Enhanced recovery after surgery in head and neck surgery: Reduced opioid use and length of stay

Jandali, Danny; Vaughan, Deborah; Eggerstedt, Michael; Ganti, Ashwin; Scheltens, Holly; Ramirez, Emily; Revenaugh, Peter C.; Al‐Khudari, Samer; Smith, Ryan M.; Stenson, Kerstin

doi:10.1002/lary.28191

Cited by 48 publications

(87 citation statements)

References 34 publications

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“…Additional study will be necessary to titrate opioid prescriptions to pain management goals in the context of aggressive multimodal opioid‐sparing analgesia for this population. Although several groups have already explored this concept, future pain management algorithms may be improved by giving more OME to patients at higher risk to experience pain based on the risk factors identified in our study and less OME for those at lower risk.…”

Section: Discussionmentioning

confidence: 99%

“…The high rates of long‐term opioid use among head and neck cancer patients underscore the vulnerability of this population to opioid dependence and the importance of thoughtful pain management by the head and neck surgical team. Indeed, several recent studies have reported successful opioid prescription reduction without compromising pain control by implementing multimodal analgesia regimens for head and neck surgery patients …”

Section: Introductionmentioning

confidence: 99%

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Age Is Associated With Pain Experience and Opioid Use After Head and Neck Free Flap Reconstruction

et al. 2020

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Objectives To describe pain experience and opioid use after major head and neck reconstructive surgery. Study Design Retrospective cohort study. Methods Patients undergoing major head and neck surgery with microvascular free tissue transfer (free flaps) at a tertiary academic center were included. Pain scores (0–10) and demographic and clinical data were ascertained from medical records. Discharge opioid prescriptions and refills obtained within 30 days were recorded. Patient characteristics were compared with pain scores using nonparametric rank‐sum tests and with likelihood of refill using logistic regression models to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Results The study population comprised 445 patients. Median age was 60 years (interquartile range 50–68). Most patients had cancer (N = 350, 78%). The majority of free flaps were fibula (N = 153, 34%) or radial forearm (N = 159, 36%). Older patients reported significantly lower pain scores, whereas patients with opioid tolerance, anxiety, current smokers, and those undergoing larger volume resections or boney free flaps reported significantly higher pain scores. One‐quarter (N = 115, 26%) of patients obtained opioid refills. Patients aged ≥ 60 years had one‐half the odds of obtaining a refill compared with patients aged < 60 years (adjusted odds ratio [aOR] = 0.52, 95% confidence interval [CI] = 0.33–0.84), whereas surgical defect volume ≥ 100 cm3 (aOR = 1.92, 95% CI = 1.21–3.07) and higher pain score (aOR = 1.19, 95% CI = 1.07–1.32 per 1 point increase) increased the odds of refill. Conclusion Continued opioid use after discharge is common among patients undergoing major head and neck reconstruction, particularly for younger patients and after more extensive surgery. Older patients reported lower pain intensity and were less likely to obtain opioid refills, highlighting the wisdom of judicious opioid use for this vulnerable population. Level of Evidence IV Laryngoscope, 130: E469–E478, 2020

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Age Is Associated With Pain Experience and Opioid Use After Head and Neck Free Flap Reconstruction

et al. 2020

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“…Appropriate study sample size was determined to provide 80% power at a two‐sided t ‐test with a significance level of .05. An assumption of an effect size of an individual outcome was based on two available directly comparable studies 12,13 . A group assignment ratio of 1:2 was chosen to reach power.…”

Section: Methodsmentioning

confidence: 99%

ERAS for Head and Neck Tissue Transfer Reduces Opioid Usage, Peak Pain Scores, and Blood Utilization

et al. 2020

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Objectives We implement a novel enhanced recovery after surgery (ERAS) protocol with pre‐operative non‐opioid loading, total intravenous anesthesia, multimodal peri‐operative analgesia, and restricted red blood cell (pRBC) transfusions. 1) Compare differences in mean postoperative peak pain scores, opioid usage, and pRBC transfusions. 2) Examine changes in overall length of stay (LOS), intensive care unit LOS, complications, and 30‐day readmissions. Methods Retrospective cohort study comparing 132 ERAS vs. 66 non‐ERAS patients after HNC tissue transfer reconstruction. Data was collected in a double‐blind fashion by two teams. Results Mean postoperative peak pain scores were lower in the ERAS group up to postoperative day (POD) 2. POD0: 4.6 ± 3.6 vs. 6.5 ± 3.5; P = .004) (POD1: 5.2 ± 3.5 vs. 7.3 ± 2.3; P = .002) (POD2: 4.1 ± 3.5 vs. 6.6 ± 2.8; P = .000). Opioid utilization, converted into morphine milligram equivalents, was decreased in the ERAS group (POD0: 6.0 ± 9.8 vs. 10.3 ± 10.8; P = .010) (POD1: 14.1 ± 22.1 vs. 34.2 ± 23.2; P = .000) (POD2: 11.4 ± 19.7 vs. 37.6 ± 31.7; P = .000) (POD3: 13.7 ± 20.5 vs. 37.9 ± 42.3; P = .000) (POD4: 11.7 ± 17.9 vs. 36.2 ± 39.2; P = .000) (POD5: 10.3 ± 17.9 vs. 35.4 ± 45.6; P = .000). Mean pRBC transfusion rate was lower in ERAS patients (2.1 vs. 3.1 units, P = .017). There were no differences between ERAS and non‐ERAS patients in hospital LOS, ICU LOS, complication rates, and 30‐day readmissions. Conclusion Our ERAS pathway reduced postoperative pain, opioid usage, and pRBC transfusions after HNC reconstruction. These benefits were obtained without an increase in hospital or ICU LOS, complications, or readmission rates. Level of Evidence 3 Laryngoscope, 131:E792–E799, 2021

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“…Though ERAS theory has become widely accepted and gradually extended to elective surgical treatments, there are only a few reports concerning the application of ERAS theory around head and neck cancer in the field of otolaryngology, head and neck surgery, probably due to the particular clinical symptoms of the diseases encountered in that therapeutic area. [3][4][5] Obstructive sleep apnoea (OSA) in children is characterised by the recurrent upper airway obstructive events that occur during sleep, and can eventually influence child's physical and mental growth. Hypertrophy of the adenoids and tonsils is a main cause of OSA in children, and adenotonsillectomy may decrease the adverse effects of OSA.…”

Section: Introductionmentioning

confidence: 99%

An enhanced recovery programme improves the comfort and outcomes in children with obstructive sleep apnoea undergoing adenotonsillectomy: A retrospective historical control study

Liu

Xiumei

et al. 2020

Clinical Otolaryngology

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Objective: To explore the effects of an enhanced recovery after surgery (ERAS) programme on postoperative rehabilitation in children with obstructive sleep apnoea (OSA) during the perioperative period of adenotonsillectomy. Design: A retrospective historical control study. Setting: Service improvement project. Participants: The study included 394 children with OSA (207 males, 187 females; age range, 2.5 years to 14 years) who underwent adenotonsillectomy. Main outcome measures: The children who had undergone adenoidal ablation and bilateral tonsillectomy were divided into an ERAS group (208 patients) treated with the combined optimisation measures and a control group (186 patients) treated with traditional measures during the perioperative period. The postoperative incidence of complications, pain scores, anxiety scores and postoperative diets in the two groups were assessed. Results: Patients in the ERAS group had significantly a lower overall complication rate and incidence of fever for 2 weeks of follow-up when compared to patients in the control group through the application of perioperative optimisation measures. Furthermore, patients in the ERAS group had less post-surgical pain, had better dietary intake at days 1, 3 and 7 after surgery and had lower preoperative anxiety scores after admission education and while waiting in the operation room. Conclusion: The ERAS programme consisting of combined optimisation measures can reduce physical and psychological trauma during the perioperative period of adenotonsillectomy performed for children with OSA.

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Enhanced recovery after surgery in head and neck surgery: Reduced opioid use and length of stay

Cited by 48 publications

References 34 publications

Age Is Associated With Pain Experience and Opioid Use After Head and Neck Free Flap Reconstruction

Age Is Associated With Pain Experience and Opioid Use After Head and Neck Free Flap Reconstruction

ERAS for Head and Neck Tissue Transfer Reduces Opioid Usage, Peak Pain Scores, and Blood Utilization

An enhanced recovery programme improves the comfort and outcomes in children with obstructive sleep apnoea undergoing adenotonsillectomy: A retrospective historical control study

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