Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
Division of General Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Division of Surgical Oncology, Department of Oncology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
J Am Coll Surg. 2019 Jan;228(1):81-88.e1. doi: 10.1016/j.jamcollsurg.2018.09.008. Epub 2018 Oct 22.
There has been a dramatic rise in opioid abuse, and diversion of excess, unused prescriptions is a major contributor. We assess the impact of implementing a new standardized pain care bundle to reduce postoperative opioids in outpatient general surgical procedures.
This study was designed to demonstrate non-inferiority for the primary end point: patient-reported average pain in the first 7 postoperative days. We prospectively evaluated 224 patients who underwent laparoscopic cholecystectomy or open hernia repair (inguinal, umbilical) pre-intervention to 192 patients post-intervention. We implemented a multimodal intra- and postoperative analgesic bundle, including promoting co-analgesia, opioid-reduced prescriptions, and patient education designed to clarify patient expectations. Patients completed a brief pain inventory at their first postoperative visit. Groups were compared using chi-square test, Mann-Whitney U test, and independent samples t-test, where appropriate.
No difference was seen in average postoperative pain scores in the pre- vs post-intervention groups (2.3 vs 2.1 of 10; p = 0.12). The reported quality of pain control improved post-intervention (good/very good pain control in 69% vs 85%; p < 0.001). The median total morphine equivalents for prescriptions filled in the post-intervention group were significantly less (100; interquartile range 75 to 116 pre-intervention vs 50; interquartile range 50 to 50 post-intervention; p < 0.001). Only 78 of 172 (45%) patients filled their opioid prescription in the post-intervention group (p < 0.001), with no significant difference in prescription renewals (3.5% pre-intervention vs 2.6% post-intervention; p = 0.62).
For outpatient open hernia repair and cholecystectomy, a standardized pain care bundle decreased opioid prescribing significantly and frequently eliminated opioid use, and adequately treating postoperative pain and improving patient satisfaction.
阿片类药物滥用急剧增加，过量未使用的处方药物的转用是主要原因之一。我们评估了实施新的标准化疼痛护理包以减少门诊普通外科手术后阿片类药物使用的效果。
本研究旨在证明主要终点的非劣效性：患者报告的术后前 7 天平均疼痛。我们前瞻性评估了 224 例接受腹腔镜胆囊切除术或开放性疝修补术（腹股沟、脐部）的患者，在干预前为 192 例患者。我们实施了一种多模式围手术期镇痛包，包括促进共同镇痛、减少阿片类药物处方和患者教育，以明确患者的期望。患者在首次术后就诊时完成简短疼痛量表。使用卡方检验、Mann-Whitney U 检验和独立样本 t 检验对组间进行比较，适当情况下使用。
干预前后组间平均术后疼痛评分无差异（2.3 与 2.1；p=0.12）。术后疼痛控制质量改善（良好/非常好疼痛控制率从 69%提高至 85%；p<0.001）。干预后组中开出的阿片类药物处方的总吗啡当量中位数明显减少（100；四分位距 75 至 116 与 50；四分位距 50 至 50；p<0.001）。仅 78 例（45%）患者在干预后组中开了阿片类药物处方（p<0.001），处方续开率无显著差异（干预前 3.5%与干预后 2.6%；p=0.62）。
对于门诊开放性疝修补术和胆囊切除术，标准化疼痛护理包可显著减少阿片类药物处方，且经常消除阿片类药物的使用，充分治疗术后疼痛并提高患者满意度。
