Post-operative Weaning of Opioids After Ambulatory Surgery: the Importance of Physician Stewardship

Roth, Brandon; Boateng, Adjoa; Berken, Allison; Carlyle, Daniel; Vadivelu, Nalini

doi:10.1007/s11916-018-0694-4

Cited by 20 publications

(11 citation statements)

References 44 publications

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“…The anesthesia literature highlights the challenges of achieving adequate pain control in the ambulatory setting. 35 , 36 Opioid analgesia remains the mainstay of postoperative pain management despite its many known drawbacks that include tolerance, difficulty weaning, and the potential for overdose in an older patient population. Achieving adequate pain control with multimodal anesthesia while minimizing amounts of opioids is difficult.…”

Section: Discussionmentioning

confidence: 99%

Readmissions After Distal Radius Fracture Open Reduction and Internal Fixation: An Analysis of 11,124 Patients

Malpani¹,

John²,

Mercier³

et al. 2020

JAAOS Glob Res Rev

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Purpose: Distal radius fracture (DRF) open reduction and internal fixation (ORIF) is a common surgical procedure. This study assesses reasons and risk factors for readmission after DRF ORIF using the large sample size and follow-up of the American College of Surgeons National Surgical Quality Improvement Program database. Methods: Adult patients who underwent DRF ORIF were identified in the 2011 to 2016 National Surgical Quality Improvement Program database. Patient demographics, comorbidity status, hospital metrics, and 30-day perioperative outcomes were tabulated. Readmission, time to readmission, and reason for readmission were assessed. Reasons for readmission were categorized. Risk factors for readmission were assessed with multivariate analyses. Results: Of 11,124 patients who underwent DRF ORIF, 196 (1.76%) were readmitted within 30 days. Based on multivariate analysis, predictors of readmission ( P < 0.05) were as follows: American Society of Anesthesiologist class > 3 (Odds ratio [OR] = 2.87), functionally dependent status (OR = 2.25), diabetes with insulin use (OR = 1.97), and staying in hospital after the index surgery (inpatient procedure, OR = 2.04). Readmissions occurred at approximately 14 days postoperatively. Of the recorded reasons for readmission after DRF ORIF, approximately one quarter were for surgical reasons, whereas over 75% of readmissions were for medical reasons unrelated to the surgery. Conclusion: This study found the rate of 30-day unplanned readmissions after DRF ORIF to be 1.76%. Demographic, comorbid, and perioperative factors predictive of readmission were defined. Most postoperative readmissions were for medical reasons unrelated to the surgical site and occurred at an average of approximately 2 weeks postoperatively. Multivariate analysis found that patients with increased American Society of Anesthesiologist class > 3, functional dependence, insulin-dependent diabetes, and those who underwent inpatient surgery for any reason were at a greater risk for readmission. Understanding these factors may aid in patient counseling and quality improvement initiatives, and this information should be used for risk stratification and risk adjustment of quality measures.

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Section: Discussionmentioning

confidence: 99%

Readmissions After Distal Radius Fracture Open Reduction and Internal Fixation: An Analysis of 11,124 Patients

Malpani¹,

John²,

Mercier³

et al. 2020

JAAOS Glob Res Rev

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“…The LOS and postoperative outcomes of these 30 patients were briefly described in Supplementary Material. Median LOS after surgery in hrs (min, 1stQ, 3rd Q, max) 6.5 (5, 6, 7.5, 8) Median total LOS in hrs (min, 1stQ, 3rd Q, max) 31 (29,31,31,32) Discharge…”

Section: Resultsmentioning

confidence: 99%

“…Although the general principles and basic concepts were similar to those of ERAS, the practical details followed the AS regime. Especially for patients with adenoma, we focused on several perioperative factors such as functional status evaluation and elevation, postoperative PONV risk assessment and prevention, surgical land anesthetic management, use of non-opioid analgesia, fluid balance, early fluid and food intake, and early ambulation [31][32][33][34] . In addition, to help achieve the target of same-day discharge, we made some modifications of the current postoperative workflow.…”

Section: Discussionmentioning

confidence: 99%

Ambulatory Surgery Protocol for Endoscopic Endonasal Resection of Pituitary Adenomas: A Prospective Single-arm Trial with Initial Implementation Experience

Liu

Zheng

et al. 2020

Sci Rep

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endoscopic endonasal transsphenoidal resection has been accepted as a routine therapy for pituitary adenoma, but the postoperative hospital stay is typically several days long. With the advantages of reduced cost and improved patient satisfaction, the application of ambulatory surgery (AS) has developed rapidly. However, AS was still rarely adopted in neurosurgery. Here we designed an AS treatment protocol for pituitary adenoma with the endoscopic endonasal approach (EEA), and reported our initial experiences regarding the safety and efficacy of the AS protocol. 63 patients who presented with pituitary adenoma were screened at the Department of Neurosurgery, Tangdu Hospital from July to September, 2017. A total of 20 pituitary adenoma patients who met the inclusion criteria underwent EEA surgery using this evidence-based AS protocol, which emphasized adequate assessment for eligibility, full preparation to minimize invasiveness, enhanced recovery, and active perioperative patient education. Of the 20 patients enrolled, 18 were discharged on the afternoon of the operation day with a median total length of stay (LOS) of 31 hours (range, 29-32) hours. The median LOS after surgery was 6.5 (range, 5-8) hours. Two patients were transferred from the AS protocol to conventional care due to intraoperative cerebrospinal fluid leakage (one case) and an unsatisfying post-anesthetic discharge score (one case). Complications included transient and reversible mild postoperative nausea and vomiting [visual analog scale (VAS) score <3], headache (VAS score <3) after the operation or early after discharge. No patient was readmitted. Our results supported the safety and efficacy of the AS protocol for pituitary adenoma patients undergoing EEA resection among eligible patients, and further evaluation of this protocol in controlled studies with a larger sample size is warranted. Current advances in perioperative surgical concepts and technologies promote the advent and prevalence of ambulatory surgery (AS) in several surgical fields. The use of AS has accounted for >60% of all surgeries performed in the United States, with improved patient satisfaction and reduced costs compared to traditional surgery 1. In the field of neurosurgery, although attempts had been made to resect supratentorial brain tumors and clip unruptured cerebral aneurysms on an outpatient basis 2,3. AS remains not widely adopted. The endoscopic endonasal approach (EEA) for the resection of pituitary adenomas has gained increasing acceptance over the past few decades. Evidence suggested that EEA features shorter operative time, minor surgical

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“…The Centers for Disease Control (CDC) estimates that more than 126 million adults, or approximately 56% of the adult population, suffer from some form of pain ranging in severity and occurrence (daily or near daily) ((Nahin, 2015; Makary, Overton, & Wang, 2017). Treating their pain has resulted in a record number of prescriptions (Nahin, 2015; Makary, Overton, & Wang, 2017; Roth, Boateng, Berken, Carlyle, & Vadivelu, 2018), including highly addictive opioids as an adjunct for pain relief in adults suffering from chronic pain. As a result, Bohnert, Guy, & Losby (2018), reported a 300% increase in opioid-related deaths from 1999 to 2016.…”

Section: The Opioid Crisismentioning

confidence: 99%

Multimodal Pain Management for Major Joint Replacement Surgery

Goode

Morgan

Muckler

et al. 2019

Orthopaedic Nursing

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Effective pain management for orthopedic major joint replacement is key to achieving earlier recovery, better functioning, and high rates of patient satisfaction. In an effort to decrease opioid dependency, practitioners are turning to multimodal pain management, which involves the use of multiple analgesic agents and techniques. In order to utilize this technique, a patient’s history of and preoperative consumption of medications to treat pain impacts the success of this regimen. Multimodal pain management involves the use of NSAIDS, acetaminophen, NMDA antagonists, gabapentin, serotonin inhibitors, regional techniques and opioids as needed. It is necessary for the nurse to understand the mechanism of pain and how the multimodal adjuncts target the pain response in order to benefit the patient’s perioperative course as well as their postoperative and discharge management.

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Post-operative Weaning of Opioids After Ambulatory Surgery: the Importance of Physician Stewardship

Cited by 20 publications

References 44 publications

Readmissions After Distal Radius Fracture Open Reduction and Internal Fixation: An Analysis of 11,124 Patients

Readmissions After Distal Radius Fracture Open Reduction and Internal Fixation: An Analysis of 11,124 Patients

Ambulatory Surgery Protocol for Endoscopic Endonasal Resection of Pituitary Adenomas: A Prospective Single-arm Trial with Initial Implementation Experience

Multimodal Pain Management for Major Joint Replacement Surgery

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