PSM
Lana Bijelic, MD, FACS (she/her/hers)
Chief, Peritoneal Surface Malignancies Unit
Department of Surgery, CHU Moises Broggi
Sant Joan Despi-Barcelona, Catalonia, Spain
Felipe Solorzano-Ferrer, MD (he/him/his)
Surgical Oncology
Clinica Vida Fundación
Medellin, Antioquia, Colombia
Julian Henao-Ardila, MD
Research Fellow
Peritoneal Surface Malignancies Unit, Department of Surgery, CHU Moises Broggi
Barcelona, Catalonia, Spain
Andrea DeMiguel Perez, MD
Surgeon
Department of General Surgery, CHU Moises Broggi
Barcelona, Spain
Paula sala Carazo, MD
Resident
Department of General Surgery, CHU Moises Broggi, Catalonia, Spain
Ana Centeno Alvarez, MD
Surgeon
Department of General Surgery, CHU Moises Broggi
Barcelona, Catalonia, Spain
Luisana Riba Combatti, MD
Resident
Department of General Surgery, CHU Moises Broggi
Barcelona, Catalonia, Spain
Domenico Sabia, MD
Surgical Oncologist
Peritoneal Surface Malignancies Unit, Department of Surgery, CHU Moises Broggi
Barcelona, Catalonia, Spain
Jaume Tur Martinez, MD
Surgical Oncologist
Peritoneal Surface Malignancies Unit, Department of Surgery, CHU Moises Broggi
Barcelona, Catalonia, Spain
Marina Bosch, MD
Surgical Oncologist
Peritoneal Surface Malignancies Unit, department of Surgery, CHU Moises Broggi, United States
Opioids after surgery are associated with significant side effects and thought to
contribute to potential opioid addiction. There is limited data on pain
management strategies in open abdominal surgery that are primarily
based on non-opioid medications. Our aim was to investigate feasibility, safety and
effectiveness of a systemic opioid free (SOF) pain pathway in cytoreductive surgery.
Methods: This cohort study analyzed patients undergoing open cytoreductive surgery between 2015 and 2018 in a tertiary center. The standardized SOF pathway included epidural infusion, scheduled paracetamol and metamizole with non-steroidal anti-inflammatories as needed. Systemic opioid analgesia (SOA) was permitted for inadequate pain control with the SOF pathway. Administered analgesia and Visual Analogue Scale (VAS) were collected retrospectively and other data from a prospective database.
Results:
There were 370 patients of which 217 (58.6%) completed a SOF postoperative stay, while 153 (41.4%) received some systemic opioids. Baseline characteristics were comparable (Table 1, Panel A). Epidural catheters were successfully placed in 348 patients (94%) and of these, 331 (95.1%) remained in use for at least 2 days. Paracetamol was administered to 365 (98.6%) patients and the mean cumulative number of doses was 33.5 while 350 patients (95%) received metamizol with a mean of 21 doses. Dexketoprofen was used in 307 patients (83%) with a mean of 13 doses. Average daily visual analogue pain scores on postoperative days 1-5 were < 2 in the SOF and < 3 in the opioid patients. Among patients needing opioids, the mean cumulative hospitalization dose was 19.8 mg morphine equivalents (MEQs). Tramadol was the most frequently used opioid with a mean of 2.7 cumulative doses per patient (5.2 mg MEQs), followed by morphine with a mean cumulative dose of 1.6 mg per patient. Epidural related complications occurred in 80 patients (20%) with catheter migration being the most frequent (35 of 348; 10%). On multivariate analysis, complications of epidural analgesia were associated with opioid use (OR 1.14; CI: 1.026-1.273; p=0.015)(Table 1, Panel B.)
Conclusions: A standardized postoperative pain management protocol free of systemic opioids is feasible, safe and effective in cytoreductive surgery. It was associated with complete avoidance of opioids in the majority (58.6%) and a very low average opioid consumption in the remaining patients. Epidural complications were associated with opioids use.