Multimodal opioid-sparing postoperative pain regimen compared with the standard postoperative pain regimen in vaginal pelvic reconstructive surgery: a multicenter randomized controlled trial

Postoperative pain control after urogynecological surgery has traditionally been opioid centered with frequent narcotic administration. Few studies have addressed optimal pain control strategies for vaginal pelvic reconstructive surgery that limit opioid use. The objective of the study was to determ...

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Published in:	American journal of obstetrics and gynecology 2019-11, Vol.221 (5), p.511.e1-511.e10
Main Authors:	Petrikovets, Andrey, Sheyn, David, Sun, Helen H., Chapman, Graham C., Mahajan, Sangeeta T., Pollard, Robert R., El-Nashar, Sherif A., Hijaz, Adonis K., Mangel, Jeffrey
Format:	Article
Language:	eng
Subjects:	Acetaminophen - therapeutic use Analgesics, Non-Narcotic - therapeutic use Analgesics, Opioid - therapeutic use Anti-Inflammatory Agents, Non-Steroidal - therapeutic use Combined Modality Therapy Cryotherapy Drug Utilization - statistics & numerical data Female Gynecologic Surgical Procedures Humans Hydromorphone - therapeutic use Ketorolac - therapeutic use Ketorolac Tromethamine - therapeutic use Middle Aged multimodal pain control opioid sparing Pain, Postoperative - prevention & control Patient Satisfaction urogynecology vaginal surgery Visual Analog Scale
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Summary:	Postoperative pain control after urogynecological surgery has traditionally been opioid centered with frequent narcotic administration. Few studies have addressed optimal pain control strategies for vaginal pelvic reconstructive surgery that limit opioid use. The objective of the study was to determine whether, ice packs, Tylenol, and Toradol, a novel opioid-sparing multimodal postoperative pain regimen has improved pain control compared with the standard postoperative pain regimen in patients undergoing inpatient vaginal pelvic reconstructive surgery. This was a multicenter randomized controlled trial of women undergoing vaginal pelvic reconstructive surgery. Patients were randomized to the ice packs, Tylenol, and Toradol postoperative pain regimen or the standard regimen. The ice packs, Tylenol, and Toradol regimen consists of around-the-clock ice packs, around-the-clock oral acetaminophen, around-the-clock intravenous ketorolac, and intravenous hydromorphone for breakthrough pain. The standard regimen consists of as-needed ibuprofen, as-needed acetaminophen/oxycodone, and intravenous hydromorphone for breakthrough pain. The primary outcome was postoperative day 1 pain evaluated the morning after surgery using a visual analog scale. Secondary outcomes included the validated Quality of Recovery Questionnaire, satisfaction scores, inpatient narcotic consumption, outpatient pain medication consumption, and visual analog scale scores at other time intervals. In all, 27 patients in each arm were required to detect a mean difference of 25 mm on a 100 mm visual analog scale (90% power). Thirty patients were randomized to ice packs, Tylenol, and Toradol and 33 to the standard therapy. Patient and surgical demographics were similar. The median morning visual analog scale pain score was lower in the ice packs, Tylenol, and Toradol group (20 mm vs 40 mm, P = .03). Numerical median pain scores were lower at the 96 hour phone call in the ice packs, Tylenol, and Toradol group (2 vs 3, P = .04). Patients randomized to the ICE-T regimen received fewer narcotics (expressed in oral morphine equivalents) from the postanesthesia care unit exit to discharge (2.9 vs 20.4, P < .001) and received fewer narcotics during the entire hospitalization (55.7 vs 91.2, P < .001). At 96 hour follow up, patients in the ice packs, Tylenol, and Toradol group used 4.9 ketorolac tablets compared with 4.6 oxycodone/acetaminophen tablets in the standard group (P = .81); however, ice packs, Tyle
ISSN:	0002-9378 1097-6868