Benefits of thoracic epidural analgesia in patients undergoing an open posterior component separation for abdominal herniorrhaphy

INTRODUCTION: The implementation of open posterior component separation (PCS) surgery has led to improved outcomes for complex hernias. While the PCS technique has been shown to decrease recurrence rates, and provide a feasible option to repair hernias in nontraditional locations, there is still significant postoperative pain associated with the laparotomy and extensive abdominal wall manipulation. Systemic opioids and thoracic epidural analgesia (TEA) are both commonly utilized, either together or independently, as postoperative analgesic regimens. The benefits of TEA have been studied following a variety of surgeries, however to date no study has been performed to investigate its efficacy in this particular surgery. The aim of this study is to evaluate the benefits of TEA following open PCS. We hypothesized that the incorporation of TEA in a patients postoperative analgesic regimen would show an advantage in time to bowel recovery. METHODS: An electronic medical record query was done to identify patients who had undergone an open PCS. Once this list was compiled, a retrospective chart review was performed and patients receiving TEA (either alone or combined with systemic opioids) were compared to patients receiving only systemic opioids. The primary endpoint compared time to resumption of a full diet, given by the patients postoperative day (POD). Secondarily, time to resumption of a liquid diet, postoperative length of stay (LOS), intensive care unit (ICU) admission rate, ICU LOS, and rates of several postoperative complications were all recorded and compared. A post-hoc analysis was also performed using the same endpoints. This analysis compared cohorts of patients receiving TEA and avoiding all systemic opioids, to patients who received systemic opioids (whether alone or combined with TEA). RESULTS: Based on inclusion parameters, 101 patients met criteria for analysis. In the initial analysis, 62 patients received TEA with or without systemic opioids, and 39 patients received only systemic opioids. In comparing these groups, there was no statistically significant difference in time to full diet (TEA 2.6 ± 1.7 vs Systemic opioids 3.1 ± 2.1 [mean POD ± SD]; P=0.21). In addition, no differences were found in the secondary outcomes of time to liquid diet, ICU admission, ICU LOS, or postoperative complications. In the post-hoc analysis, the 37 patients that received only TEA, were compared against 64 patients that received systemic opioids (either with or without TEA). In this comparison, the group receiving only TEA was found to have a statically shorter time to bowel recovery compared to patients receiving systemic opioids (TEA alone 2.2 ± 1.0 vs Systemic opioids 3.2 ± 2.2, P=0.0033). This subgroup (TEA only) also showed statically shorter time to liquid diet and a decreased postoperative LOS. CONCLUSION: For patients undergoing an open PCS, the inclusion of TEA in the postoperative analgesic regimen did not shorten return of bowel function. However, when TEA was utilized and systemic opioids were avoided, time to bowel recovery and hospital LOS were both significantly shortened

The Association of Prescription Opioid Exposure and Patient Factors with Prolonged Postoperative Opioid Use in Opioid Naive Patients

Background Research suggests prolonged postoperative opioid use occurs in 4-13% of opioid naïve patients and is related to factors other than surgical pain. However, it is unclear which patient factors and prescribing practices are associated with prolonged use after surgery among opioid naïve patients. Objectives To identify factors associated with prolonged postoperative opioid use (refills 90-180 days after surgery) in opioid naïve patients in two domains: specific patient characteristics (demographics, smoking status, comorbidities, etc.) and exposure through postoperative opioid prescriptions (in oral morphine milligram equivalents [OME]). Methods An electronic medical record dataset analysis of inpatient and outpatient opioid naïve adult orthopedic surgery patients at the University of Cincinnati Medical Center from January 1, 2012 through December 31, 2017 was conducted. Opioid naïve was defined as no opioid prescription filled in the past twelve months or only a perioperative prescription filled 30 days or less prior to surgery. Patients were excluded if they had a diagnosis of cancer or if they underwent a second surgery within 180 days of the first. A multivariate logistic regression model was used to evaluate the relationship of each domain to opioid refills 90-180 days after surgery. Results Of the 7,323 patients met inclusion criteria, 4% continued to refill opioid prescriptions more than 90 days after their surgical procedure. Independent predictors of prolonged postoperative opioid use were alcoholism (O.R. 2.0, C.I. 1.5-2.6), OME \u3e 675 (O.R. 2.3, C.I. 1.5-3.4), female gender (O.R. 1.7, C.I. 1.3-2.1), black race (O.R. 1.6, C.I. 1.2-2.2), Medicaid insurance (O.R. 1.8, C.I. 1.3-2.5), and the following co-morbidities: diabetes (O.R.1.5, C.I. 1.1-2.0), mood disorders (O.R. 1.4, C.I. 1.1-1.9), hypertension (O.R. 1.4, C.I. 1.1-1.9), and chronic kidney disease (O.R. 1.6, C.I. 1.1-2.4). Conclusions Both opioid exposure and patient characteristics increase risk for prolonged opioid use following orthopedic surgery. Since the risk of overdose increases with increased OME, patients with high OME prescriptions should also receive a prescription for naloxone. This study sheds light on the need for postoperative prescribing guidelines for clinicians. To decrease the rate of prolonged postoperative opioid use, clinical changes can be investigated and implemented including collaborative perioperative pain management strategies utilizing non-opioid pain control methods; perioperative patient screening; education of patients and clinicians; and close postoperative follow-up, especially for the most vulnerable populations

Healthcare Practitioner Education, Implementation of Clinical Guidelines, and Narcotic Use in the Surgical Patient

Abstract Background: The prevalence of opioid abuse in the United States is high and associated with a surge in mental illness, emergency department visits, hospitalizations, readmissions after discharge, and unintended overdose deaths. Previous research identifies orthopedics as a significant contributor to the crisis, most notably total knee replacements. Inconsistencies with provider education throughout the US may be contributing to the opioid epidemic. Objective: To explore the correlation between provider knowledge and decreased patient-reported use of opioids and to determine knowledge gaps for development of provider education. Clinical Question: Does increased provider knowledge decrease patient-reported use of opioids? Method: A retrospective, cross-sectional descriptive design was used for this quality improvement project. Lewin’s Theory of Change was used to guide the implementation. Use of the KnowPain-12 survey to assess provider knowledge. Patient-reported opioid use completed via FORCE-Therapeutics. Results: Ten providers participated in the project. One hundred percent identified as male, 80% were above the age of 45 years of age, 50% practiced as an orthopedic surgeon for more than 20 years, and 80% stated they received, participated, or taught pain medication education in the previous five years. A total of 1482 patient records were reviewed. Records were separated into two groups: total hip and total knee surgical replacements, there was no significant difference between laterality of procedure, age, or sex between the patient groups. Higher provider knowledge was moderately positively correlated (0.56) with overall opioid consumption postoperative week zero through six in total knee arthroplasty patients and weakly positively correlated (0.24) in total hip arthroplasty. However, at various time points throughout postoperative day zero through six, opioid consumption was negatively correlated with provider knowledge. Additional findings indicate higher provider knowledge was negatively correlated with NSAIDs, anti-inflammatories, and VAS pain. Conclusion: Overall, the results did not confirm a clear consistent correlation between patient-reported opioid use and provider-specific knowledge. Further research is recommended with a larger sample size or providers and patients

Is Preoperative Administration of Celecoxib and Pregabalin Associated with Decreased Intraoperative and Postoperative Opioid Consumption in Patients Undergoing Total Hip or Knee Arthroplasty?

Abstract: The purpose of this study was to determine if a preoperative dose of celecoxib and pregabalin in patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) was associated with less opioid consumption intraoperatively and postoperatively compared to those who did not receive this regimen. Introduction: THA and TKA have been associated with a high incidence of postoperative pain. Historically, this pain has been managed with opioids; however, these drugs have negative side effects associated with their use. Consequently, anesthesia providers have begun utilizing multimodal non-opioid analgesics. Recently, a specific combination has been utilized, which includes a nonsteroidal anti-inflammatory drug known as celecoxib (Celebrex) and an anticonvulsant known as pregabalin (Lyrica). While this combination may be a beneficial alternative for opioids, there is no consensus on the timeliness or effectiveness of a single combination dose of these drugs at alleviating perioperative pain. Methodology: A retrospective cross-sectional study design was utilized for this study that included 200 patients who underwent THA or TKA between May 1, 2008 and May 1, 2018 at Charleston Area Medical Center. A total of 100 patients were included in group one, which consisted of patients who did not receive a preoperative dose of celecoxib and pregabalin or any other preoperative analgesics. Group two consisted of 100 patients who did receive a preoperative dose of both celecoxib and pregabalin. The primary independent variable was the preoperative administration of celecoxib and pregabalin. Secondary independent variables consisted of gender, age, body mass index (BMI), and American Society of Anesthesiologists (ASA) physical classification scores. The dependent variables consisted of intraoperative opioid consumption and total opioid consumption in the postoperative anesthesia care unit (PACU). Control variables consisted of gender, age, BMI and ASA physical classification scores. The research hypotheses were that patient who underwent THA or TKA and received preoperative doses of both celecoxib and pregabalin would have less opioid consumption in the intraoperative period and less opioid consumption in the PACU, compared to those who did not receive the same combination preoperatively. Results: Comparison of the two groups yielded no differences between mean age, BMI or gender. The mean age and ASA classification between the two groups were statistically different, p=.0001 and p=.017. Group one consisted of 55 females and 45 males, while group two consisted of 52 females and 48 males. The study also revealed there was a statistical significance in terms of PACU opioid consumption (p=.001) between the two groups but no statistical difference in intraoperative opioid consumption (p\u3e.05). Group one received a mean difference of approximately 1.2 morphine equivalents more than group two. There was no statistical significance between PACU opioid consumption and age, gender, BMI, or ASA classification. Analysis showed there was a statistical association between intraoperative opioid consumption and age (p=.022) and gender (p=.025). Further analysis revealed females received a mean of 3.22 morphine equivalents more than males. Discussion: The study results supported the hypothesis that preoperative celecoxib and pregabalin would be associated with a decrease in PACU opioid consumption in patients undergoing THA or TKA. These results did not support the additional study hypothesis that this combination would also decrease intraoperative opioid consumption. Implications and Recommendations: The results of this study supported the use of preoperative celecoxib and pregabalin at reducing PACU opioid consumption. Additional prospective, randomized studies are needed to compare the use of celecoxib and pregabalin independently versus in combination. Conclusion: In conclusion, this study found an association between the preoperative administration of celecoxib and pregabalin in patients undergoing THA or TKA and decreased PACU opioid consumption; however, no association was found between the preoperative administration of celecoxib and pregabalin and decreased intraoperative opioid consumption in these patients

Characterization of Postoperative Recovery After Cardiac Surgery- Insights into Predicting Individualized Recovery Pattern

Understanding the patterns of postoperative recovery after cardiac surgery is important from several perspectives: to facilitate patient-centered treatment decision making, to inform health care policy targeted to improve postoperative recovery, and to guide patient care after cardiac surgery. Our works aimed to address the following: 1) to summarize existing approaches to measuring and reporting postoperative recovery after cardiac surgery, 2) to develop a framework to efficiently measure patient-reported outcome measures to understand longitudinal recovery process, and 3) to explore ways to summarize the longitudinal recovery data in an actionable way, and 4) to evaluate whether addition of patient information generated through different phases of care would improve the ability to predict patient’s outcome. We first conducted a systematic review of the studies reporting on postoperative recovery after cardiac surgery using patient-reported outcome measures. Our systematic review demonstrated that the current approaches to measuring and reporting recovery as a treatment outcome varied widely across studies. This made synthesis of collective knowledge challenging and highlighted key gaps in knowledge, which we sought to address in our prospective cohort study. We conducted a prospective single-center cohort study of patients after cardiac surgery to measure their recovery trajectory across multiple domains of recovery. Using a digital platform, we measured patient recovery in various domains over 30 days after surgery to visualize a granular evolution of patient recovery after cardiac surgery. We used a latent class analysis to facilitate identification of dominant trajectory patterns that had been obscured in a conventional way of reporting such time-series data using group-level means. For the pain domain, we identified 4 trajectory classes, one of which was a group of patients with persistently high pain trajectory that only became distinguishable from less concerning group after 10 days. Therefore, we obtained a potentially actionable insights to tailoring individualized follow-up timing after surgery to improve the pain control. The prospective study embodied several important features to successfully conducting such studies of patient-reported outcomes. This included the use of digital platform to facilitate efficient data collection extending after hospital discharge, iteratively improving the protocol to optimize patient engagement including evaluation of potential barriers to survey completion, and using latent class analysis to identify dominant patterns of recovery trajectories. We outlined these insights in the protocol manuscript to inform subsequent studies aiming to leverage such a digital platform to measure longitudinal patient-centered outcome. Finally, we evaluated the potential value of incorporating health care data generated in the different phases of patient care in improving the prediction of postoperative outcomes after cardiac surgery. The current standard of risk prediction in cardiac surgery is the Society of Thoracic Surgeons’ (STS) risk model, which only uses patient information available preoperatively. We demonstrated through prediction models fitted on the national STS risk model for coronary artery bypass graft surgery that the addition of intraoperative variables to the conventional preoperative variable set improved the performance of prediction models substantially. Using machine learning approach to such a high-dimensional dataset proved to be marginally important. This work demonstrated the potential value and importance of being able to leverage health care data to continuously update the prediction to inform patient outcomes and guide clinical care. Our work collectively advanced knowledge in several key aspects of postoperative recovery. First, we highlighted the knowledge gap in the existing literature through characterizing the variability in the ways such studies had been conducted. Second, we designed and described a framework to measure postoperative recovery and an analytical approach to informatively characterize longitudinal patient recovery. Third, we employed these designs in a prospective cohort study to measure and analyze recovery trajectories and described clinical insights obtained from the study. Finally, we demonstrated the potential value of a dynamic risk model to iteratively improve its predictive performance by incorporating new data generated as the patient progresses through the phase of care. Such a platform has the potential to individualize patient’s post-acute care in a data-driven manner

Increased Use of Opioids Perioperatively Leads to Unmanaged Postoperative Pain

Background: Total knee and total hip joint arthroplasty are two frequently preformed surgeries, with 5.2 million total knee arthroplasties performed the United States between the year 2000 and 2010 (Williams et al., 2015). Opioids are widely used to manage pain for patients undergoing total joint arthroplasty. However, use of opioids is associated with undesirable adverse effects, such as nausea and respiratory depression, (Johnson et al., 2011). In postoperative patients following total joint replacement, 75 % of the patients complain of inadequately controlled moderate to severe pain (De Luca et al., 2018). Increased use and overprescribing increase tolerance to opioids and can result in poorly controlled acute post-operative pain leading to chronic pain, impaired mobility, and negative long-term outcomes. Aim: Examine if long term opioid pain management has an impact on early postoperative mobilization, long-term dependence, and overuse of opioid medications after total joint arthroplasty. Proposal: Increased consumption and long-term use of opioids preoperatively can lead to unmanaged postoperative pain. Use of multimodal analgesia and preemptive analgesia can lead to improved outcomes for patients who are undergoing total joint arthroplasty of the knee and hip. The proposed study aims to examine if use of such modalities can have improved long terms outcomes in patients undergoing total joint arthroplasty

Monitoring Patient Safety in the Recovery Room

Respiratory depression is a serious complication after surgery. Early detection is a major patient safety concern for recovery room personnel as patients recover from anesthesia and experience pain. The opioids used for pain management may contribute to over-sedation effects and respiratory depression. Vital signs and pulse oximetry are standard postoperative monitoring procedures. End-tidal capnography and arterial blood gases may augment the standard-of-care procedures but may not be effective at detecting early respiratory depression. The purpose of this study was to generate baseline data trending patient safety variables and outcomes for postoperative patients using standard monitoring with standard-of-care plus transcutaneous capnography monitoring for CO2 levels. This study was guided by a retrospective, time series design with two study groups. A convenience sample of 800 patients from a large Midwestern hospital was assigned to postoperative recovery rooms equipped with standard monitoring (control group) or standard monitoring plus transcutaneous capnography (treatment group). The time series component refers to dependent measures collected at three points in time: admission to the recovery room and 30- and 60-minutes after admission. Dependent measures included respiratory rate, blood pressure, heart rate, oxygen saturation, pain score, Aldrete score, and opioid doses. Measures and time were treated as within subject factors. Data were analyzed by: group (treatment vs control), dependent measures, and time using multivariate analysis of variance. Aldrete score and opioid doses were treated as within-subject factors. Recovery time was assessed using an independent samples t-test. Trends in variables over time showed significant differences by groups. The transcutaneous capnography treatment group showed a shorter length of stay in the recovery room and overall reduction in opioid administration compared to the control group. Pain scores worsened for the treatment group over time. The transcutaneous capnography may improve management of opioids and patients’ level of consciousness but may have inadvertently heightened patients’ awareness of pain. Transcutaneous monitoring of recovery room patients may be beneficial in avoiding respiratory depression and improving patient safety and it has long-term implications for health care costs

The impact of COVID-19 on opioid use in those awaiting hip and knee arthroplasty : A retrospective cohort study

Peer reviewedPostprin

An Evaluation of a Nerve Block Protocol in Patients with Hip Fractures

BACKGROUND/PURPOSE: Pain management for hip fracture patients in the time before surgery is crucial. Literature highlights the success of local, single injection nerve blocks to aid in preoperative pain management. A local hospital implemented a preoperative, single injection nerve block protocol in March 2018. This quality improvement project investigated: (1) organization protocol compliance, and (2) if the preoperative single injection nerve block protocol reduces hip fracture pain, use of systemic opioid analgesics, decreases incidence of adverse opioid effects, and reduces cost of care. SUBJECTS: Patients ages 18 and older admitted with the primary diagnosis of an operable isolated hip fracture (n=100). METHODS: Data measures were extracted from the electronic health records and the trauma registry and were entered into REDCap encrypted software. ANALYSIS: Data was analyzed using SAS statistical software to verify whether the intervention was successful in meeting cost, quality, and compliance measures. RESULTS: Results were not statistically significant in reducing oral and intravenous narcotic use before (p=0.80; p=0.39) and after (p=0.23; p=0.10) surgical correction, nor was there statistically significant change in adverse effects (p=0.10) and length of stay (p=0.90). However, there was a statistically significant reduction in preoperative pain levels following nerve block administration (p\u3c0.0001). Protocol compliance was 66% over seven months. CONCLUSION: The results of this project were consistent with the literature; nerve block injection may reduce preoperative pain for patients with an operable hip fracture. Further investigation is needed to determine if narcotic use and length of stay could be impacted if time variability in nerve block administration were reduced and if protocol compliance were increased