Ultrasound-Guided Regional Anesthesia Using a Mixture of Dexamethasone, Dexmedetomidine, and 0.2% Levobupivacaine for Bilateral Breast Cancer Surgery Under a Spontaneous Breathing Opioid-Free Anesthesia: A Case Report.

Breast cancer is unfortunately the most common cancer in women, although survival rates have greatly increased in recent years. Breast surgery can be very aggressive and therefore highly painful, leading to high rates of acute postsurgical pain and chronic pain. In addition to general anesthesia (GA), ultrasound-guided regional anesthesia (RA) is sometimes performed to help reduce acute postoperative pain and consumption of opioids. Although effective, the main limitation of fascial plane blocks is that they require high volumes of local anesthetics, carrying the risk of local anesthetic systemic toxicity. In this article, we present the case of a 41-year-old woman, who refused GA and was successfully operated on for bilateral breast cancer, under a spontaneous breathing opioid-free sedation and ultrasound-guided RA, based on only 0.2% levobupivacaine with the addition of dexamethasone and dexmedetomidine as adjuvants. Despite this, postoperative analgesia lasted for more than 48 hours, and the patient did not require additional analgesia or opioids.

Analgesic Strategies for Urologic Videolaparoscopic or Robotic Surgery in the Context of an Enhanced Recovery after Surgery Protocol: A Prospective Study Comparing Erector Spinae Plane Block versus Transversus Abdominis Plane Block.

Regional anesthesia in postoperative pain management has developed in recent years, especially with the advent of fascial plane blocks. This study aims to compare the ultrasound-guided bilateral erector spinae plane block (ESPB) versus the ultrasound-guided bilateral transversus abdominis plane block (TAPB) on postoperative analgesia after laparoscopic or robotic urologic surgery. This was a prospective observational study; 97 patients (ESPB-group) received bilateral ultrasound-guided ESPB with 20 mL of ropivacaine 0.375% plus 0.5 mcg/kg of dexmedetomidine in each side at the level of T7-T9 and 93 patients (TAPB-group) received bilateral ultrasound-guided TAPB with 20 mL ropivacaine 0.375% or 0.25%. The primary outcome was the postoperative numeric rating scale (NRS) pain score, which was significantly lower in the ESPB group on postoperative days 0, 1, 2, and 3 (p < 0.001) and, consequently, the number of patients requiring postoperative supplemental analgesic rescue therapies was significantly lower (p < 0.001). Concerning the secondary outcomes, consumption of ropivacaine was significantly lower in the group (p < 0.001) and the total amount of analgesic rescue doses was significantly lower in the ESPB-group than the TAPB-group in postoperative days from 2 to 4 (1 vs. 3, p > 0.001). Incidence of postoperative nausea and vomiting was higher in the TAPB group and no block-related complications were observed. Our data indicate that ESPB provides postoperative pain control at least as good as TAPB plus morphine, with less local anesthetic needed.

Opioid-Free Anesthesia for Awake Neurosurgery in a Patient With Asthma and Von Willebrand Disease: A Case Report.

Anesthesia for awake neurosurgery requires meticulous planning. We report the case of a 44-year-old female with glioblastoma undergoing an awake craniotomy. Due to her asthma and von Willebrand disease, an opioid-free approach was chosen. Conscious sedation was attained using propofol and dexmedetomidine. The operation was successful after nine hours with patient comfort maintained. The patient was discharged from the intensive care unit in two days without sequelae. However, the use of desmopressin caused hyponatremia and cerebral edema. The scalp block was effective for pain management. This case highlights the importance of individualized anesthetic strategies in awake neurosurgeries.

Continuous Erector Spinae and Serratus-Intercostal Block With Ketamine-Dexmedetomidine Sedation for Quadrantectomy and Axillary Dissection in a Multimorbid Patient.

Multimorbidity is a clinical presentation that poses an increased risk of perioperative and postoperative complications. Tailored anaesthetic management could potentially minimise the risk of negative outcomes. Peripheral nerve and fasciae blocks are valid strategies for perioperative and postoperative pain management, which avoid complications related to general anaesthesia and reduce the risk of intensive care unit admission as well as the hospital length of stay. We describe the case of a 56-old patient with multimorbidity, including obesity with a BMI of 45.7, unstable angina, predicted difficult airway management and obstructive sleep apnoea syndrome (OSAS) scheduled for left mastectomy with sentinel lymph node biopsy, managed with a left continuous thoracic erector spinae plane (ESP) block plus serratus-intercostal plane block (BRanches of Intercostal nerves at the Level of Mid-Axillary line (BRILMA)), and sedation with combined ketamine-dexmedetomidine. Fascial blocks combined with opioid-free anaesthesia (OFA) proved to be effective for the multimorbid patient, ensuring successful perioperative management and a proper recovery after surgery.

Analgesic Effects of Magnesium Sulphate as an Adjuvant to Fentanyl for Monitored Anaesthesia Care During Hysteroscopy.

BACKGROUND: Magnesium sulphate (MgSO4) is conventionally used in the treatment of eclampsia, refractive arrhythmias, asthma, etc. In our study, we aimed to study the analgesic effects of MgSO4 as an adjuvant to fentanyl and reduce the intraoperative opioid requirement to decrease their adverse effects. METHODS: A total of 122 patients scheduled for hysteroscopy were randomly divided into two groups. Patients in the magnesium group (group A) received intravenous MgSO4 50 mg/kg in 100 ml of isotonic saline over 15 minutes before anaesthesia induction and then 15 mg/kg per hour by continuous intravenous infusion. Patients in the control group (group B) received an equal volume of isotonic saline as a placebo. All the patients were induced with fentanyl and propofol. Perioperative haemodynamic monitoring and postoperative assessment of pain were done. RESULTS: Only 18% of the patients in group A required rescue analgesics as compared to 39.3% of patients in group B. The patients receiving MgSO4 displayed lower verbal numeric rating scale scores in the postoperative period. In addition, the intraoperative requirement of fentanyl (101 (21.33) vs. 144 (28.4) µg, mean (SD)) and propofol (121 (13.3) vs. 140 (16.5) mg, mean (SD)) was significantly lower in group A as compared to that in group B. CONCLUSION: MgSO4, when administered as an adjuvant to opioids, provided effective postoperative analgesia thereby reducing the need for rescue analgesics. It also decreases intraoperative fentanyl consumption and its dose-related side effects.

Perioperative Challenges of Heroin Addiction: A Case Report of Opioid-Free Anesthesia in Tongue Carcinoma Excision With Free-Flap Reconstruction.

Anesthesia for major head and neck surgery is historically heavily reliant on opioids with deleterious consequences. We reported a case of a patient with a history of heroin abuse submitted to a tongue carcinoma excision, followed by free-flap reconstruction under opioid-free anesthesia. We used a propofol total intravenous anesthesia and perfusions of ketamine, dexmedetomidine, lidocaine, and magnesium sulfate for analgesia, complemented by boluses of dexamethasone, acetaminophen, parecoxib, and metamizole. Hemodynamic needs of the procedure were addressed by titrating perfusions of sodium nitroprusside or dobutamine. The patient was weaned from the ventilator at the end of the surgery. Surgical outcomes were achieved and opioid-free analgesia allowed early reestablishment of bodily functions without compromise of adequate pain control. Anesthesia protocols for free-flap surgery still lack scientific evidence, especially in the context of substance abuse: opioid-sparing approaches seem a viable option, which requires further studies and familiarity by health care professionals.

Prevalence, Risk Factors, and Management of Postoperative Nausea and Vomiting After Laparoscopic Sleeve Gastrectomy (a Retrospective Multicentric Study).

PURPOSE: Postoperative nausea and vomiting (PONV) is a frequent unappealing laparoscopic sleeve gastrectomy (LSG) sequel. The study's purpose was to determine the prevalence, risk factors of PONV, and management of PONV after LSG. PATIENTS AND METHODS: This multicenter retrospective study included patients with morbid obesity who had LSG between January 2022 and April 2023. The age range for LSG was 16 to 65 years, and the eligibility requirements included morbid obesity according to international guidelines. RESULTS: PONV was experienced by 74.6% of patients who underwent LSG at 6 h postoperative. Multivariate analysis revealed that female gender, smokers, preoperative GERD, gastropexy, and severity of pain were found to be independent risk variables of the development of PONV, while antral preservation, opioid-free analgesia, and intraoperative combined analgesia were found to be independent protective variables against the development of PONV. Combined intravenous ondansetron and metoclopramide improved 92.6% of patients who developed PONV. Dexamethasone and antihistamines drugs are given for 42 cases with persistent PONV after using intravenous ondansetron and metoclopramide. Pain management postoperatively by opioid-free analgesia managed PONV. Helicobacter pylori status has no role in the development of PONV after LSG. CONCLUSION: Female gender, smoking, presence of preoperative GERD, gastropexy, and severity of pain were found to be independent risk variables of the development of PONV, while antral preservation, opioid-free analgesia, and intraoperative combined analgesia were observed to be independent protective factors against the occurrence of PONV. Combined intravenous ondansetron and metoclopramide improved PONV. Dexamethasone and antihistamines drugs are given for persistent PONV.

Continuous Erector Spinae Plane Analgesia in Kidney Transplant Recipients: A Quality Improvement Project.

Introduction Pain management in patients with chronic kidney disease is challenging. Due to impaired kidney function, analgesic options are limited. Postoperative analgesia in transplant recipients is further complicated by their vulnerability to infections, titrated fluid management and optimal haemodynamics to maintain graft function. Erector spinae plane (ESP) blocks have been used successfully in a variety of surgeries. This study is a quality improvement project aiming to assess the efficacy of continuous erector spinae plane catheter analgesia in the postoperative management of kidney transplant recipients. Methods We conducted an initial audit over a period of three months. All patients who underwent kidney transplantation under general anaesthesia with erector spinae plane catheters were included. Erector spinae plane catheters were secured prior to induction, and continuous local anaesthetic infusion was maintained postoperatively. Pain scores using the numerical rating scale (NRS) were recorded at intervals in the first 24 hours postoperatively, and supplementary analgesics given were noted. Following satisfactory results from the initial audit, we implemented erector spinae plane catheters as part of multimodal analgesia in transplant patients in our centre. We re-audited all transplants done over the next year to reassess the quality of postoperative analgesia. Results Five patients were audited during the initial audit. The average NRS score ranged from 0 at rest to a maximum of 5 during mobilisation. All patients were given only paracetamol to supplement analgesia, and none required opioids. During the re-audit, data was collected on postoperative pain management in 13 subsequent transplants conducted over the next year. The NRS scores ranged from 0 at rest to 6 on mobilisation. Two patients required boluses of fentanyl 25 mcg via the catheter, and the rest reported satisfactory analgesia with paracetamol as needed. Conclusion This quality improvement project changed our centre's practice in managing postoperative pain in kidney transplantations. We switched from securing epidural catheters to erector spinae plane catheters due to better safety profile, minimal use of opioids and lesser adverse effects. We shall continue to re-audit our practices for the best outcomes.

S110-Opioid-free analgesia after outpatient general surgery: A qualitative study focused on the perspectives of patients and clinicians involved in a pilot trial.

BACKGROUND: Opioid-free analgesia (OFA) may mitigate opioid-related harms after outpatient general surgery; however, the comparative effectiveness of this approach should be assessed in robust randomized controlled trials (RCTs). Undertaking an RCT on OFA raises important practical concerns, including surgeon and patient hesitation regarding pain management without opioids. We conducted a qualitative study to explore patients' and clinicians' perspectives and experiences with a pilot trial focused on OFA after outpatient general surgery. METHODS: Patients undergoing outpatient abdominal and breast procedures were randomized to receive post-discharge opioid analgesia (OA) or OFA. Semi-structured interviews with patients and clinicians involved in the trial were conducted to elicit personal perspectives and experiences. Purposive sampling for maximum variation was used to recruit participants with diverse characteristics. Transcribed interviews were assessed using inductive thematic analysis. RESULTS: Ten patients (5 abdominal, 5 breast) and 10 clinicians (6 surgeons, 2 anesthesiologists, 2 nurses) were interviewed. Five major themes emerged: readiness for trial engagement, pre-trial thoughts about the interventions, postoperative pain experiences, intervention acceptability, and trial refinement. Most patients were open to OFA. Clinicians expressed willingness to prescribe OFA, particularly after less invasive procedures and when using peripheral nerve blocks (PNBs). Concerns were raised regarding the adequacy of pain control and side effects of non-opioid drugs (e.g., NSAID-induced bleeding, kidney injury). Overall, participants were enthusiastic about the trial and recognized its relevance; clinicians praised the study design and organization; and patients valued the use of electronic questionnaires. Suggestions for improvements included preventing potential bias arising from the use of PNBs (i.e., via standardization or stratification) and reducing patient burden (i.e., decreasing postoperative questionnaires). CONCLUSION: Patients and clinicians who participated in a pilot RCT generally accept the clinical equipoise between OA versus OFA after outpatient general surgery and recognize the need for methodologically robust trials to inform evidence-based analgesia prescribing.

Opioid Free Anesthesia in Thoracic Surgery: A Systematic Review and Meta Analysis.

Introduction: Recent studies showed that balanced opioid-free anesthesia is feasible and desirable in several surgical settings. However, in thoracic surgery, scientific evidence is still lacking. Thus, we conducted the first systematic review and meta-analysis of opioid-free anesthesia in this field. Methods: The primary outcome was the occurrence of any complication. Secondary outcomes were the length of hospital stay, recovery room length of stay, postoperative pain at 24 and 48 h, and morphine equivalent consumption at 48 h. Results: Out of 375 potentially relevant articles, 6 studies (1 randomized controlled trial and 5 observational cohort studies) counting a total of 904 patients were included. Opioid-free anesthesia compared to opioid-based anesthesia, was associated with a lower rate of any complication (74 of 175 [42%] vs. 200 of 294 [68%]; RR = 0.76; 95% CI, 0.65−0.89; p < 0.001; I2 = 0%), lower 48 h morphine equivalent consumption (MD −14.5 [−29.17/−0.22]; p = 0.05; I2 = 95%) and lower pain at 48 h (MD −1.95 [−3.6/0.3]; p = 0.02, I = 98%). Conclusions: Opioid-free anesthesia in thoracic surgery is associated with lower postoperative complications, and less opioid demand with better postoperative analgesia at 48 h compared to opioid-based anesthesia.

Successful Management of a Patient With a History of Postoperative Delirium Undergoing Cardiac Surgery With an Erector Spinae Plane Block and Multimodal Analgesia: A Case Report.

Perioperative delirium is an acute confusional state with fluctuating levels of consciousness, which can be precipitated by opioid-based anesthetics and inadequate pain control, especially in patients undergoing cardiac surgery. We seek to minimize opioid usage to avoid postoperative delirium in a patient with multiple risk factors undergoing aortic valve replacement. We used cardiac enhanced recovery after surgery protocols (ERAS-C), which include multimodal analgesia and regional anesthesia via bilateral erector spinae plane (ESP) blocks. Our observations suggest that bilateral ESP blocks and cardiac ERAS protocols offer a potential option to manage pain and control risk factors in patients at high risk of postoperative delirium undergoing cardiac surgery.

Role of lidocaine and its effect on postoperative outcomes in abdominal cholecystectomy.

OBJECTIVE: To investigate the role of pre- and intra-operative lidocaine infusion on post-operative pain management. METHODS: The interventional, prospective study was conducted from September 2019 to June 2020 at the Pakistan Ordnance Factories Hospital, Wah Cantt, Pakistan, and comprised patients aged 18-60 years undergoing elective cholecystectomy who were randomised into intervention group A and control group B. Group A was given a bolus dose of lidocaine hydrochloride 2 mg/kg in addition to the standard anaesthesia protocol, while group B was given continuous intravenous infusion of 0.9% normal saline along with the standard protocol. Blood samples for interleukins 6 and 8 were taken at baseline, and then at 2, 6 and 8 hours Post-operatively. Data was analysed using SPSS 23. RESULTS: Of the 40 patients, 20(50%) were in each of the two groups. There was a marked decrease in interleukins 6 and 8 levels group A compared to group B (p<0.05). Interleukin 8 level showed a marked decline compared to that of interleukin 6 (p<0.05). CONCLUSIONS: A decrease in interleukins 6 and 8 levels highlighted the anti-inflammatory role of lidocaine and resulted in a decrease in post-operative opioid consumption.

Thoracolumbar Interfascial Plane Block Results in Opioid-Free Postoperative Recovery After Percutaneous/Endoscopic Transforaminal Lumbar Interbody Fusion Surgery.

OBJECTIVE: To evaluate efficacy in reducing postoperative pain and opioid analgesia of a novel interdisciplinary strategy combining preoperative thoracolumbar interfascial plane (TLIP) block and percutaneous/endoscopic transforaminal lumbar interbody fusion surgery and to determine time to first postoperative ambulation and hospital length of stay. METHODS: In this retrospective review, 42 patients who underwent elective single-level percutaneous/endoscopic transforaminal lumbar interbody fusion surgery between 2015 and 2021 were divided into 2 groups: TLIP group with 17 patients who underwent TLIP block and non-TLIP group with 25 patients. Both groups received the same postoperative analgesia with morphine as patient-controlled rescue medication. Visual analog scale and Oswestry Disability Index scores were evaluated. Statistical evaluation was performed with Student t test. RESULTS: In contrast to the non-TLIP group, in the TLIP group, postoperative mean visual analog scale back score and mean Oswestry Disability Index score significantly decreased from 6.6 to 3.3 (P < 0.01) and 32.8 to 23.6 (P < 0.01), respectively, at hospital discharge. No differences were found between the groups at 1 month. Overall mean follow-up time was 29 ± 18 months (range, 3-78 months). Patients in the non-TLIP group were administered a median postoperative 24-hour morphine dose equivalent of 23 mg (range, 8-31 mg), while patients in the TLIP group did not require opioid analgesia (P < 0.01). Patients in the TLIP group started postoperative ambulation at a median of 4.1 hours (range, 2.5-26 hours) with a median hospital length of stay of 24 hours (range, 20-48 hours) (P = 0.112). CONCLUSIONS: TLIP block significantly improves patient outcome at hospital discharge after transforaminal lumbar interbody fusion surgery without postoperative administration of opioids. A prospective study is recommended to confirm our preliminary results.

Reducing Opioid Use in Patients Undergoing Cardiac Surgery - Preoperative, Intraoperative, and Critical Care Strategies.

Patients undergoing cardiothoracic surgery are exposed to opioids in the operating room and intensive care unit and after hospital discharge. Opportunities exist to reduce perioperative opioid use at all stages of care and include alternative oral and intravenous medications, novel intraoperative regional anesthetic techniques, and postoperative opioid-sparing sedative and analgesic strategies. In this review, currently used and investigational strategies to reduce the opioid burden for cardiothoracic surgical patients are explored.

The need for opioid in the postoperative analgesia of dogs undergoing hemilaminectomy due to intervertebral disc extrusion / A necessidade de opioide na analgesia pós-operatória de cães submetidos à hemilaminectomia devido à extrusão do disco intervertebral

The aim of this study was to evaluate the postoperative analgesic effect of protocols with and without the opioid methadone in dogs with intervertebral disc extrusion undergoing decompressive surgery. Sixteen paraplegic dogs with preserved nociception underwent hemilaminectomy/disc fenestration and were randomly assigned to two groups. The analgesic protocol consisted of methadone, meloxicam and dipyrone in Group I (G1), and meloxicam and dipyrone in Group II (G2). The animals were blindly assessed by two observers, using the visual analogue scale (VAS) and the short-form Glasgow Composite Measure Pain Scale (CMPS-SF). Assessments occurred every 2 hours during first 24 hours post-surgery, and every 4 hours afterwards. There was no statistical difference among groups regarding pain scores or analgesic rescues. Both analgesic protocols provided analgesia in the initial 48 hours postoperatively, demonstrating that opioids are not necessary in the postoperative period of dogs undergoing hemilaminectomy and disc fenestration.(AU)

O objetivo deste estudo foi avaliar a analgesia pós-operatória de protocolos com e sem o opioide metadona em cães com extrusão de disco intervertebral submetidos à descompressão cirúrgica. Dezesseis cães paraplégicos com presença de nocicepção foram submetidos à hemilaminectomia/fenestração de disco e distribuídos aleatoriamente em dois grupos. No Grupo I (G1), o protocolo analgésico consistiu em metadona, meloxicam e dipirona e, no Grupo II (G2), por meloxicam e dipirona. Os pacientes foram avaliados de maneira cega por dois avaliadores, com base na escala visual analógica (EVA) e na escala simplificada composta de dor de Glasgow (CMPS-SF). As avaliações ocorreram a cada 2 horas durante as primeiras 24 horas de pós-operatório e, por mais 24 horas, a cada 4 horas. Não houve diferença estatística entre os grupos avaliados em relação à escores de dor e nem a necessidade de resgate analgésico. Ambos os protocolos promoveram analgesia nas 48 horas iniciais de pós-operatório, demonstrando não haver a necessidade do uso de opioide em cães submetidos à hemilaminectomia e fenestração de disco.(AU)

The need for opioid in the postoperative analgesia of dogs undergoing hemilaminectomy due to intervertebral disc extrusion

ABSTRACT: The aim of this study was to evaluate the postoperative analgesic effect of protocols with and without the opioid methadone in dogs with intervertebral disc extrusion undergoing decompressive surgery. Sixteen paraplegic dogs with preserved nociception underwent hemilaminectomy/disc fenestration and were randomly assigned to two groups. The analgesic protocol consisted of methadone, meloxicam and dipyrone in Group I (G1), and meloxicam and dipyrone in Group II (G2). The animals were blindly assessed by two observers, using the visual analogue scale (VAS) and the short-form Glasgow Composite Measure Pain Scale (CMPS-SF). Assessments occurred every 2 hours during first 24 hours post-surgery, and every 4 hours afterwards. There was no statistical difference among groups regarding pain scores or analgesic rescues. Both analgesic protocols provided analgesia in the initial 48 hours postoperatively, demonstrating that opioids are not necessary in the postoperative period of dogs undergoing hemilaminectomy and disc fenestration.

RESUMO: O objetivo deste estudo foi avaliar a analgesia pós-operatória de protocolos com e sem o opioide metadona em cães com extrusão de disco intervertebral submetidos à descompressão cirúrgica. Dezesseis cães paraplégicos com presença de nocicepção foram submetidos à hemilaminectomia/fenestração de disco e distribuídos aleatoriamente em dois grupos. No Grupo I (G1), o protocolo analgésico consistiu em metadona, meloxicam e dipirona e, no Grupo II (G2), por meloxicam e dipirona. Os pacientes foram avaliados de maneira cega por dois avaliadores, com base na escala visual analógica (EVA) e na escala simplificada composta de dor de Glasgow (CMPS-SF). As avaliações ocorreram a cada 2 horas durante as primeiras 24 horas de pós-operatório e, por mais 24 horas, a cada 4 horas. Não houve diferença estatística entre os grupos avaliados em relação à escores de dor e nem a necessidade de resgate analgésico. Ambos os protocolos promoveram analgesia nas 48 horas iniciais de pós-operatório, demonstrando não haver a necessidade do uso de opioide em cães submetidos à hemilaminectomia e fenestração de disco.

Use of Dexmedetomidine With Dexamethasone for Extended Pain Relief in Adductor Canal/Popliteal Nerve Block During Achilles Tendon Repair.

The use of regional anesthetic techniques in the peri-operative period has increased as a means to improve analgesia and patient outcomes. Traditionally, various local anesthetics are used and addition of adjuncts such as epinephrine, clonidine, and dexamethasone has shown to prolong the block effect. There has been ongoing research to support the prolongation of a regional block with the addition of dexamethasone and dexmedetomidine (Dex-Dex), providing analgesia for multiple days. We present a case of a 35-year-old female who underwent an Achilles tendon repair with an adductor/popliteal nerve block. Both dexmedetomidine and dexamethasone were added to the local anesthetic mixture with substantial postoperative analgesic control. The patient also did not require any supplemental opioid medication. This case emphasizes the proposed synergistic effect of dexmedetomidine and dexamethasone when added to the local anesthesia injectate for lower extremity peripheral nerve blocks.

Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review.

Objective: Identification of pain as the fifth vital sign has resulted in over-prescription and overuse of opioids in the US, with addiction reaching epidemic proportions. In Europe, and more recently in the US, a shift has occurred with the global adoption of multimodal analgesia (MMA), which seeks to minimize perioperative opioid use. Improved functional outcomes and reduced healthcare utilization costs have been demonstrated with MMA, but wide scale use of opioids in pain management protocols continues. As a next step in the pain management evolution, opioid-free analgesia (OFA) MMA strategies have emerged as feasible in many surgical settings.Methods: Articles were limited to clinical studies and meta-analyses focusing on comparisons between opioid-intensive and opioid-free/opioid-sparing strategies published in English.Results: In this review, elimination or substantial reduction in opioid use with OFA strategies for perioperative acute pain are discussed, with an emphasis on improved pain control and patient satisfaction. Improved functional outcomes and patient recovery, as well as reduced healthcare utilization costs, are also discussed, along with challenges facing the implementation of such strategies.Conclusions: Effective MMA strategies have paved the way for OFA approaches to postoperative pain management, with goals to reduce opioid prescriptions, improve patient recovery, and reduce overall healthcare resource utilization and costs. However, institution-wide deployment and adoption of OFA is still in early stages and will require personalization and better management of patient expectations.

Analysis of predictors of opioid-free analgesia for management of acute post-surgical pain in the United States.

OBJECTIVES: Utilization of opioid-free analgesia (OFA) for post-surgical pain is a growing trend to counter the risks of opioid abuse and opioid-related adverse drug events (ORADEs). However, utilization patterns of OFA have not been examined. In this study, we investigated the utilization patterns and predictors of OFA in a surgical population in the United States. METHODS: Analysis of the Cerner Health Facts database (January 2011 to December 2015) was conducted to describe hospital and patient characteristics associated with OFA. Baseline characteristics, such as age, gender, race, discharge status, year of admission and chronic comorbidities at index admission were collected. Hospital characteristics and payer type at index admission were collected as reported in the electronic health record database. Descriptive statistics and logistic regression were used to identify statistically significant predictors of OFA on patient and institutional levels. RESULTS: The study identified 10,219 patients, from 187 hospitals, who received post-surgical OFA and 255,196 patients who received post-surgical opioids. OFA rates varied considerably by hospital. Patients more likely to receive OFA were older (OR = 1.06, 95% CI [1.03, 1.10]; p < .001), or had neurological disorders (OR = 1.24, 95% CI [1.10, 1.39]; p < .001), diabetes (OR = 1.20, 95% CI [1.08, 1.33]; p = .001) or psychosis (OR = 1.18, 95% CI [1.01, 1.37]; p = .030). Patients with obesity and depression were less likely to receive OFA (OR = 0.80, 95% CI [0.67, 0.95]; p = .010 OR = 0.85, 95% CI [0.73, 0.98]; p = .030, respectively). CONCLUSIONS: Use of post-surgical OFA was limited overall and was not favored in some patient groups prone to ORADEs, indicating missed opportunities to reduce opioid use and ORADE incidence. A substantial proportion of OFA patients was contributed by a few hospitals with especially high rates of OFA, suggesting that hospital policies, institutional structure and cross-functional departmental commitment to reducing opioid use may play a large role in the implementation of OFA.