Perioperative opioid management for minimally invasive hysterectomy

Madsen, Annetta M.; Martin, Jessica; Linder, Brian J.; Gebhart, John B.

doi:10.1016/j.bpobgyn.2022.05.006

Cited by 4 publications

(3 citation statements)

References 74 publications

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“…For instance, following recommendation implementation, the volumes prescribed at our institution continue to trend downward as we work to utilize additional measures to improve patient counseling/ expectations, perioperative pain management, and Enhanced Recovery After Surgery pathways. 21 During the postimplementation period, we saw the mean OMEs prescribed decrease below our tier 1 recommendation of 112.5 mg OME to 71.3 mg OME, which highlights the potential to further decrease opioid prescribing. Working to minimize opioid use, or even facilitate an opioid-free recovery, remains a steadfast goal of the interventions.…”

Section: Discussionmentioning

confidence: 81%

“…Although our initial intervention significantly decreased opioid prescribing from baseline levels, there remains room for further advances in opioid stewardship. For instance, following recommendation implementation, the volumes prescribed at our institution continue to trend downward as we work to utilize additional measures to improve patient counseling/expectations, perioperative pain management, and Enhanced Recovery After Surgery pathways 21 . During the postimplementation period, we saw the mean OMEs prescribed decrease below our tier 1 recommendation of 112.5 mg OME to 71.3 mg OME, which highlights the potential to further decrease opioid prescribing.…”

Section: Discussionmentioning

confidence: 90%

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Evaluating the Long-term Impact of Implementing Standardized Postoperative Opioid Prescribing Recommendations Following Pelvic Organ Prolapse Surgery

Olive¹,

Glasgow

Habermann

et al. 2023

UROGC

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Importance Improving opioid stewardship is important, given the common use of opioids and resultant adverse events. Evidence-based prescribing recommendations for surgeons may help reduce opioid prescribing after specific procedures. Objective The aim of this study was to assess longitudinal prescribing patterns for patients undergoing pelvic organ prolapse surgery in the 2 years before and after implementing evidence-based opioid prescribing recommendations. Study Design In December 2017, a 3-tiered opioid prescribing recommendation was created based on prospective data on postoperative opioid use after pelvic organ prolapse surgery. For this follow-up study, prescribing patterns, including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates, were retrospectively compared for patients undergoing prolapse surgery before (November 2015–November 2017; n = 238) and after (December 2017–December 2019; n = 361) recommendation implementation. Univariate analysis was performed using the Wilcoxon rank sum and χ 2 tests. Cochran-Armitage trend tests and interrupted time-series analysis tested for significance in the change in OMEs prescribed before versus after recommendation implementation. Results After recommendation implementation, the quantity of postoperative opioids prescribed decreased from median 225 mg OME (interquartile range, 225, 300 mg OME) to 71.3 mg OME (interquartile range, 0, 112.5 mg OME; P < 0.0001). Decreases also occurred within each subgroup of prolapse surgery: native tissue vaginal repair (P < 0.0001), robotic sacrocolpopexy (P < 0.0001), open sacrocolpopexy (P < 0.0001), and colpocleisis (P < 0.003). The proportion of patients discharged following prolapse surgery without opioids increased (4.2% vs 36.6%; P < 0.0001), and the rate of opioid refills increased (2.1% vs 6.0%; P = 0.02). Conclusions With 2 years of postimplementation follow-up, the use of procedure-specific, tiered opioid prescribing recommendations at our institution was associated with a significant, sustained reduction in opioids prescribed. This study further supports using evidence-based recommendations for opioid prescribing.

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Section: Discussionmentioning

confidence: 81%

Section: Discussionmentioning

confidence: 90%

Evaluating the Long-term Impact of Implementing Standardized Postoperative Opioid Prescribing Recommendations Following Pelvic Organ Prolapse Surgery

Olive¹,

Glasgow

Habermann

et al. 2023

UROGC

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“…PONV may also be a problem with opioids, but are dose and duration dependant and subject to effective prophylactic measures [17 ▪ ]. It seems like use of short-acting perioperative remifentanil together with NSAID and glucocorticoid and a minor dose of bridging fentanyl by the end of the procedure, renders the patients well protected from hyperalgesia [20 ▪ ,47]. Then, opioids should be used only as needed in the postoperative period, primarily by titration of short-acting opioid during the first hours [48 ▪ ].…”

Section: The Opioidsmentioning

confidence: 99%

Pain treatment and prophylaxis on pain

Ræder¹

2022

Current Opinion in Anaesthesiology

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Purpose of reviewAlso in ambulatory surgery, there will usually be a need for analgesic medication to deal with postoperative pain. Even so, a significant proportion of ambulatory surgery patients have unacceptable postoperative pain, and there is a need for better education in how to provide proper prophylaxis and treatment.Recent findingsPostoperative pain should be addressed both pre, intra- and postoperatively. The management should be with a multimodal nonopioid-based procedure specific guideline for the routine cases. In 10–20% of cases, there will be a need to adjust and supplement the basic guideline with extra analgesic measures. This may be because there are contraindications for a drug in the guideline, the procedure is more extensive than usual or the patient has extra risk factors for strong postoperative pain. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis. Opioids should be with nondepot formulations, titrated to effect in the postoperative care unit and eventually continued only when needed for a few days at maximum.SummaryMultimodal analgesia should start pre or per-operatively and include paracetamol, nonsteroidal anti-inflammatory drug (NSAID), dexamethasone (or alternative glucocorticoid) and local anaesthetic wound infiltration, unless contraindicated in the individual case. Paracetamol and NSAID should be continued postoperatively, supplemented with opioid on top as needed. Extra analgesia may be considered when appropriate and needed. First-line options include nerve blocks or interfascial plane blocks and i.v. lidocaine infusion. In addition, gabapentinnoids, dexmedetomidine, ketamine infusion and clonidine may be used, but adverse effects of sedation, dizziness and hypotension must be carefully considered in the ambulatory setting.

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