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

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

 by Barker, Jenny C.; DiBartola, Kaitlin; Wee, Corinne; Andonian, Nicole; Abdel-Rasoul, Mahmoud; Lowery, Deborah; Janis, Jeffrey E.  

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 443e–450e

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.

Opioid Use following Outpatient Breast Surgery: Are Physicians Part of the Problem?

Opioid Use following Outpatient Breast Surgery: Are Physicians Part of the Problem?

by Hart, Alexandra M.; Broecker, Justine S.; Kao, Leslieann; Losken, Albert  

Plastic and Reconstructive Surgery: September 2018 - Volume 142 - Issue 3 - p 611–620

Background: The increasing rate of opioid abuse warrants standardization of postoperative pain management. The purpose of this study was to analyze the use of opioids in pain control and patient satisfaction following ambulatory breast surgery.

Methods: This was a prospective study of a consecutive series of patients undergoing secondary breast reconstruction (n = 60) or breast reduction (n = 35). All patients were given a pain questionnaire preoperatively. Postoperatively, women received 30 tablets of oxycodone 5.0 mg/acetaminophen 325 mg. Patients were contacted three times: postoperative days 3 to 5, 8 to 10, and 30 or higher. All patients were queried on narcotic use, pain level (0 to 10), and satisfaction with pain control. Patients with allergies or taking narcotics preoperatively were excluded.

Results: Most in the secondary breast reconstruction group (61.5 percent) had stopped taking opioids by postoperative day 5. Patients consumed a mean of 11.4 tablets following secondary breast reconstruction and a mean of 17.5 tablets after breast reduction. A majority reported feeling satisfied with their pain management. At postoperative day greater than 30, most experienced very mild pain, with an improvement of 3.74 points following breast reduction. There were 18.6 and 12.5 tablets per patient left over for secondary breast reconstruction and breast reduction, respectively. A total of 1551 unused tablets were left over for the entire cohort at postoperative day greater than 30. There was no significant difference in average pain scores or interference with enjoyment or activity between those who did or did not take pain medication.

Conclusions: This commonly prescribed pain regimen provides adequate pain relief and satisfaction for breast surgery, with a substantial number of leftover tablets. Physicians as prescribers should be aware of discrepancies. Prescription of 30 opioid tablets after outpatient breast surgery appears unnecessary and excessive. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Prospective, Randomized, Controlled Comparison of Bupivacaine versus Liposomal Bupivacaine for Pain Management after Unilateral Delayed Deep Inferior Epigastric Perforator Free Flap Reconstruction

Prospective, Randomized, Controlled Comparison of Bupivacaine versus Liposomal Bupivacaine for Pain Management after Unilateral Delayed Deep Inferior Epigastric Perforator Free Flap Reconstruction

 by Gatherwright, James; Knackstedt, Rebecca W.; Ghaznavi, Amir M.; Bernard, Steven; Schwarz, Graham; Moreira, Andrea; Gurunluoglu, Raffi; Djohan, Risal  

Plastic and Reconstructive Surgery: June 2018 - Volume 141 - Issue 6 - p 1327–1330

Summary: Effective postsurgical analgesia is a critical aspect of patient recovery. The goal of this prospective, randomized, controlled, blinded study was to examine the effect that liposomal bupivacaine delivered by means of a transversus abdominis plane block has on pain control in women undergoing unilateral deep inferior epigastric perforator flap reconstruction. Institutional review board approval was granted for this prospective study. Patients were eligible if they were undergoing unilateral, delayed deep inferior epigastric perforator flap reconstruction. Patients were randomized to one of three groups: liposomal bupivacaine transversus abdominis plane block, or bupivacaine pain pump. Charts were reviewed for demographics, length of stay, and postoperative narcotic use. There were eight patients in the liposomal bupivacaine and bupivacaine transversus abdominis plane block groups and five patients in the pain pump group. A retrospective cohort of six patients who did not receive any intervention was included. Patients who received a liposomal bupivacaine transversus abdominis plane block used statistically significantly less intravenous and total postoperative narcotics in milligrams and milligrams per kilogram per day compared with all other cohorts. They were able to get out of bed at an earlier time point. Overall hospital costs were similar among the groups. This is the first study to investigate liposomal bupivacaine delivered as a transversus abdominis plane block in a prospective, randomized, blinded study in women undergoing unilateral, delayed, abdominally based autologous breast reconstruction. The authors were able to demonstrate a significant reduction in intravenous and total narcotic use when a liposomal bupivacaine transversus abdominis plane block was used. Future studies are needed to prospectively investigate the effect that liposomal bupivacaine would have on immediate and bilateral reconstructions.

Toradol following Breast Surgery: Is There an Increased Risk of Hematoma?

Toradol following Breast Surgery: Is There an Increased Risk of Hematoma?

by Nguyen, Brittany N.; Barta, Ruth J.; Stewart, Christine E.; Heinrich, Cherrie A.  

Plastic and Reconstructive Surgery: June 2018 - Volume 141 - Issue 6 - p 814e–817e

Background: Ketorolac tromethamine (Toradol), a nonsteroidal antiinflammatory drug, is used with increased frequency given its success in postoperative pain control and the subsequent decreased need for narcotics. Its use has been limited in plastic surgery for fear of postoperative bleeding and hematoma formation. In this study of breast surgery patients, the authors investigated whether ketorolac increased the risk of postoperative hematoma formation. Methods: After obtaining institutional review board approval, the authors retrospectively reviewed the records of patients undergoing breast surgery from January of 2012 through December of 2014. The authors compared the incidence of postoperative hematomas in patients who did, versus those who did not, receive ketorolac postoperatively. Results: For the entire cohort, the overall hematoma rate was 2.8 percent. Of the patients who received ketorolac, the rate was 3.5 percent; of those who did not, the rate was 2.5 percent. Of the breast reduction patients, the rate was 4 percent in those who received ketorolac versus 3.2 percent in those who did not. Of the breast reconstruction patients, the rate was 4 percent in those who received ketorolac versus 3.2 percent in those who did not. Conclusions: Recently, the high rates of prescribing postoperative narcotics have received increased attention. Aside from the risk of increased availability of narcotics in the community, the side effects can delay patient recovery. Ketorolac is controversial for postoperative pain control because of the potential risk of bleeding, but in the authors’ 3-year retrospective study, it was not associated with an increased risk of hematoma formation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Comparison of postoperative pain control in autologous abdominal free flap versus inplant-based breast reconstructions

Comparison of postoperative pain control in autologous abdominal free flap versus inplant-based breast reconstructions. Plastic and Reconstructive Surgery, Feb 2015, Vol. 135(2), p.356-67.

Gassman, A.A., et al.

http://journals.lww.com/plasreconsurg/Abstract/2015/02000/Comparison_of_Postoperative_Pain_Control_in.9.aspx

Women who undergo mastectomy and breast reconstruction are shown to express more pain than those who undergo mastectomy alone. The authors evaluated postoperative pain outcomes following breast reconstruction.

Factors associated with the development of chronic pain after surgery for breast cancer

Factors associated with the development of chronic pain after surgery for breast cancer: A prospective cohort from a tertiary center in the United States. The breast, Jan/Feb. 2014, Vol. 20(1), p.9-14.

De Oliveira, G.S., et al.

http://onlinelibrary.wiley.com/doi/10.1111/tbj.12207/full

Chronic pain has been shown to affect up to 60% of patients undergoing surgery for breast cancer. Besides younger age, other risk factors for the development of chronic pain have not been consistent in previous studies. The objective of the current investigation was to detect the prevalence and risk factors for the development of chronic pain after breast cancer surgery by examining a patient population from a tertiary cancer center in the United States.

Persistent pain and sensory disturbances after treatment for breast cancer

Persistent pain and sensory disturbances after treatment for breast cancer: six-year nationwide follow-up study. BMJ 2013; 346.

Mejdahl, M.K., et al.

http://www.bmj.com/highwire/filestream/640586/field_highwire_article_pdf/0/bmj.f1865.full.pdf

Objective: Toexamine thedevelopment of persistent pain after treatment for breast cancer and to examine risk factors associated with continuing pain.Design: Repeated cross sectional study in a previously examined

nationwide cohort.All eligible women who underwent surgery for primary breast cancer in Denmark in 2005 and 2006 and were examined in 2008 were surveyed again with the same questionnaire.

Plastic and Reconstructive Surgery Vol 127 Iss 1 January 2011

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