Author: Thomas Rosenthal
There was no difference in time to pain control or the amount of morphine equivalents used between multimodal and opioid-only pain regimens for postoperative non-ICU patients, according to research presented at the 2018 annual Critical Care Congress (abstract 1581).
The researchers performed a retrospective single-center study of 120 patients admitted for general or trauma surgery at the hospital from July 1, 2015, through June 30, 2016. Patients were assigned to two groups. Of the 60 patients in the multimodal group, 24 had emergent procedures, compared with 43 of the 60 patients in the opioid-only group (P<0.05), the authors said.
The most common surgeries performed were hernia repair, cholecystectomy and appendectomy, the authors said, whereas other surgeries included thyroidectomy, cystectomy and panniculectomy. Patients were 50% male and 75% white, and length of stay averaged about two days.
In the multimodal group, which received both nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, the mean oral morphine equivalent was 10 mg, compared with 8.5 mg for the opioid-only group (P>0.05), the authors said. The most frequently prescribed NSAID in the multimodal group was ketorolac. Fentanyl was prescribed for 85% of all patients. None of the patients in either group were admitted to the ICU, required mechanical ventilation or received naloxone due to oversedation, they said.
The time to two consecutive pain scores of less than 4 was 19±17 versus 17±19 hours in the multimodal versus opioid-only groups (P=0.554), the authors said.
One Take-Home: Improve Documentation of Pain Control
“This is a very important study, and I congratulate the authors on a well-designed review on a clinically relevant topic,” said Eduardo Smith-Singares, MD, FACS, a general surgeon in the Division of Surgical Critical Care at the University of Illinois Hospital & Health Sciences System, in Chicago, who was not associated with the study.
“Not a day goes by that another story on the ongoing so-called opioid addiction epidemic sees the light of day,” Dr. Smith-Singares said. “In a time when federal resources are being deployed and state medical boards are implementing new regulations for the initial prescription of Schedule II opioids, the need for high-quality evidence is higher than ever.
“The take-home message for clinicians should be, then, to encourage patients to report their pain control level, to improve the documentation of this pain control, and to use evidence-based strategies for their management,” he added.
Dr. Greco said if there is concern about administering multiple medications, “clinicians should use a stepwise approach and start with one agent and add other agents as needed to control pain. Based on the surgery, patients may only need one agent to control their pain. However, if there is difficulty controlling a patient’s pain, a multimodal approach may be utilized to alleviate the pain through several pathways.”
The study also found that various opioid/nonopioid regimens did not follow a postoperative order set and were based on prescribers’ preferences. A postoperative order set has been developed for pain control at Carilion Roanoke Memorial, she said, and “a study is currently underway to evaluate differences in pain control or morphine equivalents used pre- and post-implementation of the order set.”