A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery.

PURPOSE: Major spine surgery with multilevel instrumentation is followed by large amount of opioid consumption, significant pain and difficult mobilization in a population of predominantly chronic pain patients. This case-control study investigated if a standardized comprehensive pain and postoperative nausea and vomiting (PONV) treatment protocol would improve pain treatment in this population. METHODS: A new regimen with acetaminophen, NSAIDs, gabapentin, S-ketamine, dexamethasone, ondansetron and epidural local anesthetic infusion or patient controlled analgesia with morphine, was introduced in a post-intervention group of 41 consecutive patients undergoing multilevel (median 10) instrumented spinal fusions and compared with 44 patients in a pre-intervention group. RESULTS: Compared to patients in the pre-intervention group, patients treated according to the new protocol consumed less opioid on postoperative day (POD) 1 (P = 0.024) and 2 (P = 0.048), they were mobilized earlier from bed (P = 0.003) and ambulation was earlier both with and without a walking frame (P = 0.027 and P = 0.027, respectively). Finally, patients following the new protocol experienced low intensities of nausea, sedation and dizziness on POD 1-6. CONCLUSIONS: In this study of patients scheduled for multilevel spine surgery, it was demonstrated that compared to a historic group of patients receiving usual care, a comprehensive and standardized multimodal pain and PONV protocol significantly reduced opioid consumption, improved postoperative mobilization and presented concomitant low levels of nausea, sedation and dizziness.

Need for improved treatment of postoperative pain.

INTRODUCTION: A cross-sectional study was performed at Rigshospitalet, Copenhagen, a Danish tertiary university hospital, to describe current postoperative pain and nausea treatment with a view to identifying areas with improvement potential. MATERIAL AND METHODS: Data on up to four of the major and most frequent types of surgery were collected from each department based on interviews with the staff, audits of patient courses and electronic patient medication records. Staff guidelines on procedure-specific pain treatment were also collected. RESULTS: Data on 121 patients from 12 surgical departments and 44 procedures were included in the study. No reliable information about the quality of pain management was available as no data on pain scores were detectable for the first three postoperative days (POD) for 55% (day 1), 71% (day 2) and 84% (day 3) of the patients. Most patients (75%) were treated with opioids. Non-opioid analgesic treatment was insufficient as the majority of patients did not receive sufficient 24-hour treatment with paracetamol and non-steroidal anti-inflammatory drugs, and only a minority received combination therapy. Nausea was found in approx. 20% on POD 1-3. Staff pain treatment guidelines were present in 14% of the cases. CONCLUSION: Our results confirm that challenges exist in postoperative pain management as previously observed in multinational surveys. The way forward is procedure-specific treatment plans based on interdisciplinary collaboration implemented in conjunction with organizational changes. This work represents a natural extension of the work of the traditional acute pain clinic. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.