Background

Opioid prescribing guidelines for partial mastectomy (PM) and PM with sentinel lymph node biopsy (PM-SLNB) recommend prescribing anywhere from 0 to 15 oxycodone pills for postoperative pain. We sought to eliminate opioids after breast-conserving surgery.

Study Design

In January 2017, we implemented a perioperative pathway in which patients received (1) preoperative acetaminophen, (2) pre-incisional bupivacaine skin infiltration, (3) post-excision bupivacaine wound deposition, (4) intraoperative ketorolac, (5) instructions to use both acetaminophen and ibuprofen for postoperative analgesia, and (6) counseling to set the expectation that opioids would not be required. We measured the percentage of patients who received, filled, and used opioid prescriptions. We compared this to historical institutional data from 2016.

Results

There were 226 patients (mean age: 62 ± 13 years) who underwent surgery: 50% (114 of 226) underwent PM alone and 50% (112 of 226) PM-SLNB. Twenty-four patients (11%) required opioids in the recovery unit, and 14 (6%) were discharged home with a prescription. Five of the 14 patients (36%) did not fill their prescription. Among the patients who did fill their prescription, only 1 patient used opioids. In addition, 2 (1%) patients had difficulty managing their postoperative pain and were prescribed opioids within 7 days of surgery. Ultimately, 99% (223 of 226) of patients managed their postoperative pain after discharge without opioids. This represents a significant decrease in opioid use after breast conserving surgery, from 40% in 2016 to 1% after pathway implementation, p < 0.001.

Conclusions

When a multimodal nonopioid pain pathway was implemented, 99% of patients undergoing breast-conserving surgery did not require opioids after discharge.

中文翻译：

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从保乳手术中消除阿片类药物：围手术期疼痛管理途径。

背景

对于部分乳房切除术（PM）和前哨淋巴结活检（PM-SLNB）的阿片类药物处方指南建议为术后疼痛使用0至15片羟考酮药。我们寻求在保乳手术后消除阿片类药物。

学习规划

2017年1月，我们实施了围手术期途径，患者接受（1）术前对乙酰氨基酚，（2）切开前布比卡因皮肤浸润，（3）切开后布比卡因伤口沉积，（4）术中酮咯酸，（5）在术后镇痛中同时使用对乙酰氨基酚和布洛芬，以及（6）咨询以设定不需要阿片类药物的期望。我们测量了接受，填充和使用阿片类药物处方的患者百分比。我们将此与2016年的历史机构数据进行了比较。

结果

共有226例患者（平均年龄：62±13岁）接受了手术：50％（226例中的114例）单独接受PM和50％（226例中的112例）接受PM-SLNB。24例患者（11％）需要在恢复单位使用阿片类药物，而14例患者（6％）凭处方出院。14例患者中有5例（36％）没有服药。在确实满足处方要求的患者中，只有1名患者使用了阿片类药物。此外，有2名患者（1％）难以控制术后疼痛，并在手术后7天内处方了阿片类药物。最终，出院后无阿片类药物的患者中有99％（226名患者中的223名）可以解决术后疼痛。这表示保乳手术后阿片类药物的使用量显着减少，从2016年的40％减少到实施通路后的1％，p <0.001。

结论

当实施多峰非阿片类药物疼痛途径时，进行保乳手术的患者中有99％出院后不需要阿片类药物。