Post-operative pain management in gynecologic oncology: Regional anesthesia effects on inpatient opioid use and length of stay

ObjectivesPre-operative opioid use is common and should be considered a comorbidity among surgical candidates. Our objective was to describe the rate of pre-operative opioid use and patterns of post-operative outpatient opioid prescribing in a cohort of gynecologic oncology patients.MethodsA retrospective cohort study was conducted with 448 gynecologic oncology surgical patients undergoing surgery for a suspected or known cancer diagnosis from January 2016 to December 2016. Pre-operative opioid users (n=97) were identified. Patient and surgical characteristics were abstracted, as was post-operative opioid prescription (type of opioid, oral morphine equivalents amount) and length of stay. For pre-operative opioid users, the type of opioid prescribed post-operatively was compared with the type of pre-operative opioid. Pre-operative opioid users were compared with non-users, stratified by surgery type. Descriptive statistics were analyzed using χ2 statistic, and medians were compared using a Mann-Whitney U statistic.ResultsPre-operative opioid prescriptions were noted in 21% of patients, and 24% of these had two or more opioid prescriptions before surgery. The majority of pre-operative opioid users (51%) were maintained on the same agent post-operatively at the time of discharge, but 36% were switched to a different opioid and 7% were prescribed an additional opioid. Overall and in laparotomies, pre-operative opioid users received higher volume post-operative prescriptions than non-users. There was no difference in post-operative prescription volume for minimally invasive surgeries or in length of stay between pre-operative users and non-users.ConclusionsPre-operative opioid use is common in gynecologic oncology patients and should be considered during pre-operative planning. Pre-operative opioid use was associated with a higher volume and wider range of post-operative prescription. Over 40% of opioid users were discharged with either an additional opioid or a new opioid, highlighting a potential missed opportunity to optimize opioid safety. Further research is needed to characterize the relationship between pre-operative opioid use and peri-operative outcomes and to develop strategies to manage pain effectively in this population without compromising opioid safety.

Download Full-text

Expectation-setting and patient education about pain control in the perioperative setting: A qualitative study

Journal of Opioid Management ◽

10.5055/jom.2021.0680 ◽

2021 ◽

Vol 17 (6) ◽

pp. 455-464

Author(s):

Josh Bleicher, MD, MS ◽

Jordan Esplin, BS ◽

Allison N. Blumling, MS ◽

Jessica N. Cohan, MD, MAS ◽

Mark Savarise, MD, MBA, FACS ◽

...

Keyword(s):

Pain Management ◽

Patient Education ◽

Qualitative Study ◽

Pain Control ◽

Control Strategies ◽

Patient Experiences ◽

Patient Anxiety ◽

Opioid Use ◽

Post Operative Pain ◽

Preoperative Expectation

Objective: Interventions aimed at limiting opioid use are widespread. These are most often targeted toward prescribers or health systems. Patients’ perspectives are too often absent during the creation of such interventions. This qualitative study aims to understand patient experiences with education about perioperative pain control, from preoperative expectation-setting to post-operative pain control strategies and ultimately opioid disposal.Design: We performed semistructured interviews focused on patient experiences in the perioperative period. Content from interview transcripts was analyzed using a constant comparative method.Setting: All participants underwent surgery at a single, academic tertiary-care center.Participants: Adult patients who had a general surgery operation in the prior 60 days.Outcome measure: Key themes from interviews about perioperative pain management, specifically related to preoperative expectation-setting and post-operative education.Results: Patients identified gaps in communication and education in three main areas: preoperative expectation setting of post-operative pain; post-operative pain control strategies, including use of opioid medications; and the importance of appropriate opioid disposal. Failure to set expectations led to either significant patient anxiety preoperatively or poor preparation for home discharge. Poor education on pain control strategies led to misinformation on when and how to use opioids. Lack of education on opioid disposal led to most participants failing to properly dispose of leftover medication.Conclusions: Gaps in education surrounding post-operative pain and opioid use can lead to patient anxiety, inappropriate use of opioids, and poor disposal rates of leftover medications. Future interventions aimed at patient education to improve pain management and opioid stewardship should be created with an understanding of patient experiences and perceptions.

Download Full-text

2-Week Post-Operative Opioid Use after Primary Hallux Valgus Correction

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00465 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0046

Author(s):

Zachary T. Thier ◽

Kenna C. Altobello ◽

Tyler A. Gonzalez ◽

J. Ben Jackson

Keyword(s):

Body Weight ◽

Pain Management ◽

Hallux Valgus ◽

The United States ◽

Pain Medication ◽

Clinic Visit ◽

Objective Data ◽

Opioid Use ◽

Adductor Canal ◽

Post Operative Pain

Category: Bunion; Other Introduction/Purpose: More than 200,000 surgeries for hallux valgus correction occur annually in the United States. Due to the post-operative pain associated with the procedure, opioids are often prescribed to help manage pain. The opioid epidemic has led to a 78-billion-dollar economic impact. Given the lack of objective data on opioid use and the difficulty of addressing a patient’s post-operative pain, we sought to quantify, through a prospective analysis, patient’s narcotic use after hallux valgus surgery. Objective data may help guide the surgeon in the type and number of opioids utilized after surgery. Methods: Adult patients undergoing primary hallux valgus surgery were recruited from two surgeon’s institution. At the pre- operative visit, patients were consented and completed a demographical questionnaire. Data was collected from the operative and PACU record, as well as the 2-week post-operative visit. A simple statistical analysis was performed to determine average quantity and type of opioid and non-opioid pain medication used in the PACU and for post-operative pain management. Results: 33 subjects were prospectively enrolled and followed. The average time until the first post-operative clinic visit was 13.53 days. The average opioid pain medication consumption during this period was 20.766 (0-66) pills, with a morphine milligram equivalents (MME)/kg of body weight at 1.69. (78.8%) were prescribed hydrocodone/acetaminophen 5/325mg and 7 subjects (21.2%) were prescribed oxycodone/acetaminophen 5/325 for post-operative pain management. 84.8% of subjects (28/33) received a local block, including 2 femoral, 2 ankle, 13 popliteal, 3 sciatic, 3 adductor canal, 4 popliteal and saphenous, and 1 popliteal and adductor canal. 24.2% (8/33) of subjects received opioid pain medication in the PACU post-operatively with a MME/kg of body weight at 0.135 per subject. Conclusion: Based on our prospective study, we recommend an initial prescription of 30 5mg hydro/oxycodone pain pills, as this represents the 3rd quartile of consumption.

Download Full-text

MP38-12 LIPOSOMAL BUPIVACAINE (EXPAREL®) ADMINISTRATION IN OPEN RADICAL CYSTECTOMY IS ASSOCIATED WITH DECREASED POST-OPERATIVE PAIN, LENGTH OF STAY, AND OPIOID USE

The Journal of Urology ◽

10.1097/01.ju.0000556082.70020.89 ◽

2019 ◽

Vol 201 (Supplement 4) ◽

Author(s):

Carissa Chu* ◽

Lauren Law ◽

Lee-Lynn Chen ◽

Candy Tsourounis ◽

Kirsten Greene ◽

...

Keyword(s):

Length Of Stay ◽

Radical Cystectomy ◽

Opioid Use ◽

Liposomal Bupivacaine ◽

Post Operative Pain ◽

Open Radical Cystectomy

Download Full-text

Enhanced Recovery With Paravertebral and Transversus Abdominis Plane Blocks in Microvascular Breast Reconstruction

Breast Cancer Basic and Clinical Research ◽

10.1177/1178223420967365 ◽

2020 ◽

Vol 14 ◽

pp. 117822342096736

Author(s):

Ryan Guffey ◽

Grace Keane ◽

Austin Y Ha ◽

Rajiv Parikh ◽

Elizabeth Odom ◽

...

Keyword(s):

Length Of Stay ◽

Breast Reconstruction ◽

Regional Anesthesia ◽

Enhanced Recovery ◽

Paravertebral Block ◽

Transversus Abdominis ◽

Opioid Use ◽

Transversus Abdominis Plane ◽

Pain Scores ◽

Independent Ambulation

Purpose: We have shown previously that a preoperative paravertebral nerve block is associated with improved postoperative recovery in microvascular breast reconstruction. The purpose of this study was to compare the outcomes of a complete enhanced recovery after surgery (ERAS) protocol with complete regional anesthesia coverage to our traditional care with paravertebral block. Patients and methods: This was a retrospective cohort study of 83 patients who underwent autologous breast reconstruction by T.M.M. between May 2014 and February 2018 at a tertiary academic center. Patients in the ERAS group were additionally administered acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, a transversus abdominis plane block (liposomal or plain bupivacaine), and primarily oral opioids postoperatively. The patients were mobilized earlier with more rapid diet progression. All patients received a preoperative paravertebral block. Results: Forty-four patients in the ERAS cohort were compared with 39 retrospective controls. The 2 groups were similar with respect to demographics and comorbidities. The ERAS cohort required significantly less opioids (291 vs 707 mg oral morphine equivalent, P < .0001) with unchanged postoperative pain scores and a shorter time to oral only opioid use (16.0 vs 78.2 hours, P < .0001). Median length of stay (3.20 vs 4.62, P < .0001) and time to independent ambulation (1.86 vs 2.88, P < .0001) were also significantly decreased in the ERAS cohort. Liposomal bupivacaine use did not significantly affect the results ( P ⩾ .2). Conclusions: Implementation of a robust enhanced recovery protocol with complete regional anesthesia coverage was associated with significantly decreased opioid use despite unchanged pain scores, with improved markers of recovery including length of stay, time to oral only narcotics, and time to independent ambulation.

Download Full-text