Implementation of a perioperative pain management algorithm reduces the use of opioid analgesia following pelvic exenteration surgery.

AIM
This study aimed to investigate the implementation and pain-related outcomes of a peri-operative pain management regimen for patients undergoing pelvic exenteration surgery at a university teaching hospital.


METHOD
This is a single-site prospective observational cohort study involving 100 patients who underwent pelvic exenteration surgery between January 2017 and December 2018. A pain management algorithm was developed between the departments of anaesthesia, pain management and intensive care in line with opioid-sparing multimodal analgesia. The primary outcomes were: compliance with a pain treatment algorithm compared with a similar retrospective surgical patient cohort in 2013-2014, and regular opioid analgesia requirements at discharge measured in oral morphine equivalent daily dose in milligrams (oMEDD).


RESULTS
Following the introduction of a pain management algorithm, regional anaesthesia techniques (spinal anaesthesia, transversus abdominus plane block, preperitoneal catheters or epidural analgesia) were used in 83/98 (84.7%) of the 2017-2018 cohort compared to 13/73 (17.8%) of the 2013-2014 cohort (p < 0.001). There was a reduction in the median dose of opioid analgesics (oMEDD) at time of discharge from 150 mg (IQR 75.0-235.0 mg) in the 2013-2014 cohort to 10 mg (IQR 0.00-45.0 mg) in the 2017-2018 cohort (p < 0.001). There was no change in pain intensity (assessed using the Verbal Numerical Rating Score, VNRS) or oMEDD in the first seven days following surgery.


CONCLUSION
Since the implementation of a novel peri-operative pain treatment algorithm, the use of opioid-sparing regional techniques and pre-peritoneal catheters has increased. Additionally, the dose of opioids required at the time of discharge has reduced significantly.