Association of multimodal analgesia with perioperative safety and opioid use following head and neck microvascular reconstruction

Abstract

Background This study examines the association of multimodal analgesia (MMA) protocol for head and neck microvascular reconstruction with postoperative safety and opioid use. Methods Retrospective, intention‐to‐treat analysis of 226 patients undergoing head and neck microvascular reconstruction between January 1, 2014 and August 30, 2018 at a tertiary‐care hospital following MMA protocol implementation. Multivariable models examined outcomes of interest. Results There were no differences between groups in frequency of bleeding, return to operating room, complete flap loss, readmissions, wound complications, and 30‐day mortality. Patients in MMA protocol experienced reduced likelihood of partial flap loss (OR 0.18, confidence interval 0.04‐0.91), meaningful reduction in postoperative opioid use (cumulative inpatient morphine equivalents [64 vs 141 mg; P < .001], daily morphine equivalents [8 vs 22 mg/d; P < .001]; and 22.5% lower frequency of opioid prescription at discharge [55.6% vs 78.1%; P = .001]). Conclusions In patients undergoing head and neck microvascular reconstruction, MMA is safe and associated with reduced postoperative opioid use.

Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review

“…Surgical outcomes are as follows: flap dehiscence (MMA, 16.0% vs non-MMA, 13.0%; P = .78), complete flap failure rate (3.0% vs 3.4%; P = .87), return to operating room (16.4% vs 12.9%; P = .76), and bleeding event/hematoma (6.2% vs 7.4%; P = .85). In contrast, Sayal et al 19 reported reduced likelihood of partial flap failure with MMA use (odds ratio [OR], 0.18; 95% CI, 0.04-0.91). Medical complications, including gastrointestinal and cardiovascular issues, were nonsignificant between the 2 groups.…”

“…Nine of 10 studies 16-24 (n = 1151) used an 11-point numerical scale to assess pain, including the visual analog scale (VAS) (6 studies, 16,20-24 n = 774) and the Defense & Veterans Pain Rating Scale (DVPRS) (1 study, 17 n = 65) ( Table 4 ). There was wide variation in subjective pain outcomes among the included studies.…”

“…Major limitations included lack of randomization and blinding, [15][16][17][18][19]21,23 retrospective data collection using medical records, [15][16][17][18][19]21,23 small sample size, [16][17][18]21 changes in legislation affecting opioid prescription practices, 18 and inability to study the effect of single drugs. [17][18][19]23 Two RCTs were included in the review with low risk for selection, performance, and detection bias. 22,24 Both studies were at risk for other biases: Townsend et al 22 included less patients than initially determined through sample size calculation while Zhang et al 24 did not include a prospective power analysis.…”

“…However, the timing of assessing this primary outcome was highly variable, with patients evaluated as early as in the postanesthesia care unit, 23 to daily measurements, 18 to time of discharge. 17,19 Likewise, 9 of 10 studies reported subjective pain outcomes using an 11-point scale with similar lack of standardization in the timing of evaluation. When addressing the safety profile, only 6 of 10 studies reported surgical and medical complications, an important consideration when weighing the risks and benefits associated with MMA, particularly with NSAIDs.…”

“…Eight of 10 studies [15][16][17][18][19]21,23,24 (n = 1025) observed a significant decrease in overall postoperative narcotic usage (Table 3). Nine studies [15][16][17][18][19][20][21][22][23] used morphine milligram equivalents (MMEs) to assess additional narcotic usage while Zhang et al 24 reported additional use of sufentanyl. Other significantly improved functional metrics included sedation score, antiemetic use at postoperative day (POD) 1, and time from bed to chair.…”