Association of Intraoperative Opioid Administration With Postoperative Pain and Opioid Use.
Association of Intraoperative Opioid Administration With Postoperative Pain and Opioid Use.
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DOI：
10.1001/jamasurg.2023.2009
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发表时间：
2023-08-01
期刊：
影响因子：
16.9
通讯作者：
Purdon, Patrick L.
中科院分区：
文献类型：
--
作者：
Mercado, Laura A. Santa Cruz A.;Liu, Ran;Bharadwaj, Kishore M.;Johnson, Jasmine J.;Gutierrez, Rodrigo;Das, Proloy;Balanza, Gustavo;Deng, Hao;Pandit, Akriti;Stone, Tom A. D.;Macdonald, Teresa;Horgan, Caroline;Tou, Si Long (Jenny);Houle, Timothy T.;Bittner, Edward A.;Purdon, Patrick L.
术中阿片类药物给药与术后疼痛和阿片类药物使用之间的关系是什么？在这项对61249名接受手术的患者进行的队列研究中，术中给予更多芬太尼和氢吗啡酮与麻醉后护理病房的疼痛和阿片类药物给药减少相关。特别是，更大的芬太尼给药与3个月时新的慢性疼痛诊断减少，30，90和180天的阿片类药物处方减少以及新的持续阿片类药物使用减少有关，而不良反应没有显著增加。结果表明，术中阿片类药物给药与短期和长期术后疼痛和阿片类药物结局相关;手术期间减少阿片类药物给药可能会导致术后疼痛和阿片类药物使用增加的非预期结局。这项队列研究评估了术中阿片类药物使用与术后疼痛和阿片类药物使用之间的相关性。用于治疗术后疼痛的阿片类药物是阿片类药物危机的主要原因，导致相当大比例的患者长期使用。倡导无阿片类药物或阿片类药物保留的围手术期疼痛管理模式的举措已导致手术室中阿片类药物给药减少，但这种减少可能对术后疼痛结局产生不可预见的不利影响，因为术中阿片类药物使用与后期阿片类药物需求之间的关系尚不清楚。描述术中阿片类药物使用与术后疼痛和阿片类药物需求之间的相关性。这项回顾性队列研究评价了2016年4月至2020年3月期间在全身麻醉下接受非心脏手术的成人患者的四级护理学术医疗中心（马萨诸塞州综合医院）的电子健康记录数据。排除接受剖宫产手术、接受区域麻醉、接受芬太尼或氢吗啡酮以外的阿片类药物治疗、入住重症监护室或术中死亡的患者。在倾向加权数据集上拟合统计模型，以表征术中阿片类药物暴露对主要和次要结局的影响。数据分析时间为2021年12月至2022年10月。使用药代动力学/药效学模型估计术中芬太尼和术中氢吗啡酮平均效应部位浓度。主要研究结局为麻醉后监护室（PACU）停留期间的最大疼痛评分和PACU停留期间给予的累积阿片类药物剂量（以吗啡毫克当量（MME）量化）。还评估了与疼痛和阿片类药物依赖相关的中长期结局。研究队列共包括61249例接受手术的个体（平均[SD]年龄，55.44 [17.08]岁; 32778 [53.5%]女性）。术中芬太尼和术中氢吗啡酮的增加都与PACU中最大疼痛评分的降低相关。这两种暴露也与PACU中阿片类药物给药的概率降低和总剂量减少相关。特别是，增加芬太尼给药与不受控制的疼痛频率降低有关; 3个月时报告的新慢性疼痛诊断减少; 30天，90天和180天的阿片类药物处方减少;新的持续阿片类药物使用减少，不良反应没有显著增加。与流行趋势相反，手术期间减少阿片类药物给药可能会导致术后疼痛和阿片类药物消耗增加的意外结果。相反，通过优化手术期间的阿片类药物给药，可以改善长期结局。
What is the association between intraoperative opioid administration and postoperative pain and opioid use? In this cohort study of 61 249 individuals undergoing surgery, greater intraoperative fentanyl and hydromorphone administration was associated with decreased pain and opioid administration in postanesthesia care units. In particular, greater fentanyl administration was associated with decreased new chronic pain diagnoses at 3 months, decreased opioid prescriptions at 30, 90, and 180 days, and decreased new persistent opioid use, without significant increases in adverse effects. The results indicate that intraoperative opioid administration was associated with short- and long-term postoperative pain and opioid outcomes; reduced opioid administration during surgery may have the unintended outcome of increasing postoperative pain and opioid use. This cohort study evaluates associations between intraoperative opioid use and postoperative pain and opioid use. Opioids administered to treat postsurgical pain are a major contributor to the opioid crisis, leading to chronic use in a considerable proportion of patients. Initiatives promoting opioid-free or opioid-sparing modalities of perioperative pain management have led to reduced opioid administration in the operating room, but this reduction could have unforeseen detrimental effects in terms of postoperative pain outcomes, as the relationship between intraoperative opioid usage and later opioid requirements is not well understood. To characterize the association between intraoperative opioid usage and postoperative pain and opioid requirements. This retrospective cohort study evaluated electronic health record data from a quaternary care academic medical center (Massachusetts General Hospital) for adult patients who underwent noncardiac surgery with general anesthesia from April 2016 to March 2020. Patients who underwent cesarean surgery, received regional anesthesia, received opioids other than fentanyl or hydromorphone, were admitted to the intensive care unit, or who died intraoperatively were excluded. Statistical models were fitted on the propensity weighted data set to characterize the effect of intraoperative opioid exposures on primary and secondary outcomes. Data were analyzed from December 2021 to October 2022. Intraoperative fentanyl and intraoperative hydromorphone average effect site concentration estimated using pharmacokinetic/pharmacodynamic models. The primary study outcomes were the maximal pain score during the postanesthesia care unit (PACU) stay and the cumulative opioid dose, quantified in morphine milligram equivalents (MME), administered during the PACU stay. Medium- and long-term outcomes associated with pain and opioid dependence were also evaluated. The study cohort included a total of 61 249 individuals undergoing surgery (mean [SD] age, 55.44 [17.08] years; 32 778 [53.5%] female). Increased intraoperative fentanyl and intraoperative hydromorphone were both associated with reduced maximum pain scores in the PACU. Both exposures were also associated with a reduced probability and reduced total dosage of opioid administration in the PACU. In particular, increased fentanyl administration was associated with lower frequency of uncontrolled pain; a decrease in new chronic pain diagnoses reported at 3 months; fewer opioid prescriptions at 30, 90, and 180 days; and decreased new persistent opioid use, without significant increases in adverse effects. Contrary to prevailing trends, reduced opioid administration during surgery may have the unintended outcome of increasing postoperative pain and opioid consumption. Conversely, improvements in long-term outcomes might be achieved by optimizing opioid administration during surgery.
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