.0001. The opioid refill rate decreased, from 8% prior to 2018 versus 4% after 2018 (p value 0.01). Figure 1 shows the OME trends by surgical procedure and hospital site over time. Many state governments have implemented laws to encourage safe prescribing of controlled substances. Our study demonstrates that the legislative changes sustained preexisting decreases in opioid prescribing in Florida but not in Arizona. In addition, significant reductions in opioid refills after 2018 were observed in both sites. Gynecologic surgeons must not only participate in safe prescribing practices, but also educate patients about pain control alternatives to further decrease opioid dependence and misuse.

Risk Factors for a Long Hospital Stay Following Minimally Invasive Lumbar Discectomy.

Retrospective cohort study. The purpose of the study was to determine risk factors for discharge after postoperative day (POD) 0 in patients undergoing 1-level minimally invasive lumbar discectomy (MIS LD). MIS LD has proven to be an effective treatment modality for low back pain and radiculopathy associated with intervertebral disc herniations. With increasing focus on cost reduction and value-based care, minimization of postoperative length of stay has become an important topic for physicians and hospital administrators. A prospectively maintained surgical database of patients who underwent 1-level MIS LD by a single surgeon from 2011 to 2016 was reviewed. Long length of stay was defined as discharge after POD 0. Bivariate and stepwise multivariate Poisson regression with robust error variance was used to determine risk factors for discharge after POD 0. Variables analyzed included patient demographics, comorbidities, operative characteristics, preoperative pain scores, postoperative inpatient pain scores, and postoperative narcotics consumption. A total of 176 patients were included; 9.7% of included patients were discharged on POD 1 or later. On bivariate analysis, diabetic status (57.1% vs. 7.7%; relative risk [RR]=7.43; P<0.01) and narcotic consumption <6.00 oral morphine equivalents/h (13.1% vs. 1.2%; RR=11.11; P=0.019) were associated with a prolonged length of stay. On stepwise multivariate analysis, diabetic status (RR=10.5; 95% confidence interval, 3.60-30.98; P<0.001) was found to be independently associated with a prolonged length of stay after MIS LD. The results indicate that diabetic status is an independent risk factor for increased LOS following single-level MIS LD. Delayed hospital discharge can lead to increased costs, increased risk of complications, and decreased patient satisfaction. Thus, providers can use this information to better counsel diabetic patients and monitor them more closely following MIS LD. Additional work must be done to better understand risk factors for increased length of stay following MIS LD in procedure-specific populations. Level II.

Feasibility of primary sternal plating for morbidly obese patients after cardiac surgery

BackgroundMorbidly obese patients (body mass index [BMI] ≥ 35 kg/m2) who undergo cardiac surgery involving median sternotomy have a higher-than-normal risk of sternal dehiscence. To explore a potential solution to this problem, we examined the utility of transverse sternal plating for primary sternal closure in morbidly obese cardiac surgical patients.MethodsWe retrospectively reviewed data from cardiac surgical patients who underwent single primary xiphoid transverse titanium plate reinforcement for primary sternal closure from August 2009 to July 2010 (n = 8), and we compared their outcomes with those of patients with BMI ≥35 kg/m2 who underwent cardiac surgery without sternal plate reinforcement from April 2008 to July 2009 (n = 14). All cases were performed by the same surgeon.ResultsThe 2 groups of patients had similar demographics and comorbidities (P > 0.05 for all). All patients with sternal plate reinforcement reported sternal stability at last follow-up (at a median of 27 months postoperatively; range, 8.4–49.3 months), whereas 1 patient (7.1%) who underwent standard closure developed sterile sternal dehiscence (P = 0.4). Postoperative patient-controlled analgesia (PCA) morphine usage was significantly higher for patients without sternal plate reinforcement than for patients who had sternal plate reinforcement (3.6 mg/h vs 1.3 mg/h, P = 0.008). No patient in the sternal plate group had wound seroma or perioperative complications attributable to sternal closure technique.ConclusionSingle xiphoid transverse plate reinforcement for primary sternal closure is a feasible option for morbidly obese patients, who are otherwise at high risk of developing sternal dehiscence. Using this technique may decrease postoperative narcotics usage.Ultramini abstractMorbidly obese patients (body mass index ≥35 kg/m2) have a higher-than-normal risk of sternal dehiscence after cardiac surgery. In a pilot study, we found that those who underwent transverse sternal plating (n = 8) had no sternal dehiscence and required less postoperative analgesia than patients who underwent standard wire closure (n = 14).

Short-term outcomes after laparoscopic cytoreductive surgery in patients with limited peritoneal metastases from colorectal cancer

The purpose of this study was to investigate the safety of laparoscopic cytoreductive surgery versus open surgery for patients with limited peritoneal metastases from colorectal cancer. Laparoscopic surgery for patients with colorectal cancer with peritoneal metastases has been performed at our institution since December 2004. We retrospectively evaluated data from patients with colorectal cancer metastatic to the peritoneum, with a peritoneal cancer index ≤10. We compared short-term operative and survival outcomes in the laparoscopic cytoreductive surgery group and open cytoreductive surgery group. A total of 21 patients underwent open cytoreductive surgery and 42 underwent laparoscopic cytoreductive surgery, of whom 6 (14%) required open conversion. Clinicopathologic characteristics and operative outcomes were comparable between the groups. Complete cytoreduction was achieved in all patients in the laparoscopic cytoreductive surgery group and in 19 patients (91%) in the open cytoreductive surgery group (P = .042). Both the mean hospital stay and use of postoperative narcotics were significantly less in the laparoscopic cytoreductive surgery group than in the open cytoreductive surgery group. The type of operation (open cytoreductive surgery versus laparoscopic cytoreductive surgery) was not related to survival outcomes. With careful selection by experienced laparoscopic surgeons, laparoscopic cytoreductive surgery was technically feasible and safe to treat colorectal cancer patients with limited peritoneal metastases.

Sphincter of Oddi dysfunction: sphincter of Oddi dysfunction or discordance? What is the state of the art in 2018?

To review important manuscripts published over the previous 2 years relative to sphincter of Oddi dysfunction (SOD). The long-term outcomes of the Evaluating Predictors and Interventions of SOD (EPISOD) trial further substantiated results from the initial EPISOD study, reinforcing that neither endoscopic retrograde cholangiopancreatography-manometry nor endoscopic sphincterotomy are appropriate for SOD type III. Pain management in the latter patients has reverted to neuromodulating agents, and recent studies have suggested a role for duloxetine and potentially acupuncture. The functional role of the sphincter of Oddi has been reiterated with a report demonstrating a higher clinically significant pancreatic fistula rate in distal pancreatectomy patients treated with higher doses of postoperative narcotics. Moreover, the injection of periampullary botulinum toxin preoperatively has been shown to decrease these fistulas in a pilot trial. Additional studies have reinforced that eluxadoline can cause sphincter of Oddi spasm and pancreatitis. In contrast to approaching patients with acute relapsing pancreatitis using endoscopic retrograde cholangiopancreatography and manometry, previous and current studies suggest that endoscopic ultrasound should be done first and the role of SOD in idiopathic acute relapsing pancreatitis remains controversial. Finally, there remain widespread disparities in practice patterns in the approach to patients currently classified as SOD type II. In contrast to historical manuscripts which stress the classical definitions of three types of SOD and their consequences, more recent manuscripts on this topic have focused on improving surgical outcomes based on the physiologic role of sphincter of Oddi, as well as the pharmacologic causes and treatments of SOD. The simplistic view that SOD, however it has been diagnosed, requires biliary or dual sphincterotomy is just that, simplistic and potentially misguided.

Interscalene Block with and without Intraoperative Local Infiltration with Liposomal Bupivacaine in Shoulder Arthroplasty: A Randomized Controlled Trial.

Interscalene brachial plexus blockade (ISBPB) is an effective anesthetic technique for shoulder arthroplasty; however, "rebound pain" can increase the patient's postoperative pain experience and narcotic usage. Exparel (liposomal bupivacaine) injected into the soft tissues at the surgical site has theoretical efficacy for up to 72 hours after administration. The purpose of this study was to evaluate postoperative pain scores and narcotic consumption following shoulder arthroplasty performed with either ISBPB alone or ISBPB and intraoperative Exparel. Seventy-eight patients undergoing primary shoulder arthroplasty were randomized to receive an ISBPB with Exparel (39 patients) or without Exparel (39 patients). The primary outcome variable was morphine equivalent units (MEUs) consumed over the first 24 hours after surgery. Secondary outcomes included intraoperative narcotic administration and visual analog scale (VAS) scores for pain (at 0, 8, 16, 24, 48, and 72 hours after surgery). There were no significant demographic differences between the ISBPB and ISBPB + Exparel groups. Total narcotic consumption over the first 24 hours after surgery was significantly lower in the ISBPB group compared with the ISBPB + Exparel group (mean and standard deviation, 18.9 ± 25.6 MEU versus 35.3 ± 36.7 MEU, p = 0.009). VAS pain scores did not differ significantly between groups at any time point during the first 72 hours after surgery. Patients treated with Exparel required significantly more postoperative narcotics and demonstrated no significant reduction in pain scores over the first 72 hours after primary shoulder arthroplasty. Exparel does not appear to have substantial value when added to a pain protocol that includes an ISBPB. Therapeutic Level l. See Instructions for Authors for a complete description of levels of evidence.

Saturday, September 29, 2018 9:00 am–10:00 am A Fresh Look at Opioids: 271. Inpatient pain and narcotics utilization based on preoperative PHQ-9 scores after minimally invasive transforaminal lumbar interbody fusion

BACKGROUND CONTEXT Patient pain and narcotics consumption after spinal procedures has been an emerging topic within the orthopedics literature. Determination of risk factors for increased pain and narcotics utilization is necessary to produce effective analgesia protocols for all patients, while also preventing narcotics-associated side effects and dependence. Preoperative mental health has been identified as a potential predictor of postoperative outcomes in the general orthopedic literature. However, no previous study has determined whether preoperative mental health is associated with postoperative pain and narcotics utilization after minimally invasive spinal procedures. PURPOSE To determine if there is an association between preoperative mental health as assessed by the Patient Health Questionnaire-9 (PHQ-9) and inpatient pain and narcotics utilization after minimally invasive transforaminal lumber interbody fusion (MIS TLIF) procedures. STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE A total of 60 patients who underwent a primary, single-level MIS TLIF between 2015 and 2016. OUTCOME MEASURES Inpatient visual analog scale (VAS) pain scores and postoperative narcotics utilization expressed in oral morphine equivalents (OMEs). METHODS A prospectively maintained surgical database of patients undergoing primary, single-level MIS TLIF for degenerative pathology between 2015 and 2016 was retrospectively reviewed. Patients were stratified by preoperative PHQ-9 score (≤2, >2). The PHQ-9 is a validated depression-specific mental health survey in which higher scores are associated with a greater degree of depression symptoms. Student's t-test and chi-square analysis were used to determine if an association existed between PHQ-9 score group and preoperative demographic and operative characteristics. Multivariate linear regression controlling for preoperative demographic and operative characteristics was used to determine if PHQ-9 score group was associated with differences in inpatient pain and narcotics utilization. RESULTS After exclusion of those without complete PHQ-9 surveys, 60 patients were included in this analysis. A total of 51.7% (31) had a PHQ-9 score ≤ 2, while 48.3% (29) had a PHQ-9 score > 2. Patients with PHQ-9 score > 2 were more likely to smoke (20.7% vs. 3.2%, p=.049), were more likely to be obese (41.4% vs. 23.3%, p=.006), and had higher preoperative VAS pain scores (6.7 vs. 5.2, p=.026). On postoperative day (POD) 0 and POD 1, there were no significant differences between PHQ-9 score groups in regards to inpatient VAS pain scores or daily and hourly narcotics consumption (p>.05 for each). CONCLUSIONS The results of this study suggest that patients with depression symptoms are more likely to smoke, be obese and have higher preoperative pain. However, the presence of depression symptoms was not associated with increased pain or narcotics utilization in the immediate postoperative period after MIS TLIF. As such, patients should receive similar analgesic protocols irrespective of the presence of depression symptoms. Further investigation is necessary to determine the incidence of long-term postoperative narcotics dependence after MIS TLIF within a population with depression symptoms. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 2:00 PM – 3:00 PM Surgery and Opioids: 73. Narcotic consumption following minimally invasive lumbar decompression: a comparison between hospital and ambulatory-based surgery centers

BACKGROUND CONTEXT Studies have compared outcomes between hospital-based (HBC) and ambulatory surgery (ASC) centers following minimally invasive lumbar decompression (MIS LD). However, the association between narcotic consumption and pain in the immediate postoperative period has not been well characterized. PURPOSE To examine pain, narcotic consumption, and length of stay (LOS) among patients discharged on postoperative day (POD) 0 following a 1-level MIS LD between an HBC and ASC. STUDY DESIGN/SETTING Retrospective analysis of a prospectively maintained surgical database. PATIENT SAMPLE A total of 235 patients who underwent a primary, 1-level MIS LD procedure from 2013 to 2017. OUTCOME MEASURES Inpatient pain using visual analog scale (VAS) pain scores, and narcotic consumption as oral morphine equivalents (OMEs). METHODS A surgical registry of patients who underwent a primary, 1-level MIS LD during 2013-2017 was reviewed, and were stratified by operative location. Differences between groups in demographics were assessed using independent sample t tests for continuous variables and chi-squared analysis for categorical variables. The operative location and its effect on perioperative characteristics, inpatient pain scores and narcotics consumption was analyzed using multivariate linear regression adjusted for significant patient characteristics. RESULTS A total of 235 patients were identified, of which 90 and 145 underwent surgery at a HBC or ASC, respectively. The HBC cohort exhibited an increased comorbidity burden, as defined by the Charlson Comorbidity Index (HBC: 1.1, ASC: 0.8; p=.041) and were more likely to have private insurance (HBC: 76.7%, ASC: 37.2%; p=.026). Distributions of age, sex, body mass index, and smoking status was similar between groups (p>.05 for each). The HBC cohort recorded shorter operative time (p CONCLUSIONS The results of the current study suggest that patients at who underwent MIS LD at an ASC receive fewer narcotics than patients treated at a HBC, which may contribute to shortened length of stay. Additionally, there was no difference in patient-reported pain between cohorts despite the differences in narcotic utilization. As such, postoperative narcotics administration can be decreased without compromising pain control and may contribute to faster discharge. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters

BACKGROUND CONTEXT Minimally invasive lumbar discectomy (MIS LD) has proven to be an effective treatment modality for low back pain and radiculopathy associated with intervertebral disc herniations. With the increasing focus on cost reduction and value-based care, minimization of postoperative length of stay has become an important topic for physicians and hospital administrators. Despite this, risk factors for prolonged length of stay after MIS LD have not been previously described. PURPOSE To determine risk factors for discharge after postoperative (POD) 0 in patients undergoing one-level MIS LD. STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE A total of 176 patients who underwent one-level MIS LD from 2011 to 2016. OUTCOME MEASURES Relative Risk (RR) of preoperative and operative characteristics for discharge after POD 0. METHODS A prospectively maintained surgical database of patients who underwent one-level MIS LD by a single surgeon from 2011 to 2016 was reviewed. Long length of stay was defined as discharge after POD 0. Bivariate and stepwise multivariate Poisson regression with robust error variance was used to determine risk factors for discharge after POD 0. Variables analyzed included patient demographics, comorbidities, operative characteristics, preoperative pain scores, postoperative inpatient pain scores and postoperative narcotics consumption as measured by oral morphine equivalents (OMEs). A p-value RESULTS A total of 176 patients were included in this analysis. 9.7% of included patients were discharged on POD 1 or later, qualifying as having a long length of stay. On bivariate analysis, diabetic status (57.1% vs. 7.7%, Relative Risk [RR]=7.43, p CONCLUSIONS The results of this study suggest that patients with diabetes mellitus and those with low postoperative narcotic consumption have longer lengths of inpatient stay upon undergoing a one-level MIS LD. Diabetic patients may experience longer length of stay due to requiring extensive postoperative blood glucose management or as a result of increased susceptibility to postoperative infection. Surgeons can use this information to better counsel patients on expected length of stay and optimal narcotics utilization postoperatively.

Evaluation of the enhanced recovery after surgery protocol in living liver donors

Enhanced recovery after surgery (ERAS) protocol has proven to be effective in many surgery fields in controlling pain and promoting early recovery. Application of the (ERAS) protocol in living donor liver patients is a new step to promote early recovery. We analyzed outcomes in two groups. Group A included the living donors who had the ERAS protocol applied (n=30), and Group B included donors who had their surgery before the ERAS protocol (n=30). All donors had the same incision. The ERAS protocol involved a multimodality methods. This included intravenous ketamine and lidocaine intraoperatively with single dose intrathecal morphine and local injection of long-acting bupivacaine. The postoperative regimen included intravenous ketamine, lidocaine, ketorolac, and narcotics as PRN. Pain on the first three postoperative days was significantly lower in Group A (P<0.05). Narcotics were also significantly lower in Group A (P<0.01). Return of bowel function occurred earlier by 1day in Group A (P<0.003). Group A patients could tolerate a regular diet by postoperative day (POD) three vs four in Group B patients (P=0.0057). Mean length of stay was lower in Group A, but not statistically significant. Enhanced recovery after surgery protocol was effective in minimizing postoperative pain and helped to decrease the postoperative narcotics and helped early recovery.

Decreasing Postoperative Narcotic Utilization with the Use of Concentrated Bone Marrow Aspirate in First Metatarsophalangeal Joint Interposition Arthroplasty

Category: Midfoot/Forefoot Introduction/Purpose: Interposition arthroplasty is an interim procedure for the treatment of first metatarsophalangeal osteoarthritis demonstrating excellent survivorship. The procedure is commonly performed at our institution and successful long-term results have been described. Furthermore, we have utilized concentrated, autologous, bone marrow aspirate (BMAC) to augment and accelerate patient recovery, decrease postoperative pain, reduce postoperative narcotic requirement, and improve tissue healing for a variety of ankle and foot pathology. The purpose of this study was to compare the early outcomes of interpositional arthroplasty with patients receiving BMAC augmentation versus controls and to evaluate postoperative analgesia and narcotic requirements. Methods: After IRB approval, patients undergoing interposition arthroplasty for hallux rigidus at our institution from 2009-2014 were identified. All cases were performed using autograft capsular interposition by a single surgeon. 18 BMAC cases with complete records were identified. These were matched to controls in a 1:1 manner by age, gender, and laterality. A retrospective analysis of prospectively collected data was performed. Demographics, clinical range of motion, complications, VAS scoring, FAAM, FFI, AOFAS scores were recorded and analyzed. Postoperative analgesia requirements, narcotic usage, and prescription data were collected. Follow-up was conducted at 2,6,12,24, &amp; 52 weeks postoperatively. Time experiencing pain and time to achieve maximum functional satisfaction were recorded. Results: 89% (32/36) of patients undergoing interposition arthroplasty were female, average age 58 years (range, 39-74). The average number of weeks experiencing pain, narcotic utilization, and time to achieve functional satisfaction was statistically lower in the BMAC group, 11 weeks (range, 6-24) versus controls, 27.4 weeks (range, 6-52), (p=0.001). The number of post-operative days of pain requiring narcotic analgesia was significantly lower in patients receiving BMAC 4.2 days (range, 1-14) compared to controls averaging 13.8 days (range, 2-48) (p=0.02). Both groups demonstrated improvements in pre- and postoperative VAS scores, increase in motion, SF-36, FAAM, FFI, and AOFAS scores at 52 week follow up. There were no failures and there was one superficial infection requiring oral antibiotics. Conclusion: This study confirms that patients undergoing interpositional arthroplasty demonstrate excellent clinical improvements in short-term follow-up with few complications. Moreover, augmentation of this procedure with BMAC results in a significant decrease in narcotic utilization and recovery time post-operatively. BMAC may be a useful adjunct in diminishing postoperative narcotics we prescribe to our patients.

Narcotic use and total hip arthroplasty.

The purpose of this study is to: (1) characterise risk factors for prolonged narcotic use following total hip arthroplasty (THA); (2) examine preoperative and prolonged postoperative narcotic use as independent risk factors for complications following THA. A national database identified primary THA patients from 2007-2015. Preoperative (POU) and prolonged postoperative narcotics users (PPU) were identified. A multivariable logistic regression analysis was utilised to identify any patient-related risk factors for prolonged use, and examined POU and PPU as risk factors for complications following THA. 55,354 THA patients were included, 18,740 (33.8%) POU and 14,996 (27.1%) PPU. Preoperative narcotics use was the most significant factor associated with prolonged postoperative narcotic use. Preoperative and prolonged postoperative use were associated with significantly higher complications postoperatively. Preoperative narcotic use is the most significant patient specific risk factor for prolonged postoperative narcotic use. POUs and PPUs are at a significantly higher risk of postoperative infection and revision surgery.

Development of an enhanced recovery protocol for children undergoing gastrointestinal surgery.

Enhanced recovery protocols (ERPs) have been adopted for a variety of adult surgical conditions and resulted in markedly improved outcomes, including decreased length of stays, complications, costs, and narcotic utilization. In this review, we describe the development and implementation of an ERP for children undergoing gastrointestinal surgery. Existing ERP components from adult and pediatric surgical populations were reviewed and modified through an iterative process that included literature review, a national survey of practicing pediatric surgeons, and appropriateness assessment by a multidisciplinary expert panel. A single-center pilot implementing a gastrointestinal ERP demonstrated a steady increase in the number of ERP elements being employed over time with a simultaneous decrease in length of stays, decrease in median time to regular diet, decrease in median dose of intraoperative and postoperative narcotics, and decrease in median volume of intraoperative fluids. Balancing measures such as complication rates and 30-day readmission rates were stable or trended toward improved outcomes. ERPs for children undergoing gastrointestinal surgery appear feasible, safe, and associated with improved outcomes. Further validation of these results and expansion to a wider breadth of children's surgical care will help to establish ERPs as a new standard of surgical care.

Toradol following Breast Surgery: Is There an Increased Risk of Hematoma?

Ketorolac tromethamine (Toradol), a nonsteroidal antiinflammatory drug, is used with increased frequency given its success in postoperative pain control and the subsequent decreased need for narcotics. Its use has been limited in plastic surgery for fear of postoperative bleeding and hematoma formation. In this study of breast surgery patients, the authors investigated whether ketorolac increased the risk of postoperative hematoma formation. After obtaining institutional review board approval, the authors retrospectively reviewed the records of patients undergoing breast surgery from January of 2012 through December of 2014. The authors compared the incidence of postoperative hematomas in patients who did, versus those who did not, receive ketorolac postoperatively. For the entire cohort, the overall hematoma rate was 2.8 percent. Of the patients who received ketorolac, the rate was 3.5 percent; of those who did not, the rate was 2.5 percent. Of the breast reduction patients, the rate was 4 percent in those who received ketorolac versus 3.2 percent in those who did not. Of the breast reconstruction patients, the rate was 4 percent in those who received ketorolac versus 3.2 percent in those who did not. Recently, the high rates of prescribing postoperative narcotics have received increased attention. Aside from the risk of increased availability of narcotics in the community, the side effects can delay patient recovery. Ketorolac is controversial for postoperative pain control because of the potential risk of bleeding, but in the authors' 3-year retrospective study, it was not associated with an increased risk of hematoma formation. Therapeutic, III.

Does Subcutaneous Infiltration of Liposomal Bupivacaine Following Single-Level Transforaminal Lumbar Interbody Fusion Surgery Improve Immediate Postoperative Pain Control?

Study DesignRetrospective case-control study using prospectively collected data.PurposeEvaluate the impact of liposomal bupivacaine (LB) on postoperative pain management and narcotic use following standardized single-level low lumbar transforaminal lumbar interbody fusion (TLIF).Overview of LiteraturePoor pain control after surgery has been linked with decreased pain satisfaction and increased economic burden. Unfortunately, opioids have many limitations and side effects despite being the primary treatment of postoperative pain. LB may be a form of pre-emptive analgesia used to reduce the use of postoperative narcotics as evidence in other studies evaluating its use in single-level microdiskectomies.MethodsThe infiltration of LB subcutaneously during wound closure was performed by a single surgeon beginning in July 2014 for all single-level lumbar TLIF spinal surgeries at Landstuhl Regional Medical Center. This cohort was compared against a control cohort of patients who underwent the same surgery by the same surgeon in the preceding 6 months. Statistical analysis was performed on relevant variables including: morphine equivalents of narcotic medication used (primary outcome), length of hospitalization, Visual Analog Scale pain scores, and total time spent on a patient-controlled analgesia (PCA) pump.ResultsA total of 30 patients were included in this study; 16 were in the intervention cohort and 14 were in the control cohort. The morphine equivalents of intravenous narcotic use postoperatively were significantly less in the LB cohort from day of surgery to postoperative day 3. Although the differences lost their statistical significance, the trend remained for total (oral and intravenous) narcotic consumption to be lower in the LB group. The patients who received the study intervention required an acute pain service consult less frequently (62.5% in LB cohort vs. 78.6% in control cohort). The amount of time spent on a PCA pump in the LB group was 31 hours versus 47 hours in the control group (p=0.1506).ConclusionsLocal infiltration of LB postoperatively to the subcutaneous tissues during closure following TLIF significantly decreased the amount of intravenous narcotic medication required by patients. Well-powered prospective studies are still needed to determine optimal dosing and confirm benefits of LB on total narcotic consumption and other measures of pain control following major spinal surgery.

Decreasing Postoperative Narcotics in Reconstructive Pelvic Surgery: A Randomized Controlled Trial

(Abstracted from Am J Obstet Gynecol 2017;217:325.e1–325.e10) In recent years, there has been increasing emphasis on creation of programs for enhanced recovery, fast-track, or multimodal pathways to improve perioperative care. Decreasing discharge narcotic use may be important to maximize patient safety and satisfaction, decrease postoperative complications at home, and expedite return to baseline functional status.

Impact of body mass index on surgical outcomes, narcotics consumption, and hospital costs following anterior cervical discectomy and fusion.

OBJECTIVE Given the increasing prevalence of obesity, more patients with a high body mass index (BMI) will require surgical treatment for degenerative spinal disease. In previous investigations of lumbar spine pathology, obesity has been associated with worsened postoperative outcomes and increased costs. However, few studies have examined the association between BMI and postoperative outcomes following anterior cervical discectomy and fusion (ACDF) procedures. Thus, the purpose of this study was to compare surgical outcomes, postoperative narcotics consumption, complications, and hospital costs among BMI stratifications for patients who have undergone primary 1- to 2-level ACDF procedures. METHODS The authors retrospectively reviewed a prospectively maintained surgical database of patients who had undergone primary 1- to 2-level ACDF for degenerative spinal pathology between 2008 and 2015. Patients were stratified by BMI as follows: normal weight (< 25.0 kg/m2), overweight (25.0-29.9 kg/m2), obese I (30.0-34.9 kg/m2), or obese II-III (≥ 35.0 kg/m2). Differences in patient demographics and preoperative characteristics were compared across the BMI cohorts using 1-way ANOVA or chi-square analysis. Multivariate linear or Poisson regression with robust error variance was used to determine the presence of an association between BMI category and narcotics utilization, improvement in visual analog scale (VAS) scores, incidence of complications, arthrodesis rates, reoperation rates, and hospital costs. Regression analyses were controlled for preoperative demographic and procedural characteristics. RESULTS Two hundred seventy-seven patients were included in the analysis, of whom 20.9% (n = 58) were normal weight, 37.5% (n = 104) were overweight, 24.9% (n = 69) were obese I, and 16.6% (n = 46) were obese II-III. A higher BMI was associated with an older age (p = 0.049) and increased comorbidity burden (p = 0.001). No differences in sex, smoking status, insurance type, diagnosis, presence of neuropathy, or preoperative VAS pain scores were found among the BMI cohorts (p > 0.05). No significant differences were found among these cohorts as regards operative time, intraoperative blood loss, length of hospital stay, and number of operative levels (p > 0.05). Additionally, no significant differences in postoperative narcotics consumption, VAS score improvement, complication rates, arthrodesis rates, reoperation rates, or total direct costs existed across BMI stratifications (p > 0.05). CONCLUSIONS Patients with a higher BMI demonstrated surgical outcomes, narcotics consumption, and hospital costs comparable to those of patients with a lower BMI. Thus, ACDF procedures are both safe and effective for all patients across the entire BMI spectrum. Patients should be counseled to expect similar rates of postoperative complications and eventual clinical improvement regardless of their BMI.

Comparison of Surgical Outcomes, Narcotics Utilization, and Costs After an Anterior Cervical Discectomy and Fusion

Study Design: Retrospective cohort analysis of a prospectively maintained registry. Objective: To compare the surgical outcomes, narcotic utilization, and costs between a stand-alone (SA) cage and anterior plating (AP) with an interbody device for 1-level anterior cervical discectomy and fusion (ACDF). Background Data: ACDF with a SA cage has gained popularity as a potential alternative to anterior cervical plating. Few studies have compared the surgical outcomes, narcotic utilization, and costs of ACDF utilizing a SA cage versus AP with an interbody device. Methods: Patients who underwent a primary 1-level ACDF for degenerative spinal pathology between 2010 and 2013 were analyzed. Patients were stratified on the basis of the type of implant system (SA cage vs. AP) and assessed with regard to demographics, comorbidities, smoking, visual analogue scale (VAS) scores (preoperative/postoperative), procedural time, estimated blood loss (EBL), length of hospitalization, complications, reoperations, narcotic consumption, and total costs. Statistical analysis was performed with independent sample T tests for continuous variables and χ2 analysis for categorical data. An α level of &lt;0.05 denoted statistical significance. Results: Of the 93 patients included, 52 (55.9%) underwent an ACDF with a SA cage system. Patient demographics, comorbidity burden, body mass index, smoking status, and preoperative VAS score were similar between cohorts. The SA cohort incurred a significantly lower EBL (P&lt;0.001) than the AP cohort. However, none required a transfusion and the procedural time, length of hospitalization, postoperative VAS score, complication rates, 1-year arthrodesis rate, and reoperation rates were similar between cohorts. Postoperative narcotics consumption and total costs were also similar between groups. Conclusions: Our findings suggest that the SA cage may be associated with a significantly lower EBL, which may not be clinically relevant. Perioperative outcomes, complications, reoperation rates, narcotics consumption in the immediate postoperative period, and total costs may be similar regardless of the instrumentation utilized in a 1-level ACDF.