Perioperative Opioid Consumption and Clinical Outcomes in Surgical Patients With a Pre-existing Opioid-Based Intrathecal Drug Delivery System

Abstract

BACKGROUND: Intrathecal drug delivery systems (IDDS) have been utilized for over 3 decades for management of chronic pain and spasticity. Patients with IDDS may present for surgical procedures unrelated to the IDDS device, although data are limited regarding perioperative outcomes. METHODS: This is a historical matched cohort study conducted between January 1, 2007 and December 31, 2016 of patients with an opioid-based IDDS versus matched control patients undergoing surgery excluding interventional pain procedures. Patients in the IDDS group were matched with up to 2 patients without an IDDS. Multivariable regression analyses were utilized to assess differences in the primary outcome of cumulative perioperative opioid consumption (ie, intraoperative and postanesthesia care unit [PACU] opioid consumption), and opioid consumption during the first 24 and 72 postoperative hours. Postoperative clinical outcomes were also assessed including escalating oxygen requirements, naloxone administration, painsedation mismatch, and perioperative pain service consultation. RESULTS: A total of 321 surgeries were included, 112 with IDDS and 209 controls, with median (interquartile range [IQR]) age of 57 (49-64) years. Compared to matched controls, patients with an IDDS had greater perioperative opioid consumption (median [IQR] oral morphine milligram equivalents [OME] of 110 vs 93 [IQR,; adjusted multiplicative increase 1.28 [95% confidence interval {CI}, 1.03-1.59]; P = .026). IDDS patients also had greater opioid consumption in the first 24 and 72 postoperative hours (multiplicative increases of 2.23 [95% CI, 1.36-3.63], P = .001, and 2.46 [95% CI, 1.41-4.32], P = .002, respectively). There were no significant differences in postoperative oxygen requirements, naloxone administration, or pain-sedation mismatch. Inpatient pain medicine consultation was more frequent in IDDS patients compared to controls (51.8% vs 6.2%; P < .001). CONCLUSIONS: Patients with opioid-based IDDS received more perioperative opioids and were more likely to receive postoperative pain service consultation compared to matched controls. There were no significant differences in clinical safety outcomes, suggesting tolerance for higher opioid doses. Further research is warranted to optimize perioperative outcomes in those with IDDS. (Anesth Analg 2022;134:35-43) KEY POINTS• Question: How do perioperative outcomes of opioid consumption and postoperative respiratory complications compare between patients with an opioid-based intrathecal drug delivery system (IDDS) versus control patients without an IDDS? • Findings: Patients with an opioid-based IDDS consumed more perioperative opioids, yet experienced similar adverse events (ie, escalation in postoperative oxygen requirements, postoperative naloxone administration, and pain-sedation mismatch) compared to matched control patients. • Meaning: Patients with an opioid-based IDDS have greater perioperative opioid needs with no differences in safety outcomes, suggesting tolerance for higher opioid doses.

Pump IT Up—Perioperative Care of Patients With Intrathecal Drug Delivery Systems

“…The secondary outcomes detailed the patients’ opioid consumption during the 24 and 72 hours after discharge from the PACU. 6 The authors report that the IDDS patients had greater perioperative (intraoperative and PACU) opioid consumption (1.28 adjusted multiplicative increase) and greater opioid consumption in the postoperative 24- and 72-hour periods (2.23 and 2.46 respective adjusted multiplicative increase). 6 Despite this marked disparity in opioid use, the authors found no difference in postoperative oxygen requirements, respiratory complications, naloxone administration, or pain-sedation mismatch in IDDS patients compared to matched controls.…”

“…Nonopioid medications have significant impact on outcomes, and bupivacaine, clonidine, and ziconotide are often used concomitantly with opioids in IDDS to control chronic pain. 5,6 Investigations have found variable opioid-sparing effect of adjuncts or opioid monotherapy IDDS over the long term on an outpatient basis, with some data supporting decreased systemic opioid use, 4,7 decreased total opioid dose escalation, 8 or a variable effect on opioid dose based on the nonopioid IT medication administered. 5 Device complication rates among patients with IDDS have also been extensively documented in the literature.…”

“…12–14 Furthermore, the role of pain management consults for surgical patients with IDDS has not been studied and generates justifiable uncertainty in clinical decisionmaking for the care team. This month’s issue of Anesthesia & Analgesia highlights the perioperative management of patients with opioid-based IDDS with the publication of D’Souza et al 6…”

“…D’Souza et al 6 conducted a historical matched cohort study of patients with an opioid-based IDDS (n = 112) versus 2 control patients (n = 209) matched to similar surgeries unrelated to pain management. The authors reported perioperative opioid requirements, oxygen requirements, respiratory complications, pain-sedation mismatch, and involvement of the acute pain service (APS) in the care of patients with IDDS compared to matched controls.…”

Morphine Overdose After an Anterior Cervical Discectomy and Fusion in a Patient With an Intrathecal Morphine Pump

“…To JNA Readers: D'Souza et al 1 recently demonstrated that patients with intrathecal drug delivery systems (IDDS) tolerate additional perioperative opioids; however, we urge caution in opioid administration for patients with IDDS undergoing decompression of cervical spinal stenosis. 1 Cervical stenosis causes compression of the subarachnoid space and spinal cord, and disrupts normal cerebrospinal fluid (CSF) circulation which may be restored with surgical decompression. [2][3][4] Because IDDS rely on CSF flow for drug distribution, cervical stenosis may lead to caudal drug pooling with subsequent release and cephalad spread upon decompression.…”