Epidural analgesia for reduction of postoperative systemic opioid use following selective dorsal rhizotomy in children

2021 ◽  
pp. 1-6
Author(s):  
Madeline B. Karsten ◽  
Steven J. Staffa ◽  
Craig D. McClain ◽  
Jennifer Amon ◽  
Scellig S. D. Stone
Keyword(s):  
Epidural Analgesia ◽  
Hospital Stay ◽  
Respiratory Support ◽  
Long Term Effects ◽  
Opioid Use ◽  
Selective Dorsal Rhizotomy ◽  
Dorsal Rhizotomy ◽  
Pain Scores ◽  
Opioid Administration ◽  
Postoperative Epidural Analgesia

OBJECTIVE Selective dorsal rhizotomy (SDR) requires significant postoperative pain management, traditionally relying heavily on systemic opioids. Concern for short- and long-term effects of these agents has generated interest in reducing systemic opioid administration without sacrificing analgesia. Epidural analgesia has been applied in pediatric patients undergoing SDR; however, whether this reduces systemic opioid use has not been established. In this retrospective cohort study, the authors compared postoperative opioid use and clinical measures between patients treated with SDR who received postoperative epidural analgesia and those who received systemic analgesia only. METHODS All patients who underwent SDR at Boston Children’s Hospital between June 2013 and November 2019 were reviewed. Treatment used the same surgical technique. Postoperative systemic opioid dosage (in morphine milligram equivalents per kilogram [MME/kg]), pain scores, need for respiratory support, vomiting, bowel movements, and length of hospital and ICU stay were compared between patients who received postoperative epidural analgesia and those who did not, by using the Wilcoxon rank-sum test or Fisher’s exact test. RESULTS A total of 35 patients were identified, including 18 females (51.4%), with a median age at surgery of 6.1 years. Thirteen patients received postoperative epidural and systemic analgesia and 22 patients received systemic analgesia only. Groups were otherwise similar, with treatment selection based solely on surgeon routine. Patients who received epidural analgesia required less systemic morphine milligram equivalents/kg on postoperative days (PODs) 0–4 (p ≤ 0.042). Patients who did not receive epidural analgesia were more likely to require respiratory support on POD 1 (45% vs 8%; p = 0.027). Reported pain scores did not differ between groups, although patients receiving epidural analgesia trended toward less severe pain on PODs 1 and 2. Groups did not differ with respect to postoperative vomiting or time to first bowel movement, although epidural analgesia use was associated with a longer hospital stay (median 7 vs 5 days; p < 0.001). CONCLUSIONS Patients who received postoperative epidural analgesia required less systemic opioid use and had at least equivalent reported pain scores on PODs 1–4, and they required less respiratory support on POD 1, although they remained in the hospital longer when compared to patients who received systemic analgesia only. A larger prospective study is needed to confirm whether epidural analgesia lowers systemic opioid use in children, contributes to a safer postoperative hospital stay, and results in better pain control following SDR.

Postoperative Pain Protocol in Children after Selective Dorsal Rhizotomy

2020 ◽  
Vol 55 (4) ◽  
pp. 181-187
Author(s):  
Jeffrey Hatef ◽  
Luke G.F. Smith ◽  
Giorgio C. Veneziano ◽  
David P. Martin ◽  
Tarun Bhalla ◽  
...  
Keyword(s):  
Intensive Care ◽  
Postoperative Pain ◽  
Pain Control ◽  
Selective Dorsal Rhizotomy ◽  
Icu Admission ◽  
Dorsal Rhizotomy ◽  
Pain Scores ◽  
Protocol Group ◽  
Management Protocol ◽  
Opioid Administration

<b><i>Introduction:</i></b> Selective dorsal rhizotomy (SDR) provides lasting relief of spasticity for children suffering from cerebral palsy, although controlling postoperative pain is challenging. Postoperatively, escalation of therapies to include a patient-controlled analgesia (PCA) pump and intensive care unit (ICU) admission is common. <b><i>Objectives:</i></b> We developed a multimodal pain management protocol that included intraoperative placement of an epidural catheter with continuous opioid administration. We present the 3-year results of protocol implementation. <b><i>Methods:</i></b> With institutional review board approval, all patients who were subjected to SDR at our institution were identified for review. Hourly pain scores were recorded. Adverse effects of medication, including desaturation, nausea/vomiting, and pruritus, were also noted. Comparisons were made between patients treated with PCA and those treated with multimodal pain control using <i>t</i> and χ<sup>2</sup> tests as appropriate. <b><i>Results:</i></b> Thirty-nine patients undergoing the procedure with protocolized pain control (average age 6.8 years, 57% male) were compared to 7 PCA-treated controls (average age 6.6 years, 54% male). Pain control was satisfactory in both groups, with average pain scores of 1.5 in both groups on postoperative day 0, decreasing by postoperative day 3 to 1.1 in the PCA group and 0.5 in the protocol group. No patients under the protocol required ICU admission; all patients with PCA spent at least 1 day in the ICU. Desaturations were seen in 16 patients in the protocol group (41%), but none required ICU transfer. Treatment for pruritis was given to 57% of PCA patients and 15% of protocol patients. Treatment for nausea and vomiting was given to 100% of PCA patients and 51% of protocol patients. Medication requirements for the hospitalization were decreased from 1.1 to 0.28 doses per patient for pruritis, and from 3 to 1.1 doses per patient for nausea. <b><i>Conclusions:</i></b> Multimodal analgesia is an excellent alternative to PCA for postoperative pain after SDR. Actual analgesia is comparative to that of controls without the need for intensive care monitoring. Side effects of high-dose opiates were less frequent and required less medication. With the protocol, patients were safely treated outside the ICU.

scholarly journals Increased Risk of Postthoracotomy Pain Syndrome in Patients with Prolonged Hospitalization and Increased Postoperative Opioid Use

2016 ◽  
Vol 2016 ◽  
pp. 1-6 ◽  
Author(s):  
Michelle A. O. Kinney ◽  
Adam K. Jacob ◽  
Melissa A. Passe ◽  
Carlos B. Mantilla
Keyword(s):  
Epidural Analgesia ◽  
Hospital Stay ◽  
Oral Morphine ◽  
Pain Syndrome ◽  
Pain Clinic ◽  
Opioid Use ◽  
Postthoracotomy Pain ◽  
Increased Risk ◽  
Prolonged Hospital ◽  
Postoperative Epidural Analgesia

Background. Postthoracotomy pain syndrome (PTPS) is unfortunately very common following thoracotomy and results in decreased quality of life. The purpose of this retrospective study was to determine perioperative patient, surgical, and analgesic characteristics associated with the development of PTPS. Methods. Sixty-six patients who presented to the Mayo Clinic Rochester Pain Clinic were diagnosed with PTPS 2 months or more after thoracotomy with postoperative epidural analgesia. These patients were matched with sixty-six control patients who underwent thoracotomy with postoperative epidural analgesia and were never diagnosed with PTPS. Results. Median (IQR) hospital stay was significantly different between control patients (5 days (4, 6)) compared with PTPS patients (6 days (5, 8)), P<0.02. The total opioid equivalent utilized in oral morphine equivalents in milligrams for the first three days postoperatively was significantly different between control patients and PTPS patients. The median (IQR) total opioid equivalent utilized was 237 (73, 508) for controls and 366 (116, 874) for PTPS patients (P<0.005). Conclusion. Patients with a prolonged hospital stay after thoracotomy were at an increased risk of developing PTPS, and this is a novel finding. Patients who utilize higher oral morphine equivalents for the first 3 days were also at increased risk for PTPS.

Stereotactic Electroencephalography Is Associated With Reduced Pain and Opioid Use When Compared with Subdural Grids: A Case Series

2021 ◽  
Author(s):  
Jonathan P Scoville ◽  
Evan Joyce ◽  
Joshua Hunsaker ◽  
Jared Reese ◽  
Herschel Wilde ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Chart Review ◽  
Statistical Tests ◽  
Case Series ◽  
Length Of Hospital Stay ◽  
Retrospective Chart Review ◽  
Opioid Use ◽  
Pain Scores ◽  
Surgical Methods ◽  
Significant Difference

Abstract BACKGROUND Minimally invasive surgery (MIS) has been shown to decrease length of hospital stay and opioid use. OBJECTIVE To identify whether surgery for epilepsy mapping via MIS stereotactically placed electroencephalography (SEEG) electrodes decreased overall opioid use when compared with craniotomy for EEG grid placement (ECoG). METHODS Patients who underwent surgery for epilepsy mapping, either SEEG or ECoG, were identified through retrospective chart review from 2015 through 2018. The hospital stay was separated into specific time periods to distinguish opioid use immediately postoperatively, throughout the rest of the stay and at discharge. The total amount of opioids consumed during each period was calculated by transforming all types of opioids into their morphine equivalents (ME). Pain scores were also collected using a modification of the Clinically Aligned Pain Assessment (CAPA) scale. The 2 surgical groups were compared using appropriate statistical tests. RESULTS The study identified 43 patients who met the inclusion criteria: 36 underwent SEEG placement and 17 underwent craniotomy grid placement. There was a statistically significant difference in median opioid consumption per hospital stay between the ECoG and the SEEG placement groups, 307.8 vs 71.5 ME, respectively (P = .0011). There was also a significant difference in CAPA scales between the 2 groups (P = .0117). CONCLUSION Opioid use is significantly lower in patients who undergo MIS epilepsy mapping via SEEG compared with those who undergo the more invasive ECoG procedure. As part of efforts to decrease the overall opioid burden, these results should be considered by patients and surgeons when deciding on surgical methods.

Reducing opioid usage: a pilot study comparing postoperative selective dorsal rhizotomy protocols

2020 ◽  
Vol 25 (3) ◽  
pp. 305-310
Author(s):  
Ludovic P. Pao ◽  
Liang Zhu ◽  
Sarah Tariq ◽  
Christine A. Hill ◽  
Bangning Yu ◽  
...  
Keyword(s):  
Pain Management ◽  
Pilot Study ◽  
Medication Administration ◽  
Hospital Length Of Stay ◽  
Spastic Cerebral Palsy ◽  
Selective Dorsal Rhizotomy ◽  
Dorsal Rhizotomy ◽  
Pain Scores ◽  
Management Protocol ◽  
Dexmedetomidine Infusion

OBJECTIVESelective dorsal rhizotomy (SDR) is a surgical procedure used to treat spasticity in children with spastic cerebral palsy. Currently, there is a lack of work examining the efficacy of optimizing pain management protocols after single-level laminectomy for SDR. This pilot study aimed to compare the clinical outcomes of SDR completed with a traditional pain management protocol versus one designed for opioid dosage reduction.METHODSThe Texas Comprehensive Spasticity Center prospective database was queried for all patients who underwent SDR between 2015 and 2018. Demographic, surgical, and postoperative data for all patients who underwent SDR were collected from medical records. The study was designed as a retrospective study between the patient-controlled analgesia (PCA) and dexmedetomidine infusion (INF) groups with 80% power to detect a 50% difference at a significance level of 0.05. Patients in the INF group received perioperative gabapentin, intraoperative dexmedetomidine infusion, and scheduled acetaminophen and NSAIDs postoperatively.RESULTSMedication administration records, pain scores, and therapy notes were collected for 30 patients. Patients who underwent SDR between June 2015 and the end of December 2017 received traditional pain management (PCA group, n = 14). Patients who underwent SDR between January 2018 and the end of December 2018 received modified pain management (INF group, n = 16). No patients were lost to follow-up. Differences in age, weight, height, preoperative Gross Motor Function Classification System scores, operative duration, hospital length of stay, and sex distribution were not statistically different between the 2 groups (p > 0.05). Analysis of analgesic medication doses demonstrated that the INF group required fewer doses and lower amounts of opioids overall, and also fewer NSAIDs than the PCA group. When converted to the morphine milligram equivalent, the patients in the INF group used fewer doses and lower amounts of opioids overall than the PCA group. These differences were either statistically significant (p < 0.05) or trending toward significance (p < 0.10). Both groups participated in physical and occupational therapy similarly postoperatively (p > 0.05). Pain scores were comparable between the groups (p > 0.05) despite patients in the INF group requiring fewer opioids.CONCLUSIONSInfusion with dexmedetomidine during SDR surgery combined with perioperative gabapentin and scheduled acetaminophen and NSAIDs postoperatively resulted in similar pain scores to traditional pain management with opioids. In addition, this pilot study demonstrated that patients who received the INF pain management protocol required reduced opioid dosages and were able to participate in therapy similarly to the control PCA group.

Intraoperative opioid and non-opioid administration patterns and early postoperative pain: A single-center retrospective longitudinal study

2019 ◽  
Vol 15 (5) ◽  
pp. 389-405
Author(s):  
Gregory Smith, MD ◽  
Marcel E. Durieux, MD, PhD ◽  
Siny Tsang, PhD ◽  
Bhiken I. Naik, MBBCh
Keyword(s):  
Postoperative Pain ◽  
Elective Surgery ◽  
Opioid Analgesic ◽  
Oral Morphine ◽  
Median Number ◽  
Single Center ◽  
Opioid Use ◽  
Pain Scores ◽  
Opioid Administration ◽  
Over Time

Objective: Characterize changes in intraoperative opioid and non-opioid administration over time and to evaluate self-reported pain scores in the immediate postoperative period.Design: Single-center retrospective longitudinal study.Setting: Academic medical center.Patients, participants: All patients presenting for surgery between 2011 and 2017 in both an inpatient and outpatient setting.Main outcome measure(s): Determine total intraoperative opioid administration using intravenous oral morphine equivalents standardized to weight and intraoperative non-opioid use. Furthermore, postoperative self-reported pain scores within 2 hours of completion of surgery are reported.Results: A total of 112,167 individual cases were identified from March 2011 to June 2017. There was a sustained and significant reduction in intraoperative mean and median opioid administration [2011: 0.16 ± 0.15 mg/kg and 0.13 (0-4.92) mg/kg vs 2017: 0.09 ± 0.09 mg/kg and 0.07 (0-4.17) mg/kg]. These effects are seen in emergent vs elective surgery, ambulatory vs inpatient, preoperative opioid use vs no preoperative opioid use, and those with and without intraoperative loco-regional procedures. Although median number of intraoperative non-opioid analgesic agents was unchanged over time, average difference in the number of intraoperative non-opioids increased over time. Finally, pain scores decreased over time [2011: mean (standard deviation) and median (range): 5.1 ± 2.62 and 5.4 (0-10) vs 2017: 3.29 ± 3.27 and 3 (0-10)].Conclusion: This study confirms that intraoperative opioid use has decreased over time with increased utilization of non-opioid analgesic adjuncts and a commensurate decrease in immediate postoperative pain.

Long‐term effects of spasticity treatment, including selective dorsal rhizotomy, for individuals with cerebral palsy

2021 ◽  
Author(s):  
Bruce A MacWilliams ◽  
Mark L McMulkin ◽  
Elizabeth A Duffy ◽  
Meghan E Munger ◽  
Brian Po‐Jung Chen ◽  
...  
Keyword(s):  
Cerebral Palsy ◽  
Long Term Effects ◽  
Selective Dorsal Rhizotomy ◽  
Dorsal Rhizotomy

Microtia Reconstruction and Erector Spinae Block in Children: A Case Series With Chart Review

2021 ◽  
pp. 019459982110183
Author(s):  
Gabriel Gomez ◽  
Beth Osterbauer ◽  
Robert Nguyen ◽  
Choo Phei Wee ◽  
Amit Kochhar ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Hospital Stay ◽  
Chart Review ◽  
Case Series ◽  
Hospital Length ◽  
Erector Spinae ◽  
Hospital Length Of Stay ◽  
Block Group ◽  
Opioid Use ◽  
Pain Scores

Objectives Autologous reconstruction of microtia is advantageous due to its inherent biocompatibility and long-term stability, but postoperative pain associated with costal harvest is a significant issue. A well-planned pain management approach is imperative. Our objective is to introduce the novel application of erector spinae block anesthesia in pediatric microtia reconstruction and evaluate its impact on pain scores, use of opioids, and hospital length of stay. Study Design Case series with chart review. Setting Patients undergoing stage 1 microtia reconstruction at a tertiary pediatric hospital. Methods Data collected included demographics, opioid amounts, Wong-Baker FACES Pain Rating Scale scores, opioid-related side effects, and hospital length of stay. We used generalized estimating equations to examine the effect of erector spinae block use on total opioid use and pain scores and a linear regression model to assess the effect on hospital stay. Results Forty-seven patients were included: 14 in the erector spinae block group and 33 in the continuous wound pump group. The mean age was 8.3 years (SD, 2; range, 6-13), and 13 (32%) were female. Patients in the erector spinae block group had a 65.44% decrease in adjusted total opioid use (95% CI, –79.72% to –41.10%; P < .0001), a decrease in length of hospital stay (β = −1.69 [95% CI, −2.11 to −1.26], P < .0001), and no difference in reported pain scores when compared with patients in the continuous wound pump group. Conclusions This study demonstrates that early experience with an erector spinae block resulted in decreased opioid use and shorter hospital stay as compared with continuous wound infiltration with local anesthetic.

scholarly journals Enhanced recovery after cystectomy in patients with preoperative narcotic use

2021 ◽  
Vol 15 (11) ◽  
Author(s):  
Saum Ghodoussipour ◽  
Alireza Ghoreifi ◽  
Behdod Katebian ◽  
Brian H. Cameron ◽  
Anirban P. Mitra ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Radical Cystectomy ◽  
Enhanced Recovery ◽  
Opioid Use ◽  
Gastrointestinal Complications ◽  
Median Hospital Stay ◽  
Pain Scores ◽  
History Of ◽  
Open Radical Cystectomy ◽  
Eras Protocol

Introduction: The aim of this study was to evaluate the outcomes of radical cystectomy with an enhanced recovery after surgery (ERAS) protocol in patients with a history of chronic preoperative narcotic use compared to narcotic-naive patients. Methods: We identified 553 patients who underwent open radical cystectomy with ERAS. Preoperative narcotic use was identified in 34 patients who were then matched to 68 narcotic-naive patients. Postoperative outcomes, opioid use, and visual analog scale (VAS) pain scores were analyzed and compared. All routes of opioid use were recorded and converted to a morphine equivalent dose (MED). Results: Patients with preoperative narcotic use reported higher median VAS pain scores per day (POD1: 5.2 vs. 3.9, p=0.003; POD2: 5.1 vs. 3.6, p<0.001; POD3: 4.6 vs. 3.8, p=0.004) and used significantly more opioids (median MED) per day (POD1: 13.2 vs. 10.0, p=0.02; POD2: 11.3 vs. 6.4, p=0.003; POD3: 10.2 vs. 5.0, p=0.005) following surgery. Preoperative narcotic users were noted to have a significantly higher incidence of 90-day readmissions (41.2% vs. 20.6%, p=0.03). There was no difference in median hospital stay (4 vs. 4 days, p=0.6), 30- or 90-day complications (64.7% vs. 60.3%, p=0.8 and 82.4% vs. 75.0%, p=0.4, respectively) or gastrointestinal complications (29.4% vs. 26.5%, p=0.8), including postoperative ileus (11.8% vs. 20.6%, p=0.2). Conclusions: Patients with preoperative narcotic exposure report higher pain scores and require more opioid use following radical cystectomy with ERAS and are more likely to be readmitted within 90 days. However, there was no observed difference in hospital stay or complications.

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