A Multi-institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Reduction in Pain Scores and Narcotic Usage

Lucas, Jacob; Gross, Martin; Yafi, Faysal A.; DeLay, Kenneth J.; Christianson, Sarah; El‐Khatib, Farouk M.; Osman, Mahdi; Simhan, Jay

doi:10.1016/j.jsxm.2019.11.267

Cited by 28 publications

(29 citation statements)

References 21 publications

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“…Studies in other medical disciplines have also examined postoperative opioid prescription patterns with multimodal treatment, providing support for their use. The use of multimodal analgesia was associated with reduced frequency of opioid prescriptions at discharge among 528 patients undergoing thyroid and parathyroid surgery [15]; and a reduction in opioid use and improvement in pain control among patients undergoing penile implant surgery [16]. Implementation of a multimodal analgesic regimen after common arthroscopic procedures, including meniscectomy, rotator cuff repair, and ACL reconstruction, showed a significant decrease in the amount of opioid pain medication prescribed in the postoperative period with the multimodal regimen [17].…”

Section: Discussionmentioning

confidence: 99%

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

Bornstein

Husk

Lenchner

et al. 2020

JCM

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Background: Opioid use has emerged as a leading cause of death in the US. Given that 1 in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users, hospitals should strive to limit exposure to these medications. We set out to evaluate whether transitioning to a standardized order set based on multimodal combination analgesic therapy decreases the exposure to opioids after cesarean delivery. Methods: Our health system’s post-cesarean pain management electronic medical record (EMR) order set was changed from standing NSAIDs (Ibuprofen 600 mg every 6 h) and additional acetaminophen and opioid medications (Oxycodone 5 mg/acetaminophen 325 mg every 3 h or Oxycodone 10 mg/acetaminophen 650 mg every 6 h for moderate and severe pain, respectively) as needed (PRN) to a multimodal combination therapy with acetaminophen (975 mg every 6 h) and NSAIDs (Ibuprofen 600 mg every 6 h) as primary analgesics and opioids PRN (Oxycodone immediate release (IR) 5 mg every 3 h for moderate to severe pain). We performed a retrospective analysis across seven hospitals comparing inpatient opioid use, administration of other analgesics, and severe pain episodes (pain score ≥ 7) between the patients who were treated before and after implementation of the multimodal order set. Chi square and Student t-test were used for statistical analysis with significance determined as p < 0.05. Results: A total of 12,898 cesarean births were included (8696 prior and 4202 after implementation). The multimodal order set was associated with marked decrease in the incidence of post cesarean opioid use (45.4% vs. 67.5%; p < 0.0001), lower average opioid dose (26.7 mg vs. 36.6 mg of oxycodone; p < 0.0001), and increased dose of acetaminophen (8422 mg vs. 4563 mg; p < 0.0001), while severe pain scores were less frequent (46.3% vs. 56.6%, p < 0.0001). Conclusions: Multimodal analgesic therapy for post-cesarean pain management reduces inpatient opioid use while improving pain control. Incorporation of a multimodal order set as a default in the EMR facilitates effective and widespread implementation on a large scale. Obstetric units should consider standardizing post-cesarean pain management orders to include routine (not PRN) multimodal combination therapy with acetaminophen and NSAIDs as primary analgesics.

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Section: Discussionmentioning

confidence: 99%

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

Bornstein

Husk

Lenchner

et al. 2020

JCM

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“…The same protocol was validated in a multi-institutional cohort of men undergoing IPP implantation. In this investigation, men who received MMA again had lower VAS scores in PACU and through POD #1, required less opioids while hospitalized, and had less refills for opioid medication (32). To our knowledge, these investigations represent some of the only rigorous characterizations of pain response following penile implantation that help traverse the entire recovery period.…”

Section: Multimodal Analgesiamentioning

confidence: 78%

Enhanced recovery strategies after penile implantation: a narrative review

Ellis¹,

Sudhakar²,

Simhan³

2021

Transl Androl Urol

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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.

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“…The devastating effects of the opioid epidemic have prompted various interventions, including prescribing guidelines and enhanced recovery after surgery (ERAS) pathways (10)(11)(12). Recently, Lucas et al evaluated the combination of acetaminophen, meloxicam or celecoxib, gabapentin, and penile/pudendal nerve blocks with local anesthetic (using a mixture of lidocaine and bupivacaine) compared to an opioid-based pain management regimen following inflatable penile prosthesis procedures (29). Using this protocol, the authors found a significant decrease in postoperative pain coupled with lower oral opioid consumption when compared with a historical opioidbased regimen.…”

Section: Discussionmentioning

confidence: 99%

Long-acting liposomal bupivacaine and postoperative opioid use after Peyronie’s disease surgery: a pilot study

Britton¹,

Findlay²,

Parikh³

et al. 2021

Transl Androl Urol

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Background: Novel strategies have been proposed to minimize postoperative opioid use, yet many patients experience significant pain after penile surgery. Our objective was to evaluate postoperative opioid use in patients undergoing penile ring block with long-acting liposomal bupivacaine (LB; Exparel) during surgery for Peyronie's disease (PD). Methods: We identified patients who underwent tunica albuginea plication (TAP) and plaque excision/ grafting (PEG) for PD between July 2019 and September 2020. Intraoperatively, a ring block was administered at the penile base penis with 20 cc of LB. Patients were instructed to use over the counter pain medications as first line treatment for postoperative pain, and opioids were available for severe breakthrough pain as needed [7.5 oral morphine equivalents (OME) =5 mg oxycodone]. Opioid use was assessed during the first five days postoperatively.Results: In total, 28 patients met inclusion criteria including 18/28 (64%) who underwent TAP and 10/28 (36%) who underwent PEG. Median patient age was 56 years (IGR 51;61). Median postoperative 10-point visual analogue pain score was 0 (range 0-3). Duration of penile anesthesia ranged from 1.5-4 days. In total, 9/28 patients (32%) utilized opioids during the first five days postoperatively (range 7.5-75 OME). Two patients (7%) required opioids during the first two days after surgery. 27/28 (96%) were satisfied or highly satisfied with postoperative pain control.Conclusions: Intraoperative penile ring block with LB resulted in excellent pain control with local anesthetic duration of 1.5-4 days. The majority of patients did not require any opioids during the early postoperative period. Further study comparing outcomes with shorter-acting local anesthetics is necessary to balance pain control benefits with additional cost.

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A Multi-institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Reduction in Pain Scores and Narcotic Usage

Cited by 28 publications

References 21 publications

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

Implementation of a Standardized Post-Cesarean Delivery Order Set with Multimodal Combination Analgesia Reduces Inpatient Opioid Usage

Enhanced recovery strategies after penile implantation: a narrative review

Long-acting liposomal bupivacaine and postoperative opioid use after Peyronie’s disease surgery: a pilot study

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