Perioperative Gabapentin use Among Head and Neck Surgical Patients

Presentation: AHNS047
Topic: Quality of Care and Clinical Pathways
Type: Oral
Date: Thursday, April 19, 2018
Session: 1:00 PM - 1:50 PM Best Papers of AHNS 2018
Authors: Melanie E Townsend, MD, Tina Liou, MD, Schoer Morgan, BS, Miranda Lindburg, BS, Nicholas Scott-Whitenborn, BS, Dorina Kallogjeri, MD, Michael Bottros, MD, Ryan Jackson, MD, Brian Nussenbaum, MD, Jay Piccirillo, MD, FACS
Institution(s): Washington University in St Louis

Importance: An important patient-physician interface is pain management; specifically the treatment of postoperative pain.  Effective management increases patient satisfaction, reduces hospital costs, reduces postoperative morbidity and shortens hospitalizations8.  Multimodal pain therapy employs non-narcotic medications to improve overall pain control and decrease narcotic medication requirements and side effects2-5, 8.  Few prospective studies investigate multimodal pain management in postoperative otolaryngology patients9-15.  

Objective: To elucidate the impact of perioperative gabapentin use on postoperative pain in patients undergoing mucosal head and neck surgeries

Design: Double blinded, placebo-controlled randomized trial 

Participants: Adults undergoing head and neck mucosal surgeries with a planned admission of at least one night were included.  Participants were screened based on chronic narcotic use and gabapentin use. They were randomized to receive either placebo or 300mg of PO gabapentin BID, given before surgery and up to three days postoperatively. Postoperative  pain medication regimens were controlled. 

Main Outcomes: Primary outcome was total narcotic use compared between groups. Secondary outcomes included subjective pain scores utilizing the visual analogue scale (VAS), patient satisfaction surveys, and side effects associated with gabapentin use.

Results: Ninety patients were randomized to placebo (n=46) or gabapentin (n=44). Sample size calculations were based on prior studies investigating gabapentin use in adult tonsillectomy patients. Descriptive analysis revealed both groups to be similar in age, sex, race, smoking status, alcohol use, OSA risk, tumor stage, surgical site and number of necks dissected, reconstruction method, and postoperative steroid and aspirin administration.  The gabapentin group had slightly more patients with an ACE-27 comorbidity score of “none”.  Both groups had similar self-reported levels of pain tolerance, narcotic effectiveness and daily pain. Narcotic use calculated in morphine equivalents revealed a mean difference of 0.31mg/hr (95% CI -0.34-0.96) between groups, and was not statistically significant.  Narcotic use stratified into the first, second and third 24 hrs on study also was similar between groups.  VAS subjective pain scores were captured TID for resting, coughing and swallowing. To explore the difference between groups, mixed model analysis of VAS scores was performed.   After controlling for differences in comorbidity, VAS scores were found to be significantly lower in the gabapentin group for all categories (rest 7.7mm, 95% CI 0.3-15.1mm; cough 9.2mm, 95% CI 0.8-17.7mm; swallow 10.5mm, 95% CI 1.4-19.5).  Subjective satisfaction with pain control was 10% higher in the gabapentin group, but was not statistically significant (10%, 95% CI -22.1- 3.3).  There was a slightly higher incidence of nausea in the placebo group as compared to the gabapentin group, and a similar incidence of sedation and dizziness between groups. 

Conclusion: Perioperative gabapentin is shown to result in significant improvements in subjective pain scores in head and neck mucosal surgery patients. The swallow VAS improvement reached a level regarded as clinically significant in anesthesia literature1.  This regimen did not reduce total narcotic usage.  Results trended toward a higher satisfaction with pain control and a lower incidence of nausea in the gabapentin group.  Gabapentin at 300mg PO BID is able to reduce the subjective perception of pain in an acute setting in these patients.