Continuous Wound Irrigation and Intraoperative Methadone Decreases Opioid Use and Shortens Length of Stay After CRS/HIPEC.
Journal
Annals of surgical oncology
ISSN: 1534-4681
Titre abrégé: Ann Surg Oncol
Pays: United States
ID NLM: 9420840
Informations de publication
Date de publication:
01 Feb 2024
01 Feb 2024
Historique:
received:
21
06
2023
accepted:
29
12
2023
medline:
1
2
2024
pubmed:
1
2
2024
entrez:
1
2
2024
Statut:
aheadofprint
Résumé
Epidural analgesia is resource and labor intense and may limit postoperative management options and delay discharge. This study compared postoperative outcomes after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) with epidural analgesia versus continuous wound infusion system (CWIS) with/without intraoperative methadone. A single-institution, retrospective chart review was performed including all patients undergoing open CRS/HIPEC from 2018 to 2021. Patient demographics, surgical characteristics, length of stay, and in-hospital analgesic use were reviewed. In-hospital opioid exposure in morphine milligram equivalents (MME) was calculated. Multivariate analysis (MVA) for mean total and daily opioid exposure was conducted. A total of 157 patients were included. Fifty-three (34%) had epidural analgesia, 96 (61%) had CWIS, and 79 (50%) received methadone. Length of stay was significantly shorter with CWIS + methadone versus epidural (7 vs. 8 days, p < 0.01). MVA showed significantly lower mean total and daily opioid exposure with CWIS+methadone versus epidural (total: 252.8 ± 17.7 MME vs. 486.8 ± 86.6 MME; odds ratio [OR] 0.72, 95% confidence interval [CI] 0.52-0.98, p = 0.04; Daily: 32.8 ± 2.0 MME vs. 51.9 ± 5.7 MME, OR 0.72, 95% CI 0.52-0.99, p ≤ 0.05). The CWIS-only group (n = 17) had a significantly lower median oral opioid exposure versus epidural (135 MME vs. 7.5 MME, p < 0.001) and longer length of stay versus CWIS + methadone (9 vs. 7 days, p = 0.04), There were no CWIS or methadone-associated complications and one epidural abscess. CWIS + methadone safely offers better pain control with less in-hospital opioid use, shorter length of stay, and decreased resource utilization compared with epidural analgesia in patients undergoing CRS-HIPEC.
Sections du résumé
BACKGROUND
BACKGROUND
Epidural analgesia is resource and labor intense and may limit postoperative management options and delay discharge. This study compared postoperative outcomes after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) with epidural analgesia versus continuous wound infusion system (CWIS) with/without intraoperative methadone.
METHODS
METHODS
A single-institution, retrospective chart review was performed including all patients undergoing open CRS/HIPEC from 2018 to 2021. Patient demographics, surgical characteristics, length of stay, and in-hospital analgesic use were reviewed. In-hospital opioid exposure in morphine milligram equivalents (MME) was calculated. Multivariate analysis (MVA) for mean total and daily opioid exposure was conducted.
RESULTS
RESULTS
A total of 157 patients were included. Fifty-three (34%) had epidural analgesia, 96 (61%) had CWIS, and 79 (50%) received methadone. Length of stay was significantly shorter with CWIS + methadone versus epidural (7 vs. 8 days, p < 0.01). MVA showed significantly lower mean total and daily opioid exposure with CWIS+methadone versus epidural (total: 252.8 ± 17.7 MME vs. 486.8 ± 86.6 MME; odds ratio [OR] 0.72, 95% confidence interval [CI] 0.52-0.98, p = 0.04; Daily: 32.8 ± 2.0 MME vs. 51.9 ± 5.7 MME, OR 0.72, 95% CI 0.52-0.99, p ≤ 0.05). The CWIS-only group (n = 17) had a significantly lower median oral opioid exposure versus epidural (135 MME vs. 7.5 MME, p < 0.001) and longer length of stay versus CWIS + methadone (9 vs. 7 days, p = 0.04), There were no CWIS or methadone-associated complications and one epidural abscess.
CONCLUSIONS
CONCLUSIONS
CWIS + methadone safely offers better pain control with less in-hospital opioid use, shorter length of stay, and decreased resource utilization compared with epidural analgesia in patients undergoing CRS-HIPEC.
Identifiants
pubmed: 38300404
doi: 10.1245/s10434-024-14900-1
pii: 10.1245/s10434-024-14900-1
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© 2024. Society of Surgical Oncology.
Références
Wang X, Li T. Postoperative pain pathophysiology and treatment strategies after CRS + HIPEC for peritoneal cancer. World J Surg Oncol. 2020;18(1):62. https://doi.org/10.1186/s12957-020-01842-7 .
doi: 10.1186/s12957-020-01842-7
pubmed: 32234062
pmcid: 7110707
Webb C, Day R, Velazco CS, et al. Implementation of an enhanced recovery after surgery (eras) program is associated with improved outcomes in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2020;27(1):303–12. https://doi.org/10.1245/s10434-019-07900-z .
doi: 10.1245/s10434-019-07900-z
pubmed: 31605328
Webb CAJ, Weyker PD, Moitra VK, Raker RK. An overview of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for the anesthesiologist. Anesth Analg. 2013;116(4):924–31. https://doi.org/10.1213/ANE.0b013e3182860fff .
doi: 10.1213/ANE.0b013e3182860fff
pubmed: 23460568
Raspe C, Piso P, Wiesenack C, Bucher M. Anesthetic management in patients undergoing hyperthermic chemotherapy. Curr Opin Anaesthesiol. 2012;25(3):348–55. https://doi.org/10.1097/ACO.0b013e32835347b2 .
doi: 10.1097/ACO.0b013e32835347b2
pubmed: 22517311
Piccioni F, Casiraghi C, Fumagalli L, et al. Epidural analgesia for cytoreductive surgery with peritonectomy and heated intraperitoneal chemotherapy. Int J Surg Lond Engl. 2015;16(Pt A):99–106. https://doi.org/10.1016/j.ijsu.2015.02.025 .
doi: 10.1016/j.ijsu.2015.02.025
Lu PW, Fields AC, Shabat G, et al. Cytoreductive surgery and HIPEC in an enhanced recovery after surgery program: a feasibility study. J Surg Res. 2020;247:59–65. https://doi.org/10.1016/j.jss.2019.10.042 .
doi: 10.1016/j.jss.2019.10.042
pubmed: 31767280
Bhandoria G, Solanki SL, Bhavsar M, et al. Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): a cross-sectional survey. Pleura Peritoneum. 2021;6(3):99–111. https://doi.org/10.1515/pp-2021-0117 .
doi: 10.1515/pp-2021-0117
pubmed: 34676283
pmcid: 8482448
Martin RC, Marshall BM, Philips P, Egger M, McMasters KM, Scoggins CR. Enhanced recovery after surgery is safe for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Am J Surg. 2020;220(6):1428–32. https://doi.org/10.1016/j.amjsurg.2020.08.041 .
doi: 10.1016/j.amjsurg.2020.08.041
pubmed: 32921403
pmcid: 9514086
Hübner M, Kusamura S, Villeneuve L, et al. Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): enhanced Recovery After Surgery (ERAS®) Society Recommendations—part II: postoperative management and special considerations. Eur J Surg Oncol. 2020;46(12):2311–23. https://doi.org/10.1016/j.ejso.2020.08.006 .
doi: 10.1016/j.ejso.2020.08.006
pubmed: 32826114
White B, Dahdaleh F, Naffouje SA, et al. Impact of enhanced recovery after surgery on postoperative outcomes for patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2021;28(9):5265–72. https://doi.org/10.1245/s10434-020-09476-5 .
doi: 10.1245/s10434-020-09476-5
pubmed: 33469794
Song J, Choi N, Kang M, Ji SM, Kim DW, Kwon MA. Analgesic effects of ultrasound-guided fourquadrant transversus abdominis plane in patients with cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a prospective, randomized, controlled study. Anesth Pain Med. 2022;17(1):75–86. https://doi.org/10.17085/apm.21094 .
doi: 10.17085/apm.21094
Koh FH, Ng JY, Seow CS, Keh CH. ON-Q pain relief system insertion technique: intraoperative insertion of a pre-peritoneal catheter for continuous local anaesthetic infusion. Ann R Coll Surg Engl. 2020;102(2):160–1. https://doi.org/10.1308/rcsann.2019.0159 .
doi: 10.1308/rcsann.2019.0159
pubmed: 31845818
Baig MK, Zmora O, Derdemezi J, Weiss EG, Nogueras JJ, Wexner SD. Use of the ON-Q pain management system is associated with decreased postoperative analgesic requirement: double blind randomized placebo pilot study. J Am Coll Surg. 2006;202(2):297–305. https://doi.org/10.1016/j.jamcollsurg.2005.10.022 .
doi: 10.1016/j.jamcollsurg.2005.10.022
pubmed: 16427556
Murphy GS, Szokol JW. Intraoperative methadone in surgical patients: a review of clinical investigations. Anesthesiology. 2019;131(3):678–92. https://doi.org/10.1097/ALN.0000000000002755 .
doi: 10.1097/ALN.0000000000002755
pubmed: 31094758
Tabbara AK, Krishnan S, Vaynberg E, Spence NZ, Lambert DH. Intraoperative methadone: proceed with care. J Opioid Manag. 2022;18(4):377–83. https://doi.org/10.5055/jom.2022.0730 .
doi: 10.5055/jom.2022.0730
pubmed: 36052934
Lee SH, Gwak MS, Choi SJ, et al. Prospective, randomized study of ropivacaine wound infusion versus intrathecal morphine with intravenous fentanyl for analgesia in living donors for liver transplantation. Liver Transpl. 2013;19(9):1036–45. https://doi.org/10.1002/lt.23691 .
doi: 10.1002/lt.23691
pubmed: 23788468
Soliz JM, Gebhardt R, Feng L, Dong W, Reich M, Curley S. Comparing epidural analgesia and ON-Q infiltrating catheters for pain management after hepatic resection. Open J Anesthesiol. 2013;3(1):3–7. https://doi.org/10.4236/ojanes.2013.31002 .
doi: 10.4236/ojanes.2013.31002
pubmed: 25580374
pmcid: 4286355
Lee B, Kim K, Ahn S, et al. Continuous wound infiltration system for postoperative pain management in gynecologic oncology patients. Arch Gynecol Obstet. 2017;295(5):1219–26. https://doi.org/10.1007/s00404-017-4342-8 .
doi: 10.1007/s00404-017-4342-8
pubmed: 28293723
[The effects of the administration of subfacial levobupivacaine infusion with the ON-Q pain pump system on postoperative analgesia and tramadol consumption in cesarean operations] - PubMed. Accessed July 19, 2022. https://pubmed.ncbi.nlm.nih.gov/20582749/
Forastiere E, Sofra M, Giannarelli D, Fabrizi L, Simone G. Effectiveness of continuous wound infusion of 0.5% ropivacaine by On-Q pain relief system for postoperative pain management after open nephrectomy. Br J Anaesth. 2008;101(6):841–7. https://doi.org/10.1093/bja/aen309 .
doi: 10.1093/bja/aen309
pubmed: 19004914
Chung D, Lee YJ, Jo MH, et al. The ON-Q pain management system in elective gynecology oncologic surgery: management of postoperative surgical site pain compared to intravenous patient-controlled analgesia. Obstet Gynecol Sci. 2013;56(2):93–101. https://doi.org/10.5468/OGS.2013.56.2.93 .
doi: 10.5468/OGS.2013.56.2.93
pubmed: 24327987
pmcid: 3784090
Gebhardt R, Mehran RJ, Soliz J, Cata JP, Smallwood AK, Feeley TW. Epidural versus ON-Q local anesthetic-infiltrating catheter for post-thoracotomy pain control. J Cardiothorac Vasc Anesth. 2013;27(3):423–6. https://doi.org/10.1053/j.jvca.2013.02.017 .
doi: 10.1053/j.jvca.2013.02.017
pubmed: 23672860
Ried M, Schilling C, Potzger T, et al. Prospective, comparative study of the On-Q® PainBuster® postoperative pain relief system and thoracic epidural analgesia after thoracic surgery. J Cardiothorac Vasc Anesth. 2014;28(4):973–8.
doi: 10.1053/j.jvca.2013.12.028
pubmed: 25107716
Wheatley GH, Rosenbaum DH, Paul MC, et al. Improved pain management outcomes with continuous infusion of a local anesthetic after thoracotomy. J Thorac Cardiovasc Surg. 2005;130(2):464–8. https://doi.org/10.1016/j.jtcvs.2005.02.011 .
doi: 10.1016/j.jtcvs.2005.02.011
pubmed: 16077414
Sotgiu ML, Valente M, Storchi R, Caramenti G, Biella GEM. Cooperative N-methyl-D-aspartate (NMDA) receptor antagonism and mu-opioid receptor agonism mediate the methadone inhibition of the spinal neuron pain-related hyperactivity in a rat model of neuropathic pain. Pharmacol Res. 2009;60(4):284–90. https://doi.org/10.1016/j.phrs.2009.04.002 .
doi: 10.1016/j.phrs.2009.04.002
pubmed: 19717013
Tognoli E, Proto PL, Motta G, Galeone C, Mariani L, Valenza F. Methadone for postoperative analgesia: contribution of N-methyl-D-aspartate receptor antagonism: a randomised controlled trial. Eur J Anaesthesiol. 2020;37(10):934–43. https://doi.org/10.1097/EJA.0000000000001217 .
doi: 10.1097/EJA.0000000000001217
pubmed: 32516227
Machado FC, Vieira JE, de Orange FA, Ashmawi HA. Intraoperative methadone reduces pain and opioid consumption in acute postoperative pain: a systematic review and meta-analysis. Anesth Analg. 2019;129(6):1723–32. https://doi.org/10.1213/ANE.0000000000004404 .
doi: 10.1213/ANE.0000000000004404
pubmed: 31743194
Bova SE, Kruer RM, Nesbit SA, Grant MC, Jarrell AS. Perioperative methadone prescribing and association with respiratory depression. J Opioid Manag. 2020;16(6):443–9. https://doi.org/10.5055/jom.2020.0602 .
doi: 10.5055/jom.2020.0602
pubmed: 33428191
Carl A, Pasman E, Broman MJ, Lister JJ, Agius E, Resko SM. Experiences of healthcare and substance use treatment provider-based stigma among patients receiving methadone. Drug Alcohol Depend Rep. 2023;6:100138. https://doi.org/10.1016/j.dadr.2023.100138 .
doi: 10.1016/j.dadr.2023.100138
pubmed: 36994374
pmcid: 10040326