<scp>ERAS</scp> for Head and Neck Tissue Transfer Reduces Opioid Usage, Peak Pain Scores, and Blood Utilization

Objective Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. Purpose The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan. The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. Action Statements The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method. The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

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“…Specifically, ERAS protocols in head and neck surgery have been shown to decrease opioid use and improve postoperative analgesia. 89-91…”

Section: Key Action Statementsmentioning

confidence: 99%

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

Anne¹,

Mims

Tunkel

et al. 2021

Otolaryngol.--head neck surg.

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“…The reviewed research indicates that ERAS pathways in Head and Neck surgery can be successful in reducing both overall LOS [7][8][9]11,12,[15][16][17][18][19]21] and LOS in ITU [6][7][8][9][10]. There is convincing evidence that an opioid sparing/multi-modal analgesic approach is effective, as demonstrated by lower opioid requirements with no increase in pain scores in the ERAS cohorts [10][11][12]20].…”

Section: Discussionmentioning

confidence: 99%

“…The requirement of patient-controlled analgesia (PCA) was also lower in the ERAS group (31% vs. 74% (p =< 0.001)) and fewer patients required opioids on discharge in comparison to the control (64.5% vs. 81.5% (p =< 0.001)). These findings were echoed by 2.1 days vs. 3.8 days [8], 0.2 days vs. 5.0 days [9] and 1 day vs. 2 days [10]. All reductions in LOS on ITU were deemed to be statistically significant.…”

Section: Post-operative Pain Scores and Analgesic Requirementsmentioning

confidence: 92%

“…However, in this study a higher proportion of patients in the control group were taking opioids pre-operatively, so this may have impacted on their opioid requirements, both immediately post-operatively and on discharge. The findings of Clark, et al [10] support those of Kiong, et al [12] and Jandali, et al [11] in demonstrating lower post-operative peak pain scores (4.6 ± 3.6 vs. 6.5 ± 3.5 (p = 0.004)) and lower morphine milligram equivalents in the ERAS group in comparison to the non-ERAS cohort (6.0 ± 9.8 vs. 10.3 ± 10.8 (p = 0.010)). Hinther, et al [14] compared patients on a multi-modal analgesia (MMA) protocol with those on a 'pre-MMA' pathway.…”

Section: Post-operative Pain Scores and Analgesic Requirementsmentioning

confidence: 92%

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The Impact of Enhanced Recovery Pathways in Head and Neck Surgery: A Systematic Review

Ursula¹,

Denise²

2022

J Head Neck Surg

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Background: Enhanced recovery after surgery (ERAS) pathways have been implemented across multiple surgical specialties and have been found to be successful in reducing post-operative complications and length of stay (LOS) in hospital. They have only more recently been adopted by Head and Neck surgery but there is now a sufficient body of evidence which would benefit from consolidation and review. The purpose of this review is to determine what impact ERAS pathways have on patient outcomes and post-operative recovery following Head and Neck surgery. Methods:A literature search of Pubmed, CINAHL and Google Scholar was conducted. Results were limited to publication between 2013-2021 and those written in English. The search terms used were "enhanced recovery" and "head and neck surgery" or "ERAS" and "head and neck surgery" or "head and neck surgery" and "clinical pathway" or "head and neck surgery" and "fast track". Results:The search yielded 17 papers for inclusion in the review. 16 of the studies were cohort studies (50% prospective and 50% retrospective) with sample sizes ranging from 31-445. Five studies observed a statistically significant reduction in length of stay (LOS) in intensive care for those in the ERAS cohort, with an average reduction of 3.42 days. Additionally, 73% of studies (n = 11) reported a statistically significant reduction in overall LOS for ERAS patients. Lower analgesic requirements as measured by morphine equivalent dosing (MED) were reported (17.5 mg ± 46 gmg ERAS vs. 82.7 ± 116 mg in the control (p =< 0.001) in combination with lower average pain scores (2.6 ± 1.8 ERAS vs. 3.6 ± 1.9 control (p =< 0.001)). Only one study identified a statistically significant reduction in post-operative complications (pulmonary) of 30% in the ERAS cohort vs. 63% in the control (p =< 0.001). Conclusions:There is evidence to suggest that ERAS pathways can impact positively on post-operative recovery following Head and Neck surgery by reducing overall LOS, LOS in ITU and opioid requirements. However, current evidence is limited and does not give insight into long-term outcomes or the patient experience of ERAS.

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“…Pain regimens consisting of multiple opioid-sparing analgesics, such as gabapentin, acetaminophen, and non-steroidal anti-inflammatory drugs (NSAIDs), have demonstrated synergistic effects and enable the reservation of opioids for breakthrough pain alone [13] . Gabapentin, in particular, appears to provide a significant ameliorative effect on postoperative pain and analgesic consumption when administered preoperatively and continued in the postoperative setting [93,94] . Regional anesthesia through nerve blocks performed pre-and intra-operatively has demonstrated success in reducing postoperative pain scores without a significant increase in morbidity [95,96] .…”

Section: Pain Managementmentioning

confidence: 99%

Enhanced recovery and medical management after head and neck microvascular reconstruction

Gidumal¹,

Worrall²,

Phan³

et al. 2021

PAR

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Protocols to enhance and expedite recovery after surgery originally developed through efforts in gastrointestinal, colorectal, and thoracic surgery populations. Implementation of specific evidence-based interventions undertaken in the perioperative setting has been shown to decrease the length of stay, reduce cost, and improve patient outcomes and satisfaction. The basic tenets of enhanced recovery protocols are to reduce physiologic stress in the perioperative setting, improve nutritional status before and after surgery, promote respiratory and physical rehabilitation, and encourage frequent and recurring reassessment for quality improvement. Some interventions, such as the use of deep vein thrombosis prophylaxis in the perioperative setting, are now well established across surgical populations; however, the increased attention to these protocols has led to new innovative interventions in the head and neck population. This review highlights these innovative interventions designed to enhance recovery after major surgery, lends particular focus to the biological mechanisms behind these interventions, and describes their relevance to the head and neck population.

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ERAS for Head and Neck Tissue Transfer Reduces Opioid Usage, Peak Pain Scores, and Blood Utilization

Cited by 19 publications

References 56 publications

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations

The Impact of Enhanced Recovery Pathways in Head and Neck Surgery: A Systematic Review

Enhanced recovery and medical management after head and neck microvascular reconstruction

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