Postoperative Prescription Research Articles

A multi-disciplinary program for opioid sparse arthroplasty results in reduced long-term opioid consumption: a four year prospective study

IntroductionThe current opioid epidemic poses patient safety and economic burdens to healthcare systems worldwide. Postoperative prescriptions of opioids contribute, with reported opioid prescription rates following arthroplasty as high as 89%. In this multi-centre prospective study, an opioid sparing protocol was implemented for patients undergoing knee or hip arthroplasty. The primary outcome is to report our patient outcomes in the context of this protocol, and to examine the rate of opioid prescription on discharge from our hospitals following joint arthroplasty surgery. This is possibly associated with the efficacy of the newly implemented Arthroplasty Patient Care Protocol.MethodsOver three years, patients underwent perioperative education with the expectation to be opioid-free after surgery. Intraoperative regional analgesia, early postoperative mobilisation and multimodal analgesia were mandatory. Long-term opioid medication use was monitored and PROMs (Oxford Knee/Hip Score (OKS/OHS), EQ-5D-5 L) were evaluated pre-operatively, and at 6 weeks, 6 months and 1 year postoperatively. Primary and secondary outcomes were opiate use and PROMs at different time points.ResultsA total of 1,444 patients participated. Two (0.2%) knee patients used opioids to one year. Zero hip patients used opioids postoperatively at any time point after six weeks (p < 0.0001). The OKS and EQ-5D-5 L both improved for knee patients from 16 (12–22) pre-operatively to 35 (27–43) at 1 year postoperatively, and 70 (60–80) preoperatively to 80 (70–90) at 1 year postoperatively (p < 0.0001). The OHS and EQ-5D-5 L both improved for hip patients from 12 (8–19) preoperatively to 44 (36–47) at 1 year postoperatively, and 65 (50–75) preoperatively to 85 (75–90) at 1 year postoperatively (p < 0.0001). Satisfaction improved between all pre- and postoperative time points for both knee and hip patients (p < 0.0001).ConclusionsKnee and hip arthroplasty patients receiving a peri-operative education program can effectively and satisfactorily be managed without long-term opioids when coupled with multimodal perioperative management, making this a valuable approach to reduce chronic opioid use.

Bisphosphonates Prescription for Patients With Hip Fractures Based on Evaluation by a Dentist.

Background The purpose of this study is to clarify the current status of the prescription of postoperative bisphosphonates for patients with hip fractures and to explore the factors that prevent the postoperative prescription of bisphosphonates. Methods Of 180 patients with hip fractures treated surgically at our hospital between August 2019 and April 2020, 149 patients (46 men and 103 women; mean age: 83.9 ± 9.0 years), excluding 31 patients already prescribed bisphosphonates or denosumab, were included in the study. All patients were treated based on our clinical pathway, and their risk of jaw osteonecrosis was evaluated prior to the initiation of bisphosphonates by a dentist in our hospital. We collected data from the medical records on osteoporosis treatment interventions at admission and discharge, the reasons why postoperative bisphosphonates could not be prescribed at discharge, the proportion of patients who had follow-ups at our hospital, and patients' osteoporosis treatment status. Results Eighteen (12.8%) and 95 (63.8%) patients were prescribed anti-osteoporosis drugs at admission and discharge, respectively. One hundred and twenty-one patients (86.8%) could not be prescribed postoperative bisphosphonates at discharge - 71 (58.7%) because of oral hygiene problems, 34 (28.1%) because they did not have regular dental consultations, seven (5.8%) because of renal dysfunction, eight (6.6%) because of poor cognitive and swallowing function, and one (0.8%) because of medication side effects. Forty-nine patients (32.9%) went to our hospital for follow-up and 11 were introduced to bisphosphonates or denosumab at follow-up. Conclusions The number of patients with hip fractures who were prescribed postoperative bisphosphonates was low in our study. The oral hygiene problems identified by dentists accounted for responsible for the low prescription rate of postoperative bisphosphonates. Therefore, coordination with dentists may be important to increase the postoperative bisphosphonate prescription.

A Reduction in Opioid Prescription Size After Total Joint Arthroplasty Can be Safely Performed Without an Increase in Complications

BackgroundExcessive opioid prescriptions after total joint arthroplasty (TJA) increase risks for adverse opioid-related events, chronic opioid use, and unlawful opioid diversion. Decreasing postoperative prescriptions may improve quality after TJA. Concerns exist that a decrease in opioids prescribed may increase complications, such as readmissions, emergency department (ED) visits, or worsened patient-reported outcomes (PROs). The purpose of this study was to explore whether a reduction in opioids prescribed after TJA resulted in increased complications. MethodsData originated from a statewide database prospectively abstracted, including oral morphine equivalents prescribed at discharge, readmissions, ED visits, and PROs. Data were collected from 84,998 TJA occurring 1 year before and after the creation of an opioid-prescribing protocol that had decreased prescriptions by approximately 50%. Trends were monitored using Shewhart control charts. Regression models were used to determine statistically significant changes over time. ResultsAll groups showed a reduction in opioids prescribed by almost 50% without an increase in emergency room visits or readmissions and without a detrimental effect on PROs. Compared to baseline data before opioid reduction, opioid-naive total knee arthroplasty had significant improvements in all outcomes (P = .03, P = .02, P < .001, P < .001). Opioid-tolerant total knee arthroplasty and total hip arthroplasty had no worsened outcomes and significant improvement in (Knee Injury and Osteoarthritis Outcome score for Joint Replacement P = .03) and (Hip Disability and Osteoarthritis Outcome Score for Joint Replacement P = .03). Opioid-naive total hip arthroplasty had significant improvements in Hip Disability and Osteoarthritis Outcome Score Joint Replacement (P = .003) and Patient Reported Outcomes Measurement Information System (P = .001). ConclusionsPostoperative opioid prescription recommendations from a statewide registry decreased prescribing by approximately 50% without decreasing PROs or increasing ED visits or readmissions. A reduction in opioids prescribed after TJA can be accomplished safely and without increased complications.

Is Fluoroquinolone Exposure after Primary Tendon Repair Associated with Higher Rates of Reoperations? A Matched Cohort Study.

The association between tendon damage and fluoroquinolone (FQ) antibiotics has been well documented. However, there is limited data evaluating the impact of postoperative FQ use on outcomes of primary tendon repairs. The purpose of this study was to compare rates of reoperation for patients with FQ exposure after primary tendon repair versus controls. A retrospective cohort study was conducted using the PearlDiver database. All patients who underwent primary repair of distal biceps ruptures, Achilles tendon ruptures, and rotator cuff tears were identified. For each tendon, patients who were prescribed FQs within 90 days postoperatively were propensity score matched at a 1:3 ratio with controls without postoperative FQ prescriptions across age, sex, and several comorbidities. Rates of reoperation were compared at two years postoperatively with multivariable logistic regression. A total of 124,322 patients who underwent primary tendon procedures were identified, including 3,982 (3.2%) patients with FQ prescriptions within 90 days postoperatively: 448 with distal biceps repair, 2,538 with rotator cuff repair, and 996 with Achilles tendon repair. These cohorts were matched with 1,344, 7,614, and 2,988 controls, respectively. Patients with postoperative FQ prescriptions exhibited significantly higher rates of revision surgery after primary repair of distal biceps ruptures (3.6% vs.1.7%; OR 2.13; 95% CI, 1.09-4.04), rotator cuff tears (7.1% vs.4.1%; OR 1.77; 95% CI, 1.48-2.15), and Achilles tendon ruptures (3.8% vs.1.8%; OR 2.15; 95% CI, 1.40-3.27). Patients with FQ prescriptions within 90 days after primary tendon repair demonstrated significantly higher rates of reoperations for distal biceps, rotator cuff, and Achilles tendon repair at two years postoperatively. To achieve optimal outcomes and avoid complications in patients following primary tendon repair procedures, physicians should consider prescribing alternative non-FQ antibiotics and counsel patients on the risk of reoperation associated with postoperative FQ use.

Postoperative Antibiotics Confer No Protective Association After Fat Grafting for Breast Reconstruction.

Autologous fat grafting after breast reconstruction is a commonly used technique to address asymmetry and irregularities in breast contour. While many studies have attempted to optimize patient outcomes after fat grafting, a key postoperative protocol that lacks consensus is the optimal use of perioperative and postoperative antibiotics. Reports suggest that complication rates for fat grafting are low relative to rates after reconstruction and have been shown to not be correlated to antibiotic protocol. Studies have additionally demonstrated that the use of prolonged prophylactic antibiotics do not lower the complication rates, stressing the need for a more conservative, standardized antibiotic protocol. This study aims to identify the optimal use of perioperative and postoperative antibiotics that optimizes patient outcomes. Patients in the Optum Clinformatics Data Mart who underwent all billable forms of breast reconstruction followed by fat grafting were identified via Current Procedural Terminology codes. Patients meeting inclusion criteria had an index reconstructive procedure at least 90 days before fat grafting. Data concerning these patient's demographics, comorbidities, breast reconstructions, perioperative and postoperative antibiotics, and outcomes were collected via querying relevant reports of Current Procedural Terminology; International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; National Drug Code Directory, and Healthcare Common Procedure Coding System codes. Antibiotics were classified by type and temporal delivery: perioperatively or postoperatively. If a patient received postoperative antibiotics, the duration of antibiotic exposure was recorded. Outcomes analysis was limited to the 90-day postoperative period. Multivariable logistic regression was performed to ascertain the effects of age, coexisting conditions, reconstruction type (autologous or implant-based), perioperative antibiotic class, postoperative antibiotic class, and postoperative antibiotic duration on the likelihood of any common postoperative complication occurring. All statistical assumptions made by logistic regression were met successfully. Odds ratios and corresponding 95% confidence intervals were calculated. From more than 86 million longitudinal patient records between March 2004 and June 2019, our study population included 7456 unique records of reconstruction-fat grafting pairs, with 4661 of those pairs receiving some form of prophylactic antibiotics. Age, prior radiation, and perioperative antibiotic administration were consistent independent predictors of increased all-cause complication likelihood. However, administration of perioperative antibiotics approached a statistically significant protective association against infection likelihood. No postoperative antibiotics of any duration or class conferred a protective association against infections or all-cause complications. This study provides national, claims-level support for antibiotic stewardship during and after fat grafting procedures. Postoperative antibiotics did not confer a protective benefit association against infection or all-cause complication likelihood, while administering perioperative antibiotics conferred a statistically significant increase in the likelihood that a patient experienced postoperative complication. However, perioperative antibiotics approach a significant protective association against postoperative infection likelihood, in line with current guidelines for infection prevention. These findings may encourage the adoption of more conservative postoperative prescription practices for clinicians who perform breast reconstruction, followed by fat grafting, reducing the nonindicated use of antibiotics.

The impact of the Florida law HB21 on opioid prescribing patterns after spine surgery

BackgroundThe opioid epidemic represents a major public health issue in the United States and has led to significant morbidity and mortality. On July 1 2018, Florida implemented state-law House Bill 21 (HB21), limiting opioid prescriptions to a 3-day supply for acute pain or 7 days if an exception is documented. The purpose of this study is to evaluate the effects of HB21 on opioid prescribing patterns after spine surgery. MethodsPatients 18 years and older who underwent spine surgery between January 2017 and January 2021 were eligible for inclusion. Information including demographics, pills, days, and morphine milligram equivalents (MMEs) was obtained via retrospective chart review using the Florida Prescription Drug Monitoring Program and Epic Chart Review. Student's t tests and Fisher's exact tests were used for comparison of continuous variables. Multiple logistic regression was utilized to determine which variables were associated with postoperative opioid prescriptions. p<.05 was considered significant. ResultsWe reviewed 114 patients who underwent spine surgery from January 2017 to July 2018 and 264 patients from July 2018 to January 21. There were no significant differences between the groups in age, sex, ethnicity, body mass index, number of levels fused, or preoperative opioid use. The average number of MMEs, pills prescribed and days in the first postoperative prescription decreased significantly after HB21. Multiple logistic regression revealed that the variable most predictive of MMEs and number of pills in the first postoperative prescription was postlaw status (p=.002, p=.50). ConclusionsFlorida law HB21 was successful in decreasing postoperative opioid prescriptions after spine surgery, however, the need for additional progress remains. Legislation should be combined with multimodal pain regimens, as well as patient and provider education in order to further decrease postoperative opioid requirements. Future studies should include a larger number of patients treated by multiple spine surgeons across multiple institutions in order to further evaluate the effects of HB21 on postoperative opioid prescriptions.

Postoperative Antibiotics Following Reduction Mammaplasty Does Not Reduce Rates of Surgical Site Infection.

The efficacy of antibiotic utilization following reduction mammaplasty has not been well studied. Furthermore, there is a lack of data describing subgroups who are historically at high risk for surgical site infection (SSI), specifically the obese population. This study compares SSI rates in reduction mammaplasty patients who received postoperative courses of antibiotics with those who did not. Additional analysis was performed for the subgroup of patients with a body mass index (BMI) ≥30 kg/m2. The 2010 to 2021 PearlDiver Mariner data set was reviewed to identify reduction mammaplasty patients. Patients were confirmed to have received perioperative antibiotics. Postoperative antibiotic use was determined based on the presence of postoperative prescriptions, and 1:1 matching was performed for those with and without postoperative antibiotics based on age and the Elixhauser Comorbidity Index. Rates of SSI, emergency department (ED) visits, and readmissions for the 90 days following surgery were recorded and compared. A subgroup analysis was performed on patients with a BMI of ≥30 kg/m2. Among patients who were confirmed to have received perioperative antibiotics, 2230 patients who also received postoperative antibiotics were identified and matched to 2230 patients who did not. Rates of SSI, ED visits, and readmission were not statistically different. A total of 218 obese patients were identified from this group and matched. Rates of SSI, ED visits, and readmission were not statistically different. In the current study, no difference in SSI rates between patients who received postoperative antibiotics and those who did not was found. These observations were corroborated in the obese population. These data may assist surgeons when considering postoperative antibiotics following reduction mammaplasty.

The Use of Preoperative Antibiotics in Hardware-Based Hand Procedures Is Not Necessary: A Single-Surgeon Experience.

A survey to American Society for Surgery of the Hand members by Dunn et al showed that the use of preoperative antibiotics was random and not standardized for all hand procedures (Hand (N Y). 2020;15(4):534-541). Previous publications support that preoperative antibiotics for clean, soft-tissue procedures are not necessary, but there is minimal evidence regarding the need for preoperative antibiotics for hardware-based hand procedures. The purpose of our study is to compare infectious outcomes for patients undergoing hardware-based hand surgery between those who did and those who did not receive preoperative antibiotics. A retrospective cohort analysis was performed on hardware-based surgical patients from the senior author's hand practice between January 2015 and October 2021. All patients either received imbedded permanent hardware or temporary percutaneous k-wire fixation. Exclusion criteria included polytrauma patients, patients with open hand wounds, and patients with less than 2 outpatient follow-up visits. Primary outcomes measured were 30- and 90-day postoperative antibiotic prescriptions and need to return to the operating room. Basic demographic information such as age, sex, body mass index, diabetes, and smoking status were recorded and compared. Four hundred seventy-two patients were reviewed, with 365 patients meeting inclusion and exclusion criteria. Two hundred twenty patients did not receive preoperative antibiotics and 145 patients did receive preoperative antibiotics. χ2 tests to analyze for associations between the variables were used. Thirteen patients in the no preoperative antibiotic group (5.9%), compared with 5 patients in the preoperative antibiotic group (3.4%), received a postoperative antibiotic prescription within 30 days (P = 0.288). Sixteen patients in the no preoperative antibiotic group (7.3%), compared with 8 patients in the preoperative antibiotic group (5.5%) received a postoperative antibiotic prescription within 90 days (P = 0.508). One patient in the nonantibiotic group required return to the operating room for irrigation and debridement. There are no significant differences in the need for 30- and 90-day postoperative antibiotic prescriptions between those who did or did not receive preoperative antibiotics based on this single-surgeon experience.

Perioperative Education and Postoperative Discharge Medications in Gynecologic Oncology Patients: Prescribing Practices, Clinical Encounters, and Patient Satisfaction

Objectives: The effects of an algorithm for postoperative prescriptions on opioid-prescribing practices, pain-related postdischarge clinical encounters, and patient satisfaction were studied. Materials and Methods: A quality-improvement initiative was implemented at a single, tertiary-care, comprehensive cancer center. Perioperative patient education was restructured with detailed verbal and written components. An algorithm for postoperative discharge medications included prescribing nonopioid analgesics to all patients without contraindications. Opioid prescriptions were based on patients' length of stay and inpatient opioids' use. Data on opioids prescribed and postoperative encounters for pain were collected, and surveys at a postoperative visit were taken on patient satisfaction pre- and postintervention. Groups' results were compared. Results: The patients (107 preintervention and 90 postintervention) had similar demographics. The postintervention group had a 25% reduction in median number of opioids prescribed at discharge (p = 0.16), with similar patterns of postoperative encounters for pain and frequency of opioid refills. Patient satisfaction, assessed in 29 preintervention and 40 postintervention participants, had significant improvement; 95% postintervention participants answered that they were satisfied with their pain control, compared with 75% preintervention participants (p = 0.03). Conclusions: Perioperative education plus an algorithm for postoperative discharge medications in gynecologic oncology patients results in improved patient satisfaction, a trend toward fewer opioid prescriptions, and a similar pattern of postoperative pain encounters. Comprehensive perioperative education is effective for improving patient satisfaction and pairs well with an algorithmic approach to decreasing opioid prescriptions. (J GYNECOL SURG 20XX:000)

Post-Operative Order Set Decreases Opioid Prescriptions and Increases Efficiency.

Opioid addiction remains a public health crisis. We aimed to create an electronic medical record (EMR) based protocol to decrease post-operative prescribing of opioid medications and streamline the ordering process while maintaining adequate pain control. An order set was created to minimize opioid prescriptions. The post-operative prescribing practices for minor urologic procedures (MUOs) over 6-week periods at three time points were compared: one period before and two periods after implementation of the order set. 72 MUOs were performed in the pre-implementation, 52 in post-implementation, and 60 in the long-term period. Opioid medications were prescribed for 66 patients (91.7%) pre-implementation, 23 patients (44.2%) post-implementation, and 45 patients (75.0%) at the long-term time point (P < .0001 and P = .015 respectively). The mean morphine milligram equivalent (MME) prescribed was 81.52 units before implementation, 38.74 units after, and 24.21 units at the long-term time point (P = .0002 and P < .0001 respectively). The integration of a post-operative prescribing order set into our EMR substantially decreased opioid prescribing after MUO while streamlining the ordering process to improve efficiency.

ULECTOMY AS A SURGICAL OPTION IN PRIMARY HEALTH CARE

Introduction: One of the clinical challenges that comprises the phase of mixed dentition in pediatric patients is tooth impaction. This alteration has a multifactorial etiopathology, with local and systemic factors being related. When tooth eruption does not occur spontaneously, the dentist can perform a surgical procedure, called ulectomy, in order to allow a free path for the tooth to come to occupy its position in the dental arch. Objective: To present ulectomy as a surgical option for the treatment of dental impaction in Primary Health Care. Case report: A 6-year-old female patient came with her parents to the Basic Health Unit in the city of Lajedo-PE, complaining of delayed eruption of permanent teeth. The intraoral clinical examination revealed the absence of elements 11 and 21 and the presence of a thick layer of gingival tissue. The most indicated therapeutic approach was the ulectomy technique. Intraoral and extraoral antisepsis were performed; application of topical anesthetic; infiltrative terminal anesthesia; and elliptical incisions promoting removal of the coronary cap. Hemostasis was promoted by tamponade and no postoperative prescription was required. The patient returned in 15 days, and the onset of eruption of elements 11 and 21 was observed. Conclusion: Ulectomy can be considered a conservative, safe and effective therapeutic method for the resolution of prolonged retention of dental elements in pediatric dentistry. Due to the safety of the procedure, it can be performed in Primary Health Care, as a way of guaranteeing its principles, as long as there is sufficient technical and scientific knowledge to do so.

Comparative Outcomes of Surgical Treatments for Primary Stress Urinary Incontinence in Women: A Retrospective Cohort Study

Introduction: The study evaluates the outcomes of different surgical techniques, including Tension-free Vaginal Tape (TVT), Trans-Obturator Tape (TOT), Burch Colpopexy (BC), and Anterior Vaginal Wall Prolapse Repair (APR), in treating primary stress urinary incontinence (SUI) in women. Materials and Methods: A retrospective cohort study was conducted in a tertiary care center, comprising 62 women diagnosed with primary SUI who underwent one of the aforementioned surgical procedures. Demographic and clinical variables were analyzed, including age, BMI, menopausal status, reproductive history, incontinence types, anticholinergic use, and preoperative assessments. Results: No differences were found in age (p=0.227), weight (p=0.943), height (p=0.333), and BMI (p=0.642) among the four treatment groups. The distribution of menopausal patients and reproductive history variables did not differ among the groups. Postoperative anticholinergic prescription rates (p=0.769) and duration of use (p=0.531) were not different across the groups. The majority of patients in the TVT, TOT, and BC groups had a grade 2 cystocele (p=0.065). The BC group had 100% grade 1 rectocele, which was not significant compared to other groups (p=0.126). Conclusion: Our results showed no potential difference in comparable outcomes among TVT, TOT, BC, and APR for the surgical treatment of primary SUI.

How standardised are antibiotic regimens in otologic surgery?

BackgroundWithin otologic surgery, a paucity of well-controlled studies assessing the use of systemic antibiotic to reduce surgical site infections exists. Moreover, discrepancies in wound classification of procedures challenge consensus in antimicrobial prescribing patterns. We sought to compare surgeons from two different health systems to examine how surgeons’ prescribing habits compared to practice guidelines for numerous otologic procedures.MethodsAn online questionnaire was distributed to 33 Canadian and 32 Austrian surgeons who regularly perform otologic surgery. Current systemic antibiotic prescribing habits for cochlear implantation, cholesteatoma surgery, stapes surgery, and tympanoplasty ± ossiculoplasty were collected.ResultsEighteen of 33 (54.5%) Canadian surgeons provided responses, while 18 of 32 (56.3%) of Austrian surgeons answered. Clear consistency with clinical practice guidelines exists for pre-operative antibiotics use in cochlear implant surgery and infected cholesteatoma surgery. However, for stapes surgery and tympanoplasty ± ossiculoplasty, consensus is lacking for both pre- and post-operative antibiotic prescribing habits. Notable differences between the two countries include post-operative antibiotics for cochlear implant surgery (Austria: 36.4%, Canada: 71.4%) and uninfected cholesteatoma surgery (Austria: 33.3%, Canada: 77.8%). Across all procedures, both induction and post-operative antibiotic administration was not significantly associated with surgeon seniority when stratified by five-year increments.ConclusionThe lack of consensus among each country’s otologic surgeons underscores the uncertainty in wound classification and thus, adherence to clinical practice guidelines.Graphical

Association of ACEI/ARB and statin prescribing patterns with mortality after Transcatheter Aortic Valve Replacement (TAVR): Findings from real-world claims data

Transcatheter aortic valve replacement (TAVR) has become the standard of care for most patients with severe aortic stenosis (AS), but the impact of medical therapy prescribing patterns on post-TAVR patients has not been thoroughly investigated. We analyzed Optum claims data from 9,012 adults who received TAVR for AS (January 2014-December 2018). Pharmacy claims data were used to identify patients who filled ACEI/ARB and/or statin prescriptions during the study's 90-day landmark period post-TAVR. Kaplan-Meier and adjusted Cox Proportional Hazards models were used to evaluate the association of prescribing patterns with mortality during the 3-year follow-up period. Subgroup analyses were performed to examine the impact of 11 potential confounders on the observed associations. A significantly lower adjusted 3-year mortality was observed for patients with post-TAVR prescription for ACEI/ARBs (hazard ratio [HR]=0.82, 95% confidence interval [CI] 0.74-0.91, P=.0003) and statins (HR=0.85, 95% CI 0.77-0.94, P=.0018) compared to patients who did not fill prescriptions for these medications post-TAVR. Subgroup analyses revealed that the survival benefit associated with ACEI/ARB prescription was not affected by any of the potential confounding variables, except preoperative ACEI/ARB prescription was associated with significantly lower risk of mortality vs postoperative prescription only. No other subgroup variables had significant interactions associated with survival benefits, including preoperative use of statins. In this large-scale, real-world analysis of patients undergoing TAVR, the prescription of ACEI/ARB and statins was associated with a significantly lower risk of mortality at 3-years, especially in those where the medications were initiated preoperatively.

Postoperative opioid protocol: A 5-year resident-led effort to standardize prescribing patterns

ObjectivesThe combined impact of variable surgeon prescribing preferences and low resident prescribing comfort level can lead to significant disparity in opioid prescribing patterns. We report an update on the expanded scope of this now 5-year, resident led initiative to standardize postoperative prescription practices within the Department of Otolaryngology. MethodsWith Institutional Review Board approval, performed a retrospective review of 12 months before (July 2016 – June 2017) and 48 months after (July 2019–June 2021) implementation of the Expanded Postoperative Analgesia Protocol. The Pre-Protocol and Expanded Protocol cohorts were compared using ANOVA, chi-squared and Fisher Exact tests, with ANCOVA and binary logistic regression for covariate analysis. Cost impact was calculated using average medication spending data for 2018–2019. Results470 patients were included in the Pre-Protocol cohort (54 % male, mean age 35 years) and 679 in the Expanded Protocol cohort (63 % male, mean age 36 years). The protocol was effectively implemented as reflected in the reduction of combination opioid medications from 429 (91.3 %) to 26 (3.8 %) (87 % reduction, 95 % CI 86 % to 89 %, p < .001). The protocol resulted in a 66 % reduction in average morphine milligram equivalents per patient (333 mg to 114 mg, mean reduction 219 mg, 95 % CI 206 mg to 232 mg, p < .001), a 68 % reduction in medication refills (refill rate 20 % to 6 %; 14 % reduction, 95 % CI 12 % to 16 %, p < .001) and a 74 % reduction in cost of postoperative medications ($93.82 to $24.64 per patient). ConclusionThrough purposeful standardization, this 5-year resident led effort resulted in sustained changes to departmental wide prescribing practices yielding reduced variability, reduced cost, improved opioid management and superior pain control for postoperative patients.

Does a High Postoperative Opioid Dose Predict Chronic Use After ACDF?

The purpose of this study is to determine if increased postoperative prescription opioid dosing is an isolated predictor of chronic opioid use after anterior cervical diskectomy and fusion (ACDF). A retrospective cohort analysis of patients undergoing ACDF for degenerative diseases from 2016-2019 at a single institution was performed. Preoperative and postoperative opioid and benzodiazepine prescriptions, including morphine milligram equivalents (MMEs) and duration of use, were obtained from the Pennsylvania Prescription Drug Monitoring Program. Univariate analysis compared patient demographics and surgical factors across groups on the basis of postoperative opioid dose (high: MME ≥90, low: MME <90) and chronicity of use (chronic: ≥120 days or >10 prescriptions). Logistic regressions identified predictors of high opioid dose and chronic use. A total of 385 patients were included. Preoperative opioid tolerance and tobacco use were associated with high postoperative opioid dose and chronic usage. Younger age correlated with high-dose prescriptions. Increased body mass index and preoperative benzodiazepine use were associated with chronic opioid use. Chronic postoperative opioid use correlated with high-dose prescriptions, change in opioid prescribed, private pay scripts, and more than 1 prescriber and pharmacy. Logistic regression identified high postoperative opioid dose, opioid tolerance, increased body mass index, and no prior cervical surgery as predictors of chronic opioid use. Regression analysis determined younger age, increased medical comorbidities, and opioid tolerance to be predictors for high MME prescriptions. High postoperative opioid dose independently predicted chronic opioid use after ACDF regardless of preoperative opioid tolerance.

Opioid and non-opioid analgesic prescribing practices for pediatric adenotonsillectomy in a tertiary care center.

The U.S. is in an opioid epidemic with greater than 40,000 deaths annually. Pediatric adenotonsillectomy is one of the most common and painful otolaryngology surgeries performed, often associated with opioid prescriptions. To understand postoperative prescribing practices of adenotonsillectomy in a tertiary care institution and associated postoperative emergency department (ED) visits. Descriptive analysis of retrospective cohort data. Tertiary academic healthcare institution. Pediatric patients <18yo undergoing adenotonsillectomy between 2013 and 2016. Postoperative analgesic regimens assessed including opioid and non-opioid analgesic prescriptions upon discharge from tonsillectomy surgery. Main outcomes included ED presentation within 30-days of surgery and reoperation. Secondary outcomes included reason for ED presentation and relation to prescribed analgesics. Data was analyzed between November 2021-February 2022. 200 patients were included in the study with 69% prescribed opioids, and 51% prescribed non-opioid analgesics. Number of opioid doses ranged widely with a median of 37 (Q1, Q3: 0, 62). There were no demographic differences in patients prescribed opioids from those who were not. Of those patients who presented to the ED, 81% were not specifically prescribed acetaminophen (p<0.001). Regression analysis models were not predictive of postoperative analgesic regimen or 30-day ED presentation (p>0.05) CONCLUSIONS: Wide ranges of post tonsillectomy prescribing practices currently exist in our institution. Prescribing acetaminophen may help to reduce 30-day ED presentation rate. Larger prospective studies are needed to optimize pain control regimens and reduce variability of opioid prescribing practices. Standardization of postoperative pain medication doses may also reduce postoperative ED presentations.

Modifying Post-operative Opioid Stewardship Through a System of Educational Feedback.

Background: The opioid overdose epidemic remains one of the leading focuses of the United States' public health agenda. Current literature has suggested that many surgical procedures are associated with an increased risk of chronic opioid use in the post-operative period of opioid-naïve patients. We aimed to assess whether providing feedback on the average morphine milligram equivalents (MMED) and opioid utilization by selected post-operative patients would impact the provider opioid prescribing patterns.Methods: An opioid stewardship educational intervention provided didactic and email feedback to general surgeons about their prescribing patterns and summary feedback on opioid usage among post-operative patients from the pre-intervention period. We used descriptive statistics, Chi Square, Fisher's Exact test, Wilcoxon Rank Sum, two sample t test, and Spearman's rho to analyze the data gathered.Results: A total of 5142 patients with an average age of 43.9 years were included in the study period. Women accounted for 3096 (60.2%) and 2046 (39.8%) were men. The surgeries during the study period included 1928 (37.5%) appendectomies and 3214 (62.5%) cholecystectomies. The predominant surgical approach was laparoscopic 5028 (97.8%). In both groups, the total MMED and total number of pills prescribed decreased significantly after the intervention was implemented. There were no refill prescriptions nor 30-day readmissions among those discharged with an opioid prescription in either study phase.Discussion: An intervention that provided general surgeons with feedback about their post-operative prescription patterns and data on post-operative opioid utilization by patients decreased prescribed MMED.

Efficacy of red low-level laser for postoperative pain management: A review of literature.

Many patients who undergo surgical procedures experience acute postoperative pain, with less than half receiving adequate pain relief. Recent advancements in postoperative pain management include the market clearance by the US Food and Drug Administration for the utilisation of red low-level laser therapy in providing postoperative pain relief. The Food and Drug Administration market clearance was based on clinical data from randomised controlled trials that supported the safety and effectiveness of visible red laser therapy across various surgical procedures. This review of literature aims to evaluate the mechanisms of action, the dose-response curves and clinical outcomes of red low-level laser for postoperative pain management. A literature search was limited to randomised controlled trials that evaluated the use of red low-level laser therapy on postoperative pain. The results from the literature search found that seven studies met the search qualifications. The literature review findings demonstrated that red low-level laser therapy is a safe and effective treatment alternative for postoperative pain management. In addition to postoperative pain reduction, the findings of the literature revealed that red low-level laser therapy may promote healing and reduce the consumption of postoperative prescription analgesic drugs.

What's New in Adult Reconstructive Knee Surgery.

What's New in Adult Reconstructive Knee Surgery.