Evaluation of early postoperative intravenous opioid rescue as a novel quality measure in patients who receive thoracic epidural analgesia: a retrospective cohort analysis and prospective performance improvement intervention

Abstract

Background In this study, we explored the utility of intravenous opioid rescue analgesia in the post anesthesia care unit (PACU-OpResc) as a single marker of thoracic epidural analgesia (TEA) failure and evaluated the resource implications and quality improvement applications of this measure. Methods We performed a retrospective analysis of all TEA placements over a three-year period at a single academic medical center in Boston, Massachusetts. The study exposure was PACU-OpResc. Primary outcome was PACU length of stay (LOS). Secondary outcomes included reasons for delayed PACU discharge and intraoperative hypotension. The analyses were adjusted for confounding variables including patient comorbidities, surgical complexity, intraoperative intravenous opioids, chronic opioid use and local anesthetic bolus through TEA catheter. Post analysis chart review was conducted to determine the positive predictive value (PPV) of PACU-OpResc for inadequate TEA. As a first Plan-Do-Study-Act cycle, we then introduced a checkbox for documentation of a sensory level check after TEA placement. Post implementation data was collected for 7 months. Results PACU-OpResc was required by 211 (22.1%) patients who received preoperative TEA, was associated with longer PACU LOS (incidence rate ratio 1.20, 95% CI:1.07–1.34, p = 0.001) and delayed discharge due to inadequate pain control (odds ratio 5.15, 95% CI 3.51–7.57, p < 0.001). PACU-OpResc had a PPV of 76.3 and 60.4% for re-evaluation and manipulation of the TEA catheter in PACU, respectively. Following implementation of a checkbox, average monthly compliance with documented sensory level check after TEA placement was noted to be 39.7%. During this time, a reduction of 8.2% in the rate of PACU-OpResc was observed. Conclusions This study demonstrates that PACU-OpResc can be used as a quality assurance measure or surrogate for TEA efficacy, to track performance and monitor innovation efforts aimed at improving analgesia, such as our intervention to facilitate sensory level checks and reduced PACU-OpResc. Trial registration not applicable.

Effect of Topical Application of an NSAID Lateral to the Incision on Postoperative Pain Following Unicompartmental Knee Arthroplasty: A Double‐Blind Randomized Controlled Trial

“…found that 18% of patients developed transient motor block the day after surgery. Additionally, related studies have shown that localized epidural application of opioids increases the risk of respiratory depression and other side effects, which limits their widespread application 28,29 …”

“…Additionally, related studies have shown that localized epidural application of opioids increases the risk of respiratory depression and other side effects, which limits their widespread application. 28,29 A recent study showed that topical NSAIDs have clinical effects similar to those of oral NSAIDs and that topical NSAIDs have higher drug safety because systemic absorption is reduced. 19 Therefore, topical NSAIDs may be an attractive approach for postoperative pain relief because they can theoretically improve pain control in the early postoperative period and minimize the demand for opioids, thereby reducing the well-known side effects of opioids.…”

The association of nitrous oxide on length of stay in the postanesthesia care unit: a retrospective observational study

“…First, our PACU length of stay was long but similar to values observed in Harvard hospitals and other institutions in the United States. [40][41][42][43] Second, although the large cohort permitted wide confounder adjustment, residual unmeasured confounding cannot completely be ruled out. In addition, the lack of availability of certain parameters from electronic medical records limited our analyses and prevented us from including potentially important confounders.…”