IntroductionGeneral surgery is commonly performed with minimally invasive techniques utilizing laparoscopic or robotic assistance. However, despite advances in surgical procedures, patients report postoperative pain that... [ view full abstract ]
Introduction
General surgery is commonly performed with minimally invasive techniques utilizing laparoscopic or robotic assistance. However, despite advances in surgical procedures, patients report postoperative pain that requires high dose opioids. Enhanced recovery after surgery (ERAS) protocols have been described for minimally invasive surgeries and include interventions to optimize postoperative pain control. We implemented an intraoperative multimodal analgesic protocol for minimally invasive general surgery (MIGS) to minimize opioid use and enhance postsurgical recovery. We hypothesized that a standardized protocol will reduce use of postoperative intravenous (IV) opioid patient-controlled analgesia (PCA).
Materials and Methods
With IRB approval, we retrospectively reviewed the electronic medical records of consecutive MIGS performed six months before and after implementation of a multimodal analgesic protocol (Table 1). Initially all patients who underwent MIGS were included. Exclusion criteria include: emergent surgery, admission to an intensive care unit, or conversion to an “open” approach. Patients were divided into Pre- and Post-protocol groups. For subsequent analysis, Pre- and Post-patients were categorized according to surgery duration (low, mid, and high tertiles – Subgroups 1, 2, and 3, respectively). The primary outcome was proportion of patients requiring IV opioid PCA use in the Pre- and Post-protocol groups. Secondary outcomes included post-anesthesia care unit (PACU) length of stay (min), time to IV opioid cessation (hours), lowest and highest pain scores using a numeric rating scale (NRS, 0-10) and total opioid consumption in IV morphine equivalents (mg) on POD 1 and 2, and hospital length of stay (days).
Results
Between May 2014 and May 2015, 139 MIGS cases were performed and 118 patients were included in the analysis (57 Pre-protocol and 61 Post-protocol; Table 2). For the primary outcome, 24/57 (42%) patients in the Pre- and 19/61 (31%) in the Post-protocol group received IV opioid PCA after surgery (P=0.217). PACU length of stay [median (10th-90th percentiles)] for the Pre-group was 130 (67-194) min compared to 110 (60-168) min in the Post-group (p=0.034). Highest pain score on POD1 in the Pre- and Post-groups was 4 (0-8) and 7 (1-10), respectively (p=0.001) and lowest pain score on POD2 was 0 (0-0) and 0 (0-4) for Pre- and Post-groups, respectively (p=0.009). There was no difference in other outcomes. In the Pre- and Post-protocol groups categorized by surgery duration, PACU length of stay was different in Subgroup 1 [Pre- 143 (66-226) min versus Post- 97 (59-128) min, p=0.007] but not in Subgroups 2 or 3 (Figure 1). For hospital length of stay, there was no difference except in Subgroup 3 [Pre- 5 (3-8) days versus Post- 3.5 (3-8) days, p=0.026].
Discussion
Implementation of an intraoperative multimodal analgesic protocol reduced PACU length of stay, especially among patients undergoing surgeries of short duration. These results may have implications for workflow and allocation of resources at high volume surgery centers. To enhance recovery, numerous perioperative interventions are required; our protocol only addressed intraoperative analgesia without standardizing pre- or postoperative pain management. Although comparison of pain scores reached statistical significance, these secondary outcomes are suggestive, but not conclusive, and warrant further study.
