Low-opioid Multimodal Pain Control Strategies Reduce Narcotic Utilization in Sleeve Gastrectomy Patients

Kyle Kleppe, MD, Hien Le, MD, Gregory Mancini, MD. UT Medical Center – Knoxville

Introduction: With the advent of enhanced recovery protocols, peri-operative multimodal pain control methodologies have been employed increasingly in an effort to reduce opioid use, improve post-operative pain control, and decrease length of stay. Our bariatric program has adopted use of low-opioid multimodal therapies in an effort to accomplish these goals in sleeve gastrectomy patients. Utilization of liposomal bupivacaine as intra-operative local anesthetic as well as pre- and post-operative administration of intravenous acetaminophen has allowed for us to transition from traditional use of patient controlled analgesia (PCA) pumps. This study evaluates our sleeve gastrectomy population for significant effects from instituting these strategies on analgesic use and length of stay.

Methods: A single institution, retrospective cohort study of 282 successive sleeve gastrectomy patients from 2010 to 2015 were selected from our bariatric database. Inclusion criteria required single operation during hospital admission, no utilization of opioids preoperatively, and complete data for analysis. Patient data points analyzed included intraoperative local anesthetic choice, IV acetaminophen use, and post-operative PCA use on post-anesthesia care unit (PACU) time to floor readiness, PACU narcotic administration, floor narcotic use, and floor length of stay. Nonparametric between subjects statistics were used as our findings were not normally distributed.

Results: Significant reduction in PACU narcotic use was observed dependent on choice of local anesthetic.  Lidocaine 1% / bupivicaine 0.25% versus bupivacaine 0.25% (median PO morphine equivalents 10 vs 20mg p < .001) and liposomal bupivacaine versus bupivacaine 0.25% (median PO morphine equivalents 16 vs 20mg p = .01) demonstrated a reduction. PACU time to readiness and narcotic consumption was not influenced by preoperative IV acetaminophen use. Post-operative PCA use resulted in significantly higher floor narcotic consumption (76.5mg vs. 23.5mg PO morphine equivalents, p < .001). Increased floor narcotic use had a significant positive correlation with increased length of stay (r = .31, p < .001, r2 = .10).

Conclusion: A multimodal, opioid-sparing approach to perioperative analgesia, compared to standard pain control methods utilizing PCA, contributes to reduced narcotic use in the peri-operative period of sleeve gastrectomy patients and may lead to shorter hospital length of stay. Narcotic related peri-operative complications have been well documented and should be evaluated in further prospective studies.

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