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Martin AN, Newhook TE, Arvide EM, Kim BJ, Dewhurst WL, Kawaguchi Y, Tran Cao HS, Chun YS, Katz MH, Vauthey JN, Tzeng CWD. Utilizing risk-stratified pathways to personalize post-hepatectomy discharge planning: A contemporary analysis of 1,354 patients. Am J Surg 2024; 233:17-23. [PMID: 38129274 DOI: 10.1016/j.amjsurg.2023.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND While risk-stratified post-hepatectomy pathways (RSPHPs) reduce length-of-stay, can they stratify hepatectomy patients by risk of early postoperative events. METHODS 90-day outcomes from consecutive hepatectomies were analyzed (1/1/2017-12/31/2021). Pre/post-pathway analysis was performed for pathways: minimally invasive surgery ("MIS"); non-anatomic resection/left hepatectomy ("low-intermediate risk"); right/extended hepatectomy ("high-risk"); "Combination" operations. Time-to-event (TTE) analyses for readmission and interventional radiology procedures (IRPs) was performed. RESULTS 1354 patients were included: MIS/n= 119 (9 %); low-intermediate risk/n= 443 (33 %); high-risk/n= 328 (24 %); Combination/n= 464 (34 %). There was no difference in readmission (pre: 13 % vs. post:11.5 %, p = 0.398). There were fewer readmissions in post-pathway patients amongst MIS, low-intermediate risk, and Combination patients (all p > 0.1). 114 (8.4 %) patients required IRPs. Time-to-readmission and time-to-IR-procedure plots demonstrated lower plateaus and flatter slopes for MIS/low-intermediate-risk pathways post-pathway implementation (p < 0.001). CONCLUSION RSPHPs can reliably stratify patients by risks of readmission or need for an IR procedure by predicting the most frequent period for these events.
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Affiliation(s)
- Allison N Martin
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bradford J Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yun Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew Hg Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Rubin JB, Aby ES, Barman P, Tincopa M. Opioid use and risks in candidates and recipients of liver transplant. Liver Transpl 2024:01445473-990000000-00369. [PMID: 38669598 DOI: 10.1097/lvt.0000000000000388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
Opioid use is extremely prevalent among patients with cirrhosis and those who received liver transplant (LT), despite concerns regarding opioid-related risks in this population. While there are many theoretical risks of opioids in patients with hepatic dysfunction, there is limited evidence on the effect of opioid use on clinical outcomes in cirrhosis and patients before and after LT specifically. As a result, there is significant center-level variability in opioid-related practices and policies. The existing data-largely based on retrospective observational studies-do suggest that opioids are associated with increased health resource utilization pre-LT and post-LT and that they may precipitate HE in patients with cirrhosis and increase the risk of graft loss and death after LT. The strongest predictor of opioid use after LT is opioid use before transplant; thus, a focus on safe opioid use in the pretransplant and peritransplant periods is essential for minimizing opioid-related harms. We describe 3 strategies to guide LT providers including (1) improved characterization of pain, mental health symptoms, and opioid and polysubstance use; (2) minimization of opioid prescriptions for those at highest risk of adverse events; and (3) safe prescribing strategies for those who do use opioids and for the management of opioid use disorder. Ultimately, our goal is to improve the quality of life and transplant outcomes among patients with cirrhosis and those who received LT, particularly those living with concurrent pain, mental health, and substance use disorders.
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Affiliation(s)
- Jessica B Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Department of Medicine, Gastroenterology Section, San Francisco VA Health Care System, San Francisco, California, USA
| | - Elizabeth S Aby
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pranab Barman
- Division of Digestive Diseases, Department of Medicine, University of California-San Diego, San Diego, California, USA
| | - Monica Tincopa
- Division of Digestive Diseases, Department of Medicine, University of California-San Diego, San Diego, California, USA
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Bedar M, Dejam D, Caprini RM, Huang KX, Cronin BJ, Khetpal S, Morgan KBJ, Lee JC. An enhanced recovery after surgery protocol for facial feminization surgery reduces perioperative opioid usage, pain, and hospital stay. J Plast Reconstr Aesthet Surg 2023; 85:393-400. [PMID: 37572387 DOI: 10.1016/j.bjps.2023.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/18/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Prescription drug misuse in transgender individuals is estimated to be three times higher than that of the general population in the United States, suggesting that opioid-reduction strategies deserve significant consideration in gender-affirming surgeries. In this work, we describe the implementation of an enhanced recovery after surgery (ERAS) protocol to reduce opioid use after facial feminization surgery. METHODS A total of 79 patients who underwent single-stage facial feminization surgery before (n = 38) or after (n = 41) ERAS protocol implementation were included. Primary outcomes assessed were perioperative opioid consumption (morphine equivalent dose/kilogram, MED/kg), average patient-reported pain scores, and length of hospital stay. Comparisons between groups and multivariable linear regression analyses were conducted to define the contribution of the ERAS protocol to each of the three primary outcomes. RESULTS Age, body mass index, mental health diagnoses, and length of surgery did not differ between pre-ERAS and ERAS groups. Compared to pre-ERAS patients, patients treated under the ERAS protocol consumed less opioids (median [interquartile range, IQR], 0.8 [0.5-1.1] versus 1.5 [1.0-2.1] MED/kg, p < 0.001), reported lower pain scores (2.5 ± 1.8 versus 3.7 ± 1.6, p = 0.002), and required a shorter hospital stay (median [IQR], 27.3 [26.3-49.8] versus 32.4 [24.8-39.1] h, p < 0.001). When controlling for other contributing variables such as previous gender-affirming surgeries, mental health diagnoses, and length of surgery using multivariable linear regression analyses, ERAS protocol implementation independently predicted reduced opioid use, lower pain scores, and shorter hospital stay after facial feminization surgery. CONCLUSIONS The current work details an ERAS protocol for facial feminization surgery that reduces perioperative opioid consumption, patient-reported pain scores, and hospital stays.
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Affiliation(s)
- Meiwand Bedar
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Dillon Dejam
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Rachel M Caprini
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Kelly X Huang
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Brendan J Cronin
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Sumun Khetpal
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Katarina B J Morgan
- T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Justine C Lee
- Division of Plastic and Reconstructive Surgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States; UCLA Gender Health Program, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, United States.
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Jiang F, Wu A, Liang Y, Huang H, Tian W, Chen B, Liu D. Assessment of Ultrasound-Guided Continuous Low Serratus Anterior Plane Block for Pain Management After Hepatectomy: A Randomized Controlled Trial. J Pain Res 2023; 16:2383-2392. [PMID: 37469957 PMCID: PMC10353558 DOI: 10.2147/jpr.s406498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 07/06/2023] [Indexed: 07/21/2023] Open
Abstract
Purpose Adequate postoperative analgesia is a key to earlier recovery from open surgery. This work investigated the pain control and quality of patient recovery after hepatectomy to evaluate the modified continuous serratus anterior plane block (called low SAPB) for postoperative analgesia. Patients and Methods This single-center, blinded, randomized, controlled study included 136 patients who underwent hepatectomy under general anesthesia. For postoperative analgesia, the patients in the SAPB group were given a continuous low SAPB at the 7th intercostal space in the right mid-axillary line, and the patients in the control group were given continuous intravenous opioid analgesia. The numeric pain rating scale (NPRS) was used for pain assessment. The postoperative assessment focused on the remedial drug consumption, the occurrence of adverse postoperative analgesic reactions, and the quality of patient recovery evaluated with the QoR-15 questionnaire. Results Compared to the controls, the SAPB patients had significantly lower NPRS scores at 12 h and 24 h at rest and 6 h, 12 h, and 24 h in motion, and a longer time to first use of remedial analgesics at 24 h, and higher overall QoR-15 scores at 24 h [124 (121, 126) vs 121 (120, 124)] and 48 h [129 (126, 147) vs 126 (125, 128)], after surgery. There was no significant difference in the incidence of analgesia-related adverse reactions between the two groups. Conclusion The continuous low SAPB could achieve superior pain control, especially for motor pain, to intravenous opioid analgesia during the first 24 h post-surgery. Even with no significant difference in the incidence of postoperative adverse reactions, patients with continuous low SAPB appeared to have a higher quality of recovery in the first two days post-surgery than patients with continuous intravenous analgesia.
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Affiliation(s)
- Fei Jiang
- Department of Anesthesiology, The First People’s Hospital of Neijiang, Neijiang, Sichuan, People’s Republic of China
| | - Ailing Wu
- Department of Anesthesiology, The First People’s Hospital of Neijiang, Neijiang, Sichuan, People’s Republic of China
| | - Yan Liang
- Department of Anesthesiology, The First People’s Hospital of Neijiang, Neijiang, Sichuan, People’s Republic of China
| | - Hui Huang
- Department of Anesthesiology, The First People’s Hospital of Neijiang, Neijiang, Sichuan, People’s Republic of China
| | - Wei Tian
- Department of Anesthesiology, The First People’s Hospital of Neijiang, Neijiang, Sichuan, People’s Republic of China
| | - Bogang Chen
- Department of Anesthesiology, The First People’s Hospital of Neijiang, Neijiang, Sichuan, People’s Republic of China
| | - Di Liu
- Department of Anesthesiology, The First People’s Hospital of Neijiang, Neijiang, Sichuan, People’s Republic of China
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Supplemental Regional Block Anesthesia Reduces Opioid Utilization Following Free Flap Reconstruction of the Oral Cavity: A Prospective, Randomized Clinical Trial. J Oral Maxillofac Surg 2023; 81:140-149. [PMID: 36442533 DOI: 10.1016/j.joms.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Regional anesthesia has been shown to effectively manage acute pain and reduce opioid utilization in the early postoperative period following colorectal, orthopedic, and thoracic surgeries. The same effect, however, has not been demonstrated in major head and neck surgery. The purpose of this study is to determine whether supplemental regional anesthesia reduces opioid utilization following microvascular free flap reconstruction of the oral cavity. METHODS A prospective, randomized clinical trial was conducted for patients undergoing oral cavity reconstruction using microvascular free tissue transfer between January 2020 and March 2022. The predictor variable was a regional anesthetic nerve block, delivered preoperatively, at the flap donor site. The primary and secondary outcomes were opioid utilization, measured in oral morphine equivalent (OME), from postoperative day 1 to 5, and hospital length of stay (LOS), respectively. Covariates included age, sex, tobacco and alcohol history, prior radiation therapy, pathology, oral site, flap type, tracheostomy, and neck dissection. Student's t test, χ2 test, and linear regression models were computed using correlations with 95% confidence intervals (CIs). For all statistical tests, P values of <.05 were regarded as statistically significant. RESULTS Ninety-eight participants completed the study. The mean age was 56 years with 55% male. Forty-eight patients received a presurgical regional anesthesia block, and 50 patients served as control subjects. Bivariate analysis demonstrated an even distribution of all study variables. Total OME utilization was significantly less in the treatment group compared to the control group, (166.32 vs 118.43 OME; 95% CI, 1.32 to 94.45; P = .04). The LOS was comparable (6.60 vs 6.48 days; 95% CI, -0.53 to 0.77; P = .71). Tobacco use had a positive effect (B = 0.28; 95% CI, 21.63 to 115.31; P = .005) while the block had a negative effect with total OME, (B = -0.19; 95% CI, -90.39 to -0.59; P = .047). The extent of the neck dissection (B = 0.207; 95% CI, 0.026 to 1.403; P = .042) was a positive predictor for LOS. Overall, there were no adverse events associated with the regional block throughout the study period. CONCLUSIONS Supplemental regional anesthesia is safe and associated with reduced opioid utilization in patients undergoing vascularized free flap reconstruction of composite oral cavity defects and does not prolong the length of hospitalization.
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Comparison of Liposomal Bupivacaine to a Local Analgesic Cocktail for Transversus Abdominis Plane-Blocks in Abdominally-Based Microvascular Breast Reconstruction. Plast Reconstr Surg 2022; 150:506e-515e. [PMID: 35749219 DOI: 10.1097/prs.0000000000009398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Transversus Abdominis Plane (TAP) blocks can improve pain control and decrease opioid usage within an ERAS protocol, in patients undergoing abdominally-based autologous breast reconstruction. The author has transitioned to using a local analgesic cocktail in place of liposomal bupivacaine for TAP blocks. The purpose of this study is to compare post-operative opioid use in patients who received the different TAP blocks. METHODS A retrospective review of patients undergoing abdominally-based autologous breast reconstruction between November 2015 and December 2019 was performed. The study group received Bupivacaine, Ketorolac, Dexmedetomidine, and Dexamethasone, and the control group received Liposomal Bupivacaine +/- Bupivacaine, Ketorolac, or Dexmedetomidine, as a TAP block. The primary outcome of interest was post-operative opioid use and pain scores. RESULTS A total of 104 women met inclusion criteria: 36 in Group A (pre-ERAS, pre-TAP), 38 in Group B (ERAS, TAP with liposomal bupivacaine), and 30 in Group C (ERAS, TAP with local anesthetic cocktail). Total and average daily OME consumption were significantly less for Group C in the inpatient phase (Group A: 633, B: 240, C: 135; p<0.0001) (Group A: 137, B: 56, C: 29; p<0.0001). Patients in Group C were prescribed significantly less outpatient OMEs (Group A: 79, B: 74, C: 52; p=0.01). CONCLUSION TAP blocks are a significant component of an ERAS protocol for abdominally-based breast reconstruction. Liposomal bupivacaine is a popular option for TAP blocks. Our results demonstrate that a local anesthetic cocktail, composed of economical and readily available medications, can provide excellent patient pain control and decrease post-operative opioid use.
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Kim BJ, Arvide EM, Gaskill C, Martin AN, Kawaguchi Y, Chiang YJ, Dewhurst WL, Lee T, Tran Cao HS, Chun YS, Katz MH, Vauthey JN, Tzeng CWD, Newhook TE. Risk-Stratified Post-Hepatectomy Pathways Based Upon the Kawaguchi-Gayet Complexity Classification and Impact on Length of Stay. Surg Open Sci 2022; 9:109-116. [PMID: 35747509 PMCID: PMC9209704 DOI: 10.1016/j.sopen.2022.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 10/25/2022] Open
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Witt RG, Cope B, Chiang YJ, Newhook T, Lillemoe H, Tzeng CWD, Chen IB, Fisher SB, Lucci A, Wargo JA, Lee JE, Ross MI, Gershenwald JE, Robinson J, Keung EZ. Utilization and evolving prescribing practice of opioid and non-opioid analgesics in patients undergoing lymphadenectomy for cutaneous malignancy. J Surg Oncol 2022; 125:719-729. [PMID: 34904258 PMCID: PMC9108995 DOI: 10.1002/jso.26768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/30/2021] [Accepted: 12/05/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Opioids are commonly prescribed following surgery and can lead to persistent opioid use. We assessed changes in prescribing practices following an opioid education initiative for patients undergoing lymphadenectomy for cutaneous malignancy. METHODS A single-institution retrospective study of all eligible patients (3/2016-3/2020) was performed. RESULTS Indications for lymphadenectomy in 328 patients were metastatic melanoma (84%), squamous cell carcinoma (10%), and Merkel cell carcinoma (5%). At discharge, non-opioid analgesics were increasingly utilized over the 4-year study period, with dramatic increases after education initiatives (32%, 42%, 59%, and 79% of pts, respectively each year; p < 0.001). Median oral morphine equivalents (OMEs) prescribed also decreased dramatically starting in year 3 (250, 238, 150, and 100 mg, respectively; p < 0.001). Patients discharged with 200 mg OMEs were less likely to also be discharged with non-opioid analgesics (40% vs. 64%. respectively, p < 0.001). CONCLUSIONS Analgesic prescribing practices following lymphadenectomy for cutaneous malignancy improved significantly over a 4-year period, with use of non-opioids more than doubling and a 60% reduction in median OME. Opportunities exist to further increase non-opioid use and decrease opioid dissemination after lymphadenectomy for cutaneous malignancy.
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Affiliation(s)
- Russell G. Witt
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Brandon Cope
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Timothy Newhook
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Heather Lillemoe
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D. Tzeng
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Iris B. Chen
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Sarah B. Fisher
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Anthony Lucci
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jennifer A. Wargo
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jeffrey E. Lee
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Merrick I. Ross
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Jeffrey E. Gershenwald
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Justine Robinson
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
| | - Emily Z. Keung
- Department of Surgical Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, Texas
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Response to the Comment on "Patient Factors Associated With Opioid Consumption in the Month Following Major Surgery". Ann Surg 2021; 274:e199-e200. [PMID: 31804394 DOI: 10.1097/sla.0000000000003710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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10
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Pu T, Erali RA, Share M, Russell GB, Clark CJ, Levine EA, Shen P. Persistent opioid use after curative-intent hepatectomy for neoplastic disease. J Surg Oncol 2021; 124:301-307. [PMID: 34156105 DOI: 10.1002/jso.26472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/14/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES This study analyzed persistent opioid use in opioid-naïve and nonopioid-naïve patients undergoing hepatectomy for neoplastic disease. METHODS A retrospective review was performed of a prospective database using inclusion criteria of hepatectomy for neoplastic disease from October 2013 to December 2017. Prescription data were collected from the North Carolina Controlled Substance Reporting System. Persistent opioid use was defined as patients who continued filling opioid prescriptions 90 days to 1 year after surgery. Patients who did not receive opioid prescriptions between 12 months and 31 days before surgery were defined as naïve. RESULTS The analysis included 75 surgeries on naïve and 58 surgeries on nonnaïve patients. 56% of naïve patients and 79% of nonnaïve patients developed persistent opioid use, respectively (p = .0056). Naïve patients received 2.24 ± 4.30 MMEs/day, while nonnaïve patients received 5.50 ± 5.98 MMEs/day during Postoperative days 90-360 (95% CI, 1.41-5.10; p < .001). Naïve patients with a lower Preoperative ECOG score were more likely to develop persistent opioid use (OR, 0.45; 95% CI, 0.21-0.99; p = .048). CONCLUSION More than half of naïve patients undergoing hepatectomy developed persistent opioid use within the first year, though significantly less than nonnaïve patients. Improved performance status was associated with an increased risk of persistent opioid use in naïve patients.
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Affiliation(s)
- Tracey Pu
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Richard A Erali
- Department of Surgery, Wake Forest Baptist Medical Center, Winston, Salem, North Carolina, USA
| | - Michael Share
- Department of Surgery, Wake Forest Baptist Medical Center, Winston, Salem, North Carolina, USA
| | - Gregory B Russell
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston, Salem, North Carolina, USA
| | - Clancy J Clark
- Department of Surgery, Wake Forest Baptist Medical Center, Winston, Salem, North Carolina, USA
| | - Edward A Levine
- Department of Surgery, Wake Forest Baptist Medical Center, Winston, Salem, North Carolina, USA
| | - Perry Shen
- Department of Surgery, Wake Forest Baptist Medical Center, Winston, Salem, North Carolina, USA
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Burns S, Urman R, Pian R, Coppes OJM. Reducing New Persistent Opioid Use After Surgery: A Review of Interventions. Curr Pain Headache Rep 2021; 25:27. [PMID: 33760983 PMCID: PMC7990836 DOI: 10.1007/s11916-021-00943-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 12/02/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize interventions used in the perioperative period to reduce the development of new persistent postoperative opioid use in opioid-naïve patients. RECENT FINDINGS The development of new persistent opioid use after surgery has recently been identified as a common postoperative complication. The existing literature suggests that interventions across the continuum of care have been shown to decrease the incidence of new persistent postoperative opioid use. Specific preoperative, intraoperative, and postoperative interventions will be reviewed, as well as the use of clinical pathways and protocols that span throughout the perioperative period. Common to many of these interventions include the use of multimodal analgesia throughout the perioperative period and an emphasis on a patient-centered, evidence-based approach to the perioperative pain management plan. While the incidence of new persistent postoperative opioid use appears to be high, the literature suggests that there are both small- and large-scale interventions that can be used to reduce this. Technological advances including prescription monitoring systems and mobile applications have enabled studies to monitor opioid consumption after discharge. Interventions that occur preoperatively, such as patient education and expectation setting regarding postoperative pain management, and interventions that occur postoperatively, such as the implementation of procedure-specific, evidence-based prescribing guidelines and protocols, have been shown to reduce post-discharge opioid consumption. The use of multimodal analgesia and opioid-sparing adjuncts throughout the perioperative period is central to many of these interventions and has essentially become standard of care for management of perioperative pain.
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Affiliation(s)
- Stacey Burns
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Richard Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Center for Perioperative Research, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel Pian
- Department of Biology, Boston University, Boston, MA, USA
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Hecht S, Halstead NV, Boxley P, Brockel MA, Rove KO. Opioid prescribing patterns following implementation of Enhanced Recovery After Surgery (ERAS) protocol in pediatric patients undergoing lower tract urologic reconstruction. J Pediatr Urol 2021; 17:84.e1-84.e8. [PMID: 33229228 DOI: 10.1016/j.jpurol.2020.10.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND With increasing awareness of the opioid epidemic, there is a push for providers to minimize opioid prescriptions. Enhanced Recovery After Surgery (ERAS) is a comprehensive multidisciplinary perioperative protocol that includes minimization of opioid analgesia in favor of non-opioid alternatives and regional analgesia. While ERAS protocols have consistently been shown to decrease inpatient opioid utilization, the impact on opioid prescribing practices and use after discharge in pediatric surgical patients is unclear. OBJECTIVE This study aims to assess the impact of an ERAS protocol on outpatient opioid prescription patterns after pediatric lower urinary tract reconstructive surgery. We hypothesize that implementation of an ERAS protocol leads to fewer outpatient opioid prescriptions as measured by number and total quantity of oral morphine milligram equivalents by body weight per patient. METHODS All patients who underwent bladder augmentation, creation of a continent catheterizable channel, bladder neck reconstruction or closure, or revision of prior reconstructive procedures at our tertiary care facility between 2011 and 2017 were reviewed. Patients were divided into pre-ERAS and ERAS cohorts based on whether surgery occurred before or after ERAS implementation. The Colorado Prescription Drug Monitoring Program was used to track filling of postoperative opioid prescriptions for patients covered by the database. RESULTS A total of 167 urologic reconstructive surgeries were analyzed, including 83 before ERAS and 84 after ERAS implementation. Patients in the ERAS cohort received and filled more outpatient opioid prescriptions at time of discharge (82.6% historical vs 93.9% ERAS, p = 0.015; 76.1% vs 57.9%, p = 0.012). There were no differences in prescription total morphine milligram equivalents normalized to body mass, total days supplied, or 90-day opioid prescription refill rates. DISCUSSION We found an unexpected increase in postoperative outpatient opioid prescriptions following implementation of an ERAS protocol for lower urinary tract reconstructive surgery. Possible reasons include worry about pain crisis at home in the setting of decreased hospital length of stay in the ERAS cohort or generalized upward drift in opioid prescribing patterns over time. ERAS protocols in other subspecialties reveal mixed findings but consistently suggest standardization of outpatient opioid prescribing patterns leads to a decrease in opioid prescriptions. CONCLUSIONS Patients received more, not fewer, outpatient opioid prescriptions following major urologic reconstructive surgery after implementation of an ERAS protocol. Purposeful efforts should be made to standardize opioid prescriptions at discharge based on meaningful clinical criteria.
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Affiliation(s)
- Sarah Hecht
- Department of Urology Doernbecher Children's Hospital, Oregon Health & Science University Portland, Oregon, USA.
| | - N Valeska Halstead
- Department of Urology Children's Hospital Colorado, University of Colorado School of Medicine Aurora, Colorado, USA
| | - Peter Boxley
- Department of Urology Children's Hospital Colorado, University of Colorado School of Medicine Aurora, Colorado, USA
| | - Megan A Brockel
- Department of Anesthesiology Children's Hospital Colorado, University of Colorado School of Medicine Aurora, Colorado, USA
| | - Kyle O Rove
- Department of Urology Children's Hospital Colorado, University of Colorado School of Medicine Aurora, Colorado, USA
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Patel S, Suz P, Powers BD, Anaya DA. Epidural analgesia for hepatopancreatobiliary operations and postoperative urinary tract infections: an unrecognized association of "best-practices" and adverse outcomes. HPB (Oxford) 2021; 23:71-79. [PMID: 32414659 DOI: 10.1016/j.hpb.2020.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/03/2020] [Accepted: 04/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Thoracic epidural analgesia (TEA) is considered "best-practices" for pain-control following HPB operations. It is unknown if TEA increases the risk of UTI. We sought to examine the association of TEA and UTI following HPB operations. METHODS A retrospective cohort study of patients undergoing elective HPB operations was performed (ACS-NSQIP [2014-2016]). Patients were categorized by TEA utilization. The primary outcome was UTI. Multivariable logistic regression models were created to examine the association of TEA with UTI; including sensitivity and interaction analyses for age and gender. RESULTS Among 28,571 patients included, 5764 (20.2%) had TEA. UTI occurred more frequently with TEA (3.5% vs. 2.2%, p < 0.01). After multivariable analysis, TEA was associated with increased risk of UTI (1.59 [1.34-1.89]); when stratified by age and gender, the association persisted with an incremental increased risk observed in males over 70 years (1.91 [1.41-2.59]). UTI was associated with increased risk of sepsis (16.8% vs. 5.6%, P < 0.001), LOS (9 versus 6 days, P < 0.001) and readmission rates (21.4% vs. 12.3%, P < 0.001). CONCLUSION Despite TEA recommended as a best-practice standard for HPB operations, the increased risk of UTI calls for evaluation of current practices and consideration of alternative strategies for high-risk vulnerable populations - elderly males.
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Affiliation(s)
- Sephalie Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Pilar Suz
- Department of Anesthesiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Benjamin D Powers
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Daniel A Anaya
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
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Opioid exposure after injury in United States trauma centers: A prospective, multicenter observational study. J Trauma Acute Care Surg 2020; 88:816-824. [PMID: 32459447 DOI: 10.1097/ta.0000000000002679] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Efforts to reduce opioid use in trauma patients are currently hampered by an incomplete understanding of the baseline opioid exposure and variation in United States. The purpose of this project was to obtain a global estimate of opioid exposure following injury and to quantify the variability of opioid exposure between and within United States trauma centers. STUDY DESIGN Prospective observational study was performed to calculate opioid exposure by converting all sources of opioids to oral morphine milligram equivalents (MMEs). To estimate variation, an intraclass correlation was calculated from a multilevel generalized linear model adjusting for the a priori selected variables Injury Severity Score and prior opioid use. RESULTS The centers enrolled 1,731 patients. The median opioid exposure among all sites was 45 MMEs per day, equivalent to 30 mg of oxycodone or 45 mg of hydrocodone per day. Variation in opioid exposure was identified both between and within trauma centers with the vast majority of variation (93%) occurring within trauma centers. Opioid exposure increased with injury severity, in male patients, and patients suffering penetrating trauma. CONCLUSION The overall median opioid exposure was 45 MMEs per day. Despite significant differences in opioid exposure between trauma centers, the majority of variation was actually within centers. This suggests that efforts to minimize opioid exposure after injury should focus within trauma centers and not on high-level efforts to affect all trauma centers. LEVEL OF EVIDENCE Epidemiological, level III.
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Yip L, Carty SE, Holder-Murray JM, Recker A, Nicholson KJ, Boisen ML, Esper SA, McCoy KL. A specific enhanced recovery protocol decreases opioid use after thyroid and parathyroid surgery. Surgery 2020; 169:197-201. [PMID: 32690334 DOI: 10.1016/j.surg.2020.04.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/21/2020] [Accepted: 04/29/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery protocols have not been investigated previously for cervical endocrine surgery. The study aim was to determine whether systematic implementation of an enhanced recovery protocol specific for thyroid/parathyroid surgery can improve postoperative outcomes. METHODS A customized enhanced recovery protocol for thyroid/parathyroid surgery was designed and utilized systematically for all patients who underwent parathyroidectomy, thyroid lobectomy, or total thyroidectomy. Outcomes were assessed 12 months before enhanced recovery protocol implementation (n = 464 patients) and after enhanced recovery protocol implementation (n = 654 patients). RESULTS Enhanced recovery protocol implementation was associated with a 72% decrease in mean oral morphine equivalents utilized in-house (before 82 ± 64 versus after 23 ± 28; P < .0001) and many enhanced recovery protocol patients were entirely opioid-free (0.2% vs 21%, P < .0001). When used, the enhanced recovery protocol was associated with a lesser mean amount of ondansetron to treat postoperative nausea and vomiting (5.5 mg ± 3 vs 4.5 ± 2: P < .0001). Duration of stay was short before implementation of the enhanced recovery protocol and did not change substantially after implementation (1.1 days ± 0.7 vs 1.1 ± 0.7; P = .26). CONCLUSION The systematic use of a simple, cervical, endocrine surgery-specific enhanced recovery protocol decreased perioperative opioid use by ~70%, with significantly less postoperative nausea and vomiting. Implementation of a multidisciplinary enhanced recovery protocol may be an important initial step toward limiting opioid overuse during common operative procedures.
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Affiliation(s)
- Linwah Yip
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA.
| | - Sally E Carty
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer M Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Arydann Recker
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Kristina J Nicholson
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Kelly L McCoy
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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