Fan Kenneth L, Luvisa Kyle, Black Cara K, Wirth Peter, Nigam Manas, Camden Rachel, Won Lee Dong, Myers Joseph, Song David H
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C.
Georgetown University, School of Medicine, Washington, D.C.
Plast Reconstr Surg Glob Open. 2019 Aug 8;7(8):e2350. doi: 10.1097/GOX.0000000000002350. eCollection 2019 Aug.
The opioid crisis is public health emergency, in part due to physician prescribing practices. As a result, there is an increased interest in reducing narcotic use in the postsurgical setting.
From January 1, 2018, to October 31, 2018, we employed a multidisciplinary, multimodal Enhanced Recovery After Surgery (ERAS) pathway abdominally based free tissue transfer involving the rectus. Preoperative, intraoperative, and postoperative nonnarcotic modalities were emphasized. Factors in reducing narcotic consumption, pain scores, and antiemetic use were identified.
Forty-two patients were included for a total of 66 free flaps, with a 98.4%(65/66) success rate. Average postoperative in-hospital milligram morphine equivalent (MME) use was 37.5, but decreased 85% from 80.9 MME per day to 12.9 MME per day during the study period. Average pain scores and antiemetic doses also decreased. Postoperative gabapentin was associated with a significant 59.8 mg decrease in postoperative MME use, 21% in self-reported pain, and a 2.5 fewer doses of antiemetics administered but increased time to ambulation by 0.89 days. Postoperative acetaminophen was associated with a significant 3.0 point decrease in self-reported pain.
This study represents our early experience. A shift in the institutional mindset of pain control was necessary for adoption of the ERAS protocol. While the ERAS pathway functions to reduce stress and return patients to homeostasis following surgery, postoperative gabapentin resulted in the greatest reduction in postoperative opioid use, self-reported pain, and postoperative nausea vomiting compared to any other modality.
阿片类药物危机是一场公共卫生紧急事件，部分原因在于医生的处方行为。因此，人们对减少术后麻醉药物使用的兴趣日益浓厚。
从2018年1月1日至2018年10月31日，我们采用多学科、多模式的术后加速康复（ERAS）路径，进行涉及腹直肌的腹部游离组织移植。强调术前、术中和术后的非麻醉方式。确定了减少麻醉药物消耗、疼痛评分和止吐药物使用的因素。
纳入42例患者，共进行66次游离皮瓣移植，成功率为98.4%（65/66）。术后住院期间平均吗啡当量（MME）使用量为37.5毫克，但在研究期间从每天80.9毫克降至每天12.9毫克，减少了85%。平均疼痛评分和止吐药物剂量也有所下降。术后加巴喷丁与术后MME使用量显著减少59.8毫克、自我报告疼痛减少21%以及止吐药物使用剂量减少2.5剂相关，但行走时间增加了0.89天。术后对乙酰氨基酚与自我报告疼痛显著降低3.0分相关。
本研究代表了我们的早期经验。采用ERAS方案需要在机构疼痛控制观念上有所转变。虽然ERAS路径的作用是减轻应激并使患者在术后恢复内环境稳定，但与任何其他方式相比，术后加巴喷丁在减少术后阿片类药物使用、自我报告疼痛和术后恶心呕吐方面效果最为显著。
