Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX.
Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX.
Surgery. 2022 Feb;171(2):504-510. doi: 10.1016/j.surg.2021.08.039. Epub 2021 Nov 2.
Enhanced Recovery After Surgery programs have been shown to effectively reduce opioid prescriptions at discharge after their implementation in several institutions, but little is known regarding the sustainability of this effect. Understanding opioid prescribing patterns after long-term implementation of Enhanced Recovery After Surgery initiatives may help guide further opioid prescription reduction and improvements. Our group aimed to determine whether reductions in opioid prescriptions at discharge are sustained in an Enhanced Recovery After Surgery program for thoracic surgery.
This retrospective cohort included 2,081 patients undergoing thoracic surgery within a 4-year Enhanced Recovery After Surgery program from March 2016 through April 2020. Our Enhanced Recovery After Surgery protocol included a standardized multimodal analgesic regimen (ie, preoperative gabapentin, tramadol, intercostal nerve block with liposomal bupivacaine, and intraoperative acetaminophen, and ketorolac) and the rest of the interventions recommended by the Enhanced Recovery After Surgery society guidelines. Our primary outcomes were the presence of opioid prescriptions at discharge (hydrocodone, hydromorphone, and oxycodone) and the total opioid amount prescribed (morphine equivalent daily dose). Multilevel generalized linear models were used to account for surgeon variabilities and types of thoracic resection.
Over the study period, the rate of opioid prescriptions at discharge reduced from 35% (Mar 2016) to 25% (Apr 2020), and the amount of opioid prescribed declined from 184 ± 321 morphine equivalent daily dose to 94 ± 251 morphine equivalent daily dose. In multilevel generalized linear models, there was a sustained downward trend in opioid prescriptions over the study period (β -11.8 morphine equivalent daily dose per year, P = .048), which was also directly correlated with the use of minimally invasive surgery (β -84.9 morphine equivalent daily dose for video-assisted thoracoscopic surgery, P < .001; β -139.2 morphine equivalent daily dose for robotic-assisted thoracic surgery, P < .001), intraoperative opioid administration (β -1.4 morphine equivalent daily dose per 1 morphine equivalent dose, P = .026), and the amount of postoperative acetaminophen (β -18.2 morphine equivalent daily dose per 1 g, P = .026). The sustained reduction of opioid prescriptions at discharge did not impact hospital readmission rates within 30 days (odds ratio 1.17, 95% confidence interval 0.86-1.59, P = .306). Subgroup analysis showed a significant, sustained decrease in hydromorphone (β -10.9 morphine equivalent daily dose per year, P = .004), but not for hydrocodone prescriptions (β -5.7 morphine equivalent daily dose per year, P = .168) or oxycodone (β +4.78 morphine equivalent daily dose per year, P = .183).
Our Enhanced Recovery After Surgery program for thoracic surgery contributed to a sustained reduction of opioid prescriptions at discharge, which positively correlated with the duration of its implementation and the use of minimally invasive surgical techniques but was negatively impacted by the amount of intraoperative opioid administration.
增强型术后恢复计划在多个机构实施后，已被证明可有效减少出院时的阿片类药物处方，但对这种效果的可持续性知之甚少。了解增强型术后恢复计划长期实施后的阿片类药物处方模式可能有助于指导进一步减少阿片类药物处方和改进。我们的小组旨在确定在胸外科的增强型术后恢复计划中，出院时阿片类药物处方的减少是否持续。
本回顾性队列纳入了 2081 名在 2016 年 3 月至 2020 年 4 月为期 4 年的增强型术后恢复计划中接受胸外科手术的患者。我们的增强型术后恢复方案包括标准化的多模式镇痛方案（即术前加巴喷丁、曲马多、脂质体布比卡因肋间神经阻滞和术中对乙酰氨基酚和酮咯酸）和增强型术后恢复协会指南推荐的其他干预措施。我们的主要结局是出院时存在阿片类药物处方（氢可酮、氢吗啡酮和羟考酮）和开出的阿片类药物总量（吗啡等效日剂量）。使用多水平广义线性模型来解释外科医生的变异性和胸科手术的类型。
在研究期间，出院时开具阿片类药物处方的比例从 35%（2016 年 3 月）降至 25%（2020 年 4 月），开出的阿片类药物量从 184±321 吗啡等效日剂量降至 94±251 吗啡等效日剂量。在多水平广义线性模型中，研究期间阿片类药物处方呈持续下降趋势（每年 -11.8 吗啡等效日剂量，P=0.048），这与微创手术的使用直接相关（电视辅助胸腔镜手术每例 -84.9 吗啡等效日剂量，P<0.001；机器人辅助胸腔镜手术每例 -139.2 吗啡等效日剂量，P<0.001）、术中阿片类药物的使用（每 1 吗啡当量剂量增加 1.4 吗啡当量日剂量，P=0.026）和术后对乙酰氨基酚的用量（每增加 1g 对乙酰氨基酚增加 18.2 吗啡当量日剂量，P=0.026）。出院时阿片类药物处方的持续减少并未影响 30 天内的医院再入院率（比值比 1.17，95%置信区间 0.86-1.59，P=0.306）。亚组分析显示，氢吗啡酮的显著、持续减少（每年 -10.9 吗啡当量日剂量，P=0.004），但氢可酮（每年 -5.7 吗啡当量日剂量，P=0.168）或羟考酮（每年 +4.78 吗啡当量日剂量，P=0.183）的处方无显著变化。
我们的胸外科增强型术后恢复计划有助于出院时阿片类药物处方的持续减少，这与该计划的实施时间长短和微创手术技术的使用呈正相关，但与术中阿片类药物的使用量呈负相关。
