Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
Ann Surg Oncol. 2019 Oct;26(11):3428-3435. doi: 10.1245/s10434-019-07528-z. Epub 2019 Jun 26.
Despite advances in enhanced surgical recovery programs, strategies limiting postoperative inpatient opioid exposure have not been optimized for pancreatic surgery. The primary aims of this study were to analyze the magnitude and variations in post-pancreatectomy opioid administration and to characterize predictors of low and high inpatient use.
Clinical characteristics and inpatient oral morphine equivalents (OMEs) were downloaded from electronic records for consecutive pancreatectomy patients at a high-volume institution between March 2016 and August 2017. Regression analyses identified predictors of total OMEs as well as highest and lowest quartiles.
Pancreatectomy was performed for 158 patients (73% pancreaticoduodenectomy). Transversus abdominus plane (TAP) block was performed for 80% (n = 127) of these patients, almost always paired with intravenous patient-controlled analgesia (IV-PCA), whereas 15% received epidural alone. All the patients received scheduled non-opioid analgesics (median, 2). The median total OME administered was 423 mg (range 0-4362 mg). Higher total OME was associated with preoperative opioid prescriptions (p < 0.001), longer hospital length of stay (LOS; p < 0.001), and no epidural (p = 0.006). The lowest and best quartile cutoff was 180 mg of OME or less, whereas the highest and worst quartile cutoff began at 892.5 mg. After adjustment for inpatient team, only epidural use [odds ratio (OR) 0.3; p = 0.04] predicted lowest-quartile OME. Preoperative opioid prescriptions (OR 8.1; p < 0.001), longer operative time (OR 3.4; p = 0.05), and longer LOS (OR 1.1; p = 0.007) predicted highest-quartile OME.
Preoperative opioid prescriptions and longer LOS were associated with increased inpatient OME, whereas epidural use reduced inpatient OME. Understanding the predictors of inpatient opioid use and the variables predicting the lowest and highest quartiles can inform decision-making regarding preoperative counseling, regional anesthetic block choice, and novel inpatient opioid weaning strategies to reduce initial postoperative opioid exposure.
尽管增强型外科康复方案取得了进展，但限制胰腺手术后住院内阿片类药物暴露的策略尚未针对胰腺手术进行优化。本研究的主要目的是分析胰腺切除术后阿片类药物使用的程度和变化，并确定低剂量和高剂量住院使用的预测因素。
从 2016 年 3 月至 2017 年 8 月，在一家高容量机构的连续胰腺切除术患者的电子记录中下载临床特征和住院口服吗啡等效物（OME）。回归分析确定了总 OME 以及最高和最低四分位数的预测因素。
158 例患者接受了胰腺切除术（73%为胰十二指肠切除术）。80%（n=127）的患者接受了腹横肌平面（TAP）阻滞，几乎总是与静脉自控镇痛（IV-PCA）联合使用，而 15%的患者单独接受了硬膜外麻醉。所有患者均接受了预定的非阿片类镇痛药（中位数 2 种）。给予的 OME 总量中位数为 423mg（范围 0-4362mg）。更高的 OME 总量与术前阿片类药物处方（p<0.001）、更长的住院时间（LOS；p<0.001）和无硬膜外麻醉（p=0.006）相关。最低和最佳四分位的截断值为 180mg 或更少，而最高和最差四分位的截断值从 892.5mg 开始。调整住院团队后，只有硬膜外麻醉的使用（比值比[OR]0.3；p=0.04）预测了最低四分位数的 OME。术前阿片类药物处方（OR 8.1；p<0.001）、手术时间延长（OR 3.4；p=0.05）和 LOS 延长（OR 1.1；p=0.007）预测了最高四分位数的 OME。
术前阿片类药物处方和 LOS 延长与住院 OME 增加相关，而硬膜外麻醉的使用则减少了住院 OME。了解住院阿片类药物使用的预测因素以及预测最低和最高四分位数的变量，可以为术前咨询、区域麻醉阻滞选择以及减少初始术后阿片类药物暴露的新的住院内阿片类药物减药策略提供信息。
