Effect of standardized multimodal analgesia on opioid consumption after major upper abdominal surgery under enhanced recovery after surgery pathway_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

CHEN Yu ^1,2 , YU Hong ¹ , LI Chengyu ¹ , CHEN Dongxu ¹ , YANG Lei ¹ , LIU Fei ¹ ,  LI Qian ¹

1. Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;
2. Department of Anesthesiology, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu 610041, P. R. China;

Corresponding author：

LI Qian, Email: hxliqian@foxmail.com

Keywords：

multimodal analgesia; enhanced recovery after surgery; major upper abdominal surgery; opioid consumption

DOI：

10.7507/1007-9424.202111057

Video：

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Objective To explore the effect of standardized multimodal analgesia (SMA) on opioid consumption after major upper abdominal surgery under enhanced recovery after surgery pathway. Methods Patients who underwent major upper abdominal surgery in the West China Hospital of Sichuan University between August and November 2020 were included prospectively. The patients were divided into two groups: SMA group (n=175) and control group (n=632). The SMA was defined as preoperative and postoperative use of non-steroidal anti-inflammatory drugs, combined with regional anesthesia, local anesthetic wound infiltration or intrathecal opioid. The postoperative opioid consumption in oral morphine equivalents, the pain scores on movement and at rest, the postoperative rehabilitation were recorded and compared between the two groups. Results Patients in the SMA group had a lower opioid consumption during the first 72 h compared to patients in the control group (median: 51 mg vs. 85 mg, P<0.001). The pain scores on movement and at rest at 24, 48, 72 h after surgery in the SMA group were lower than those in the control group (P<0.05). Time to first flatus, time to first ambulation, postoperative hospital stay in the SMA group were significantly shorter than those in the control group (P<0.05), and the quality of life scores at 5 d after surgery increased significantly (P<0.05). The satisfaction with analgesia and the incidence of adverse effects on day 5 after surgery had no statistical significances between the two groups (P>0.05). After controlling for confounding factors, multiple linear regression analysis showed that SMA was associated with less opioid consumption on hour 72 after surgery (P<0.001). Conclusion SMA can reduce postoperative opioid consumption in patients undergoing major upper abdominal surgery.

Citation： CHEN Yu, YU Hong, LI Chengyu, CHEN Dongxu, YANG Lei, LIU Fei, LI Qian. Effect of standardized multimodal analgesia on opioid consumption after major upper abdominal surgery under enhanced recovery after surgery pathway. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2022, 29(4): 475-480. doi: 10.7507/1007-9424.202111057 Copy

1.	Gerbershagen HJ, Aduckathil S, van Wijck AJ, et al. Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology, 2013, 118(4): 934-944.
2.	Sommer M, de Rijke JM, van Kleef M, et al. The prevalence of postoperative pain in a sample of 1 490 surgical inpatients. Eur J Anaesthesiol, 2008, 25(4): 267-274.
3.	Ahmed A, Latif N, Khan R. Post-operative analgesia for major abdominal surgery and its effectiveness in a tertiary care hospital. J Anaesthesiol Clin Pharmacol, 2013, 29(4): 472-477.
4.	Kharasch ED, Brunt LM. Perioperative opioids and public health. Anesthesiology, 2016, 124(4): 960-965.
5.	Shah A, Hayes CJ, Martin BC. Factors influencing long-term opioid use among opioid naive patients: an examination of initial prescription characteristics and pain etiologies. J Pain, 2017, 18(11): 1374-1383.
6.	Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review. JAMA Surg, 2017, 152(7): 691-697.
7.	Colvin LA, Bull F, Hales TG. Perioperative opioid analgesia-when is enough too much? A review of opioid-induced tolerance and hyperalgesia. Lancet, 2019, 393(10180): 1558-1568.
8.	Bell TM, Raymond J, Vetor A, et al. Long-term prescription opioid utilization, substance use disorders, and opioid overdoses after adolescent trauma. J Trauma Acute Care Surg, 2019, 87(4): 836-840.
9.	Chen Q, Chen E, Qian X. A narrative review on perioperative pain management strategies in enhanced recovery pathways-the past, present and future. J Clin Med, 2021, 10(12): 2568. doi: 10.3390/jcm10122568.
10.	Weston E, Noel M, Douglas K, et al. The impact of an enhanced recovery after minimally invasive surgery program on opioid use in gynecologic oncology patients undergoing hysterectomy. Gynecol Oncol, 2020, 157(2): 469-475.
11.	Reiterer C, Kabon B, Taschner A, et al. Perioperative supplemental oxygen and NT-proBNP concentrations after major abdominal surgery—a prospective randomized clinical trial. J Clin Anesth, 2021, 73: 110379.doi: 10.1016/j.jclinane.2021.110379.
12.	Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain, 2016, 17(2): 131-157.
13.	中华医学会麻醉学分会. 成人手术后疼痛处理专家共识. 临床麻醉学杂志, 2017, 33(9): 911-917.
14.	Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet, 2019, 393(10180): 1547-1557.
15.	Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician, 2008, 11(2 Suppl): S105-S120.
16.	Hill MV, Stucke RS, Billmeier SE, et al. Guideline for discharge opioid prescriptions after inpatient general surgical procedures. J Am Coll Surg, 2018, 226(6): 996-1003.
17.	中华医学会外科学分会, 中华医学会麻醉学分会. 加速康复外科中国专家共识及路径管理指南 (2018版). 中国实用外科杂志, 2018, 38(1): 1-20.
18.	Botti MA, Rasmussen B, Khaw DA, et al. Analgesic outcomes in a danish acute care hospital following electronic prescribing and analgesic self-administration. Pain Manag Nurs, 2020, 21(4): 345-353.
19.	Martinez L, Ekman E, Nakhla N. Perioperative opioid-sparing strategies: utility of conventional NSAIDs in adults. Clin Ther, 2019, 41(12): 2612-2628.
20.	Dieu A, Huynen P, Lavand’homme P, et al. Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations. Reg Anesth Pain Med, 2021, 46(5): 433-445.
21.	Abdelsalam K, Mohamdin OW. Ultrasound-guided rectus sheath and transversus abdominis plane blocks for perioperative analgesia in upper abdominal surgery: a randomized controlled study. Saudi J Anaesth, 2016, 10(1): 25-28.
22.	Dichtwald S, Ben-Haim M, Papismedov L, et al. Intrathecal morphine versus intravenous opioid administration to impact postoperative analgesia in hepato-pancreatic surgery: a randomized controlled trial. J Anesth, 2017, 31(2): 237-245.
23.	Wu YF, Li XP, Yu YB, et al. Postoperative local incision analgesia for acute pain treatment in patients with hepatocellular carcinoma. Rev Assoc Med Bras (1992), 2018, 64(2): 175-180.
24.	Liu R, Qin H, Wang M, et al. Transversus abdominis plane block with general anesthesia blunts the perioperative stress response in patients undergoing radical gastrectomy. BMC Anesthesiol, 2019, 19(1): 205. doi: 10.1186/s12871-019-0861-0.
25.	Kong M, Li X, Shen J, et al. The effectiveness of preemptive analgesia for relieving postoperative pain after video-assisted thoracoscopic surgery (VATS): a prospective, non-randomized controlled trial. J Thorac Dis, 2020, 12(9): 4930-4940.
26.	Sun JX, Bai KY, Liu YF, et al. Effect of local wound infiltration with ropivacaine on postoperative pain relief and stress response reduction after open hepatectomy. World J Gastroenterol, 2017, 23(36): 6733-6740.
27.	Ge X, Pan Y, Jin D, et al. Effect of perioperative use of parecoxib on chronic post-surgical pain in elderly patients after hepatectomy: a prospective randomized controlled study. BMC Pharmacol Toxicol, 2021, 22(1): 35. doi: 10.1186/s40360-021-00501-1.
28.	Jien H, Xiaohua L. Laparoscopic versus open surgery in the treatment of hepatic hemangioma: a meta-analysis. Medicine (Baltimore), 2021, 100(8): e24155. doi: 10.1097/MD.0000000000024155.
29.	Wild J, Yamada T, Arjona Ferreira JC, et al. Onset of action of naldemedine in the treatment of opioid-induced constipation in patients with chronic noncancer pain: results from 2 randomized, placebo-controlled, phase 3 trials. Pain, 2019, 160(10): 2358-2364.
30.	Sun EC, Darnall BD, Baker LC, et al. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med, 2016, 176(9): 1286-1293.

1. Gerbershagen HJ, Aduckathil S, van Wijck AJ, et al. Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology, 2013, 118(4): 934-944.
2. Sommer M, de Rijke JM, van Kleef M, et al. The prevalence of postoperative pain in a sample of 1 490 surgical inpatients. Eur J Anaesthesiol, 2008, 25(4): 267-274.
3. Ahmed A, Latif N, Khan R. Post-operative analgesia for major abdominal surgery and its effectiveness in a tertiary care hospital. J Anaesthesiol Clin Pharmacol, 2013, 29(4): 472-477.
4. Kharasch ED, Brunt LM. Perioperative opioids and public health. Anesthesiology, 2016, 124(4): 960-965.
5. Shah A, Hayes CJ, Martin BC. Factors influencing long-term opioid use among opioid naive patients: an examination of initial prescription characteristics and pain etiologies. J Pain, 2017, 18(11): 1374-1383.
6. Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review. JAMA Surg, 2017, 152(7): 691-697.
7. Colvin LA, Bull F, Hales TG. Perioperative opioid analgesia-when is enough too much? A review of opioid-induced tolerance and hyperalgesia. Lancet, 2019, 393(10180): 1558-1568.
8. Bell TM, Raymond J, Vetor A, et al. Long-term prescription opioid utilization, substance use disorders, and opioid overdoses after adolescent trauma. J Trauma Acute Care Surg, 2019, 87(4): 836-840.
9. Chen Q, Chen E, Qian X. A narrative review on perioperative pain management strategies in enhanced recovery pathways-the past, present and future. J Clin Med, 2021, 10(12): 2568. doi: 10.3390/jcm10122568.
10. Weston E, Noel M, Douglas K, et al. The impact of an enhanced recovery after minimally invasive surgery program on opioid use in gynecologic oncology patients undergoing hysterectomy. Gynecol Oncol, 2020, 157(2): 469-475.
11. Reiterer C, Kabon B, Taschner A, et al. Perioperative supplemental oxygen and NT-proBNP concentrations after major abdominal surgery—a prospective randomized clinical trial. J Clin Anesth, 2021, 73: 110379.doi: 10.1016/j.jclinane.2021.110379.
12. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain, 2016, 17(2): 131-157.
13. 中华医学会麻醉学分会. 成人手术后疼痛处理专家共识. 临床麻醉学杂志, 2017, 33(9): 911-917.
14. Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet, 2019, 393(10180): 1547-1557.
15. Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician, 2008, 11(2 Suppl): S105-S120.
16. Hill MV, Stucke RS, Billmeier SE, et al. Guideline for discharge opioid prescriptions after inpatient general surgical procedures. J Am Coll Surg, 2018, 226(6): 996-1003.
17. 中华医学会外科学分会, 中华医学会麻醉学分会. 加速康复外科中国专家共识及路径管理指南 (2018版). 中国实用外科杂志, 2018, 38(1): 1-20.
18. Botti MA, Rasmussen B, Khaw DA, et al. Analgesic outcomes in a danish acute care hospital following electronic prescribing and analgesic self-administration. Pain Manag Nurs, 2020, 21(4): 345-353.
19. Martinez L, Ekman E, Nakhla N. Perioperative opioid-sparing strategies: utility of conventional NSAIDs in adults. Clin Ther, 2019, 41(12): 2612-2628.
20. Dieu A, Huynen P, Lavand’homme P, et al. Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations. Reg Anesth Pain Med, 2021, 46(5): 433-445.
21. Abdelsalam K, Mohamdin OW. Ultrasound-guided rectus sheath and transversus abdominis plane blocks for perioperative analgesia in upper abdominal surgery: a randomized controlled study. Saudi J Anaesth, 2016, 10(1): 25-28.
22. Dichtwald S, Ben-Haim M, Papismedov L, et al. Intrathecal morphine versus intravenous opioid administration to impact postoperative analgesia in hepato-pancreatic surgery: a randomized controlled trial. J Anesth, 2017, 31(2): 237-245.
23. Wu YF, Li XP, Yu YB, et al. Postoperative local incision analgesia for acute pain treatment in patients with hepatocellular carcinoma. Rev Assoc Med Bras (1992), 2018, 64(2): 175-180.
24. Liu R, Qin H, Wang M, et al. Transversus abdominis plane block with general anesthesia blunts the perioperative stress response in patients undergoing radical gastrectomy. BMC Anesthesiol, 2019, 19(1): 205. doi: 10.1186/s12871-019-0861-0.
25. Kong M, Li X, Shen J, et al. The effectiveness of preemptive analgesia for relieving postoperative pain after video-assisted thoracoscopic surgery (VATS): a prospective, non-randomized controlled trial. J Thorac Dis, 2020, 12(9): 4930-4940.
26. Sun JX, Bai KY, Liu YF, et al. Effect of local wound infiltration with ropivacaine on postoperative pain relief and stress response reduction after open hepatectomy. World J Gastroenterol, 2017, 23(36): 6733-6740.
27. Ge X, Pan Y, Jin D, et al. Effect of perioperative use of parecoxib on chronic post-surgical pain in elderly patients after hepatectomy: a prospective randomized controlled study. BMC Pharmacol Toxicol, 2021, 22(1): 35. doi: 10.1186/s40360-021-00501-1.
28. Jien H, Xiaohua L. Laparoscopic versus open surgery in the treatment of hepatic hemangioma: a meta-analysis. Medicine (Baltimore), 2021, 100(8): e24155. doi: 10.1097/MD.0000000000024155.
29. Wild J, Yamada T, Arjona Ferreira JC, et al. Onset of action of naldemedine in the treatment of opioid-induced constipation in patients with chronic noncancer pain: results from 2 randomized, placebo-controlled, phase 3 trials. Pain, 2019, 160(10): 2358-2364.
30. Sun EC, Darnall BD, Baker LC, et al. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med, 2016, 176(9): 1286-1293.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Effect of standardized multimodal analgesia on opioid consumption after major upper abdominal surgery under enhanced recovery after surgery pathway

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