2 Impact of Multimodal Analgesia on Critically Ill Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S5-S5
Author(s):  
Sierra R Young ◽  
Jeremiah Duby ◽  
Erin Louie
Keyword(s):  
Pain Control ◽  
Total Body Surface Area ◽  
Oral Morphine ◽  
Multimodal Analgesia ◽  
Power Calculation ◽  
Opioid Use ◽  
Icu Discharge ◽  
Opioid Medications ◽  
Oral Morphine Equivalent ◽  
The Impact

Abstract Introduction Opioids are considered the cornerstone of treatment for post-operative burn pain. However, detrimental adverse effects of opioid use include over-sedation, respiratory depression and dependence. Multimodal analgesia is an alternative method of pain control that utilizes a combination of opioid and non-opioid medications. Multimodal analgesia offers different mechanisms of action which may be beneficial in burn-injured patients. This study examines the impact of multimodal therapy for post-operative pain control in a burn intensive care unit (BICU). Methods This retrospective cohort study was performed at an academic burn center between 2012 and 2018. Consecutively admitted patients with burns greater than or equal to 10% total body surface area (TBSA) and BICU length of stay (LOS) greater than seven days were eligible for inclusion. Patients were excluded if they received an opioid continuous infusion greater than 48 hours. Patients treated with multimodal analgesia were compared to those treated with opioids alone. The total oral morphine equivalent (OME) dose was calculated for each 24-hour period for 5 days after a grafting surgery. Secondary endpoints included pain scores, BICU LOS, and ventilator days. Data analysis was performed with descriptive statistics. A power calculation determined that 60 patients per group were needed to detect a 30% difference in the primary endpoint. Results There were 100 patients in the non-multimodal group and 100 patients in the multimodal group. Mean cumulative OME dose was significantly lower in the multimodal group (1,028 mg vs. 1,438 mg, P < 0.002). Patients with over 20% TBSA burns had a larger reduction in mean OME doses in the multimodal group (1,097 mg vs. 1,624 mg, P = 0.0049) compared to patients with 10% to 20% TBSA burns (949 mg vs 1,282 mg, P = 0.057). Utilizing more multimodal agents was not associated with lower OME doses. There was no difference in pain score on post-operative day 5 (5.5 + 2.3 vs. 6.2 + 2.2, P=0.07) or at ICU discharge (4.7 + 2.4 vs 4.7 + 2.8, P = 0.99). There was no difference in other secondary outcomes. Conclusions The use of multimodal analgesia significantly reduced cumulative OME doses without compromising pain control. Applicability of Research to Practice Multimodal analgesia may be a beneficial adjunct to burn pain management to mitigate opioid use without compromising pain control.

126 Multimodal Analgesia and Discharge Opioid Requirements in Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S85-S85
Author(s):  
Jin A Lee ◽  
Michael Wright
Keyword(s):  
Total Body Surface Area ◽  
Oral Morphine ◽  
Multimodal Analgesia ◽  
Burn Patients ◽  
Post Discharge ◽  
Icu Length Of Stay ◽  
Total Body ◽  
Long Acting ◽  
The Impact

Abstract Introduction Analgesia in burn patients is significantly challenging given the complexity of burn pain. Opioids are a mainstay of therapy, but studies demonstrate varying outcomes with respect to the efficacy of adjunctive non-opioid agents in the treatment of burn pain. The need for analgesia extends beyond hospital admission—given the known risks of opioids, the impact of multimodal analgesia on opioid requirements post-discharge needs to be further elucidated in this population. Methods In this retrospective, single-center cohort study, adult burn patients who were consecutively admitted to the burn ICU service and subsequently followed in the burn clinic between 2/2015 and 9/2018 were evaluated up to 6 months post-discharge. The subjects were divided into two cohorts based on discharge pain regimens: multimodal vs non-multimodal. Individuals taking long-acting opioids prior to admission were excluded. The primary outcome was the change in oral morphine equivalents (OME) between discharge and follow up occurring between 2 - 6 weeks post-discharge. Secondary outcomes included the number of multimodal agents utilized and a comparison of OME between the last 24 hours of admission and discharge. Results A total of 152 patients were included for analysis (n= 76 per cohort). The multimodal cohort demonstrated increased total body surface area burned (23.9% ± 15.4 vs 16.6% ± 7.1; p < 0.001) and prolonged number of days spent in the ICU (22.7 ± 23.1 vs 10.7 ± 8.9; p < 0.001). The change in OME from discharge to first follow up was -106.6 mg in the multimodal vs -75.4 mg in the non-multimodal cohort (p = 0.039; figure 1). In each cohort, discharge OME did not statistically differ from last 24 hour OME (multimodal: p = 0.067; non-multimodal: p = 0.537). The most common non-opioid agents utilized were acetaminophen and gabapentin. Conclusions Despite extended ICU length of stay and larger TBSA, burn patients discharged with multimodal pain regimens demonstrated a statistically significant reduction in oral morphine equivalents from discharge to first follow up compared to those discharged on opioid-only regimens. Applicability of Research to Practice This study demonstrates promising results with respect to lowering discharge opioid requirements by utilizing a multimodal analgesic approach in the management of burn pain.

No Pain, More Gain: Reduced Postoperative Opioid Consumption with a Standardized Opioid-Sparing Multimodal Analgesia Protocol in Opioid-Tolerant Patients Undergoing Colorectal Surgery

2019 ◽  
Vol 85 (10) ◽  
pp. 1155-1158
Author(s):  
Adam Truong ◽  
Angela Mujukian ◽  
Phillip Fleshner ◽  
Karen Zaghiyan
Keyword(s):  
Colorectal Surgery ◽  
Surgical Outcomes ◽  
Oral Morphine ◽  
Multimodal Analgesia ◽  
Study Cohort ◽  
Opioid Use ◽  
Single Institution ◽  
Opioid Sparing ◽  
Robotic Resection ◽  
The Impact

The utility of opioid-sparing multimodal analgesia protocols (OSMMAPs) in opioid-tolerant (OT) patients is unknown. We sought to determine the impact of a standardized OSMMAP in OT versus opioid-naïve (ON) patients after major colorectal surgery. Consecutive patients undergoing surgery before (January 2015–March 2017) and after OSMMAP implementation (April 2017–March 2018) were identified from a single-institution prospective colorectal surgery registry. OT was defined by the presence of an opioid on the preadmission medication record. Opioid use (measured in oral morphine equivalents (OMEs)) and surgical outcomes were compared between OT and ON patients pre- and post-OSMMAP. The study cohort of 201 patients included 59 OT patients (25 pre- and 34 post-OSMMAP) and 142 ON controls (34 pre- and 108 post-OSMMAP). The median age was 47.5 years (IQR 32), and 50% were male. 185 patients (92%) had a laparoscopic/ robotic resection and 16 (8%) open. There were statistically significant reductions in OME required post-OSMMAP on each postoperative day (days 1 to 4) and cumulative OME for both OT and ON patients. The reduction in opioid requirements was significantly larger in OT than ON patients. We present the first study highlighting a larger opioid usage reduction in OT than in ON patients after OSMMAP implementation.

Efficacy of a password-protected pill-dispensing device to enhance disposal of unused opioids after cancer surgery.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 264-264
Author(s):  
Jacob Cogan ◽  
Melissa Kate Accordino ◽  
Melissa Parsons Beauchemin ◽  
Sophie Ulene ◽  
Elena B. Elkin ◽  
...  
Keyword(s):  
Pain Control ◽  
Cancer Surgery ◽  
High Rate ◽  
Smartphone App ◽  
Opioid Use ◽  
Structured Interviews ◽  
Health Crisis ◽  
Patient Reported ◽  
After Cancer ◽  
The Impact

264 Background: Opioid misuse is a public health crisis. Initial opioid exposures often occur post-operatively, and 10% of opioid-naïve patients who undergo cancer surgery subsequently become long-term opioid users. It has been shown that 70% of opioids prescribed post-operatively go unused, but only 9% of unused pills are disposed appropriately, which increases the risk of unintended use. We evaluated the impact of an inexpensive, password-protected dispensing device with mail return capacity on retrieval of unused pills after cancer surgery. Methods: Adult patients scheduled for major cancer-related surgery were eligible. Enrolled patients received opioid prescriptions in a password-protected, pill-dispensing device (Addinex) from a specialty pharmacy. The mechanical device links to a smartphone app, which provides passwords on a prescriber-defined schedule. Patients request a password when they are in pain, enter the password into the device and receive a pill if the prescribed time has elapsed. The smartphone app provides clinical guidance based on patient-reported pain levels, and suggests tapering strategies. Patients are instructed to return the device in a DEA-approved mailer when opioid use is no longer required for pain control. Unused pills are destroyed upon receipt. The primary objective was to determine the feasibility of device return, defined as > 50% of patients with device return. We also explored patterns of device use, patient reported outcomes, and device satisfaction via surveys and semi-structured interviews. Results: Between October, 2020 and April, 2021, 13 patients completed the study; 4 patients are currently enrolled. Among the initial 13 patients, 7 underwent abdominal hysterectomy, 4 underwent mastectomy and 2 underwent cutaneous tumor resections. The majority of these patients (n = 10, 77%) returned the device, and more than half (n = 7, 54%) returned the device within 6 weeks of surgery. Only a minority of patients (n = 5, 38%) used the device to obtain opioids; most (n = 8, 62%) used no opioids at home, and all of these patients returned the device and the unused pills. Of 11 patients who participated in semi-structured interviews, most (n = 7, 64%) said they felt safer having opioids in the device instead of a regular pill bottle. Among device users, the majority (n = 4, 80%) reported an overall positive experience. All non-users reported having no opioid requirement for pain control. Conclusions: Our early findings suggest that use of an inexpensive, password-protected, pill-dispensing device to assist with opioid dispensing and return is feasible, with a high rate of device and unused opioid return to the pharmacy. This strategy may be effective for reducing opioid diversion. Analyses and recruitment are ongoing to evaluate the benefits of reducing post-operative opioid consumption.

The Impact of Preventative Multimodal Analgesia on Postoperative Opioid Requirement and Pain Control in Patients Undergoing Lumbar Fusions

2020 ◽  
Vol 33 (3) ◽  
pp. E135-E140
Author(s):  
Sharad Rajpal ◽  
Steven L. Hobbs ◽  
E. Lee Nelson ◽  
Alan Villavicencio ◽  
Christopher Zielenski ◽  
...  
Keyword(s):  
Pain Control ◽  
Multimodal Analgesia ◽  
The Impact

scholarly journals Multimodal Analgesia and Discharge Opioid Requirements in Burn Patients

2020 ◽  
Vol 41 (5) ◽  
pp. 963-966
Author(s):  
Michael Wright ◽  
Jin A Lee
Keyword(s):  
Surface Area ◽  
Body Surface Area ◽  
Body Surface ◽  
Total Body Surface Area ◽  
Multimodal Analgesia ◽  
Burn Patients ◽  
Area Burned ◽  
Total Body ◽  
The Impact

Abstract Analgesia in burn patients is challenging given the complexity of burn pain and prolonged need beyond hospital admission. Given the risks of opioids, the impact of multimodal analgesia postdischarge needs to be further elucidated in this population. This retrospective, single-center cohort study evaluated adult burn patients who were consecutively admitted to the burn service with at least 10% total body surface area burned and subsequently followed in the burn clinic between February 2015 and September 2018. Subjects were separated into two cohorts based on discharge pain regimens: multimodal and nonmultimodal. The primary outcome was the change in opioid requirements (measured in oral morphine equivalents) between discharge and first follow-up interval. Secondary outcomes included the classes of multimodal agents utilized and a comparison of opioid requirements between the last 24 hours of admission and discharge. A total of 152 patients were included for analysis, 76 in the multimodal cohort and 76 in the nonmultimodal cohort. The multimodal cohort was noted to have increased total body surface area burned and prolonged number of days spent in the intensive care unit at baseline; however, the multimodal cohort exhibited a more significant decrease in opioid requirements from discharge to first follow-up interval when compared with the nonmultimodal cohort (106.6 vs 75.4 mg, P = .039).

Multimodal Analgesia Protocol after Head and Neck Surgery: Effect on Opioid Use and Pain Control

2019 ◽  
Vol 161 (3) ◽  
pp. 424-430 ◽  
Author(s):  
Eugenie Du ◽  
Zainab Farzal ◽  
Elizabeth Stephenson ◽  
April Tanner ◽  
Katherine Adams ◽  
...  
Keyword(s):  
Head And Neck ◽  
Pain Control ◽  
Neck Surgery ◽  
Multimodal Analgesia ◽  
Quality Improvement Initiative ◽  
Opioid Use ◽  
Protocol Implementation ◽  
Pain Scores ◽  
Before And After ◽  
Average Pain

Objective To assess the effect that implementation of a multimodal analgesic plan has on opioid requirements and pain control in head and neck (H&N) surgery patients. Study Design Prospective cohort. Setting Tertiary academic hospital. Subjects and Methods An institutional review board (IRB)–approved quality improvement initiative was undertaken to implement a multimodal analgesic protocol for all admitted H&N surgery patients starting November 2017. Postprotocol data from January to May 2018 were compared to preprotocol data from May to October 2017. Data were obtained from the electronic health records as well as through preoperative and postoperative surveys. Average pain scores and opioid use in morphine milligram equivalents (MMEs) before and after protocol implementation were compared. Results In total, 139 postprotocol patients were compared to 89 preprotocol patients. The adjusted MMEs in the first 24 hours after surgery decreased significantly from 93.7 mg to 58.6 mg ( P = .026) with protocol implementation. When averaged over the length of stay (MME/hospital day), the change was no longer statistically significant (57.9 vs 46.8 mg, P = .211). The average pain score immediately after surgery and on day of discharge did not change with protocol implementation. Conclusion Implementation of a multimodal analgesia plan reduced opioid use immediately after surgery but not over the course of hospitalization without any change in reported pain scores. This study shows that multimodal opioid-sparing analgesia after H&N surgery is feasible. Future studies are needed further refine the optimal analgesic strategy for H&N patients and assess the long-term efficacy, safety, and cost of such regimens.

Multimodal Analgesia and Decreased Opioid Use in Adult Trauma Patients

2020 ◽  
Vol 86 (8) ◽  
pp. 950-954
Author(s):  
Andrew L. Drahos ◽  
Anthony M. Scott ◽  
Tracy J. Johns ◽  
Dennis W. Ashley
Keyword(s):  
Acute Kidney Injury ◽  
Management Strategies ◽  
Kidney Injury ◽  
Multimodal Analgesia ◽  
The United States ◽  
Control Group ◽  
Trauma Patients ◽  
Opioid Use ◽  
Trauma Service ◽  
The Impact

Background There is an opioid epidemic in the United States. With the increased concern of over-prescribing opioids, physicians are seeking alternative pain management strategies. The purpose of this study is to review the impact of instituting a multimodal analgesia (MMA) guideline on decreasing opioid use in trauma patients at a Level 1 trauma center. Methods In 2017, an MMA guideline was developed and included anti-inflammatories, muscle relaxants, neuropathic agents, and local analgesics in addition to opioids. Staff were educated and the guideline was implemented. A retrospective review of medications prescribed to patients admitted from 2016 through 2018 was performed. Patients admitted in 2016 served as the control group (before MMA). In 2018, all patients received multimodal pain therapy as standard practice, and served as the comparison group. Results A total of 10 340 patients were admitted to the trauma service from 2016 through 2018. There were 3013 and 3249 patients for review in 2016 and 2018, respectively. Total morphine milligram equivalents were 2 402 329 and 1 975 935 in 2016 and 2018, respectively, a 17.7% decrease ( P < .001). Concurrently, there was a statistically significant increase in the use of multimodal pain medications. A secondary endpoint was studied to evaluate for changes in acute kidney injury; there was not a statistically significant increase (0.56% versus 0.68%, P = .55). Discussion Implementation of an MMA guideline significantly reduced opioid use in trauma patients. The use of nonopioid MMA medications increased without an increased incidence of acute kidney injury.

scholarly journals β-blocker Use is Associated with a Reduction in Opioid Use 30 Days After Total Knee Arthroplasty

2019 ◽  
Vol 5 (22;5) ◽  
pp. E395-E406
Author(s):  
Jordan Starr
Keyword(s):  
Total Knee Arthroplasty ◽  
Oral Morphine ◽  
Veterans Affairs ◽  
Prescription Opioid ◽  
Opioid Use ◽  
Total Knee ◽  
Β Blocker ◽  
Β Blockers ◽  
Oral Morphine Equivalent ◽  
Morphine Equivalent

Background: Total knee arthroplasty (TKA) can lead to chronic pain and prolonged postoperative opioid use. There are few evidence-based interventions to prevent these outcomes. Recently, β-blockers have emerged as possible novel analgesics. Objectives: The objective of this study was to determine whether perioperative β-blocker use is associated with reduced prolonged postoperative opioid use after TKA. Study Design: This study used a retrospective cohort design. Setting: The research took place within Department of Veterans Affairs hospitals in the United States between April 2012 and April 2016. Methods: Patients: IRB approval was obtained to examine the records of Veterans Affairs (VA) patients undergoing TKA. Patients using opioids 60 days before surgery were excluded. Intervention: The intervention being investigated was perioperative β-blocker use, overall and by class. Measurement: Oral morphine equivalent usage through postoperative day 1 and prescription opioid refills through 30, 90, and 365 days after TKA were recorded. Adjusted models were created controlling for relevant demographic and comorbidity covariates. A secondary analysis examined the same outcomes separated by β-blocker class. Results: The cohort was 93.8% male with a mean age of 66 years. Among the 11,614 TKAs that comprised the cohort, 2,604 (22.4%) were performed on patients using β-blockers. After adjustment, β-blocker use was associated with reduced opioid use through 30 days after surgery (odds ratio [OR] 0.89 [95% confidence interval (CI), 0.80-0.99], P = .026). Selective β-blockers were associated with reduced opioid use at 30 days (OR 0.88 [95% CI, 0.78-0.98], P = .021), and nonselective β-blockers were associated with reduced oral morphine equivalent usage through postoperative day 1 (β = -17.9 [95% CI, -29.9 to -5.8], P = .004). Limitations: Generalizability of these findings is uncertain, because this study was performed on a cohort of predominantly white, male VA patients. This study also measured opioid use, but opioid use is not a perfect surrogate for pain. Nevertheless, opioid use offers value as an objective measure of pain persistence in a national cohort for which patient-reported outcomes are otherwise unavailable. Conclusions: Perioperative β-blocker use was associated with reduced prescription opioid use at 30 days after surgery. Both selective and nonselective β-blockers were associated with reduced opioid use when analyzed individually. Key words: Analgesics, opioid, arthroplasty, replacement, knee, adrenergic beta-antagonists, pain management

Using oral morphine-equivalent values to track the analgesic effect of treatments in clinical trials.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e14075-e14075
Author(s):  
Stephen A Raymond ◽  
John F Hutchin ◽  
Arnold Degboe ◽  
Kenneth G Faulkner
Keyword(s):  
Oral Morphine ◽  
Route Of Administration ◽  
Handheld Device ◽  
Analgesic Effects ◽  
Pain Medications ◽  
Patient Reported ◽  
Strong Opioids ◽  
Oral Morphine Equivalent ◽  
The Impact ◽  
Time Dose

e14075 Background: Patient reported pain is subjective, requiring individuals to grade the feeling of pain as “high” or “low”, typically using a numeric scale. As a supplement to self-reported pain, monitoring the dosage and type of treatment needed to keep pain at a tolerable or comfortable level has been suggested. However, differences in treatments can complicate the ability to compare analgesic effects. One approach to this problem uses a 30 mg oral dose of morphine as a standard to quantify the relative analgesic strength of different pain medications. Methods: For use in clinical research, we developed an application on a handheld device for logging opioid consumption and supporting automated determination of oral morphine equivalents (OME) for commonly prescribed analgesics. We reviewed the literature to prepare a comprehensive database of OMEs for more than 450 commonly prescribed pain medications. From treatment logs (time, dose, and route of administration), the application determines a daily “OME Score” in standardized units of mg of oral morphine. Results: As prescriptions change, the daily OME Score gives a comparable measure to track the utilization of diverse analgesic medications. OME Scores can be categorized using the Analgesic Quantification Algorithm (AQA scale) developed by Chung (1). The AQA scale has eight categories and provides 5 gradations for patients in advanced pain who receive strong opioids, each gradation reflecting adoubling in the daily OME Score. The impact of a therapy on pain may be considered clinically significant depending on the changes in self-reported pain and AQA scores related to the treatment. Conclusions: We have developed a method and associated application for easily logging the time, dose, and route of administration of analgesic treatments. This information can be used to compute the daily OME Score for a wide variety of analgesics. The daily OME score can then be tracked and used to report the AQA score alongside self-reported pain for evaluating pain relief in clinical studies. Reference: 1) Chung KC, Barlev A, Braun AH, Qian Y, Zagari M. Pain Medicine 2014; 15:225-232.

scholarly journals Safety of benzodiazepines and opioids in interstitial lung disease: a national prospective study

2018 ◽  
Vol 52 (6) ◽  
pp. 1801278 ◽  
Author(s):  
Sabrina Bajwah ◽  
Joanna M. Davies ◽  
Hanan Tanash ◽  
David C. Currow ◽  
Adejoke O. Oluyase ◽  
...  
Keyword(s):  
Interstitial Lung Disease ◽  
Lung Disease ◽  
Low Dose ◽  
Cox Regression ◽  
Oral Morphine ◽  
High Dose ◽  
Opioid Use ◽  
Respiratory Compromise ◽  
Oral Morphine Equivalent ◽  
Morphine Equivalent

Safety concerns are a barrier to prescribing benzodiazepines (BDZs) and opioids in interstitial lung disease (ILD). We therefore examined the association of BDZs and opioids on risk of admission to hospital and death.We conducted a population-based longitudinal cohort study of fibrotic ILD patients starting long-term oxygen therapy in Sweden between October 2005 and December 2014. Effects of BDZs and opioids on rates of admission to hospital and mortality were analysed using Fine–Gray and Cox regression while adjusting for potential confounders.We included 1603 patients (61% females). BDZs were used by 196 (12%) patients and opioids were used by 254 (15%) patients. There was no association between BDZs and increased admission. Treatment with high- versus low-dose BDZs was associated with increased mortality (subdistribution hazard ratio (SHR) 1.46, 95% CI 1.08–1.98 versus 1.13, 95% CI 0.92–1.38). Opioids showed no association with increased admission. Neither low-dose opioids (≤30 mg·day−1 oral morphine equivalent) (SHR 1.18, 95% CI 0.96–1.45) nor high-dose opioids (>30 mg·day−1 oral morphine equivalent) (SHR 1.11, 95% CI 0.89–1.39) showed association with increased mortality.This first ever study to examine associations between BDZ and opioid use and harm in ILD supports the use of opioids and low-dose BDZs in severely ill patients with respiratory compromise.

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