Pre-Operative Multimodal Analgesia Decreases Opioid Use and Pain Scores in Outpatient Breast Surgery
Jenny C. Barker, M.D., Ph.D., Kaitlin Wandell, M.D., Corinne Wee, M.D., Nicole Andonian, M.D., Mahmoud Abdel-Rasoul, M.S., M.P.H., Deborah Lowery, M.D., Jeffrey E. Janis, M.D..
The Ohio State University Wexner Medical Center, Columbus, OH, USA.
Purpose: The opioid epidemic demands changes in perioperative pain management. Of the 33,000 deaths due to opioid overdose in 2015, half received prescription opioids. Multimodal analgesia (MMA) is a practice-altering evolution that reduces reliance on opioid medications. Ambulatory breast surgery is an ideal opportunity to implement these strategies.
Methods: A retrospective review of 560 patients undergoing outpatient breast plastic surgery procedures was conducted. Patients received 1) no preoperative analgesia (n=333), 2) intraoperative IV acetaminophen (n=78), 3) preoperative oral acetaminophen and gabapentin (n=95), or 4) preoperative oral acetaminophen, gabapentin and celecoxib (n=54). Outcomes included PACU narcotic use, pain scores, PACU length-of-stay, rescue anti-emetic use and 30-day complications.
Results: Both oral MMA regimens significantly reduced PACU narcotic use (14.3 +/-1.7 and 11.9 +/-2.2 versus 19.2 +/-1.1 mg oral morphine equivalents, p= p=0.0006), initial pain scores (3.9 +/-0.4 and 3.4 +/-0.7 versus 5.3 +/-0.3 on a 1-10 scale, p=0.003) and maximum pain scores (4.3 +/-0.4 and 3.6 +/-0.7 versus 5.9 +/-0.3 on a 1-10 scale, (p<0.0001). Both oral MMA regimens were significantly better than no medications or IV acetaminophen alone, even after controlling for age, BMI, ASA, length of surgery, prior opioid use, and intraoperative local anesthetic. PACU length of stay, anti-emetic use and 30-day complications were not significantly different.
Conclusions: Pre-operative oral multimodal analgesia reduces opioid use and pain scores in outpatient breast plastic surgery. These regimens are inexpensive, improve pain control and contribute to narcotic-sparing clinical practice in the setting of a national opioid epidemic.
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