Opioid sparing multimodal analgesia treats pain after head and neck microvascular reconstruction

Abstract

Objective To compare pain control (opioid consumption and postsurgical pain scores) in head and neck (H&N) free flap reconstruction patients who undergo traditional means of postoperative analgesia including use of opioids versus a novel protocol that includes ketamine and gabapentin. Methods Single‐institution retrospective cohort study. Results Eighty‐six patients who underwent H&N free flap reconstruction from 2015 to 2018 were included. Forty‐three patients were in the control cohort treated with opioids only, and 43 patients were in the treatment group. There was a statistically significant decrease in opioid consumption in each of the first 5 postoperative days ranging from 80% to 83% in the treatment group. The daily pain scores were significantly lower in the treatment group in the first 2 postoperative days. At the 1‐month postoperative visit, there was no significant difference in pain scores between the groups; however, by the 2‐month visit, the treatment group reported significantly lower pain scores than the control group (P = 0.001). No adverse outcomes of ketamine or gabapentin were experienced. Conclusion Ketamine and gabapentin are safe and effective analgesics in H&N free flap surgery that significantly decrease opioid use in the acute postoperative setting and may improve pain control. Level of Evidence 3a Laryngoscope, 130:1686–1691, 2020

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

“…The average score was 15.1 ± 1.6, with all studies reporting a clearly stated aim, end points appropriate to study aim, follow-up period appropriate to study aim, and an adequate control group. Five studies 15-18,20 included consecutive patients while 1 study 21 included prospective data collection with the other studies comparing against historical data. Only 1 study performed a prospective calculation of study size.…”

“…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.…”

“…This systematic review highlights the significant variability between studies, including type of drug, drug dosage, route and timing of drug administration, and type of rescue analgesia. While 8 studies [15][16][17][18][19]21,23,24 demonstrated significant improvement in additional postoperative opioid consumption, there was wider variation in subjective pain outcome scores. No difference in incidence of surgical or medical complications was noted when aggregated.…”

“…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.…”