A Standardized Multimodal Analgesia Protocol Reduces Perioperative Opioid Use in Minimally Invasive Colorectal Surgery
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ORIGINAL ARTICLE
A Standardized Multimodal Analgesia Protocol Reduces Perioperative Opioid Use in Minimally Invasive Colorectal Surgery Angela Mujukian 1 & Adam Truong 1 & Hai Tran 2 & Rita Shane 2 & Phillip Fleshner 1 & Karen Zaghiyan 1 Received: 24 July 2019 / Accepted: 27 August 2019 # 2019 The Society for Surgery of the Alimentary Tract
Abstract Background Multimodal analgesia protocols are becoming a common part of enhanced recovery pathways after colorectal surgery. However, few protocols include a robust intraoperative component in addition to pre-operative and post-operative analgesics. Method A prospective cohort study was performed in an urban teaching hospital in patients undergoing minimally invasive colorectal surgery before and after implementation of a multimodal analgesia protocol consisting of pre-operative (gabapentin, acetaminophen, celecoxib), intraoperative (lidocaine and magnesium infusions, ketorolac, transversus abdominis plane block), and post-operative (gabapentin, acetaminophen, celecoxib) opioid-sparing elements. The main outcome measure was use of morphine equivalents in the first 24-h post-operative period. Results The study cohort (n = 71) included 41 patients before and 30 patients after implementation of a multimodal analgesia protocol. Mean age of the entire study cohort was 47 ± 19.7 years and 46% were male. Patients undergoing surgery postmultimodal analgesia vs. pre-multimodal analgesia had significantly lower use of IV morphine equivalents in first 24-h postoperative period (5.8 ± 6.4 mg vs. 22.8 ± 21.3 mg; p = 0.005) and first 48-h post-operative period (7.6 ± 9.4 mg vs. 42 ± 52.9 mg; p = 0.0008). This reduction in IV morphine equivalent use post-multimodal analgesia was coupled with improved pain scores in the post-operative period. Post-operative hospital length of stay, post-operative ileus, and overall complications were not significantly different between groups. Conclusions Multimodal analgesia incorporating pre-operative, intraoperative, and post-operative opioid-sparing agents is an effective method for reducing perioperative opioid utilization and pain after minimally invasive colorectal surgery. Keywords Multimodal analgesia . Enhanced recovery . ERAS . Transversus abdominis plane block . Colorectal surgery
Introduction Perioperative opioid overuse contributes to various complications after colorectal surgery including post-operative ileus, prolonged hospital length of stay, and increased healthcare costs.1–4 Multimodal analgesia (MMA) protocols include various opiod-sparing medications and techniques which provide an opportunity to standardize pain management and opioid prescriptions after surgery. MMA protocols are increasingly * Karen Zaghiyan [email protected] 1
Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA
2
Department of Pharmacy, Cedars Sinai Medical Center, Los Angeles, CA, USA
being incorporated into enhanced recovery pathways (ERPs) after colorectal surgery1, 2; however, i
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