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Preoperative Multimodal Analgesia Decreases Postanesthesia Care Unit Narcotic Use and Pain Scores in Outpatient Breast Surgery

Barker, Jenny C. M.D., Ph.D.; DiBartola, Kaitlin M.D.; Wee, Corinne M.D.; Andonian, Nicole M.D.; Abdel-Rasoul, Mahmoud M.S., M.P.H.; Lowery, Deborah M.D.; Janis, Jeffrey E. M.D.

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 443e-450e
doi: 10.1097/PRS.0000000000004804
Breast: Original Articles
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Patient Safety CME
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Background: The opioid epidemic demands changes in perioperative pain management. Of the 33,000 deaths attributable to opioid overdose in 2015, half received prescription opioids. Multimodal analgesia 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 procedures was conducted. Patients received (1) no preoperative analgesia (n = 333); (2) intraoperative intravenous acetaminophen (n = 78); (3) preoperative oral acetaminophen and gabapentin (n = 95); or (4) preoperative oral acetaminophen, gabapentin and celecoxib (n = 54). Outcomes included postanesthesia care unit narcotic use, pain scores, postanesthesia care unit length of stay, rescue antiemetic use, and 30-day complications.

Results: Both oral multimodal analgesia regimens significantly reduced postanesthesia care unit narcotic use (oral acetaminophen and gabapentin, 14.3 ± 1.7; oral gabapentin, acetaminophen, and celecoxib, 11.9 ± 2.2; versus no drug, 19.2 ± 1.1 mg oral morphine equivalents; p = 0.0006), initial pain scores (oral acetaminophen and gabapentin, 3.9 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.4 ± 0.7; versus no drug, 5.3 ± 0.3 on a 1 to 10 scale, p = 0.0002) and maximum pain scores (oral acetaminophen and gabapentin, 4.3 ± 0.4; oral gabapentin, acetaminophen, and celecoxib, 3.6 ± 0.7; versus no drug, 5.9 ± 0.3 on a 1 to 10 scale; p < 0.0001). Both oral regimens were better than no medications or intravenous acetaminophen alone in multivariate models after controlling for age, body mass index, American Society of Anesthesiologists class, length of surgery, prior narcotic prescription availability, and intraoperative local anesthetic. Postanesthesia care unit length of stay, antiemetic use, and 30-day complications were not different.

Conclusions: Preoperative oral multimodal analgesia reduces narcotic 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.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Patient Safety CME.

Columbus, Ohio

From the Departments of Plastic Surgery, Anesthesia, and Biomedical Informatics, Center for Biostatistics, The Ohio State University Medical Center.

Presented at the American Association of Plastic Surgeons Annual Meeting, April 9, 2018, in Seattle, Washington, and the Plastic Surgery Research Council Annual Meeting, May 17, 2018, in Birmingham, Alabama.

Received for publication December 24, 2017; accepted March 26, 2018.

Disclosure:Dr. Janis is a prior consultant for LifeCell, Bard, Daiichi Sankyo, Pacira, KCI, and Allergan within the last 36 months of submission of this article, but does no active consulting currently. He receives royalties from Thieme. The other authors have no pertinent financial disclosures.

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Jeffrey E. Janis, M.D., Department of Plastic Surgery, The Ohio State University Medical Center, 915 Olentangy River Road, Suite 2100, Room 2114, Columbus, Ohio 43212, jeffrey.janis@osumc.edu

Copyright © 2018 by the American Society of Plastic Surgeons