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