Development of Multimodal Analgesia Pathways in Outpatient Thyroid and Parathyroid Surgery and Association With Postoperative Opioid Prescription Patterns
Development of Multimodal Analgesia Pathways in Outpatient Thyroid and Parathyroid Surgery and Association With Postoperative Opioid Prescription Patterns
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DOI：
10.1001/jamaoto.2018.0987
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发表时间：
2018-11-01
影响因子：
7.8
通讯作者：
Panwar, Aru
中科院分区：
文献类型：
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作者：
Militsakh, Oleg;Lydiatt, William;Panwar, Aru
重要性 处方阿片类药物的使用会导致药物相关的不良反应以及依赖和滥用的风险。多模式镇痛 (MMA) 已被证明可有效减少骨科、妇科和结直肠手术后阿片类药物的使用，但在头颈手术中的采用却滞后。最近，我们发表了有关 MMA 方案在甲状腺、甲状旁腺和腮腺当天手术中的可行性的研究结果。然而，这些策略是否会导致阿片类药物处方频率有效且持久地减少，并影响医生处方实践，仍不清楚。目的观察甲状腺和甲状旁腺手术后采用和遵守机构 MMA 方案的趋势，并评估机构多模式（非阿片类）镇痛方案与门诊甲状腺和甲状旁腺手术后阿片类药物使用和医生处方模式的关联。设计、设置和参与者队列研究一家三级护理医院的头颈外科服务，在 2015 年实施可选机构 MMA 方案后，根据术前使用对乙酰氨基酚、非甾体类抗炎药 (NSAID) 和加巴喷丁，以及术后使用对乙酰氨基酚和布洛芬进行甲状腺和甲状旁腺手术后镇痛，对处方模式和患者病历进行回顾性审查。 2015 年 1 月 1 日至 2017 年 6 月 30 日期间，有 528 名成年患者接受了甲状腺和甲状旁腺手术。 主要结果和措施 我们报告了研究期间对 MMA 方案的遵守情况，作为医生认可和采用该技术的衡量标准。在研究期间报告甲状腺和甲状旁腺手术后阿片类药物的使用频率和医生处方模式，以研究可用的 MMA 途径与这些变量的关联。 结果 共有 528 名患者（平均 [SD] 年龄，53.1[15.7] 岁；80.3% 女性）接受了门诊甲状腺和甲状旁腺手术。研究期间，术后阿片类药物处方频率下降（2015 年 122 例中 16 例 [13.1%]，2016 年 244 例中 22 例 [9.0%]，2017 年 162 例中 3 例 [1.9%]）。对 MMA 方案的依从性有所增加（2015 年 122 例中的 0 例，2016 年 244 例 [43.4%] 例中的 106 例，2017 年 162 例 [87.7%] 例中的 142 例），出院时开出阿片类药物处方的可能性降低（2017 年与 2015 年比值比，0.13；95% Cl， 0.04-0.44）。研究队列中仅记录了 1 例术后血肿，352 例 (66.7%) 患者当天出院，而 176 例 (33.3%) 患者保持门诊状态，但在出院前接受过夜观察。 结论和相关性 在研究期间，接受甲状腺和甲状旁腺手术的患者对 MMA 方案的采用和依从性大幅增加，并且与术后阿片类镇痛药处方量同时显着下降相关。使用非阿片类多模式药物（结合非甾体抗炎药）是安全的，不会导致出血发生率增加。有效的非阿片类药物 MMA 途径的可用性可能会对医生的处方实践产生有利影响，并避免不必要的阿片类药物处方。
IMPORTANCE Prescription opioid use contributes to drug-related adverse effects and risk for dependence and abuse. Multimodal analgesia (MMA) has been shown to be useful in reducing opioid use following orthopedic, gynecologic, and colorectal surgery, but adoption in head and neck surgery has lagged. Recently, we published findings related to the feasibility of MMA protocols in same-day thyroid, parathyroid, and parotid surgery. However, whether such strategies lead to effective and durable reduction in frequency of opioid prescriptions, and affect physician prescribing practices, remains unclear.OUJECTIVE To observe trends in adoption and adherence to institutional MMA protocols following thyroid and parathyroid surgery, and to assess the association of institutional multimodal (nonopioid) analgesia protocols with opioid use and physician prescribing patterns following outpatient thyroid and parathyroid surgery.DESIGN, SETTING, AND PARTICIPANTS Cohort study at a head and neck surgery service at a tertiary care hospital of prescription patterns and retrospective review of patient medical records following implementation of an optional institutional MMA protocol in 2015, based on preoperative administration of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentin, and postoperative use of acetaminophen and ibuprofen for analgesia after thyroid and parathyroid surgery. There were 528 adult patients who underwent thyroid and parathyroid surgery between January 1, 2015, and June 30, 2017.MAIN OUTCOMES AND MEASURES We report on adherence to the MMA protocol over the study period as measure of physician buy-in and adoption of the technique. The frequency of opioid use and physician prescription patterns following thyroid and parathyroid surgery is reported over the study period to study the association of the available MMA pathway with these variables.RESULTS A total of 528 patients (mean [SD] age, 53.1[15.7] years; 80.3% female) underwent outpatient thyroid and parathyroid surgery. The frequency of postoperative opioid prescriptions decreased during the study period (16 of 122 [13.1%] in 2015, 22 of 244 [9.0%] in 2016, 3 of 162 [1.9%] in 2017). Adherence to the MMA protocol increased (0 of 122 cases in 2015,106 of 244 [43.4%] cases in 2016, 142 of 162 [87.7%] cases in 2017), with reduced likelihood of opioid prescription on discharge (2017 vs 2015 odds ratio, 0.13; 95% Cl, 0.04-0.44). Only 1 postoperative hematoma was recorded in the study cohort, and 352 (66.7%) patients achieved same-day discharge, whereas 176 (33.3%) maintained outpatient status but received overnight observation prior to discharge.CONCLUSIONS AND RELEVANCE Adoption and adherence to the MMA protocol increased substantially over the study period for patients undergoing thyroid and parathyroid surgery and was associated with a simultaneous significant decline in prescription of postoperative opioid analgesics. Use of nonopioid multimodal agents, incorporating NSAIDs, was safe and did not lead to increased incidence of bleeding. Availability of effective nonopioid MMA pathways may favorably influence physician prescribing practices and avoid unnecessary opioid prescriptions.