MULTIMODAL ANALGESIA IN OUTPATIENT HEAD AND NECK SURGERY: A FEASIBILITY AND SAFETY STUDY

Presentation: S009
Topic: Clinical Research
Type: Oral
Date: Wednesday, April 26, 2017
Session: 10:15 AM - 11:00 AM Survivorship
Authors: Justin Oltman, BSE1, Oleg Militsakh, MD2, Mark D'Agostino, MD3, Brittany Kauffman, BSN2, Aru Panwar, MD, FACS4
Institution(s): 1College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, 2Head and Neck Surgery, Nebraska Methodist Hospital, Omaha, Nebraska, 3Department of Anesthesiology, Nebraska Methodist Hospital, Omaha, Nebraska, 4Division of Head and Neck Surgery, University of Nebraska Medical Center & Nebraska Methodist Hospital, Omaha, Nebraska

Background:  Narcotic based analgesia strategies contribute to peri-operative side effects such as nausea, pruritis, constipation and other adverse events. Additional concerns about opioid prescriptions and their contribution to an emerging epidemic of opioid dependence and abuse, has prompted a re-examination of pain management strategies and a search for alternative multimodal analgesia protocols.

Multimodal analgesia protocols incorporate non-narcotic agents to reduce the need for opioid agents and to avoid adverse outcomes. While these protocols have been assessed and established in surgical specialties such as orthopedics and gastrointestinal surgery, the feasibility and safety of this approach has not been explored for outpatient head and neck surgery.

Objectives:

  • To evaluate the feasibility and safety of a non-narcotic multimodal analgesia protocol for outpatient head and neck surgical procedures
  • Identify impact of the multimodal analgesia protocol on post-operative pain perception scores
  • Assess patient satisfaction with the alternative pain management strategy

Methods: Retrospective evaluation of prospectively collected data on adult patients (n=48) who underwent outpatient thyroid, parathyroid, and parotid surgery between July and September 2016, utilizing a multimodal analgesia strategy. All patients received pre-operative counseling about the pain management strategy.

Multimodal analgesia revolved on pre-operative administration of a combination of acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and gabapentin; prudent use of intra-operative narcotics; and reliance on NSAIDs and acetaminophen for post-operative analgesia. Patients who demonstrated poor pain control with this strategy were allowed use of narcotics as clinically indicated.

Details were recorded on patient characteristics, operative variables, and in-hospital and post-discharge use of analgesics. Dedicated health coaches recorded patient responses to a standardized questionnaire utilizing validated tools to assess outcomes including ‘pain perception scores’, ‘Overall Benefit of Analgesia Score (OBAS)’, and incidence of failure of multimodal analgesia. Patient satisfaction scores with peri-operative pain management experience were recorded. 

Results: Forty-eight patients underwent outpatient thyroid, parathyroid or parotid surgery in an outpatient setting with use of multimodal analgesia protocol. On a 10-point rating scale, patients reported a low resting pain perception score (mean 1.73, observed range 0-7). Similarly, the mean of the ‘peak’ post-operative pain score remained low as well (mean 3.58, observed range 0-8).

The OBAS assessment for composite effectiveness of analgesia in optimizing pain control; minimizing nausea, itching, freezing, diaphoresis, and dizziness; and as a measure of patient satisfaction with pain management, indicated effectiveness of the multimodal analgesia strategy (mean score 2.27, observed range in patient cohort 0-9, permissible range 0-28 with low OBAS scores considered to be favorable).

Over 91.6% patients reported ‘high’ or ‘very high’ satisfaction with multimodal analgesia strategy. No complications related to bleeding, hematoma, significant adverse events, or re-admissions were observed.  

Clinical Implications:

  • Multimodal analgesia strategy is feasible and safe in patients undergoing outpatient head and neck surgery, and may reduce need for narcotic use and promote enhanced recovery
  • Patients on multimodal analgesia protocol reported low pain perception scores, favorable OBAS assessment, and overall satisfaction scores
  • Role of multimodal analgesia needs additional evaluation through comparative effectiveness assessment versus conventional pain management strategies