Intrathecal Morphine and Effect on Opioid Consumption and Functional Recovery after Pancreaticoduodenectomy

Comparison of epidural infusion versus intrathecal morphine block as part of enhanced recovery after open pancreatoduodenectomy

BACKGROUND AND OBJECTIVES

The accepted approach to pain management following open pancreatoduodenectomy (PD) remains controversial, with the most recent enhanced recovery after surgery (ERAS) protocols recommending epidural anesthesia (EA). Few studies have investigated intrathecal (IT) morphine, combined with transversus abdominis plane (TAP) blocks. We aim to compare the different approaches to pain management for open PD.

METHODS

Patients who underwent open PD at our institution from 2020 to 2022 were included in the study. Patient characteristics, pain management, and postoperative outcomes between EA, IT morphine with TAP blocks, and TAP blocks only were compared using univariate analysis.

RESULTS

Fifty patients were included in the study (58% male, median age 66 years [interquartile range, IQR: 58-73]). Most patients received IT morphine (N = 24, 48%) or EA (N = 18, 36%). The TAP block-only group required higher doses of postoperative narcotics while hospitalized (p = 0.004) and at discharge (p = 0.017). The IT morphine patients had a shorter median time to Foley removal (p = 0.007). Postoperative pain scores, non-opioid administration, postoperative bolus requirements, postoperative outcomes, and length of stay were similar between pain modalities.

CONCLUSIONS

IT morphine and EA showed comparable efficacy with superior results compared to TAP blocks alone. Integration of IT morphine into PD ERAS protocols should be considered.

Endogenous opiates and behavior: 2022

This paper is the forty-fifth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2022 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Are postoperative opioid stewardship protocols sustainable? Results from a 2-year quality improvement project

BACKGROUND

Opioid stewardship protocols reduce opioid overprescription, but many require corrective action within 1 year. Because there are limited data on the sustainability of opioid reduction protocols, we sought to evaluate prescribing trends beyond 1 year.

METHODS

We reviewed prescribing data from a tertiary care center to establish a consensus discharge opioid-prescribing guideline. Subsequently, we performed a prospective quality-improvement study for patients on an enhanced recovery protocol undergoing elective colectomies, proctectomies, and stoma-related procedures. We gathered process (protocol compliance), balance (rates of patient-controlled analgesia and nerve blocks, inpatient opioid utilization, pain scores within 48 hours of discharge), and clinical measures (median discharge opioid pills, postdischarge day 7 satisfaction).

RESULTS

In total, 1,049 patients with similar ages, operative indications, and rates of substance use pre- and postintervention were included. Over 2 years, compliance was 88.6%, and there was a 43.6% reduction in the total discharge number of opioid pills. Phone calls for opioid refills were stable (10.2% pre- vs 7.8% postintervention, P = .16), and the following all decreased significantly: intraoperative nerve blocks, patient-controlled analgesia use, and final 48-hour and total median inpatient opioid use. There was a clinically negligible, statistically significant reduction in pain scores within 48 hours of discharge. Fifty patients provided satisfaction data, and 92% were satisfied or somewhat satisfied with their analgesia.

CONCLUSION

Over 2 years, reduced opioid prescribing was maintained without escalating resources. Sustainability suggests that after successfully implementing an opioid reduction protocol, institutions may safely redeploy quality improvement resources elsewhere.

Analgesic Modalities in Patients Undergoing Open Pancreatoduodenectomy-A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review explored the efficacy of different analgesic modalities and the impact on perioperative outcome in patients undergoing pancreatoduodenectomy.

METHODS

A systematic literature search was performed on PubMed, Embase, Web of Science, Scopus, and Cochrane Library Database using the PRISMA framework. The primary outcome was pain scores on postoperative day one (POD1) and postoperative day two (POD2). The secondary outcomes included length of hospital stay (LOS) and specific procedure-related complications.

RESULTS

Five randomized controlled trials and ten retrospective cohort studies were included in the systematic review. Studies compared epidural analgesia (EA), patient-controlled analgesia (PCA), continuous wound infiltration (CWI), continuous bilateral thoracic paravertebral infusion (CTPVI), intrathecal morphine (ITM), and sublingual sufentanil. The pain scores on POD1 (p < 0.001) and POD2 (p = 0.05) were higher in the PCA group compared with the EA group. Pain scores were comparable between EA and CWI plus PCA or CTPVI on POD1 and POD2. Pain scores were comparable between EA and ITM on POD1. The procedure-related complications and length of hospital stay were not significantly different according to the type of analgesia.

CONCLUSIONS

EA provided lower pain scores compared with PCA on the first postoperative day after pancreatoduodenectomy; the length of hospital stay and procedure-related complications were similar between EA and PCA. CWI and CTPVI provided similar pain relief to EA.