331. Significant Reduction of In-Hospital and Post-Discharge Use of Potent Opioid Analgesic by Implementation of a Multi-Modal Pain Management Strategy as Part of an Enhanced Recovery After Thoracic Surgery (ERATS) Protocol
Syed Shahzad Razi, Safi Haq, Joy Stephens-McDonnough, Michael Fabbro, II, Nestor Villamizar, *Dao M. Nguyen
Jackson Memorial Hospital/University of Miami Hospital, Miami, FL
Invited Discussant: *Gail E. Darling
Objective: A comprehensive postoperative pain management strategy, part of our Enhanced Recovery After Thoracic Surgery (ERATS) protocol, was implemented to improve outcomes of patients undergoing thoracic surgical procedures and to reduce dependence on potent opioid for postoperative pain control.
Methods: An IRB-approved retrospective analysis was performed using a prospectively maintained database of patients undergoing pulmonary resections (wedge, anatomic resections: segmentectomy, lobectomy, pneumonectomy) by robotic thoracoscopy or thoracotomy from 1/1/2017 to 9/30/2018 at an academic medical center. Multimodal pain management [peri- and post-operative scheduled Acetaminophen, Ketorolac (absence of contraindications), Gabapentin, Tramadol, PRN oral oxycodone or intravenous morphine, infiltration of liposomal bupivacaine to intercostal spaces 2 to 10 and surgical sites and elimination of thoracic epidural analgesia for thoracotomy cases] was implemented on all thoracic patients on 2/1/2018. Discharge prescriptions for analgesics were tailored according to postoperative in-hospital pain levels and opioid requirements. Outcome metrics include subjective pain levels (visual pain scores), in-hospital and post-discharge opioid utilization (milligram of morphine equivalent - MME), postoperative complications and length of hospital stay (LOS).
Results: 248 robotic cases and 49 thoracotomy cases were eligible for this study. Pre- and post-ERATS cohorts are comparable (Table 1). Reduction of daily pain scores was observed in post-ERATS robotic patients (p<0.05) along with significant reduction of in-hospital opioid use (p<0.001) [Figure 1]. This pain management strategy allowed discontinuation of epidural use without affecting postoperative pain (pre- versus post-ERATS daily pain scores, p>0.05) or increase of in-hospital systemic opioid use (Figure 1). Most importantly, substantial reduction of post-discharge prescription of opioid analgesics was observed in both post-ERATS robotic and thoracotomy patients, p<0.05 (Figure 2 and 3).
Conclusions: Stringent and systemic implementation of a multi-modal analgesic regime allows elimination of epidural use and drastic reduction of in-hospital opioid use in thoracic surgical patients, without affecting outcomes i.e. complications and LOS. Adaptive post-discharge analgesic prescription minimized opioid dependence for postoperative pain management.