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Nonopioid analgesics, patient selection may reduce adverse events
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Implementing an enhanced recovery strategy for outpatient total knee replacement and spine surgery that uses multimodal analgesia strategy instead of predominantly opioids may reduce postoperative adverse events, according to anesthesiologist Tong Joo (TJ) Gan, MD, MBA, FRCA, MHS, professor and chairman of the department of anesthesiology at Stony Brook Medicine in Stony Brook, New York. Longer hospital stays are often related to the pain and opioid-related side effects after these procedures, he said.
“Enhanced recovery strategy integrates evidence-based practice into routine postoperative care. Pain, nausea, vomiting, rehabilitation are major constraints for patients having same day surgery,” Gan said. “Carefully selecting your patient in combination with enhanced recovery principles and pathway can enable total knee replacement [and] spine surgery to be performed on an outpatient basis.”
Studies show 70% to 80% of patients experience some severe pain postoperatively. To reduce pain and make patients more comfortable, surgeons tend to use opioids, Gan said.
The adverse events of opioid use may increase surgical costs, as well as length of stay. Two new classes of opioids — kappa opioids and opioid modulators — may provide pain relief with fewer traditional opiate-related adverse events, Gan told Orthopedics Today.
In his presentation Gan noted the American Society of Anesthesiologists promotes starting patients on nonopioid local analgesics as a foundation for analgesia and supports using opioids only in rescue situations.
“In fact, many programs across the country are now starting to use nonopioid techniques, as well as nerve blocks using local anesthetic, and many of them can achieve a minimal opioid, even opioid-free, surgery,” Gan said.
Acetaminophen has shown positive results when administered via IV or orally depending on the patient’s nulla per os or NPO status. Low-dose gabapentin used in the perioperative period can reduce nausea and vomiting because it reduces the amount of opioid. Similarly, low-dose ketamine reduces the need for opioids, Gan noted.
He told Orthopedics Today nonopioid treatments now under investigation include a drug that is similar to long-acting bupivacaine, but with a different formulation. “It lasts about 48 to 72 hours longer than the standard bupivacaine,” Gan said.
Another treatment in phase 3 trials is a combination drug of long-acting bupivacaine with meloxicam, which is a NSAID, according to Gan.
“There is another drug that is called a local anesthetic sponge and ... you put it in before you close the wound,” he said. “You can lay it along the tissues and then it gradually releases the local anesthetic.”
Steroids also may be effective and “have many positive effects in the perioperative patients,” Gan said in a presentation. In addition to being an anti-inflammatory and a drug to reduce postoperative nausea and vomiting, it can significantly reduce pain, he noted.
Steroids, however, can also increase the risk of infection and are associated with avascular necrosis of the bone and cancer, although the risk is extremely low during a short period of use, according to Gan. – by Casey Tingle
- References:
- Viscusi ER, et al. Posters #3681 and #3682. Presented at: Annual Regional Anesthesiology and Acute Pain Medicine Meeting; April 6-8, 2017; San Francisco.
- For more information:
- Tong Joo Gan, MD, MBA, FRCA, MHS, can be reached at Stony Brook University Hospital, 101 Nicolls Rd., Stony Brook, NY 11794; email: tong.gan@stonybrookmedicine.edu.
Disclosure: Gan reports no relevant financial disclosures.