Multimodal Analgesia Protocol after Head and Neck Surgery: Effect on Opioid Use and Pain Control

Du, Eugenie; Farzal, Zainab; Stephenson, Elizabeth D.; Tanner, April Michelle; Adams, Katherine; Farquhar, Douglas R.; Weissler, Mark C.; Patel, Samip; Blumberg, Jeffrey M.; Jowza, Maryam; Hackman, Trevor; Zanation, Adam M.

doi:10.1177/0194599819841885

Cited by 29 publications

(46 citation statements)

References 23 publications

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“…As physicians shoulder increasing pressure to improve healthcare effectiveness, efficiency, and cost, these protocols are gaining popularity in HNC surgeries. However, implementation for HNC in the United States has been slow 12,13 …”

Section: Discussionmentioning

confidence: 99%

“…The first formal protocol was released by the Enhanced Recovery After Surgery (ERAS) Society in 2012 for colorectal surgery 11 . A HNC pathway was introduced in 2017 by the ERAS Society 12 …”

Section: Introductionmentioning

confidence: 99%

“…Studies investigating the effects of ERAS protocols in patients who undergo HNC tissue transfer reconstruction are limited and outcomes vary 12,13 . The aim of this initiative was to implement a standardized, multidisciplinary peri‐ and intraoperative protocol founded on evidence based practices to improve patient comfort, reduce morbidity, and accelerate recovery after surgery.…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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“…16 A similar study on inpatient head and neck surgery showed mixed results, with a decrease in morphine use within the first 24 hours but not overall. 17…”

Section: Discussionmentioning

confidence: 99%

“…16 A similar study on inpatient head and neck surgery showed mixed results, with a decrease in morphine use within the first 24 hours but not overall. 17 However, to our knowledge, this concept has yet to be studied in rhinology procedures. This needs to be studied within the context of endoscopic sinus surgery.…”

Section: Discussionmentioning

confidence: 99%

Patterns in Pain and Opiate Use after Endoscopic Sinus Surgery

Ndon

Spock²,

Torabi

et al. 2020

Otolaryngol.--head neck surg.

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Objective To evaluate postoperative opiate use and patients’ opinions regarding pain management after endoscopic sinus surgery (ESS). Study Design Case series with planned data collection. Setting Tertiary referral medical center. Subjects and Methods We prospectively evaluated postoperative opiate utilization in adults undergoing ESS over a 2-year period at an academic medical facility. Exclusion criteria included use of nasal packing, intracranial or orbital procedures, tumor surgery, and any use of endoscopic drills. All patients underwent bilateral maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with or without septoplasty. Patients were discharged with 30 oxycodone-acetaminophen (5-325 mg) and a survey assessing pain and narcotic/nonnarcotic use on postoperative days 0 to 7. Results A total of 64 patients completed surveys. Mean ± SD narcotic use over the 7-day postoperative period was 7.7 ± 7.6 pills. Patients with high narcotic use (>6 pills total) had no differences in demographic or surgical factors from those with low use (≤6 pills) but did report a higher level of postoperative day 1 pain (4.8 ± 1.1 vs 2.0 ± 1.4, P < .001). Narcotic use declined during this period, with <30% of patients requiring narcotics by postoperative day 3. Conclusion Our results support reduced opiate prescription and encouragement of nonnarcotic use after ESS without compromising effective pain management.

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Association Between Multimodal Analgesia Administration and Perioperative Opioid Requirements in Patients Undergoing Head and Neck Surgery With Free Flap Reconstruction

Lewis

Bailard

et al. 2020

JAMA Otolaryngol Head Neck Surg

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IMPORTANCEThe opioid epidemic has reignited interest in opioid-sparing strategies in managing pain. However, few studies have focused on opioid use during perioperative care in patients undergoing head and neck surgery with free flap reconstruction.OBJECTIVES To examine the association between multimodal analgesia (MMA) administration and perioperative opioid requirements in patients undergoing head and neck surgery with free flap reconstruction and to investigate whether MMA alters the duration of stay in the postanesthesia care unit (PACU). DESIGN, SETTING, AND PARTICIPANTSIn this retrospective case-control study, data were collected between April 1, 2016, and December 31, 2017. The study was conducted at a single cancer center in the United States. Participants were 357 patients 18 years or older scheduled for head and neck surgery with free flap reconstruction.EXPOSURES Patients in the treatment group received oral celecoxib, gabapentin, and/or tramadol hydrochloride before surgery. Control group patients did not receive any of these medications. MAIN OUTCOMES AND MEASURESThe amount of opioid administered in the operating room and in the PACU was converted to morphine equivalent daily dose (MEDD) for comparison between the 2 groups. The duration of stay in the PACU was based on the start time and end time of PACU care recorded by nurses in the PACU. RESULTS Intotal, 149 patients (mean [SD] age, 60.3 [13.7] years; 104 [69.8%] men) were included in the treatment group, and 208 patients (mean [SD] age, 64.2 [13.6] years; 146 [70.2%] men) were included in the control group. The mean (SD) MEDD of opioid given during surgery was 51.7 (19.8) in the treatment group and 67.9 (24.7) in the control group, for a difference in the means (treatment vs control) of −16.17 (95% CI, −20.81 to −11.52). In the PACU, the mean (SD) MEDD of opioid given was 11.7 (13.3) in the treatment group and 14.9 (15.7) in the control group, for a difference in the means (treatment vs control) of −3.22 (95% CI, −6.40 to −0.03). The MMA treatment remained largely associated with reduced amount of opioid given during surgery, in the PACU, and both combined after controlling for other important factors.CONCLUSIONS AND RELEVANCE This case-control study found that the patients who received MMA before head and neck surgery with free flap reconstruction required less opioid medication. The treatment group also had shorter duration of stay in the PACU compared with the control group.

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Multimodal Analgesia Protocol after Head and Neck Surgery: Effect on Opioid Use and Pain Control

Cited by 29 publications

References 23 publications

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

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

Patterns in Pain and Opiate Use after Endoscopic Sinus Surgery

Association Between Multimodal Analgesia Administration and Perioperative Opioid Requirements in Patients Undergoing Head and Neck Surgery With Free Flap Reconstruction

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