New Post-op Pain Management Technique Cuts Need for Opioids

Neil Chesanow


August 07, 2015

In This Article

An Orthopedic Surgeon-Fueled Opioid Epidemic

A report by the Journal of the American Academy of Orthopaedic Surgeons last May noted that "the past few decades have seen an alarming rise in opioid use in the United States," that "a significant number of orthopaedic patients are at risk for the repercussions from both therapeutic and nontherapeutic opioid use," and that "orthopaedic surgeons are the third highest prescribers of opioid prescriptions among physicians in the United States, contributing to what the journal called an "opioid epidemic."[1]

While patients undergoing orthopedic procedures often experience a considerable amount of pain, new techniques for managing postoperative pain can substantially reduce narcotic consumption with stable or improved pain scores and yield greater patient satisfaction for patients with acute pain, as two recent studies—one in anterior lumbar interbody fusion (ALIF), the other in complex foot and ankle surgery—illustrate.

In both studies, the surgeons employed the ON-Q* Pain Relief System (Halyard Health [formerly Kimberly-Clark Health Care]; Alpharetta, Georgia), a nonnarcotic elastomeric pump that automatically and continuously delivers a regulated flow of local anesthetic to a patient's surgical site in close proximity to nerves.[2] Study data were presented in posters at the American Society of Regional Anesthesia and Pain Medicine (ASRA) Annual Meeting in Las Vegas last May.

Reducing Opioid Need in Post-op Lumbar Fusion Patients

In one study, continuous infusion of local anesthetic (ropivacaine) via transversus abdominus plane (TAP) block using ON-Q* for postoperative pain management was compared with a single injection of liposomal bupivacaine following ALIF.[3] A retrospective review of 100 cases was conducted in which bilateral TAP blocks were placed at the conclusion of the surgery prior to the emergence of all patients.

As detailed in the poster, 50 patients received bilateral continuous TAP block with a loading dose of 30 mL 0.5% ropivacaine per side followed by a 0.2% ropivacaine infusion.[3] Another 50 patients received bilateral single-injection TAP blocks with 10 mL of 0.5% bupivacaine followed by 10 mL of liposomal bupivacaine (133 mg) expanded to 20 mL with 10 mL of normal saline, for a total loading volume of 30 mL per side. Ultrasound visualization was used during the performance of the TAP blocks.

All patients had access to analgesics for breakthrough pain after surgery.[3] Catheters in the continuous-TAP group remained in place until the morning of postop day 2, approximately 36-40 hours after placement. Outcome measures included opioid use, return of bowel function, patient-reported pain intensity, and length of hospital stay. Patients undergoing spine procedures with an anterior surgical approach and who had an American Society of Anesthesiologists Physical Status category of 1-5 were included. Those with a prior allergic reaction to bupivacaine, ropivacaine, lidocaine, or related drugs were excluded.

In the continuous-TAP group, opioid consumption was statistically reduced throughout the hospital stay, with reductions of 46%, 35%, and 34% on days 1, 2, and in total (P < .0001, .02, and .0004, respectively), the investigators found, with bowel function returning 1 day earlier (P = .008).[3] Patients in the continuous-TAP group met discharge criteria and were discharged home 1 day earlier (3.0 vs 4.0, P < .0001). There were no differences in mean reported pain scores despite the reduction in narcotics.

Although the study was limited by being a retrospective chart review, it was the first published report to compare continuous TAP vs liposomal bupivacaine for TAP infiltration as primary analgesia following ALIF procedures. Continuous TAP block provided superior analgesia compared with a TAP block with liposomal lidocaine by reducing narcotic consumption without loss of analgesia. Once the continuous-TAP catheters were removed and no longer functional, no difference in analgesia was seen.


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