Implementation of a Multimodal Pain Management Order Set Reduces Perioperative Opioid Use after Liver Transplantation

Background: Opioid use has emerged as a leading cause of death in the US. Given that 1 in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users, hospitals should strive to limit exposure to these medications. We set out to evaluate whether transitioning to a standardized order set based on multimodal combination analgesic therapy decreases the exposure to opioids after cesarean delivery. Methods: Our health system’s post-cesarean pain management electronic medical record (EMR) order set was changed from standing NSAIDs (Ibuprofen 600 mg every 6 h) and additional acetaminophen and opioid medications (Oxycodone 5 mg/acetaminophen 325 mg every 3 h or Oxycodone 10 mg/acetaminophen 650 mg every 6 h for moderate and severe pain, respectively) as needed (PRN) to a multimodal combination therapy with acetaminophen (975 mg every 6 h) and NSAIDs (Ibuprofen 600 mg every 6 h) as primary analgesics and opioids PRN (Oxycodone immediate release (IR) 5 mg every 3 h for moderate to severe pain). We performed a retrospective analysis across seven hospitals comparing inpatient opioid use, administration of other analgesics, and severe pain episodes (pain score ≥ 7) between the patients who were treated before and after implementation of the multimodal order set. Chi square and Student t-test were used for statistical analysis with significance determined as p < 0.05. Results: A total of 12,898 cesarean births were included (8696 prior and 4202 after implementation). The multimodal order set was associated with marked decrease in the incidence of post cesarean opioid use (45.4% vs. 67.5%; p < 0.0001), lower average opioid dose (26.7 mg vs. 36.6 mg of oxycodone; p < 0.0001), and increased dose of acetaminophen (8422 mg vs. 4563 mg; p < 0.0001), while severe pain scores were less frequent (46.3% vs. 56.6%, p < 0.0001). Conclusions: Multimodal analgesic therapy for post-cesarean pain management reduces inpatient opioid use while improving pain control. Incorporation of a multimodal order set as a default in the EMR facilitates effective and widespread implementation on a large scale. Obstetric units should consider standardizing post-cesarean pain management orders to include routine (not PRN) multimodal combination therapy with acetaminophen and NSAIDs as primary analgesics.

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Multimodal Pain Management for Cesarean Delivery: A Double-Blinded, Placebo-Controlled, Randomized Clinical Trial

American Journal of Perinatology ◽

10.1055/s-0039-1681096 ◽

2019 ◽

Vol 36 (11) ◽

pp. 1097-1105 ◽

Cited By ~ 2

Author(s):

Emily E. Hadley ◽

Luis Monsivais ◽

Lucia Pacheco ◽

Rovnat Babazade ◽

Giuseppe Chiossi ◽

...

Keyword(s):

Pain Management ◽

Drug Use ◽

Cesarean Delivery ◽

Primary Outcome ◽

Opioid Use ◽

Multimodal Pain Management ◽

Significant Difference ◽

History Of ◽

Secondary Outcomes ◽

Double Blinded

Objective Our objective was to evaluate the efficacy of perioperative multimodal pain management in reducing opioid use after elective cesarean delivery (CD). Study Design A single-center, double-blinded, placebo-controlled randomized trial of women undergoing elective CD. Participants were allocated 1:1 to receive the multimodal protocol or matching placebos. The multimodal protocol consisted of a preoperative dose of intravenous acetaminophen, preincision injection of subcutaneous bupivacaine, and intraoperative injection of intramuscular ketorolac. Primary outcome was total opioid intake at 48 hours postoperatively. Secondary outcomes were pain scores, time to first opioid intake, neonatal outcomes, and total outpatient opioid intake on postoperative day (POD) 7. Data were analyzed using parametric and nonparametric tests and quantile regression as appropriate. Results A total of 242 women were screened with 120 randomized, 60 to the multimodal group and 60 to control group. There was no significant difference in the primary outcome of opioid use nor in the secondary outcomes. Smokers and patients with a history of drug use had higher median postoperative opiate use and earlier administration. On POD 7, only 40% of prescribed opioids had been used, and there was no difference between the groups. Conclusion This perioperative multimodal pain regimen did not reduce opioid use in 48 hours after CD. Patients who smoke or with a history of drug use required more opioids in the postoperative period. Providers significantly overprescribed opioids after CD.

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Evaluation of an Enhanced Recovery After Surgery Protocol Including Parasternal Intercostal Nerve Block in Cardiac Surgery Requiring Sternotomy

The American Surgeon ◽

10.1177/00031348211024638 ◽

2021 ◽

pp. 000313482110246

Author(s):

Arad Abadi ◽

Robbin Cohen

Keyword(s):

Cardiac Surgery ◽

Pain Management ◽

Length Of Stay ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Intercostal Nerve ◽

Opioid Use ◽

Intercostal Nerve Block ◽

Multimodal Pain Management ◽

Management Protocol

Background Recent guidelines for perioperative care in cardiac surgery recommend multimodal pain management to decrease opioid use. We evaluated the effect of multimodal pain management including parasternal intercostal nerve block on pain control and opioid use in patients who underwent coronary artery bypass grafting (CABG) requiring sternotomy and cardiopulmonary bypass. Study Design Medical records of consecutive patients who underwent CABG from 2018 to 2019 at Huntington Hospital were retrospectively queried. Patients were divided in 2 groups based on whether an Enhanced Recovery After Surgery (ERAS) pain management protocol including parasternal intercostal nerve blocks was employed. Outcomes, including length of stay, pain scores, and opioid use, were compared. Results There was no difference in length of stay (days) 5.43 vs. 5.38 ( P = .45 and average pain score 2.23 vs. 3.27 ( P = .137) for patients in the ERAS and non-ERAS groups. Maximum pain score, 7.74 to 6.15 ( P = .015), and opioid use (total morphine mg equivalent), 149.64 to 32.01 ( P < .01), were reduced in the ERAS group. Conclusion The ERAS multimodal pain management protocol utilizing intraoperative parasternal blocks appears to reduce pain and decrease opioid use after CABG.

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COULD ASA AND CHARLSON COMORBIDITY INDEX SCORES HELP THE CURRENT COMORBIDITIES STRATIFICATION IN NON-SURGICAL KNEE OSTEOARTHRITIS MULTIMODAL PAIN MANAGEMENT?

10.26226/morressier.598b05d8d462b80290b53960 ◽

2017 ◽

Author(s):

Dimitar Tonev

Keyword(s):

Pain Management ◽

Knee Osteoarthritis ◽

Charlson Comorbidity Index ◽

Multimodal Pain Management ◽

Comorbidity Index

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Faculty Opinions recommendation of Educating Patients Regarding Pain Management and Safe Opioid Use After Surgery: A Narrative Review.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.736688126.793571556 ◽

2020 ◽

Author(s):

Peter John Lee

Keyword(s):

Pain Management ◽

Narrative Review ◽

Opioid Use

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A Multimodal Pain Management Regimen for Open Treatment of Distal Radius Fractures: A Randomized Blinded Study

Hand ◽

10.1177/1558944720975146 ◽

2020 ◽

pp. 155894472097514

Author(s):

Julian Zangrilli ◽

Nura Gouda ◽

Armen Voskerijian ◽

Mark L. Wang ◽

Pedro K. Beredjiklian ◽

...

Keyword(s):

Pain Management ◽

Distal Radius ◽

Bone Healing ◽

Pain Control ◽

Distal Radius Fractures ◽

Study Group ◽

Radius Fractures ◽

Multimodal Pain Management ◽

Regional Block ◽

Rebound Increase

Background Adequate pain control is critical after outpatient surgery where patients are not as closely monitored. A multimodal pain management regimen was compared to a conventional pain management method in patients undergoing operative fixation for distal radius fractures. We hypothesized that there would be a decrease in the amount of narcotics used by the multimodal group compared to the conventional pain management group, and that there would be no difference in bone healing postoperatively. Methods Forty-two patients were randomized into 2 groups based on pain protocols. Group 1, the control, received a regional block, acetaminophen, and oxycodone. Group 2 received a multimodal pain regimen consisting of daily doses of pregabalin, celecoxib, and acetaminophen up until postoperative day (POD) #3. They also received a regional block with oxycodone for breakthrough pain. Results From POD#3 to week 1, there was a significant increase in oxycodone use in the study group correlating with the point in time when the multimodal regimen was discontinued. The shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) scores taken at 2 weeks postoperation showed a significantly lower average score in the study group compared to the control. There was no difference in bone healing. Conclusions The 2 regimens yielded similar pain control after surgery. The rebound increase in narcotic use after the multimodal regimen was discontinued, and significant difference in QuickDASH scores seen at 2 weeks postoperatively supported that multimodal regimens may not necessarily lead to decreased narcotic use in outpatient upper extremity surgery, but in the short term are shown to improve functional status.

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