A collaborative, multimodal protocol for the delivery of opioid-sparing analgesics effectively manages postoperative pain in patients undergoing above- and below-the-knee amputation, with minimal adverse events, according to retrospective research presented at the 2017 Annual Meeting of the American Society of Anesthesiologists (ASA).
Presenter Joseph Myers, MD, MedStar Georgetown University Hospital, Washington, DC and colleagues demonstrated that the use of multimodal analgesia can achieve adequate analgesia without the use of intraoperative opioids, and can reduce the need for postoperative opioids.
Dr. Myers and colleagues used a protocol called the ComfortSafe Pyramid®. This collaborative checklist is constructed on based on a risk/benefit ratio in which clinicians:
1. Start at the base of the pyramid and evaluate a patient’s level of sensation.
2. Consider local anaesthesia (unless the patient is insensate).
3. Follow by considering use of non-opioid analgesics.
The idea is that by considering multimodal analgesia, opioids are rarely required.
The researchers evaluated the records of 96 patients undergoing below- and above-the-knee amputation (2013 to 2017) for intraoperative and postoperative opioid administration, time until administration of first pain medication in the post-anaesthesia care unit (PACU), and incidence of postoperative nausea and vomiting.
The authors divided subjects into 2 groups: 20 patients for whom the ComfortSafe steps were used for general anaesthesia and 76 who received a traditional path for general anaesthesia. The researchers used the Wilcoxon rank sum test for statistical analysis.
Patients in the ComfortSafe (CS) group received significantly less opioid following surgery compared with the non-CS group (5.23 morphine equivalents vs 10.29, respectively).
In addition, the mean time until the first pain medication was received in the PACU was 61.30 minutes in the CS group compared with 53.68 minutes in the non-CS group.
No patient in the CS group experienced nausea and vomiting, compared with 11 patients (14%) in the non-CS group.
“ComfortSafe anaesthesia provides potent multimodal analgesia while minimising opioid-related adverse effects,” Dr. Myers concluded.
The authors noted that, while current recommendations call for the use of perioperative multimodal analgesic therapy, a recent nationwide study showed that there has been “tremendous variation” in the use of this technique that cannot be explained by hospital or patient characteristics, suggesting a need for a standard protocol like ComfortSafe.
[Presentation title: Opioid-Sparing Analgesia in Patients Undergoing Above and Below Knee Amputation. Abstract #: A1072]