TARGETING MINIMAL CUMULATIVE OPIOID REQUIREMENTS IN BARIATRIC SURGERY
Patrick J. Sweigert*1, Ashley Wang2, Marissa Andreassi3, Nasir Khan3, Tyler Cohn3, James N. Lau3, Bipan Chand3
1The Ohio State University Wexner Medical Center Department of Surgery, Columbus, OH; 2Loyola University Chicago Stritch School of Medicine, Maywood, IL; 3Loyola University Health System, Maywood, IL
Introduction:
Despite pharmacologic advances and recognition of deleterious side effects, opioids remain a cornerstone of pain management in bariatric surgery. Although minimization of post-operative opioids is increasingly employed, the impact of multimodal pain management protocol adherence on cumulative opioid requirements remains poorly understood.
Methods:
Consecutive adult patients who underwent primary laparoscopic Roux-en-Y Gastric Bypass (RYGB) or sleeve gastrectomy (SG) at a single institution between 1/1/2020 and 11/15/2022 were included. A multimodal analgesic pathway was used, including preoperative, intraoperative, and postoperative non-narcotic medications to minimize opioids. Medications were quantified in morphine milligram equivalents (MME). Patients were retrospectively stratified based on adherence to a target aspect of the protocol: Group 1 received preoperative acetaminophen and gabapentin, as well as intraoperative ketorolac and ketamine, while Group 2 was characterized by non-adherence to at least 1 of the 4 medications perioperatively. Values are listed as means ± standard deviation.
Results:
Of 427 patients who met inclusion criteria, mean age was 43.6 and 85.0% were female. 159 (37.2%) patients underwent RYGB and 268 (62.8%) underwent SG. All four perioperative non-narcotic medications were administered in 110 (25.8%) patients (Group 1), while 317 (74.2%) patients demonstrated non-adherence to at least 1 medication (Group 2). Intraoperative ketamine was only administered in 146 patients (34.2%). All patients in Group 1 received intraoperative ketamine (mean 45.0±9.95 mg, range 30-80 mg) and ketorolac (mean 29.2±3.43 mg, range 15-30mg). No difference was found between groups in intraoperative opioids (Group 1: 64.4±28.7 MME, Group 2: 60.2±27.8 MME, p=0.191), recovery unit opioids (Group 1: 78.6±45.8 MME, Group 2: 84.9±129.1 MME, p=0.476), or mean recovery unit pain scores (Group 1: 5.83±1.62, Group 2: 5.81±1.58, p=0.925). Postoperative inpatient use of scheduled acetaminophen (>96%), gabapentin (>91%), and methocarbamol (>38%) were similar between groups, while ketorolac use was increased in Group 1 (93.6% vs 79.2%). Postoperative inpatient pain scores did not differ among groups (Group 1: 4.03±1.42, Group 2: 4.06±1.35, p=0.827). While not statistically significant, postoperative inpatient opioid use (Group 1: 27.5±27.68 MME, Group 2: 66.6±391.43 MME, p=0.142) and cumulative aggregate opioid use (Group 1: 157.8±70.63 MME, Group 2: 188.91±357.47 MME, p=0.143) were decreased in Group 1. Protocol adherence was associated with a decreased mean length of stay (Group 1: 37.2±14.6 hours, 45.4±55.6 hours, p=0.017). The 30-day readmission rate was 3.7%.
Conclusion:
Cumulative perioperative opioid use following elective bariatric surgery can be safely minimized by adherence to a multifaceted non-narcotic analgesic protocol.
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