A report by the Journal of the American Academy of Orthopaedic Surgeons last May noted that “the past few decades have seen an alarming rise in opioid use in the United States,” that “a significant number of orthopaedic patients are at risk for the repercussions from both therapeutic and nontherapeutic opioid use,” and that “orthopaedic surgeons are the third highest prescribers of opioid prescriptions among physicians in the United States, contributing to what the journal called an “opioid epidemic.”
While patients undergoing orthopedic procedures often experience a considerable amount of pain, new techniques for managing postoperative pain can substantially reduce narcotic consumption with stable or improved pain scores and yield greater patient satisfaction for patients with acute pain, as two recent studies—one in anterior lumbar interbody fusion (ALIF), the other in complex foot and ankle surgery—illustrate.
In both studies, the surgeons employed the ON-Q* Pain Relief System (Halyard Health [formerly Kimberly-Clark Health Care]; Alpharetta, Georgia), a nonnarcotic elastomeric pump that automatically and continuously delivers a regulated flow of local anesthetic to a patient’s surgical site in close proximity to nerves. Study data were presented in posters at the American Society of Regional Anesthesia and Pain Medicine (ASRA) Annual Meeting in Las Vegas last May.Reducing Opioid Need in Post-op Lumbar Fusion Patients
In one study, continuous infusion of local anesthetic (ropivacaine) via transversus abdominus plane (TAP) block using ON-Q* for postoperative pain management was compared with a single injection of liposomal bupivacaine following ALIF. A retrospective review of 100 cases was conducted in which bilateral TAP blocks were placed at the conclusion of the surgery prior to the emergence of all patients.
As detailed in the poster, 50 patients received bilateral continuous TAP block with a loading dose of 30 mL 0.5% ropivacaine per side followed by a 0.2% ropivacaine infusion.[3] Another 50 patients received bilateral single-injection TAP blocks with 10 mL of 0.5% bupivacaine followed by 10 mL of liposomal bupivacaine (133 mg) expanded to 20 mL with 10 mL of normal saline, for a total loading volume of 30 mL per side. Ultrasound visualization was used during the performance of the TAP blocks.
All patients had access to analgesics for breakthrough pain after surgery.[3] Catheters in the continuous-TAP group remained in place until the morning of postop day 2, approximately 36-40 hours after placement. Outcome measures included opioid use, return of bowel function, patient-reported pain intensity, and length of hospital stay. Patients undergoing spine procedures with an anterior surgical approach and who had an American Society of Anesthesiologists Physical Status category of 1-5 were included. Those with a prior allergic reaction to bupivacaine, ropivacaine, lidocaine, or related drugs were excluded.
In the continuous-TAP group, opioid consumption was statistically reduced throughout the hospital stay, with reductions of 46%, 35%, and 34% on days 1, 2, and in total (P < .0001, .02, and .0004, respectively), the investigators found, with bowel function returning 1 day earlier (P = .008).[3] Patients in the continuous-TAP group met discharge criteria and were discharged home 1 day earlier (3.0 vs 4.0,P < .0001). There were no differences in mean reported pain scores despite the reduction in narcotics.
Although the study was limited by being a retrospective chart review, it was the first published report to compare continuous TAP vs liposomal bupivacaine for TAP infiltration as primary analgesia following ALIF procedures. Continuous TAP block provided superior analgesia compared with a TAP block with liposomal lidocaine by reducing narcotic consumption without loss of analgesia. Once the continuous-TAP catheters were removed and no longer functional, no difference in analgesia was seen.
Improved Pain Management, Earlier Discharge, Significant Cost Savings
Continuous TAP blocks led to statistically significant earlier discharge from the hospital, which at The Christ Hospital in Cincinnati, Ohio, where the study was conducted, would have resulted in a cost savings of $800-$1000 per day, according to the researchers’ calculations.
“Excellent postoperative pain management is important not only because pain is a negative experience in and of itself, but also because the pain influences the patients’ perception of their entire hospital course and care,” the investigator, Brian N. Vaughan, MD, a member of The Christ Hospital’s Department of Anesthesiology and director of the Acute Pain Service at Anesthesia Associates of Cincinnati said.
“At The Christ Hospital, we take pride in our ability to provide excellent acute pain control for a wide variety of surgical procedures,” Dr Vaughan added. “We are committed to finding and providing the best, most advanced care for our patients. The recent study looked at two alternative TAP block techniques that are used to provide postoperative analgesia for the abdominal incision in ALIF. The study clearly demonstrated the superiority of continuous TAP blocks with ON-Q* over single injection with liposomal bupivacaine in terms of pain control (significant decrease in narcotic utilization), as well as faster recovery (decreased length of stay).”
“Providing postoperative analgesia with catheters, as opposed to single-injection techniques, allows us to truly customize therapy for our patients,” Dr Vaughan said. “We can increase or decrease the intensity of blocks as needed, prolong or shorten the duration of the block, slowly titrate/fractionate initial boluses, etc. By customizing what we do for each patient, we are able to provide better care.”
Reducing Opioid Need in Post-op Foot and Ankle Surgery
The second study was prospective. Like the first study, it was designed to compare two regional analgesia techniques—in this case following invasive foot and ankle surgical procedures—with the primary goal of preventing emergency department admissions and hospital readmissions for pain control.
As detailed in the poster, 60 patients were sequentially enrolled to receive either a continuous infusion of 0.2% ropivacaine via popliteal catheter with single-injection saphenous (adductor canal) nerve block (“Group Single”) or two continuous infusions of 0.2% ropivacaine via popliteal and saphenous (adductor canal) catheters (“Group Dual”) for postoperative pain management.
Once again, the ON-Q* pump was used to deliver a regulated flow of local anesthetic to the surgical site of patients in Group Dual.
The surgeries were performed at the Jefferson Surgical Center at the Navy Yard in Philadelphia, Pennsylvania, by a single surgeon, and blocks were placed by a single anesthesiologist.[4] All patients were discharged home from the surgery center on the day of the surgery. Data were collected via patient diary and daily phone interviews through postoperative day (POD) 3.
Primary outcomes included pain scores (0-10 numeric rating scale) at rest and with activity; opioid consumption; incidence of nausea/vomiting; sleep disturbance related to pain; satisfaction with pain management; and the need for emergency department and/or hospital admission for uncontrolled pain. Secondary outcomes included use of IV acetaminophen and the need for medication to treat postoperative nausea/vomiting.
The two groups were balanced in age, gender, body mass index, American Society of Anesthesiologists Physical Status category, degree of saphenous involvement, surgery time, and analgesia time.
Dual Continuous Approach Proves Superior for Pain Control
Patients in Group Dual showed a significant reduction in the consumption of opioid analgesics on POD 1 and 2 (P < .05) and pain at < 4 for all time points. They also reported significantly less pain during activities (P < .01; POD 1, 2, and 3).
Group Single patients were 2.85 times more likely to require medication to control nausea following discharge. Compared with patients who did not receive acetaminophen, patients in Group Dual (the continuous-block group) showed significant reductions in opioid use and pain (at rest and with activity) on POD 1 and 2 (P < .01) and significantly higher patient satisfaction with pain management on POD 1, 2, and 3 (P < .05).
Compared with patients who received acetaminophen in Group Single vs all patients in Group Dual, the dual continuous approach provided significant reductions in pain at rest and with activity and higher patient satisfaction for POD 1.
These data suggest that exposure to this adjunctive medication does not provide additional benefit when a dual continuous block is used, the investigators noted. There were no readmissions or need for emergency department visits in either group.
The use of two continuous blocks—popliteal and saphenous, placed in the adductor canal—resulted in a reduced need for opioid analgesics and lower pain scores, with higher patient satisfaction following discharge from the surgery center when compared with a continuous popliteal block with a single-injection saphenous block.
The investigators found that the need for catheters was most important on POD 1 when higher readmission rates for pain control were observed once the single injections wore off. The data showed the greatest advantage in pain control at rest and with activity on POD 1 while the dual catheters were infusing.
Complex Foot and Ankle Surgery as Outpatient Procedures
This study also showed that complex foot and ankle procedures can be well managed in the outpatient setting using a dual block, resulting in superior outcomes compared with the traditional technique, and that a continuous saphenous nerve block should routinely be included in blocks for foot and ankle surgery, the investigators concluded.
“Many [patients with] complex foot and ankle surgeries are admitted to an inpatient facility due to the complexity of postoperative pain management,” lead investigator Vincent P. Kasper, MD, director of regional anesthesia at United Anesthesia Services in Bryn Mawr, Pennsylvania, and chief of anesthesia at Rothman Orthopaedic Specialty Hospital in Bensalem, Pennsylvania, said. “Now, because of advanced pain care offerings, these complex procedures can be performed in an outpatient setting.”
“Complex foot and ankle surgery typically has a high rate of hospital readmissions for pain control, which can negatively impact patient care and satisfaction and increase overall healthcare costs,” Dr Kasper added.
“Some of the most important goals in a postoperative setting are (1) to avoid or minimize the amount of opioids patients are taking post-surgery, since there is a greater risk of dependence and adverse side effects; and (2) to find a successful postoperative pain management solution that allows for reduced hospital readmissions,” Dr Kasper explained. “We now have evidence to show that using nerve blocks/continuous infusions in outpatient settings can accomplish this.”
“The positive results obtained by using nonnarcotic pain management techniques—like nerve blocks/continuous infusions with ON-Q*—have allowed patients to recover faster postoperatively and have reduced the need for narcotics,” Dr Kasper said. “This means a higher patient satisfaction rate and the potential for many fewer readmissions for pain control.”
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