Yan Chen, Wink Jason D, Ligh Cassandra A, Kanchwala Suhail
From the Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia, PA.
Ann Plast Surg. 2020 Nov;85(5):e3-e6. doi: 10.1097/SAP.0000000000002249.
The purposes of this study were to quantify the amount of opioid medication used postoperatively in the hospital setting after abdominally based microsurgical breast reconstruction, to determine factors that are associated with increased opioid use, and to identify other adjunctive medications that may contribute to decreased opioid use.
An electronic medical record data pull was performed at the University of Pennsylvania from November 2016 to October 2018. Cases were identified using Current Procedural Terminology code 19364. Only traditional recovery after surgery protocol patients were included. Patient comorbidities, surgical details, and pain scores were captured. Postoperative medications including non-patient-controlled analgesia opioid use and adjunctive nonopioid pain medications were recorded. Non-patient-controlled analgesia total opioid use was calculated and converted to oral morphine milligram equivalents (mme). Statistical analysis was performed using t test analyses and linear regression.
A total of 328 patients satisfied our inclusion criteria. Five hundred forty free flaps were performed (212 bilateral vs 116 unilateral, 239 immediate vs 89 delayed). Bilateral patients used on average 115.2 mme (95% confidence interval [CI], 103.4-127.0 mme) compared with 89.0 mme in unilateral patients (95% CI, 70.0-108.0 mme; P = 0.015). Patients with abdominal mesh placement (n = 249) required 113.0 mme (95% CI, 100.5-125.5 mme) compared with 83.8 mme (95% CI, 68.8-98.7 mme) for patients without mesh (n = 79; P = 0.016). Each additional hour of surgery increased postoperative mme by 9.4 (P < 0.01). Patients with a nonzero preoperative pain score required 100.3 mme (95% CI, 90.2-110.4 mme) compared with 141.1 mme (95% CI, 102.7-179.7 mme) for patients with preoperative pain score greater than 0/10 (P < 0.01). Patients with postoperative index pain score ≤5/10 required 89.2 mme (95% CI, 78.6-99.8 mme) compared with 141.1 mme (95% CI, 119.9-162.2 mme) for patients with postoperative index pain score >5/10 (P < 0.01). After regression analysis, a dose of intravenous acetaminophen 1000 mg was found to decrease postoperative mme by 11.7 (P = 0.024). A dose of oral ibuprofen 600 mg was found to decrease postoperative mme by 8.3 (P < 0.01).
Bilateral reconstruction and longer surgery resulted in increased postoperative mme. Patients with no preoperative pain required less opioids than did patients with preexisting pain. Patients with good initial postoperative pain control required less opioids than did patients with poor initial postoperative pain control. Intravenous acetaminophen and oral ibuprofen were found to significantly decrease postoperative mme.
本研究的目的是量化腹部显微外科乳房重建术后在医院环境中使用的阿片类药物量，确定与阿片类药物使用增加相关的因素，并识别可能有助于减少阿片类药物使用的其他辅助药物。
2016年11月至2018年10月在宾夕法尼亚大学进行了电子病历数据提取。使用当前手术操作术语代码19364识别病例。仅纳入采用传统术后恢复方案的患者。记录患者的合并症、手术细节和疼痛评分。记录术后药物，包括非患者自控镇痛阿片类药物的使用和辅助性非阿片类疼痛药物。计算非患者自控镇痛阿片类药物的总使用量并转换为口服吗啡毫克当量（mme）。使用t检验分析和线性回归进行统计分析。
共有328例患者符合我们的纳入标准。共进行了540次游离皮瓣移植手术（212例双侧，116例单侧；239例即刻手术，89例延迟手术）。双侧手术患者平均使用115.2 mme（95%置信区间[CI]，103.4 - 127.0 mme），单侧手术患者为89.0 mme（95% CI，70.0 - 108.0 mme；P = 0.015）。放置腹部网片的患者（n = 249）需要113.0 mme（95% CI，100.5 - 125.5 mme），未放置网片的患者（n = 79）为83.8 mme（95% CI，68.8 - 98.7 mme；P = 0.016）。手术每增加一小时，术后mme增加9.4（P < 0.01）。术前疼痛评分为非零的患者需要100.3 mme（95% CI，90.2 - 110.4 mme），术前疼痛评分大于0/10的患者为141.1 mme（95% CI，102.7 - 179.7 mme）（P < 0.01）。术后指数疼痛评分≤5/10的患者需要89.2 mme（95% CI，78.6 - 99.8 mme），术后指数疼痛评分>5/10的患者为141.1 mme（95% CI，119.9 - 162.2 mme）（P < 0.01）。回归分析后发现，静脉注射1000 mg对乙酰氨基酚可使术后mme减少11.7（P = 0.024）。口服600 mg布洛芬可使术后mme减少8.3（P < 0.01）。
双侧重建和手术时间延长导致术后mme增加。术前无疼痛的患者比有疼痛的患者需要更少的阿片类药物。术后初始疼痛控制良好的患者比术后初始疼痛控制不佳的患者需要更少的阿片类药物。发现静脉注射对乙酰氨基酚和口服布洛芬可显著减少术后mme。
