The impact of a postoperative multimodal analgesia pathway on opioid use and outcomes after cardiothoracic surgery.

OBJECTIVE: The Enhanced Recovery after Surgery Cardiac Society recommends using multimodal analgesia (MMA) for postoperative pain however, evidence-based guidelines have yet to be established. This study examines the impact of a standardized postoperative MMA pathway in reducing opioid consumption and related complications after cardiothoracic surgery (CTS). METHODS: Within a multicenter healthcare system, a postoperative MMA pathway was developed and implemented at two CTS intensive care units (ICU) while the other CTS ICU opted to maintain the existing opioid-based pathway. A retrospective chart review was conducted on patients admitted to a CTS ICU within this healthcare system after conventional coronary artery bypass grafting and/or valve surgery from September 1, 2018, to June 30, 2019. Comparative analysis was conducted on patients prescribed MMA versus those managed with an opioid-based pathway. The primary outcome was total opioid consumption, converted to morphine milligram equivalents, 72-h post-surgery. Secondary outcomes included mobility within one-day post-surgery, ICU length of stay (LOS), time to first bowel movement (BM), and time to first zero Richmond Agitation-Sedation Scale (RASS). RESULTS: Seven hundred sixty-two adults were included for final analysis. The MMA group had a higher body mass index, higher percentage of females, were more likely classified as African American and had higher scores for risk-adjusted complications. General Linear Model analysis revealed higher opioid consumption in the MMA group (Est. 0.22, p < 0.0009); however, this was not statistically significant after adjusting for differences in fentanyl usage. The MMA group was more likely to have mobility within one-day post-surgery (OR 0.44, p < 0.0001), have longer time to first BM (OR 1.93, p = 0.0011), and longer time to first zero RASS (OR 1.62, p = 0.0071). The analgesia groups were not a predictor for ICU LOS. CONCLUSIONS: Opioid consumption was not reduced secondary to this postoperative MMA pathway. The MMA group was more likely to have mobility within one-day post-surgery. Patients in the MMA group were also more likely to have prolonged time to first BM and first zero RASS. Development and evaluation of a perioperative MMA pathway should be considered.

Group-based trajectory analysis of acute pain after spine surgery and risk factors for rebound pain.

Background: This retrospective study was designed to explore the types of postoperative pain trajectories and their associated factors after spine surgery. Materials and methods: This study was conducted in a single medical center, and patients undergoing spine surgery with intravenous patient-controlled analgesia (IVPCA) for postoperative pain control between 2016 and 2018 were included in the analysis. Maximal pain scores were recorded daily in the first postoperative week, and group-based trajectory analysis was used to classify the variations in pain intensity over time and investigate predictors of rebound pain after the end of IVPCA. The relationships between the postoperative pain trajectories and the amount of morphine consumption or length of hospital stay (LOS) after surgery were also evaluated. Results: A total of 3761 pain scores among 547 patients were included in the analyses and two major patterns of postoperative pain trajectories were identified: Group 1 with mild pain trajectory (87.39%) and Group 2 with rebound pain trajectory (12.61%). The identified risk factors of the rebound pain trajectory were age less than 65 years (odds ratio [OR]: 1.89; 95% CI: 1.12-3.20), female sex (OR: 2.28; 95% CI: 1.24-4.19), and moderate to severe pain noted immediately after surgery (OR: 3.44; 95% CI: 1.65-7.15). Group 2 also tended to have more morphine consumption (p < 0.001) and a longer length of hospital stay (p < 0.001) than Group 1. Conclusion: The group-based trajectory analysis of postoperative pain provides insight into the patterns of pain resolution and helps to identify unusual courses. More aggressive pain management should be considered in patients with a higher risk for rebound pain after the end of IVPCA for spine surgery.

A randomized clinical trial: optimal strategies of paravertebral nerve block combined with general anesthesia for postoperative analgesia in patients undergoing lobectomy: a comparison of the effects of different approaches for serratus anterior plane block.

BACKGROUND: To observe the analgesic effect of different ultrasound-guided methods of serratus anterior plane block (SAPB) after surgery in patients who have undergone thoracoscopic lobectomy with general anesthesia combined with thoracic paravertebral nerve block. METHODS: A total of 120 patients aged 18-65 years old scheduled for video-assisted thoracoscopic surgery (VATS) were selected. Patients were randomly divided into 3 groups: patient-controlled intravenous analgesia (PCIA) group, serratus anterior plane block (SPB) group and continuous serratus anterior plane block (CSPB) group (n=40 each). All patients were treated with general anesthesia combined with double-point (T4, T7) thoracic paravertebral block. The SPB group received an ultrasound-guided single serratus plane block. The CSPB group underwent the same procedure as the SPB group, with an epidural catheter inserted. Both the PCIA and SPB groups received PCIA after surgery. Patients in the CSPB group were connected to a continuous serratus block automatic analgesia pump after surgery. RESULTS: There were no significant differences among the 3 groups in terms of the general condition. Compared with the PCIA group, the resting and exercise VAS pain scores at T2, T3, T4, and T5, cortisol level at T1, T4 and T5 in SPB group and CSPB group were lower (P<0.05), the times of the first analgesia were significantly prolonged, and the times of pressing the PCA pump and opioid use were significantly less in the SPB and CSPB groups, and the CSPB group used no opioids (P<0.05), the SPB group and CSPB group had shorter times of the first postoperative activity, longer mobilization distance and the total number of days in hospital was significantly lower (P<0.05). Postoperative complications in the SPB and CSPB groups were significantly less and the CSPB group had an even lower incidence of postoperative complications (P<0.05). Compared with the SPB group, active VAS pain scores at T4 and T5 were higher in the CSPB group (P<0.05). Compared with the PCIA group, the total QoR-40 score at T6 was significantly higher in the SPB and CSPB groups, and compared with the SPB group, this data was higher in the CSPB group (P<0.05). CONCLUSIONS: Single ultrasound-guided SAPB combined with PCIA can provide a better analgesic effect, improve the quality of early postoperative recovery, and accelerate ERAS. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2000041350.

Enhanced recovery strategies after penile implantation: a narrative review.

Optimizing pain management strategies in penile implantation has historically been a challenge to urologists assuming care of patients post-operatively. In addition to the complex pathophysiology of male genital pain, the responsibility of opioid stewardship in the face of the ongoing narcotics epidemic presents its own set of challenges to experienced implanters. Recent innovations in pre- and intra-operative analgesia have provided some improvement in patient-reported pain outcomes. When used together in protocols spanning each phase of operative care, multimodal analgesia (MMA) regimens provide superior patient pain control and successfully decrease opioid usage compared to traditional opioid-based pain control. This review will systematically present literature that discusses interventions in the preoperative and intraoperative spaces aimed at optimally controlling pain. We will also highlight surgical techniques that have been demonstrated to help ameliorate post-operative pain in penile implant recipients. We will discuss the impact of MMA protocols across urology and further explore its larger impact on reducing opioid burden in the ongoing epidemic.

Prevention of Chronic Postsurgical Pain: The Effect of Preventive and Multimodal Analgesia.

ABSTRACT: Chronic post-surgical pain (CPSP) is a chronic pain condition, affecting many people who have undergone surgery. The development of CPSP is complex and the treatment options are limited; therefore, postsurgical pain management is crucial for satisfactory pain relief and prevention of CPSP development. In this review, we analyzed the existing treatment modalities for patients with CPSP. The treatments include opioids, acetaminophen, N-methyl-D-aspartate (NMDA) receptor antagonists, anticonvulsants, and local anesthesia. All treatments had signifi cant effect on CPSP and opioid-sparing effect; moreover, preventive analgesic treatment is important for improving quality of postoperative pain management. However, since most of the studies had limitations, further research on determining effective combinations and treatment modalities is required.