Optimizing Multimodal Analgesia with Intravenous Acetaminophen and Opioids in Postoperative Bariatric Patients

Abstract

STUDY OBJECTIVE To evaluate the effect of therapeutic doses of intravenous acetaminophen (IV APAP)on postoperative opioid use following bariatric surgery. DESIGN Retrospective review of medical records. SETTING A 654-bed academic hospital. PATIENTS Records for 104 patients who underwent laparoscopic sleeve gastrectomy (LSG; 44 patients) or laparoscopic Roux-en-Y gastric bypass (LRYGB; 60 patients) were reviewed. Patients received IV APAP 1 g every 6 hours postoperatively (22 LSG patients and 30 LRYGB patients) or no IV APAP (22 LSG patients and 30 LRYGB patients). MEASUREMENTS AND MAIN RESULTS Baseline demographic features were similar for both groups. Patients receiving IV APAP required fewer intravenous morphine equivalents than patients treated with opioids alone. Reductions in morphine equivalents with IV APAP were 21 mg (LSG), 33 mg (LRYGB), and 28 mg (all patients) (p<0.001 for all comparisons). IV APAP was associated with a shorter hospital length of stay (LOS) for the LRYGB (mean difference 1.47 days; p=0.039) and combined groups (mean difference 0.95 days; p=0.025). Patients who received IV APAP had earlier return of bowel sounds and flatus. IV APAP did not reduce mean pain scores in any group. CONCLUSION Patients undergoing bariatric surgery who received IV APAP during the 24-hour postoperative period consumed fewer intravenous morphine equivalents and had similar pain scores as patients who were treated with opioids alone. Use of IV APAP reduced the hospital LOS and resulted in earlier return of bowel sounds and passage of flatus. KEY WORDS intravenous acetaminophen, multimodal, opioids, laparoscopic, bariatric, respiratory depression, obstructive sleep apnea.

Non-opioid analgesic modes of pain management are associated with reduced postoperative complications and resource utilisation: a retrospective study of obstructive sleep apnoea patients undergoing elective joint arthroplasty

“…32e34 Collectively, these factors have raised concerns among perioperative caregivers and spurred the release of recommendations on the use of risk-mitigating strategies including opioid dose reduction and safer analgesic pathways, such as multimodal analgesia. 5 Consistent with previous publications, 35,36 the current analysis demonstrates that, with additional analgesic modes, a gradual decrease in opioid prescription dose is observed. However, the sheer reduction in utilised opioid dose does not per se establish a clinically meaningful benefit of multimodal analgesia unless its utilisation also results in reduced adverse events in the absence of adverse effects attributable to supplemental analgesic techniques.…”

Acetazolamide reduces postoperative pain following laparoscopic inguinal herniorrhaphy

“…Cavalcanti et al [9] evaluated the safety of oxycodone for postoperative pain control and found that side effects, including: nausea, dizziness, constipation, and pruritus, occur at significant frequency. Decreasing opioid requirements in surgical patients has also been found to decrease time for return of bowel function as well as hospital length of stay [10,11]. Preoperative narcotic use could lead to an increase in tolerance and require greater amounts of Indicates p values from Fischer's exact test a Reported as mean (±SD) Surg Endosc narcotic to achieve a state of analgesia.…”

Management of Acute Pain in Obese Patients with Sleep Apnea

“…Obese bariatric surgical patients receiving postoperative intravenous acetaminophen 1 gram every 6 hours required fewer morphine equivalents [46]. Acetaminophen lowers cumulative narcotic consumption, regardless of the route of administration [47,48]. It has the most favorable effect on blood pressure and should be considered as the first line treatment option in patients with hypertension or cardiovascular disease.…”