Effect of preoperative intravenous vs oral acetaminophen on postoperative opioid consumption in an enhanced recovery after surgery (ERAS) program in patients undergoing open gynecologic oncology surgery

Oral versus intravenous acetaminophen for perioperative pain management in adult patients undergoing non-cardiac surgery: A quantile segmented regression analysis

STUDY OBJECTIVE

Determine whether preferential use of perioperative enteral acetaminophen is associated with changes in perioperative pain, narcotic administration, or time to meeting criteria for post anesthesia care unit (PACU) discharge, compared to preferential parenteral administration.

DESIGN

Retrospective Cohort with quantile segmented regression analysis. Groups determined by date of surgery, one year pre-initiative and one year post-initiative.

SETTING

Operating room and PACU of a tertiary academic medical center.

PATIENTS

Adult (age > 18 years), ASA status 1-5, non-pregnant patients undergoing non-cardiac surgery of less than six hours duration admitted to the PACU postoperatively.

INTERVENTIONS

A multidisciplinary initiative to preferentially utilize enteral over parenteral acetaminophen.

MEASUREMENTS

The primary outcome was narcotic consumption in the PACU. Secondary outcomes were intraoperative narcotic administration, pain score on PACU admission and discharge, and time to meeting criteria for PACU discharge.

RESULTS

24,701 patients were included in the analysis; 12,379 had surgery prior to the initiative and 12,322 after. Enteral acetaminophen administration increased preoperatively from 13.49% to 26.84%, and postoperatively from 43.16% to 51.45%, while intraoperative parenteral APAP use dropped from 43.23% to 6.81%. Quantile Segmented regression analysis after adjusting for period (pre versus postintervention), day, age, gender, inpatient status, and ASA class demonstrated a decrease in adjusted median perioperative acetaminophen dose (-175 mg P < 0.001), with no significant difference in level change of intraoperative or PACU narcotic administration. There was no significant difference in median time to meet criteria for PACU discharge, though there was a significant change in the slope, (-0.36, p = 0.007.) Median pain scores measured on a standard 0-10 numeric rating scale at PACU admission did not change, while median pain scores at PACU discharge decreased slightly (-0.24 p < 0.001). There was no change in the probability of PONV.

CONCLUSION

In adult patients undergoing non-cardiac surgery of <6 h duration, preferential use of enteral rather than parenteral acetaminophen is associated with non-inferior outcomes in narcotic requirements, pain scores, time to PACU discharge, and probability of PONV when compared with routine parenteral administration. Further studies are needed to validate these findings.

Effect of Multimodal Preemptive Analgesia of Flurbiprofen Axetil, Nalbuphine, and Retrobulbar Block on Postoperative Pain and Enhanced Recovery in Patients Undergoing Oculoplastic Day Surgery: A Prospective, Randomized, Double-Blinded Study

PURPOSE

To evaluate the effect of either flurbiprofen axetil or nalbuphine combined with retrobulbar block (RB) before surgery on postoperative pain control and enhanced recovery in day-care patients undergoing orbital implantation.

METHODS

A total of 45 patients undergoing orbital implantation with general anesthesia were randomly divided into three groups: flurbiprofen axetil (1 mg/kg) combined with RB (group F), nalbuphine (0.1 mg/kg) combined with RB (group N), and placebo as normal saline with RB (group C). The primary outcome was the average pain score (numeric rating scale: 0-10) within the first 24 hours. Other outcomes including the peak pain score, paracetamol requirement, quality of recovery (QoR)-15, and adverse effects (AEs) were assessed.

RESULTS

The average and peak pain scores within 24 hours after surgery in group F were significantly lower than in other groups ( p < 0.0167). Compared with group C, the NRS scores were significantly decreased at 2 and 4 hours in group F, and 2 hours in group N after surgery ( p < 0.0167), but without significant differences at other measured time points. The time to first paracetamol oral intake displayed a significant difference among the three groups ( p < 0.0167).

CONCLUSION

Preemptive use of flurbiprofen axetil 1 mg/kg combined with RB is an optimal choice for multimodal analgesia for day-care patients undergoing orbital implantation in terms of efficient acute pain control, without impeding patient-enhanced recovery.

Variability in Pain Management Practices for Pediatric Anterior Cruciate Ligament Reconstruction

BACKGROUND

The opioid epidemic in the United States is a public health crisis. Pediatric orthopaedic surgeons must balance adequate pain management with minimizing the risk of opioid misuse or dependence. There is limited data available to guide pain management for anterior cruciate ligament reconstruction (ACLR) in the pediatric population. The purpose of this study was to survey current pain management practices for ACLR among pediatric orthopaedic surgeons.

METHODS

A cross-sectional survey study was conducted, in which orthopaedic surgeons were asked about their pain management practices for pediatric ACLR. The voluntary survey was sent to members of the Pediatric Orthopaedic Society of North America. Inclusion criteria required that the surgeon perform anterior cruciate ligament repair or reconstruction on patients under age 18. Responses were anonymous and consisted of surgeon demographics, training, practice, and pain management strategies. Survey data were assessed using descriptive statistics.

RESULTS

Of 64 included responses, the average age of the survey respondent was 48.9 years, 84.4% were males, and 31.3% practiced in the southern region of the United States. Preoperative analgesia was utilized by 39.1%, 90.6% utilized perioperative blocks, and 89.1% prescribed opioid medication postoperatively. For scheduled non-narcotic medications postoperatively 82.8% routinely advocated and 93.8% recommended cryotherapy postoperatively.Acetaminophen was the most used preoperative medication (31.3%), the most common perioperative block was an adductor canal block (81.0%), and the most common postoperative analgesic medication was ibuprofen (60.9%). Prior training or experience was more frequently reported than published research as a primary factor influencing pain management protocols.

CONCLUSIONS

Substantial variability exists in pain management practices in pediatric ACLR. There is a need for more evidence-based practice guidelines regarding pain management.

LEVEL OF EVIDENCE

Level V.

Intra- and post-operative outcomes in benign gynaecologic surgeries before and after the implementation of enhanced recovery after surgery protocols: A comparison

Objective

To compare intra- and post-operative outcomes in patients undergoing benign gynaecologic surgery before and after the implementation of enhanced recovery after surgery (ERAS) protocols.

Introduction

ERAS is a multidisciplinary teamwork with the aim to reduce the body's reaction to surgical stress. The key components of ERAS include pre-operative counselling, avoiding prolonged fasting, standardised analgesic and anaesthetic regimes, early mobilisation and early discharge.

Materials and Methods

Women undergoing hysterectomy and myomectomy were included in the study. The pre-ERAS group had 100 cases and the ERAS group had 104. Demographic data of both the groups were compared. Duration of surgery, amount of blood loss, intra-abdominal drain, oral feed, catheter removal, ambulation, passage of flatus and length of stay were compared.

Results

The demographic profiles of both the groups were comparable. Time taken to intake of liquids (P < 0.001), solid food (P < 0.001), passage of flatus (P = 0.001), removal of Foley's catheter (P = 0.023), ambulation (P = 0.007), pain score (P = 0.001) and length of stay in hospital (P < 0.001) were statistically significantly shorter in the ERAS group when compared to the pre-ERAS group. A significant difference was seen in the use of intraperitoneal drains in the ERAS group (81% vs. 23.1%), and if used, drains were removed early in the ERAS group (66.66% vs. 28.39%) within 40 h. Both the groups had similar intra- and immediate post-operative complications.

Conclusion

ERAS helps in reducing length of stay with early feeding and ambulation, leading to early discharge without increase in intra- and post-operative complications in women undergoing benign gynaecological surgeries.

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews

The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.

Preemptive local analgesia at vaginal hysterectomy: a systematic review

INTRODUCTION AND HYPOTHESIS

We conducted a systematic review of the effectiveness of local preemptive analgesia for postoperative pain control in women undergoing vaginal hysterectomy.

METHODS

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews were searched systematically to identify eligible studies published through September 25, 2019. Only randomized controlled trials and systematic reviews addressing local preemptive analgesia compared to placebo at vaginal hysterectomy were considered. Data were extracted by two independent reviewers. Results were compared, and disagreement was resolved by discussion. Forty-seven studies met inclusion criteria for full-text review. Four RCTs, including a total of 197 patients, and two SRs were included in the review.

RESULTS

Preemptive local analgesia reduced postoperative pain scores up to 6 h and postoperative opioid requirements in the first 24 h after surgery.

CONCLUSION

Preemptive local analgesia at vaginal hysterectomy results in less postoperative pain and less postoperative opioid consumption.

Elimination of postoperative narcotics in infant robotic pyeloplasty using caudal anesthesia and a non-narcotic pain pathway

INTRODUCTION

Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary for post-operative pain control in most infants undergoing robotic pyeloplasty. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of eliminating postoperative narcotics following infant robotic pyeloplasty.

METHODS

We reviewed 24 consecutive patients who underwent robotic pyeloplasty by a single surgeon treated with an end-procedure caudal block followed by a non-narcotic postoperative pain pathway treated between May 2017 and May 2021. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating intravenous acetaminophen and ketorolac. We reviewed demographics, outcomes and unscheduled healthcare encounters within 30 postoperative days.

RESULTS

63% (15/24) patients were male and average age was 12.1 months (range 4-34 months). 58% (9/15) underwent surgery on the left. 16.7% (4/24) of patients received a single postoperative dose of narcotics in the PACU. No patient required narcotic prescriptions at discharge or anytime thereafter. The average length of stay was 1.13 days. There was no pain-related, unscheduled visits or phone calls after discharge.

CONCLUSIONS

This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. Post procedure caudal block is a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use.

Paracetamol for multimodal analgesia

Pain and related disability remain a major social and therapeutic problem. Comorbidities and therapies increase drug interactions and side effects making pain management more compounded especially in the elderly who are the fastest-growing pain population. Multimodal analgesia consists of using two or more drugs and/or techniques that target different sites of pain, increasing the level of analgesia and decreasing adverse events from treatment. Paracetamol enhances multimodal analgesia in experimental and clinical pain states. Strong preclinical evidence supports that paracetamol has additive and synergistic interactions with anti-inflammatory, opioid and anti-neuropathic drugs in rodent models of nociceptive and neuropathic pain. Clinical studies in young and adult elderly patients confirm the utility of paracetamol in multimodal, non-opioid or opioid-sparing, therapies for the treatment of acute and chronic pain.

Multimodal Analgesia in the Era of the Opioid Epidemic

This article attempts to review the key components of a multimodal analgesic regimen for the treatment of acute pain. Adhering to these key components will help reduce the opioid burden to surgical patients while reducing acute pain. As well, this regimen is intended to reduce further negative contributions to the opioid crisis.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.