Difference in postoperative opioid consumption after spinal versus general anaesthesia for ankle fracture surgery—A retrospective cohort study

Abstract

Background: Surgical treatment of ankle fracture is associated with significant pain and high postoperative opioid consumption. The anaesthesia method may affect early postoperative pain. The main objective of the study was to compare postoperative opioid consumption after ankle-fracture surgery between patients treated with spinal anaesthesia and general anaesthesia. Methods:We reviewed retrospectively the files of 586 adult patients with surgically treated ankle fracture in the years 2014 through 2016. The primary outcome was opioid consumption during the first 48 postoperative hours. Secondary outcomes were maximal pain scores, postoperative nausea and vomiting, the length of stay in the post-anaesthesia care unit, and opioid use in different time periods up to 48 h postoperatively. Propensity score matching was used to mitigate confounding variables.Results: Total opioid consumption 48 h postoperatively was significantly lower after spinal anaesthesia (propensity score-matched population: effect size −13.7 milligrams; 95% CI −18.8 to −8.5; P < .001). The highest pain score on the numerical rating scale in the post-anaesthesia care unit was significantly higher after general anaesthesia (propensity score-matched population: effect size 3.7 points; 95% CI 3.2-4.2; P < .001). A total of 60 patients had postoperative nausea and vomiting in the postanaesthesia care unit, 53 (88.3%) of whom had general anaesthesia (P = .001). Conclusions:Patients with surgically treated ankle fracture whose operation was performed under general anaesthesia used significantly more opioids in the first 48 h postoperatively, predominantly in the post-anaesthesia care unit, compared with patients given spinal anaesthesia.Surgical treatment of ankle fracture is associated with significant postoperative pain. 1,2 Inadequately treated pain and high opioid consumption after surgery can delay functional recovery, increase the risk of postoperative complications, prolong the hospital stay, and increase overall cost. High postoperative opioid consumption may be associated with an increased risk of long-term opioid use. 3,4 Persistent postsurgical pain is a common phenomenon after ankle fracture surgery. 5 Most studies comparing the postoperative outcome, including opioid consumption, 6 between spinal anaesthesia (SA) and general anaesthesia (GA) after lower limb surgical procedures have been performed in patients with total hip and/or knee arthroplasty, [6][7][8] in which neuraxial anaesthesia is recommended over GA. 8 Only a few studies have compared differences between SA and GA in patients with surgically treated ankle fracture. A prospective cohort study compared postoperative pain and function after surgical ankle fracture fixation between patients given SA and GA.SA was associated with better functional outcome and less pain, but the evaluation took place 3 months after operation and opioid consumption was not reported. 9 A retrospective cohort study investigating primary surgical ankle fracture fixation compared opioid consumption betw...

Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review

“…Christensen et al [10] found that, compared with general anesthesia alone, general anesthesia plus peripheral adductor/popliteal nerve block (difference: -15.0 OME [95% CI -25.8 to -3.9]; p < 0.01) and spinal anesthesia with (difference: -21.0 OME [95% CI -31.5 to -10.2]; p < 0.01) or without (difference: -13.5 OME [95% CI -24.3 to -2.7]; p = 0.01) adductor/popliteal nerve block was associated with less opioid consumption over 24 hours. Similarly, Lehto et al [28] also found that spinal anesthesia was associated with fewer OMEs during the first 48 hours postoperatively (difference: -41.1 [95% CI -56.4 to -25.5]; p < 0.001) compared with general anesthesia. Kruse et al [26] reported that time of tourniquet use was linearly associated with increased opioid use (slope: 0.12 OMEs/min [95% CI 0.06 to 0.21]).…”

“…After exclusions, 18 articles were included (Fig. 1) [6,8,10,12,14,15,18,20,25,26,28,31,38,41,42,47,51,54]. Two studies were randomized controlled trials, whereas the remainder were observational.…”

“…After risk-stratifying patients for opioid misuse potential, surgeons should implement appropriate interventions to decrease this risk. In addition to the included randomized trial that found that ketorolac use decreases opioid consumption [31], and the two observational studies that found associations between spinal/regional blocks and decreased opioid use [10,28], numerous clinical trials have investigated interventions to decrease postoperative opioid use. One randomized trial of 1805 patients undergoing various surgical procedures found that perioperative gabapentin use led to a 24% increase in successful opioid weaning [19].…”

“…These are presented as defined by each respective study. Fourteen studies, including two randomized trials, described the factors associated with increased or decreased opioid use after foot or ankle fracture surgery (Table 4) [6,8,10,12,18,20,25,26,28,31,41,42,51,54]. Three studies described outcomes associated with opioid use (Table 5) [14,20,35].…”

“…The impact of chronic opioid use represents a major public health burden in the United States, with rates of premature deaths from opioid-related causes increasing in recent years [17]. Nonetheless, both undertreated postoperative pain and overuse of opioid medication can increase hospital stays, complication risks, and costs [9,16,28]. Thus, achieving a balance between adequate pain control and moderate opioid use is crucial.…”