scholarly journals Adoption of Enhanced Surgical Recovery (ESR) Protocol for Lumbar Fusion Decreases In-Hospital Postoperative Opioid Consumption

2021 ◽  
pp. 219256822110156
Author(s):  
Ehsan Jazini ◽  
Alexandra E. Thomson ◽  
Andre D. Sabet ◽  
Leah Y. Carreon ◽  
Rita Roy ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Length Of Stay ◽  
Transition Period ◽  
Urinary Catheter ◽  
Lumbar Fusion ◽  
Secondary Analysis ◽  
Opioid Consumption ◽  
Catheter Removal ◽  
Pain Scores ◽  
The Impact

Study Design: Retrospective observational cohort. Objectives: We sought to evaluate the impact of ESR on in-hospital and 90-day postoperative opioid consumption, length of stay, urinary catheter removal and postoperative ambulation after lumbar fusion for degenerative conditions. Methods: We evaluated patients undergoing lumbar fusion surgery at a single, multi-surgeon center in the transition period prior to (N = 174) and after (N = 116) adoption of ESR, comparing in-hospital and 90-day postoperative opioid consumption. Regression analysis was used to control for confounders. Secondary analysis was preformed to evaluate the association between ESR and length of stay, urinary catheter removal and ambulation after surgery. Results: Mean age study participants was 52.6 years with 62 (47%) females. Demographic characteristics were similar between the Pre-ESR and ESR groups. ESR patients had better 3-month pain scores, ambulated earlier, had urinary catheters removed earlier and decreased in-hospital opioid consumption compared to Pre-ESR patients. There was no difference in 90-day opioid consumption between the 2 groups. Regression analysis showed that ESR was strongly associated with in-hospital opioid consumption, accounting for 30% of the variability in Morphine Milligram Equivalents (MME). In-hospital opioid consumption was also associated with preoperative pain scores, number of surgical levels, and insurance type (private vs government). Pre-op pain sores were associated with 90-day opioid consumption. Secondary analysis showed that ESR was associated with a shorter length of stay and earlier ambulation. Conclusions: This study showed ESR has the potential to improve recovery after lumbar fusion for degenerative conditions with reduced in-hospital opioid consumption and improved postoperative pain scores.

Impact of ultrasound-guided erector spinae plane block on outcomes after lumbar spinal fusion: a retrospective propensity score matched study of 242 patients

2021 ◽  
pp. rapm-2021-103199
Author(s):  
Ellen M Soffin ◽  
Ichiro Okano ◽  
Lisa Oezel ◽  
Artine Arzani ◽  
Andrew A Sama ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Propensity Score ◽  
Care Pathway ◽  
Lumbar Fusion ◽  
Opioid Consumption ◽  
Erector Spinae ◽  
Block Group ◽  
Ultrasound Guided ◽  
Erector Spinae Plane Block ◽  
Pain Scores

BackgroundWe evaluated the impact of bilateral ultrasound-guided erector spinae plane blocks on pain and opioid-related outcomes within a standardized care pathway for lumbar fusion.MethodsA retrospective propensity score matched cohort study. Clinical data were extracted from the electronic medical records of patients who underwent lumbar fusion (January 2019–July 2020). Propensity score matching based on common confounders was used to match patients who received or did not receive blocks in a 1:1 ratio. Primary outcomes were Numeric Rating Scale pain scores (0–10) and opioid consumption (morphine equivalent dose) in the first 24 hours after surgery (median (IQR)). Secondary outcomes included length of stay and opioid-related side effects.ResultsOf 1846 patients identified, 242 were matched and analyzed. Total 24-hour opioid consumption was significantly lower in the erector spinae plane block group (30 mg (0, 144); without-blocks: 45 mg (0, 225); p=0.03). There were no significant differences in pain scores in the postanesthesia care unit (with blocks: 4 (0, 9); without blocks: 4 (0,8); p=0.984) or on the nursing floor (with blocks: 4 (0,8); without blocks: 4 (0,8); p=0.134). Total length of stay was 5 hours shorter in the block group (76 hours (21, 411); without blocks: 81 (25, 268); p=0.001). Fewer patients who received blocks required postoperative antiemetic administration (with blocks: n=77 (64%); without blocks: n=97 (80%); p=0.006).ConclusionsErector spinae plane blocks were associated with clinically irrelevant reductions in 24-hour opioid consumption and no improvement in pain scores after lumbar fusion. The routine use of these blocks in the setting of a comprehensive care pathway for lumbar fusion may not be warranted.

Continuous Pecto-Intercostal Fascial Block Provides Effective Analgesia in Patients Undergoing Open Cardiac Surgery: A Randomized Controlled Trial

Pain Medicine ◽  
2021 ◽  
Author(s):  
Yang Zhang ◽  
Jia Min ◽  
Shibiao Chen
Keyword(s):  
Cardiac Surgery ◽  
Postoperative Pain ◽  
Length Of Stay ◽  
Hospital Stay ◽  
Urinary Catheter ◽  
Controlled Trial ◽  
Length Of Hospital Stay ◽  
Catheter Removal ◽  
Secondary Outcome ◽  
Pain Scores

Abstract Background The optimal analgesia regimen after open cardiac surgery was unclear. The aim of this study was to investigate the beneficial effects of continuous Pecto-Intercostal Fascial Block (PIFB) blocks initiated before surgery on outcomes following open cardiac surgery. Methods A group of 116 patients were randomly allocated to either receive bilateral continuous PIFB (PIF group) or the same block with saline (SAL group). The primary endpoint was postoperative pain at 4, 8, 16, 24, 48, and 72 h after extubation at rest and exercise. The secondary outcome measures included analgesia requirements (sufentanil and flurbiprofen consumption), time to extubation, length of stay in the ICU, incidence of postoperative nausea and vomiting (PONV), time until return of bowel function, time to mobilization, urinary catheter removal and the length of hospital stay. Results The length of stay in the ICU (29 ± 7 h vs 13 ± 4 h, p < 0.01) and length of hospital stay (8.9 ± 0.9 d vs 6.5 ± 1.1 d, p < 0.01) was significantly longer in the SAL group than in the PIF group. Resting pain scores (2 h after extubation : 1.1 vs 3.3, p < 0.01; 4 h after extubation : 1.0 vs 3.5, p < 0.01; 8 h after extubation : 1.2 vs 3.7, p < 0.01; 16 h after extubation : 1.3 vs 3.7, p < 0.01; 24 h after extubation : 1.4 vs 2.8, p < 0.01; 48 h after extubation : 0.9 vs 2.2, p < 0.01; 72 h after extubation : 0.8 vs 2.1, p < 0.01) and dynamic pain scores (2 h after extubation : 1.4 vs 3.7, p < 0.01; 4 h after extubation : 1.3 vs 3.8, p < 0.01; 8 h after extubation : 1.4 vs 3.5, p < 0.01; 16 h after extubation : 1.2 vs 3.4, p < 0.01; 24 h after extubation : 1.1 vs 3.1, p < 0.01; 48 h after extubation : 1.0 vs 2.9, p < 0.01; 72 h after extubation: 0.9 vs 2.8, p < 0.01) were significantly lower in PIF group compared with SAL group at all time points. The PIF group required significantly less intraoperative (123 ± 32 μg vs 63 ± 16 μg, p < 0.01) and postoperative sufentanil (102 ± 22 μg vs 52 ± 17 μg, p < 0.01) consumption, postoperative flurbiprofen consumption (350 ± 100 mg vs 100 ± 100 mg, p < 0.01) than the SAL groups. Time to extubation (8.9 ± 2.4 h vs 3.2 ± 1.3 h, p < 0.01), time to first flatus (43 ± 6 h vs 30 ± 7 h, p < 0.01), time until mobilization (35 ± 5 h vs 24 ± 7 h, p < 0.01), time until urinary catheter removal (47 ± 9 h vs 31 ± 4 h, p < 0.01) was significantly earlier in the PIF group than in the SAL group. The incidence of PONV was significantly lower in the PIF group (9.1% vs 27.3%, p < 0.01). Conclusion Bilateral continuous PIFB reduced the length of hospital stay and provided effective postoperative pain for three days.

The Institute for Healthcare Improvement–NeuroPoint Alliance collaboration to decrease length of stay and readmission after lumbar spine fusion: using national registries to design quality improvement protocols

2020 ◽  
Vol 33 (6) ◽  
pp. 812-821
Author(s):  
Scott L. Zuckerman ◽  
Clinton J. Devin ◽  
Vincent Rossi ◽  
Silky Chotai ◽  
E. Hunter Dyer ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Length Of Stay ◽  
Discharge Planning ◽  
Lumbar Fusion ◽  
Nonparametric Tests ◽  
Learning System ◽  
Design Quality ◽  
Implementation Phase ◽  
Healthcare Improvement ◽  
The Impact

OBJECTIVENational databases collect large amounts of clinical information, yet application of these data can be challenging. The authors present the NeuroPoint Alliance and Institute for Healthcare Improvement (NPA-IHI) program as a novel attempt to create a quality improvement (QI) tool informed through registry data to improve the quality of care delivered. Reducing the length of stay (LOS) and readmission after elective lumbar fusion was chosen as the pilot module.METHODSThe NPA-IHI program prospectively enrolled patients undergoing elective 1- to 3-level lumbar fusions across 8 institutions. A three-pronged approach was taken that included the following phases: 1) Research Phase, 2) Development Phase, and 3) Implementation Phase. Primary outcomes were LOS and readmission. From January to June 2017, a learning system was created utilizing monthly conference calls, weekly data submission, and continuous refinement of the proposed QI tool. Nonparametric tests were used to assess the impact of the QI intervention.RESULTSThe novel QI tool included the following three areas of intervention: 1) preoperative discharge assessment (location, date, and instructions), 2) inpatient changes (LOS rounding checklist, daily huddle, and pain assessments), and 3) postdischarge calls (pain, primary care follow-up, and satisfaction). A total of 209 patients were enrolled, and the most common procedure was a posterior laminectomy/fusion (60.2%). Seven patients (3.3%) were readmitted during the study period. Preoperative discharge planning was completed for 129 patients (61.7%). A shorter median LOS was seen in those with a known preoperative discharge date (67 vs 80 hours, p = 0.018) and clear discharge instructions (71 vs 81 hours, p = 0.030). Patients with a known preoperative discharge plan also reported significantly increased satisfaction (8.0 vs 7.0, p = 0.028), and patients with increased discharge readiness (scale 0–10) also reported higher satisfaction (r = 0.474, p < 0.001). Those receiving postdischarge calls (76%) had a significantly shorter LOS than those without postdischarge calls (75 vs 99 hours, p = 0.020), although no significant relationship was seen between postdischarge calls and readmission (p = 0.342).CONCLUSIONSThe NPA-IHI program showed that preoperative discharge planning and postdischarge calls have the potential to reduce LOS and improve satisfaction after elective lumbar fusion. It is our hope that neurosurgical providers can recognize how registries can be used to both develop and implement a QI tool and appreciate the importance of QI implementation as a separate process from data collection/analysis.

scholarly journals Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery

2018 ◽  
Vol 28 (1) ◽  
pp. 119-126 ◽  
Author(s):  
Lauren K. Dunn ◽  
Marcel E. Durieux ◽  
Lucas G. Fernández ◽  
Siny Tsang ◽  
Emily E. Smith-Straesser ◽  
...  
Keyword(s):  
Spine Surgery ◽  
Rating Scale ◽  
Psychological Intervention ◽  
Opioid Consumption ◽  
Anxiety And Depression ◽  
Opioid Use ◽  
Quality Of Recovery ◽  
Pain Scores ◽  
The Impact

OBJECTIVEPerception of perioperative pain is influenced by various psychological factors. The aim of this study was to determine the impact of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain scores, and quality of recovery in adults who underwent spine surgery.METHODSPatients undergoing spine surgery were enrolled in this study, and the preoperatively completed questionnaires included the verbal rating scale (VRS), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), and Oswestry Disability Index (ODI). Quality of recovery was assessed using the 40-item Quality of Recovery questionnaire (QoR40). Opioid consumption and pain scores according to the VRS were recorded daily until discharge.RESULTSOne hundred thirty-nine patients were recruited for the study, and 101 completed the QoR40 assessment postoperatively. Patients with higher catastrophizing scores were more likely to have higher maximum pain scores postoperatively (estimate: 0.03, SE: 0.01, p = 0.02), without increased opioid use (estimate: 0.44, SE: 0.27, p = 0.11). Preoperative anxiety (estimate: 1.18, SE: 0.65, p = 0.07) and depression scores (estimate: 1.06, SE: 0.71, p = 0.14) did not correlate with increased postoperative opioid use; however, patients with higher preoperative depression scores had lower quality of recovery after surgery (estimate: −1.9, SE: 0.56, p < 0.001).CONCLUSIONSCatastrophizing, anxiety, and depression play important roles in modulating postoperative pain. Preoperative evaluation of these factors, utilizing a validated tool, helps to identify patients at risk. This might allow for earlier psychological intervention that could reduce pain severity and improve the quality of recovery.

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients

2021 ◽  
pp. 1-9
Author(s):  
Marie-Jacqueline Reisener ◽  
Alexander P. Hughes ◽  
Ichiro Okano ◽  
Jiaqi Zhu ◽  
Artine Arzani ◽  
...  
Keyword(s):  
Side Effects ◽  
Spine Surgery ◽  
Effect Size ◽  
Lumbar Fusion ◽  
Opioid Consumption ◽  
Opioid Use ◽  
Chi Square ◽  
Opioid Prescribing ◽  
Pain Scores ◽  
Stewardship Program

OBJECTIVE Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. METHODS The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0–10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher’s exact tests) and multivariable (Wald’s chi-square test) analyses. RESULTS In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20–60 mg] vs 20 mg [IQR 11–39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188–575 mg] vs 199 mg [100–372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60–135 mg] vs 60 mg [IQR 45–80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3–6] vs 5 [IQR 3–6], p = 0.33), nursing floor pain scores (4 [IQR 3–5] vs 4 [IQR 3–5], p = 0.93), or total LOS (118 hours [IQR 81–173 hours] vs 103 hours [IQR 81–132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald’s chi square = 9.45, effect size −52.4, 95% confidence interval [CI] −86 to −19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald’s chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald’s chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). CONCLUSIONS A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

P2769Racial differences in outcomes among acute pulmonary embolism patients: a nationwide analysis

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T Shi
Keyword(s):  
Pulmonary Embolism ◽  
Regression Analysis ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Acute Pulmonary Embolism ◽  
Primary Diagnosis ◽  
Total Cost ◽  
Rehabilitation Facilities ◽  
The Impact ◽  
White Patients

Abstract Background Limited data is available regarding racial disparities in patients admitted for acute pulmonary embolism. Purpose We aimed to examine the impact of racial differences on outcomes in patients admitted for acute pulmonary embolism. Methods We used the Nationwide Inpatient Sample, which represents 20% of community hospital discharges in the US, to identify adult patients who were discharged with the primary diagnosis of acute pulmonary embolism in 2016 with ICD-10 codes. Logistic regression analysis and linear regression analysis were used to compare patients with different races. Outcomes were focused on in-hospital mortality, total cost, length of stay and disposition, adjusting gender, age, Charlson comorbid index and socioeconomic variables. Results In 2016, 35,526 patients were admitted with a primary diagnosis of acute pulmonary embolism. White patients were more likely to be older and with higher income. After adjusting for the above variables, white patients had lower total cost of hospitalization (p<0.0001), shorter length of stay (p<0.0001), lower in-hospital mortality (adjusted odds ratio = 0.79, p=0.001), and more likely to be discharged to rehabilitation facilities compared to being discharged home. Outcomes in white vs non-white patients Conclusion Among acute pulmonary embolism hospitalizations, white patients generally had better outcomes despite being older in age, and were more likely to be transferred to rehabilitation facilities after discharge.

scholarly journals Impact Of Surgical Technique And Analgesia On Clinical Outcomes After Lung Transplantation

2020 ◽  
Author(s):  
Marc Gimenez-Milà ◽  
Sebastián Videla ◽  
Natalia Pallares ◽  
Antoni Sabate ◽  
Jasvir Parmar ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Length Of Stay ◽  
Lung Transplantation ◽  
Postoperative Hemorrhage ◽  
Surgical Incision ◽  
Surgical Access ◽  
Pain Scores ◽  
End Stage ◽  
The Impact ◽  
Median Blood Loss

Abstract Background: Lung transplantation is the ultimate treatment for end stage lung disease. There is paucity of data on the impact of surgical incision and analgesia on clinically relevant outcomes. Methods: A single centre retrospective study was performed between July 2007 and August 2017 of patients undergoing single or double lung transplantation. Gender, age, indication for lung transplantation, and the three types of surgical access (Thoracotomy (T), Sternotomy (S) and Clamshell (C)) were used, as well as two analgesic techniques: epidural and intravenous opioids. Outcome variables of the study were: Pain scores; Postoperative hemorrhage in the first 24 hours, duration of mechanical ventilation and length of stay at ICU. Results: 341 patients were identified. Thoracotomy was associated with higher pain scores than Sternotomy (OR 1.66, 95% CI: 1.01;2.74, p: 0.045) and no differences were found between Clamshell and Sternotomy incision.The median blood loss was 800 ml [IQR: 500; 1238], thoracotomy patients had 500 ml [325;818] (p < 0.001). Median duration of mechanical ventilation in Thoracotomy, Sternotomy and Clamshell groups were 19 [11; 37] hours, 34 [IQR 16; 57.5] hours and 27 [IQR 15; 50.5] hours respectively. Thoracotomy group were discharged earlier from ICU (p<0.001). Conclusions : Thoracotomy access produces less postoperative hemorrhage, duration of mechanical ventilation and lower length of stay in ICU, but higher pain scores and need for epidural analgesia.

scholarly journals Benefits of Transversus Abdominis Plane Block on Postoperative Analgesia after Bariatric Surgery: A Systematic Review and Meta-Analysis

2021 ◽  
pp. 345-358
Keyword(s):  
Bariatric Surgery ◽  
Postoperative Pain ◽  
Length Of Stay ◽  
Multimodal Analgesia ◽  
Opioid Consumption ◽  
Transversus Abdominis ◽  
Hospital Length Of Stay ◽  
Tap Block ◽  
Transversus Abdominis Plane ◽  
Pain Scores

BACKGROUND: Patients undergoing bariatric surgery present unique analgesic challenges, including poorly controlled pain, increased prevalence of obstructive sleep apnea, and opioid-induced respiratory depression. The transversus abdominis plane (TAP) has been demonstrated to be a safe and effective component of multimodal analgesia for a variety of abdominal surgeries. OBJECTIVE: To determine the benefits of the TAP block on postoperative analgesia and recovery in patients undergoing bariatric surgery. STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs) and non-randomized studies. METHODS: We conducted a comprehensive search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to April 2020 for studies using TAP block in bariatric surgeries and reporting postoperative pain, opioid consumption, and recovery-related outcomes. Primary outcomes included postoperative pain scores, opioid consumption, and recovery-related outcomes (e.g., length of stay, time to ambulation). Outcomes were pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CI). RESULTS: Twenty-one studies (15 RCTs [n = 1410] and 6 nonrandomized studies [n = 1959]) were included. Among RCTs, the TAP block group required fewer opioid rescues (RR 0.28; 95% CI 0.18 to 0.42, P < 0.001) (moderate quality); reduced total opioid use over 24 hours (MD –8.33; 95% CI –14.78 to –1.89, P = 0.01); decreased time to ambulation (MD –1.12 hours; 95% CI –1.50 to –0.73, P < 0.001) (high quality); and had significantly lower pain scores at 6 hours (MD –1.52; 95% CI –1.90 to –1.13, P < 0.01) and 12 hours (MD –0.95; 95% CI –1.34 to –0.56, P < 0.001) on a 0-10 pain scale (moderate quality). No difference was observed for nausea and vomiting, or hospital length of stay. Meta-analyzed outcomes from observational studies supported these results, suggesting decreased postoperative pain and opioid consumption. LIMITATIONS: Studies varied with respect to type of surgery and components of comparator multimodal analgesia, likely contributing to heterogeneity. Subgroup analyses by type of comparator group were conducted to address these differences. We were unable to extract data from all trials included due to variability in outcomes reporting, such as non-opioid drugs for postoperative pain management or invalid dosages. Pain-related outcomes may be affected by operative differences leading to variation in visceral pain. Observational studies have their inherent limitations, such as confounding due to lack of participant randomization and intervention blinding, potentially affecting subjective outcomes, such as pain scores, as well as provider-dependent outcomes, such as hospital length of stay. Lastly, there was significant variation of TAP block technique across all studies. CONCLUSION: TAP block is an effective, safe modality that can be performed under anesthesia. It decreases pain, opioid use, and time to ambulation after bariatric surgeries and should be considered in multimodal analgesia for enhanced recovery in this high-risk surgical population. KEY WORDS: Analgesia, bariatric surgery, enhanced recovery after surgery, multimodal analgesia, opioid-sparing analgesia, pain, postoperative, regional block, transversus abdominis plane block

Sign in / Sign up

Export Citation Format

Share Document