Author: Michael Vlessides
In orthopedic surgery patients with obstructive sleep apnea (OSA), multimodal analgesia may significantly decrease postoperative opioid consumption and severe complications, according to an analysis by a team of New York City researchers. The study also revealed a stepwise relationship between the number of nonopioid analgesics used and the magnitude of the effect.
“Obstructive sleep apnea is a topic of interest for our group,” said Crispiana Cozowicz, MD, an anesthesia research fellow at the Hospital for Special Surgery. “We decided it would be interesting to look into these patients because we know they are at increased risk of respiratory complications, and giving these patients opioids and other sedative medications is a concern in the postoperative setting.
“So we sought to determine how multimodal analgesia impacts opioid utilization and postoperative outcomes in this patient population,” she added.
The study’s primary outcome was opioid use, as defined by opioid prescription. “With this database we’re not able to determine how much opioids patients consumed, but we know how much they were prescribed,” Dr. Cozowicz said. The study also analyzed opioid-related adverse events, rate of postoperative mechanical ventilation, critical care admission, hospital length of stay (LOS) and cost of care.
Opioids Significantly Decreased
As Dr. Cozowicz reported at the 2018 Joint World Congress on Regional Anesthesia and Pain Medicine and annual meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 5652), 88.5% of patients in the analysis received multimodal analgesia. The use of multimodal analgesia also was found to increase over time.
Multivariable models revealed that the use of increasing modes of multimodal analgesia was associated with a significant decrease in opioid prescription dose. “When we look at postoperative day 1, we see a decrease in opioid prescription by 5% with one additional analgesic mode,” Dr. Cozowicz said. “Adding two additional modes decreased it by 10.4%, and adding more than two analgesic modes saw a decrease in opioid prescription by 14.9% [P<0.0001].
“And those figures could be underestimated because we’re looking at prescription, not actual, postoperative opioid use,” she said. Decreased opioid prescription also was sustained after postoperative day 1.
The analysis also revealed a stepwise decrease in odds for gastrointestinal complications, postoperative mechanical ventilation and critical care admission, as well as a stepwise decrease in hospital LOS and cost with increasing analgesic modes. The strongest effect was observed in the reduced risk for postoperative mechanical ventilation and critical care services.
Indeed, the addition of one, two or more than two analgesic modes to opioid analgesia reduced the odds for gastrointestinal complications by 26%, 31% and 35%, respectively (P<0.001). Similarly, the odds for mechanical ventilation also were reduced in a stepwise manner with increasing analgesic modes: by 40%, 67% and 77% (P<0.0001), respectively. “That was pretty striking for us,” Dr. Cozowicz noted.
The odds for critical care admission decreased by 19%, 27% and 40%, respectively, with increasing modes of analgesia (P<0.0001). Likewise, LOS significantly decreased in a stepwise manner by as much as 11.8%.
“When we looked at cost, we found a stepwise decrease with increasing analgesic modes, but the differences were not really meaningful,” she added. “We think the effect might not be as pronounced because these patients only stay in the hospital for two or three days, so the weight of the day of surgery is very high on the overall cost. We’d probably need to see longer lengths of stay to see an effect there.”
Increasing Patient Benefits
Costs notwithstanding, the investigators concluded that these findings point to significant benefits in a patient population at higher risk for perioperative complications. “Of course, clinical studies have to prove these outcomes,” Dr. Cozowicz concluded. “But if they’re true, then this shows that adding additional modes could increase safety in this patient population.”
For Edward R. Mariano, MD, MAS, the study’s findings are clinically important from a public health perspective. “Twenty-five million Americans are thought to have obstructive sleep apnea,” said Dr. Mariano, a professor of anesthesiology, perioperative and pain medicine at VA Palo Alto Health Care System and Stanford University Medical Center, in Stanford, Calif. “Physician anesthesiologists play a key role in decreasing perioperative opioids and their associated complications through the use of nonopioid analgesics.
“Although I agree with Dr. Cozowicz that clinical trials are needed, the results of this study have face validity and support previous studies that have demonstrated the risks of opioids in the OSA population,” Dr. Mariano continued.
“In addition, now the use of nonopioid analgesics is part of a national multimodal quality measure that anesthesiologists can report to CMS [the Centers for Medicare & Medicaid Services] through a qualifying clinical data registry [www.asra.com/ news/ 185/ four-new-quality-pain-measures-approved], and thereby get credit for providing good care.”