Multimodal perioperative pain protocol for gynecologic laparotomy is associated with reduced hospital length of stay

Abstract

Objectives The primary objective was to evaluate the impact of a multimodal perioperative pain regimen on length of hospital stay for patients undergoing laparotomy with a gynecologic oncologist. Methods We compared 52 patients who underwent laparotomy with a gynecologic oncologist at a single institution between 2017 and 2018, after implementation of a multimodal perioperative pain regimen, to a historic cohort of 94 patients (2016–2017). The multimodal pain regimen included pre‐ and post‐operative administration of oral acetaminophen, gabapentin, and celecoxib, in addition to standard narcotics and optional epidural analgesia. Demographic, surgical, and post‐operative data were collected. Results On multivariable analysis, bowel resection, stage, surgery length, age, and cohort group were retained as significant independent predictors of length of stay. Patients undergoing laparotomy prior to the pain protocol had a length of stay 1.26 times longer than patients during the post‐implementation period (p < 0.01). For complex surgical patients, this translated into a reduction in length of hospital stay of 1.73 days. There was a significant reduction in pain scale score on post‐operative day zero from 5 to 3 (p = 0.02) and a non‐significant overall reduction of post‐operative morphine equivalents, with similar adverse outcomes. Conclusion Implementation of a multimodal perioperative pain regimen in patients undergoing gynecologic oncology laparotomy was associated with a significant reduction of length of hospital stay and improved patient‐perceived pain, even in the absence of a complete Enhanced Recovery After Surgery (ERAS) protocol.

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews

“…However, large randomized trials are needed before IV lidocaine becomes standard of practice [ 45 ]. The increased cost of IV acetaminophen is not offset by any additional benefit in pain management, LOS, or readmission [ 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 ]. With concomitant opioid treatment, alvimopan use may be associated with shorter times to tolerance of a soft diet, return of gastrointestinal function, and decreased LOS.…”

A randomized controlled trial evaluating the effects of transversus abdominis plane block with compound lidocaine hydrochloride injection on postoperative pain and opioid consumption and gastrointestinal motility in patients undergoing gynecological laparotomy

“…Although laparoscopic surgery has the advantages of minimal invasive incision, fewer complications, faster recovery, and less pain after operation, exploratory laparotomy was preferred for gynecological cancer due to the complexity of surgical procedures including hysterectomy, bilateral salpingectomy or salpingo-oophorectomy, lymph node dissection, omentectomy, and other tumor debulking ( Huepenbecker et al, 2019 ). Major incision and intra-abdominal procedures may cause moderate and severe somatic and visceral pain, and increase opioid prescription ( Brummett et al, 2017 ; Mattson et al, 2021 ). When opioid is administered in excess, patients frequently experience several dose-limiting adverse-effects including nausea, ileus, respiratory depression, addiction, tolerance and hyperalgesia, which delaying bowel function recovery and hospital discharge ( Colvin et al, 2019 ; Kent et al, 2019 ).…”

“…When opioid is administered in excess, patients frequently experience several dose-limiting adverse-effects including nausea, ileus, respiratory depression, addiction, tolerance and hyperalgesia, which delaying bowel function recovery and hospital discharge ( Colvin et al, 2019 ; Kent et al, 2019 ). Multimodal opioid-sparing analgesia approaches involve using multiple, simultaneous agents and procedures to target pain transmission signaling peripherally and centrally to improve analgesia and reduce opioid demand to minimize risks of side-effects ( Beverly et al, 2017 ; Wu et al, 2019 ; Allen et al, 2020 ; Mattson et al, 2021 ). However, recent investigations have revealed that multimodal analgesia can be particularly challenging in several patients due to the efficacy of anticonvulsant agents and concerns regarding the safety of acetaminophen and NSAIDs ( Bindu et al, 2020 ; Ishitsuka et al, 2020 ; Maheshwari et al, 2020 ).…”

“…However, recent investigations have revealed that multimodal analgesia can be particularly challenging in several patients due to the efficacy of anticonvulsant agents and concerns regarding the safety of acetaminophen and NSAIDs ( Bindu et al, 2020 ; Ishitsuka et al, 2020 ; Maheshwari et al, 2020 ). Another facet of multimodal analgesia is neuraxial block and regional anesthesia ( Mattson et al, 2021 ). Although perioperative epidural anesthesia exhibits potent analgesic properties for patients with surgeries in gynecological oncology, the prevalence of postoperative hypotension and urinary retention is unexpectedly increased ( Huepenbecker et al, 2019 ).…”

Physical and psychological recovery after vaginal childbirth with and without epidural analgesia: A prospective cohort study

“…Although we initially hypothesized that those with severe pain would have poorer physical recovery [ 6 , 26 ], there was little to no correlation between postpartum pain and daily step count. One potential explanation is that the pain after vaginal delivery is usually milder than postoperative pain after major surgeries; cesarean delivery is associated with greater postpartum pain than vaginal delivery [ 27 , 28 ].…”