Total Opioid Use Research Articles

Comparative Analgesic Efficacies of Ropivacaine and Bupivacaine for Postoperative Rectus Sheath Block in Paediatric Abdominal Surgery: A Meta-Analysis of Randomized Controlled Trial and Retrospective Cohort Studies.

Background The optimal dose and concentration of analgesic efficacy of ropivacaine (RPV) and bupivacaine (BPV) for postoperative pain relief in paediatric abdominal surgery patients is still unclear. Therefore, this meta-analysis compared the efficacy of these analgesics, their administered modes (ultrasound-guided RSB versus LAI) for postoperative pain relief, and side effects. Methods Three databases, PubMed, Embase, and Cochrane Database of Systematic Reviews, were exhaustively searched with predefined keywords. Eight randomized clinical trials and retrospective studies were selected. Analgesic effect, postoperative pain score, level of side effect, applied dose, and concentration of drug were analysed. Results Drug dose ranged from 0.5–2.5 mL/kg of 0.2 to 0.5% concentrations. Male participant for RSB and LAI treatment groups varied from 40–62% and 25–83%, respectively. Mean age of RSB and LAI groups ranged from 3.8–11.65 years and 4.3–11.27 years, respectively. Our meta-analysis revealed that RSB could reduce total opioid use postoperatively (WMD = −0.02, 95% CI: −0.02, −0.02), with I2 value of 15%. We found that the RPV (0.25%, 2.5 ml/kg) was optimal in suppressing the pain. Its lower concentration (0.2%) was ineffective, whereas higher one (0.375%) seems to increase risk of systemic toxicity. Similarly, BPV (0.25%, 2.5 mg/kg) efficaciously reduced the pain score, while its lower concentration was ineffective. The combined postoperative pain score in the RPV-treated group was found to be significantly reduced (p < 0.01) with I2 value of 85% indicating high heterogeneity. Conclusion Both RPV and BPV were significantly effective in reducing postoperative pain score. It appears that RSB could be a preferred choice to deliver analgesia, due to reduced opiate dose requirement and improved clinical safety without significant postoperative adverse events.

Preoperative Counseling Method and Postoperative Opioid Usage: A Secondary Analysis of the PREOP Study.

The purpose of this analysis is to determine if postoperative opioid usage differs among women randomized to office or phone preoperative counseling for pelvic organ prolapse surgery. This was a planned exploratory analysis of the Patient Preparedness for Pelvic Organ Prolapse Surgery study, which randomized women to standardized preoperative counseling by office visit or phone call before prolapse surgery. Inclusion criteria were the completion of the assigned counseling intervention and submission of a 7-day postoperative pain and medication diary. Multivariable logistic regression was done to assess the association between counseling method and total opioid use while controlling for variables significant on univariate analysis (surgery type and county of residence). There were 84 participants with postoperative data (41 office, 43 phone). Median total number of 5-mg oxycodone tablets used was higher for the office group (5 [interquartile range, 0-10]) than the phone group (0 [interquartile range, 0-2], P = 0.002). On multivariable logistic regression, women who underwent phone counseling were less likely to be in the highest third of opioid use when controlling for surgery type and county of residence (odds ratio, 0.23; P = 0.012; 95% confidence interval, 0.07-0.72). Daily pain scores and nonopioid medication use (nonsteroidal anti-inflammatory medications and acetaminophen) were similar between groups (P > 0.05). Despite similar pain scores, women who received preoperative phone counseling before pelvic organ prolapse surgery had lower opioid utilization than those with office counseling. Further research is needed to determine the optimal method of preoperative counseling and its role in postoperative pain management.

Minimizing Opioids After Joint Operation: Protocol to Decrease Postoperative Opioid Use After Primary Total Knee Arthroplasty.

For decades, opioids have been the mainstay in pain management after total joint arthroplasty despite evidence that their use should be curtailed. To limit unnecessary prescribing of opioids, the US Department of Veterans Affairs (VA) Portland Health Care System Total Joints Service implemented the Minimizing Opioids After Joint Operation (MOJO) postoperative pain protocol in 2018 to reduce opioid use following total knee arthroplasty (TKA). This protocol included reductions of inpatient and outpatient opioid prescribing, preoperative optimization, use of perioperative nerve blocks, and surgery without a tourniquet. We performed a retrospective chart review that compared the first 20 consecutive patients undergoing TKA using the MOJO protocol with the last 20 patients using the prior routine. Outcomes included total inpatient opioid use, daily opioid use, emergency department (ED) visits or readmissions within 90 days, phone calls for pain or medication refills, length of stay (LOS), and pain during inpatient hospital stay. There were significant differences between the pre-MOJO and the MOJO groups with regard to daily inpatient morphine equivalent dose (MED) (82 mg vs 31 mg, P < .01) and total inpatient MEDs (306 mg vs 33 mg, P < .01). There was less self-reported pain on postoperative day 1 in the MOJO group (5.5 vs 4.1, P = .01), decreased LOS (4.4 days vs 1.1 days, P < .01), fewer total ED visits (6 vs 2, P < .07), and fewer discharges to skilled nursing facilities (12 vs 0, P < .01). The MOJO protocol reduced postoperative opioid use after TKA in the VA setting without compromising pain control or increasing ED visits. The framework and routines described are potentially applicable to other institutions and surgical specialties.

404 ERAS protocol to improve racial and ethnic disparities in pain management following cesarean delivery

To assess efficacy of an enhanced recovery after surgery (ERAS) protocol on racial/ ethnic disparities in pain management after cesarean. We performed a retrospective cohort study of all scheduled cesarean deliveries 6 months before and after ERAS implementation at our institution. Pre-ERAS, only sodium citrate was given preoperatively, and all postoperative medications were given as needed. The ERAS protocol included preoperative acetaminophen, celecoxib, ondansetron, and sodium citrate. Postoperatively, patients received scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Oral oxycodone was used as needed. The primary outcome was total opioid use in the first 48 hours post-cesarean before and after ERAS, reported in equivalents of 5mg Oxycodone tablets. Data were also analyzed by racial/ethnic groups; non-Hispanic Black (NHB), non-Hispanic White (NHW), Asian (A), and Hispanic (H). Analysis was by chi squared, independent t-tests, ANOVA, Mann Whitney U, and Kruskal-Wallis tests depending on variable and data normality. Pre-ERAS and post-ERAS groups included 50 and 99 women. There were more women and a higher percentage of Hispanic women in the post-ERAS group due to closure of another city hospital. Post-ERAS, total opioid use in 48 hours was less (13.6 vs 3.0 5mg Oxycodone tablets, p<0.001) and pain scores were lower on postoperative day 1 (POD1) and 2 (POD2) (POD1 max rest- 6.7 vs 5.3, p= 0.001; POD2 max rest 6.9 vs 6.0, p = 0.041). Pre-ERAS pain scores differed by race with NHB and Hispanic patients reporting the highest mean and max VAS pain scores POD1 and POD2 (POD1, max VAS rest: NHB-7.5, NHW-6.3, A-3.8 H-8.0, p=0.007). Pre-ERAS there were also differences in acetaminophen use and number of pain assessments by group on POD1. Post-ERAS, analgesic use, number of pain assessments and max VAS pain scores on POD1 were similar in all racial/ ethnic groups. A standardized ERAS protocol for post-cesarean pain management may improve disparities in post-cesarean pain control. More research is needed to continue addressing this important topic.

208 Implementation of an enhanced recovery protocol post-cesarean delivery decreases opioid utilization and improves pain perception

Enhanced recovery after surgery (ERAS) is a multifaceted, standardized perioperative care protocol associated with improved surgical recovery. Its use has not been widely studied in obstetrics. Given the high rate of opioid dependence after cesarean delivery (CD), our aim was to evaluate the impact of an Enhanced Recovery for Obstetric Surgery (EROS) protocol on post-CD opioid use and perceived pain. EROS was implemented at Lehigh Valley Health Network (LVHN) 9/2018 (changes summarized in Figure 1). This retrospective cohort study compared post-CD opioid use between women undergoing CD before (7/1/17 – 6/30/18) and after (1/1/19 – 12/31/19) EROS implementation. Women with a significant surgical complication, history of chronic pain, current illicit drug use or current treatment for substance abuse disorder were excluded. A separate paired analysis compared outcomes of those delivering in both groups. Primary outcome was median total post-CD inpatient opioid use (morphine milligram equivalents; MME). Secondary outcomes included median discharge prescription MME, and mean pain scores on standardized assessment (10-point Likert scale). 1475 women in the pre-EROS group and 1546 women in the post-EROS group were identified. Median inpatient post-CD opioid MME and discharge MME were both significantly decreased post-EROS [75 (IQR 45-75) vs 30 (IQR 15-60) MME, p<0.001 and 900 (IQR 600-1125) vs 562.5 (IQR 360-750) MME, P<0.001, respectively], as were average pain score and mean highest pain score (3.5 vs 3.1 MME, p<0.001 and 7.3 vs 7.1 MME, p<0.003, respectively). Paired analysis of the 77 women who had a CD in both groups showed similar decreases in both opioid requirements and pain scores post-EROS. There was less variation in opioid use patterns post-EROS (Figure 2). Use of an Enhanced Recovery Protocol results in decreased post-cesarean delivery opioid use and improved pain perception. Given the scope of the opioid crisis, future studies should address whether use of this protocol can lead to decreased opioid dependence in this population.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Safety and Efficacy of Perioperative Intravenous Meloxicam for Moderate-to-Severe Pain Management in Total Knee Arthroplasty: A Randomized Clinical Trial

ObjectiveTo evaluate the effect of perioperative meloxicam IV 30 mg on opioid consumption in primary total knee arthroplasty (TKA).DesignMulticenter, randomized, double-blind, placebo-controlled trial.SubjectsIn total, 181 adults undergoing elective primary TKA.MethodsSubjects received meloxicam 30 mg or placebo via an IV bolus every 24 hours, the first dose administered prior to surgery as part of a multimodal pain management protocol. The primary efficacy parameter was total opioid use from end of surgery through 24 hours.ResultsMeloxicam IV was associated with less opioid use versus placebo during the 24 hours after surgery (18.9 ± 1.32 vs 27.7 ± 1.37 mg IV morphine equivalent dose; P < 0.001) and was superior to placebo on secondary endpoints, including summed pain intensity (first dose to 24 hours postdosing, first dose to first assisted ambulation, and first dose to discharge) and opioid use (48–72 hrs., 0–48 hrs., 0–72 hrs., hour 0 to end of treatment, and the first 24 hours after discharge). Adverse events (AEs) were reported for 69.9% and 92.0% of the meloxicam IV and placebo groups, respectively; the most common AEs were nausea (40% vs. 59%), vomiting (16% vs 22%), hypotension (14% vs 15%), pruritus (15% vs 11%), and constipation (11% vs 13%).ConclusionsPerioperative meloxicam IV 30 mg as part of a multimodal analgesic regimen for elective primary TKA reduced opioid consumption in the 24-hour period after surgery versus placebo and was associated with a lower incidence of AEs typically associated with opioid use.

Duloxetine for the reduction of opioid use in elective orthopedic surgery: a systematic review and meta-analysis.

Background Duloxetine is currently approved for chronic pain management; however, despite some evidence, its utility in acute, postoperative pain remains unclear Aim of the review This systematic review and meta-analysis is to determine if duloxetine 60mg given perioperatively, is safe and effective at reducing postoperative opioid consumption and reported pain following elective orthopedic surgery. Method CINAHL, Medline, Cochrane Central Registry for Clinical Trials, Google Scholar, and Clinicaltrials.gov were searched using a predetermined search strategy from inception to January 15, 2019. Covidence.org was used to screen, select, and extract data by two independent reviewers. Individual study bias was assessed using the Cochrane Risk of Bias tool. Opioid consumption data were converted to oral morphine milligram equivalents (MME) and exported to RevMan where meta-analysis was conducted using a DerSimonian and Laird random effects model. Results Six randomized-controlled trials were included in the literature review of postoperative pain and adverse effects. Five studies were utilized for the meta-analysis of postoperative opioid consumption; totaling 314 patients. Postoperative pain analysis showed variable statistical significance with overall lower pain scores with duloxetine. Adverse effects included an increase in insomnia with duloxetine but lower rates of nausea and vomiting. Meta-analysis revealed statistically significant [mean difference (95% CI)] lower total opioid use with duloxetine postoperatively at 24h [- 31.9 MME (- 54.22 to - 9.6), p = 0.005], 48h [- 30.90 MME (- 59.66 to - 2.15), p = 0.04] and overall [- 31.68 MME (- 46.62 to - 16.74), p < 0.0001]. Conclusion These results suggest that adding perioperative administration duloxetine 60mg to a multimodal analgesia regimen within the orthopedic surgery setting significantly lowers total postoperative opioid consumption and reduces pain without significant adverse effects.

Paravertebral Anesthetic Nerve Block for Pain Control After Peroral Endoscopic Myotomy

Background And AimsExcess postoperative opioid medication use can delay recovery and is associated with long-term misuse, addiction, and overdose. We aimed to explore the effect of preprocedural thoracic paravertebral nerve block (PNB) on pain-related outcomes after POEM. MethodsIn this retrospective cohort study, consecutive patients who did and did not receive a PNB prior to POEM were compared. The outcomes were peak and cumulative pain scores, total opioid use during hospitalization, and length of stay. After adjusting for confounders, the associations between nerve block and the outcomes of interest were explored. ResultsForty-nine consecutive patients were enrolled; 25 patients received a block whereas the subsequent 24 did not. There were no differences in baseline characteristics between the study groups. In unadjusted analyses, there was no significant difference between patients who did and did not undergo PNB in peak pain score (7.8 vs 8.7, P = 0.14), cumulative pain score in the first 12 hours (area under curve 66.5 vs 75.8, P = 0.22), median total opioid use (38.9 mg morphine equivalent dosing vs 42, P = 1.00), and median length of hospitalization (26.5 hours vs 24, P = 0.35). In multivariable regression models, PNB was not associated with a reduction in pain scores, opioid use, or hospitalization. There were no adverse events related to the block. ConclusionIn this exploratory, observational study, paravertebral nerve block immediately before POEM did not result in a statistically significant reduction in pain-related outcomes or hospitalization. Additional observational studies may elucidate whether higher anesthetic doses or longer acting formulations would be of value.

The Use of Local Anaesthetic Wound Catheter Infiltration for Post-Operative Pain after Hepatic Surgery: A Systematic Review and Meta-analysis

Introduction: The gold standard regime for analgesia following liver resection remains under debate. Studies have suggested that local anaesthetic (LA) infiltration via a wound catheter may provide analgesic benefits. The aim of this study was to analyse whether LA wound catheter infiltration (LA-WCI) as an adjunct to intravenous patient-controlled analgesia (IV-PCA) provides superior analgesic outcomes compared to IV-PCA alone. Methods: A systematic literature search and meta-analysis was conducted according to PRISMA guidelines. Randomised control trials (RCTs) comparing LA-WCI with IV-PCA versus IV-PCA alone were included. Primary outcomes were total opioid use in the first 48 hours and pain scores at multiple time points at rest and on exertion. Secondary outcomes were length of hospital stay, length of intensive care unit (ICU) stay, time to ambulation, time to first bowel movement, incidence of surgical site infections and incidence of nausea and vomiting. Results: Of 958 articles screened, six RCTs with a total of 440 patients were included in the meta-analysis. In all studies, IV-PCA with LA-WCI (LA-WCI group) was compared to IV-PCA alone (IV-PCA group). Total opioid use (mg morphine equivalent) via IV-PCA in the initial 48 hours post-operatively was significantly less in the LA-WCI group compared to the IV-PCA group [MD -21.27mg (-39.39, -3.15), I2 = 98%, p=0.02]. Pain scores were significantly lower in the LA-WCI group at rest at POD0 (post-operative day 0) 6-8hrs (p=0.0009), POD1 AM (p=0.01), POD 1 PM (p=0.02) and POD2 (p=0.0006), and on exertion at POD0 0-2hrs (p=0.05), POD1 AM (p=0.03), POD1 PM (p=0.03), POD2 (p=0.03) and POD3 (p=0.01), but similar at all other time points. The LA-WCI group had significantly reduced length of hospital stay [MD -1.32 days (-2.23, -0.40), I2 = 0%, p=0.005], time to ambulation [MD -5.94 hours (-8.47, -3.42), I2 = 0%, p=0.00001] and incidence of nausea and vomiting [OR 0.16 (0.06, 0.42), I2 = 0%, p=0.0002]. No significant differences were observed in length of ICU stay, time to first bowel movement and incidence of wound infection. Conclusions: LA-WCI as an adjunct to opiate IV-PCA post-hepatectomy reduces opioid use in the post-operative period, pain scores at multiple time points at rest and exertion, length of hospital stay, time to ambulation and incidence of nausea and vomiting. However, LA-WCI use does not alter length of ICU stay, time to first bowel movement and incidence of wound infection.

Lumbar-Sacral Plexus Block Anesthesia versus General Anesthesia for Total Hip Arthroplasty: Case Control Study

Background: Peripheral block techniques for total hip arthroplasty have been used as an analgesic strategy, only a few studies described it as an anesthetic technique, so the perioperative performance and safety are poorly studied. Methods: 78 total hip arthroplasties were prospectively observed in our hospital. Divided into 2 groups: 1) General anesthesia; and 2) Lumbar sacral plexus block anesthesia. Variables measured in both groups were: demographics, conversion to general anesthesia, total opioid doses, surgical time, blood loss, postoperative pain, use and total dose of vasopressors drugs, transfusion and ICU transfer needs, postoperative ambulation time, and length of hospital stay. T student and chi-square tests were used upon the case. A significant difference was considered when a value of p Results: 3 patients (7.3%) anesthetized with combined lumbar sacral plexus block were converted to general anesthesia. When comparing peripheral nerve block and general anesthesia, less intraoperative (p = 0.000) and postoperative (p = 0.002) opioid consumption were noted, less postoperative pain in PACU (p = 0.002) and in the first 24 hours (p = 0.005), as well as earlier onset of ambulation (p = 0.008) and shorter hospital stay (p = 0.031). Conclusions: In our study, the lumbar and sacral plexus block anesthesia technique provided anesthetic conditions to perform hip joint arthroplasty and it was proved to be advantageous in comparison to general anesthesia.

Continuous local bupivacaine wound infusion reduces oral opioid use for acute postoperative pain control following myelomeningocele repair

For pregnancies complicated by fetal myelomeningocele who meet the established criteria, prenatal closure is a viable management option. Prenatal closure is an open procedure, with some techniques requiring greater dissection of maternal tissue than cesarean delivery; pain control is an important postoperative goal. Given the rising rates of opioid dependence and concerns regarding the fetal and neonatal effects of opioid use, our practice has turned to nonopioid pain management techniques. This study aimed to compare postoperative opioid use and pain scores in women undergoing open fetal myelomeningocele repair with and without continuous local bupivacaine wound infusion. This was a retrospective, single-center chart review of all consecutive patients who underwent open myelomeningocele repair from March 2013 to December 2019. Women were enrolled at the time of referral and locally followed for 2 weeks postoperatively. The control group received patient-controlled epidural analgesia for 48 hours with acetaminophen and oral and intravenous opioids as needed. The treatment group received patient-controlled epidural analgesia for 24 hours with acetaminophen, oral and intravenous opioids, and continuous local bupivacaine infusion. Pain scores, medication use, and postoperative milestones and complications through discharge were abstracted from the chart and compared. Of 72 subjects, 51 were in the control group and 21 in the treatment group. Total opioid use, including intravenous doses (165 vs 52.5 mg; P=.001) and daily average oral opioid use (30 vs 10.5 mg; P=.002) were lower in the treatment group. In addition, 24% of women in the treatment group used no opioid postoperatively, compared with 4% in the control group. There was no difference in postoperative day 1 to 4 pain scores, antiemetic use, or bowel function; the treatment group was discharged significantly earlier. Postoperative opioid use was reduced in women who received continuous local wound infusion of bupivacaine for incisional pain control after prenatal myelomeningocele repair. Pain control is paramount following open myelomeningocele repair; local bupivacaine wound infusion is an important adjunct to reduce opioid use postoperatively.

Liposomal Bupivacaine Decreases Postoperative Length of Stay and Opioid Use in Patients Undergoing Radical Cystectomy

To analyze differences in length of stay, opioid use, and other perioperative outcomes in patients undergoing radical cystectomy with urinary diversion who received either liposomal bupivacaine (LB) or epidural analgesia. This was a single center, retrospective cohort study of patients undergoing open radical cystectomy with urinary diversion from 2015-2019 in the early recovery after surgery (ERAS) pathway. Patients received either LB or epidural catheter analgesia for post-operative pain control. LB was injected at the time of fascial closure to provide up to 72 hours of local analgesia. The primary outcome was post-operative length of stay. Secondary outcomes were post-operative opioid use, time to solid food, time to ambulation, and direct hospitalization costs. Multivariable Cox proportional hazards regression was used to determine associations between analgesia type and discharge. LB use was independently associated with shorter post-operative length of stay compared to epidural use (median (IQR) 4.9 days (3.9-5.8) vs 5.9 days (4.9-7.9), P<.001), less total opioid use (mean 188.3 vs 612.2 OME, P <.001), earlier diet advancement (mean 1.6 vs 2.4 days, P <.001), and decreased overall direct costs ($23,188 vs $29,628, P <.001). 45% of patients who received LB were opioid-free after surgery, none in the epidural group. On multivariable Cox proportional hazards regression modeling, LB use was independently associated with earlier discharge (HR 2.1, IQR 1.0-4.5). Use of LB in open radical cystectomy is associated with reduced LOS, less opioid exposure, and earlier diet advancement.

The Efficacy of Liposomal Bupivacaine on Postoperative Pain Following Abdominal Wall Reconstruction: A Randomized, Double-blind, Placebo-controlled Trial.

To study the efficacy of liposomal bupivacaine on postoperative opioid requirement and pain following abdominal wall reconstruction. Despite the widespread use of liposomal bupivacaine in transversus abdominis plane block, there is inadequate evidence demonstrating its efficacy in open abdominal wall reconstruction. We hypothesized that liposomal bupivacaine plane block would result in decreased opioid requirements compared with placebo in the first 72 hours after surgery. This was a single-center double-blind, placebo-controlled prospective study conducted between July 2018 and November 2019. Adult patients (at least 18 yrs of age) undergoing open, elective, ventral hernia repairs with mesh placed in the retromuscular position were enrolled. Patients were randomized to surgeon-performed transversus abdominis plane block with liposomal bupivacaine, simple bupivacaine, or normal saline (placebo). The main outcome was opioid requirements in the first 72 hours after surgery. Secondary outcomes included total inpatient opioid use, pain scores determined using a 100 mm visual analog scale, length of hospital stay, and patientreported quality of life. Of the 164 patients who were included in the analysis, 57 patients received liposomal bupivacaine, 55 patients received simple bupivacaine, and 52 received placebo. There were no differences in the total opioid used in the first 72 hours after surgery as measured by morphine milligram equivalents when liposomal bupivacaine was compared with simple bupivacaine and placebo (325 ± 225 vs 350 ± 284 vs 310 ± 272, respectively, P = 0.725). Similarly, there were no differences in total inpatient opioid use, pain scores, length of stay, and patient-reported quality of life. There are no apparent clinical benefits to using liposomal bupivacaine transversus abdominis plane block when compared with simple bupivacaine and placebo for open abdominal wall reconstruction.

Naloxone Continuous Infusion for Spinal Cord Protection in Endovascular Aortic Surgery Leads to Higher Opioid Administration and More Pain

Compare total perioperative opioid use in patients receiving naloxone continuousinfusion (NCI) for spinal cord ischemia prophylaxis, versus patients not receiving NCI, in endovascular aortic repair. Single-center, retrospective cohort review. Academic medical center. Patients undergoing elective thoracic, thoracoabdominal, or abdominal aortic endovascular repair. Patients were separated based on the use of naloxone continuous infusion as part of a spinal protection protocol. Primary endpoint was opioid requirements, in milligram morphine equivalents (MME), during the first 48 hours or during NCI. Secondary endpoints included: postoperative pain scores during the same interval; opioid requirements during hours 48 to 72; and pain scores during hours 48 to 72. Ninety-five procedures were included; 43 received naloxone continuous infusion and 52 patients were in the non-naloxone group. Opioid use from a linear mixed model was elevated across the entire continuum in the naloxone group (18 MMEs, 95% CI 13-24), with the greatest difference seen at the 24-to-48-hour interval (51 MMEs, 95% CI 26-75) after adjustment for age, incisions, and prehospital opioid use. In the naloxone group, pain score estimates were elevated at each postoperative interval of evaluation, with similar adjustment. Across the continuum this was 0.7 higher (95% CI 0.2-1.3); the zero-six-hour and six-to-12-hour intervals were 0.9 (95% CI 0.4-1.4) and 1.2 higher (95% CI 0.7-1.7). Patients receiving anloxone continuous infusion to prevent spinal cord ischemia required greater quantities of opioids and had higher postoperative pain, compared with patients not requiring naloxone.

Impact of Oral Arginine Therapy on Global Arginine Bioavailability in Nigerian Children with Sickle Cell Anemia and Vaso-Occlusive Pain

Introduction: Severe vaso-occlusive pain episodes (VOE) are a major cause of morbidityand mortality in sickle cell anemia (SCA). Low arginine bioavailability is associated with pain severity and predicts need for pediatric hospitalization (Morris et. al, 2000). Arginine supplementation has opioid-sparing effects and was found to significantly decrease pain scores in children hospitalized with SCA-VOE compared to placebo in phase-2 randomized placebo-controlled trials (RCT) performed in the United States (US, Morris et. al, 2013) and Nigeria (Onalo et al, ASH 2019), while also significantly decreased time-to-crisis-resolution and length of hospital stay (LOS) in Nigerian children (Onalo et al, ASH 2019). Its mechanism-of-action and impact on arginine bioavailability is unclear. Objectives: To determine the impact of oral arginine supplementation on arginine bioavailability and total opioid use in children with SCA-VOE. Methods: A double-blind RCT of oral L-arginine (100 mg/kg/dose every 8 hours until discharge; up to 15 doses maximum) was performed in children with SCA hospitalized with severe VOE defined as a Numerical Pain Scale Score (PS) of at least 7 on a scale of 0-10, at one of two hospitals in Abuja, Nigeria (clinical outcomes previously reported, Onalo et al ASH 2019). Plasma arginine concentration and the global arginine bioavailability ratio (GABR, defined as arginine/[ornithine+citrulline]) was measured with high performance liquid chromatography tandem mass spectrometry before supplementation and at day 5 or discharge, whichever came first. Indices of arginine bioavailability were calculated and compared between the study groups. Demographics, clinical characteristics and total opioid use (mg/kg of morphine equivalents) were obtained. The impact of oral arginine supplementation on arginine bioavailability, and correlation of changes in arginine bioavailability with total opioid use was assessed. Results: Sixty-eight children with SCA were recruited, aged 5-17years (mean: 10.6±0.4 years), and 85% were male; 35 children were randomized into the arginine arm and 33 into the placebo arm. Baseline characteristics were similar between arms. Clinical outcomes of significantly lower total analgesic use, lower pain scores, decreased time-to-crisis resolution and shorter LOS in the arginine group vs. placebo were previously reported (Onalo et al, ASH 2019). Oral arginine supplementation increases plasma arginine levels by 125% [95% CI, 61-187%] in the arginine as against 29% [1-58%] in the placebo group (Table 1), p=0.007. GABR was higher after supplementation in patients treated with arginine: 59% [20-98%] vs. -2% [-27-22%] in the placebo group (p=0.009). Patients with the lowest arginine level at presentation experienced the greatest increase in plasma arginine concentration, particularly patients with acute chest syndrome (ACS). Percent increase in GABR inversely correlated with total opioid used (mg/kg; r=-0.35;p=0.02, figure 1). Conclusion: Arginine deficiency plays a role in acute pain requiring hospitalization in Nigerian children with SCA, similar to what has been reported in the US. Plasma arginine levels significantly increased with arginine supplementation, and improved global arginine bioavailability was inversely associated with total opioids used in VOE management. Lowest arginine levels were found in children with ACS, as previously reported in the US (Morris et al, 2000), a phenomenon that warrants further investigation. Low arginine bioavailability in children with SCA-VOE is improved by oral arginine supplementation. Funded by Tertiary Education Trust Fund (to RO) and in part by NIH/NCCIH K24AT009893 (to CRM); Pan African Clinical Trial Registry number PACTR 201611001864290). Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Oral L-arginine for treatment of sickle cell anemia; it is a nutritional supplement

Effectiveness, cost-effectiveness and safety of gabapentin versus placebo as an adjunct to multimodal pain regimens in surgical patients: protocol of a placebo controlled randomised controlled trial with blinding (GAP study)

IntroductionGabapentin is an antiepileptic drug currently licensed to treat epilepsy and neuropathic pain but has been used off-label to treat acute postoperative pain. The GAP study will compare the effectiveness,...

Perioperative Opioid Requirements in Minimally Invasive Gynecologic Surgery

Study Objective To evaluate postoperative opioid use and the impact of a patient educational intervention regarding the opioid epidemic and proper opioid use/disposal after benign MIGS procedures. Design Prospective Cohort Study Setting Academic hospital center Patients or Participants Adult patients undergoing benign MIGS procedures were enrolled 1/1/2019-1/1/2020. Exclusion criteria: conversion to laparotomy, preoperative opioid use, incapable of written informed consent, non-English speaking. Interventions Educational pamphlets were provided preoperatively. Patients underwent hysterectomy(HYS), myomectomy(MYO), or other laparoscopic(LSC) procedures. Opioid prescriptions were standardized with 25 tablets oxycodone 5mg for HYS/MYO, 10 tablets oxycodone 5mg for LSC (oral morphine equivalents [OME] were maintained for alternative options). Pill diaries were reviewed and patient surveys completed during postoperative visits. Measurements and Main Results Of 106 consented patients, 65(61%) completed their pill diaries (36 HYS, 17 MYO, 12 LSC). Median opioid use was 35 OME for HYS (∼5 oxycodone tablets; IQR 11.25-102.5), 30 OME for MYO (∼4 tablets; IQR 15-75), and 18.75 OME for LSC (∼3 tablets; IQR 7.5-48.75). Median last post-operative day(d) of use was 3d for HYS (IQR 2, 8), 4d for MYO (IQR 1, 7), and 2d for LSC (IQR 0.5-3.5). One patient (MYO) required a refill of 5mg oxycodone (10 tablets). No difference was found between total opioid use and presence of pelvic pain, chronic pain disorders, or psychiatric co-morbidities. Overall satisfaction with pain control (≥4 on a 5-point Likert scale) was 91% for HYS, 100% for MYO, 83% for LSC. Of the 33 patients who read the pamphlet, 32(97%) felt it increased their awareness/knowledge. Conclusion The vast majority of patients required

Effects of intraoperative liposomal bupivacaine on pain control and opioid use after pediatric Chiari I malformation surgery: an initial experience.

Pediatric Chiari I malformation decompression is a common neurosurgical procedure. Liposomal bupivacaine (LB) is a novel formulation that can have an impact on postoperative recovery for particular procedures, but its potential role in pediatric neurosurgery is largely unexplored. The authors sought to describe and assess their initial experience with LB in pediatric Chiari I malformation decompression to better define its potential role as an analgesic agent in a procedure for which the postoperative course is often remarkably painful. A retrospective review of all pediatric Chiari procedures performed at the authors' institution between 2018 and 2020 was conducted. Patients were divided into those who were treated with a single intraoperative dose of LB (LB group) and those who were not (control group). Comparisons of total opioid use and pain control were made using chi-square and Wilcoxon rank-sum tests. A total of 18 patients were identified, 9 (50%) in the LB group and 9 (50%) in the control group. Overall, there were 13 (72%) female and 5 (28%) male patients with a mean age of 15.9 years. No surgical complications were observed over a mean length of stay of 2.7 days. Within the first 24 hours after surgery, the LB group had significantly lower total opioid use than the control group (17.5 vs 47.9 morphine milligram equivalents, respectively; p = 0.03) as well as lower mean pain scores reported by patients using a 10-point visual analog scale (3.6 vs 5.5 for the LB vs control groups, p = 0.04). However, from the first 24 postoperative hours to discharge, total opioid use (p = 0.51) and mean pain scores (p = 0.09) were statistically comparable between the two groups. There were 2/9 (22%) LB patients versus 0/9 (0%) control patients who did not require opioid analgesia at any point during hospitalization. The use of a single intraoperative dose of LB in pediatric Chiari I malformation surgery appears to be safe and has the potential to reduce pain scores and opioid use when administered during the first 24 postoperative hours. From that time period to discharge, however, there may be no significant difference in total opioid use or pain scores.

Levorphanol in the Perioperative Setting: Decreasing Opioid Requirements While Improving Pain Management.

Levorphanol is a Food and Drug Administration (FDA)-approved long-acting opioid. Most information on perioperative use of levorphanol comes from the early- and mid-1950s when this drug emerged in the field of experimental pharmacology and anesthesia. It was mainly studied during this period with some additional data being generated in the 1960s and 70s. Since this time, perioperative use has declined and research is limited. This review of literature aims to provide pharmacologic and historic description of levorphanol as a tool for perioperative pain management and as an aid to potentially decrease total postoperative opioid use during the current opioid crisis.

Implementation of Enhanced Recovery in Gynecologic Surgery to Improve Outcomes at an Urban Safety-Net Hospital

Background: This study aims to implement an enhanced recovery pathway (ERP) for patients undergoing gynecologic surgery and to track clinical outcomes, including perioperative opioid use and adverse events. Methods: Patients undergoing gynecologic surgery with a planned overnight stay were eligible. The primary outcome measure was perioperative opioid use in oral morphine milligram equivalents. Secondary outcome measures included bundle completion and length of stay. Balancing measures included rates of total and specific adverse events. Data were stratified by route of surgery and univariate analyses were performed between pre- and post-ERP groups to compare demographic factors and outcome measures. Linear regression analyses were run to assess mean differences in perioperative opioid use and length of stay when adjusting for route of surgery, age, body mass index (BMI), American Society of Anesthesiologists (ASA) status, surgical subspecialty, and postoperative hemoglobin change, and/or bundle completion score. Results: The ERP was implemented in 16 weeks and selected in 63 eligible patients from February 1 to April 30, 2017. ERP bundle completion was significantly higher for all surgical categories following formal pathway implementation. Compared to the pre-ERP cohort, the ERP cohort demonstrated significantly decreased total opioid use in laparotomies (175.5 mg vs. 209.8 mg, P = 0.03) and minimally invasive surgeries (125 mg vs. 170.3 mg, P = 0.018). Additionally, significantly decreased intraoperative opioids were used in both laparotomies (95 mg vs. 105 mg, P = 0.03) and minimally invasive surgeries (75 mg vs. 108.5 mg, P < 0.0001), as well as significantly decreased postoperative opioid use in minimally invasive surgeries (15 mg vs. 45 mg, P = 0.04). A one-point increase in ERP bundle completion score was associated with a 9.2 mg decrease in total opioid used (P = 0.0375) as well as a 4.8 h decrease in length of stay (P < 0.0001) when adjusting for route of surgery, age, BMI, ASA status, surgical subspecialty, and case length. There were no significant differences in adverse events when ERP was used. Conclusions: ERP implementation was rapidly accomplished at our urban, safety-net hospital. The pathway reduced perioperative opioid use without increasing adverse events. Continued monitoring of enhanced recovery quality improvement measures, including bundle completion, is essential to ensure adherence, safety, and effectiveness. J Clin Gynecol Obstet. 2020;9(3):43-52 doi: https://doi.org/10.14740/jcgo666