Preoperative Multimodal Analgesia Decreases Postanesthesia Care Unit Narcotic Use and Pain Scores in Outpatient Breast Surgery.

BACKGROUND: The opioid epidemic demands changes in perioperative pain management. Of the 33,000 deaths attributable to opioid overdose in 2015, half received prescription opioids. Multimodal analgesia is a practice-altering evolution that reduces reliance on opioid medications. Ambulatory breast surgery is an ideal opportunity to implement these strategies. METHODS: A retrospective review of 560 patients undergoing outpatient breast procedures was conducted. Patients received (1) no preoperative analgesia (n = 333); (2) intraoperative intravenous acetaminophen (n = 78); (3) preoperative oral acetaminophen and gabapentin (n = 95); or (4) preoperative oral acetaminophen, gabapentin and celecoxib (n = 54). Outcomes included postanesthesia care unit narcotic use, pain scores, postanesthesia care unit length of stay, rescue antiemetic use, and 30-day complications. RESULTS: Both oral multimodal analgesia regimens significantly reduced postanesthesia care unit narcotic use (oral acetaminophen and gabapentin, 14.3 ± 1.7; oral gabapentin, acetaminophen, and celecoxib, 11.9 ± 2.2; versus no drug, 19.2 ± 1.1 mg oral morphine equivalents; p = 0.0006), initial pain scores (oral acetaminophen and gabapentin, 3.9 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.4 ± 0.7; versus no drug, 5.3 ± 0.3 on a 1 to 10 scale, p = 0.0002) and maximum pain scores (oral acetaminophen and gabapentin, 4.3 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.6 ± 0.7; versus no drug, 5.9 ± 0.3 on a 1 to 10 scale; p < 0.0001). Both oral regimens were better than no medications or intravenous acetaminophen alone in multivariate models after controlling for age, body mass index, American Society of Anesthesiologists class, length of surgery, prior narcotic prescription availability, and intraoperative local anesthetic. Postanesthesia care unit length of stay, antiemetic use, and 30-day complications were not different. CONCLUSIONS: Preoperative oral multimodal analgesia reduces narcotic use and pain scores in outpatient breast plastic surgery. These regimens are inexpensive, improve pain control, and contribute to narcotic-sparing clinical practice in the setting of a national opioid epidemic. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

An Artificial Cadaveric Leg Blood Flow System for Endoscopic Vein Harvesting Simulation.

Despite being the most common training model for endoscopic vein harvesting, cadaveric legs are limited by their absence of blood flow, resulting in a faded vascular appearance. Because the saphenous vein and the surrounding tissue seem less distinguishable, dissection of the saphenous vein and bipolar coagulation of its branches becomes increasingly inefficient and difficult. An inexpensive artificial blood flow system was developed to overcome this limitation. A cadaveric leg was thawed to a soft and yielding degree, and the saphenous vein was dissected medial and proximal to the medial malleolus. An artificial blood solution was prepared by dissolving 4% protein powder, red dye, and a contrast agent-for x-ray visualization-in saline. The solution was perfused through the saphenous vein and artery. The open ends of the vessels were temporarily clamped after the perfusion had been completed. Blood flow within the vessels was confirmed via angiography and endoscopic visualization of the leg's vessels. A bleeding effect was observed when the saphenous vein was perforated or when a vascular branch was transected. Conversely, a tight seal indicated successful bipolar coagulation of a branch, providing an objective, quantifiable assessment parameter. The artificial blood flow system helps overcome the limitations of the cadaveric leg, creating a more realistic and inexpensive model for endoscopic vein harvesting simulation training.