A. McQuaid1, K. Subramaniam2, M. Boisen2, S. Esper2, K. Meister2, J. Gealey2, J. Holder-Murray3, A. Hamad3, M. Hogg3, H. Zeh3, A. Zureikat3 1University Of Pittsburgh,School Of Medicine,Pittsburgh, PA, USA 2University Of Pittsburgh Medical Center,Department Of Anesthesia,Pittsburgh, PA, USA 3University Of Pittsburgh Medical Center,Department Of GI Surgical Oncology,Pittsburgh, PA, USA
Introduction: Enhanced recovery protocols in pancreatic surgery have been shown to reduce length of hospital stay without compromising outcomes. Assessing the relative contribution of individual interventions, however, is difficult when multiple practice changes are implemented simultaneously. We implemented similar pancreatectomy pathways that differ in anesthesia management at 2 hospitals with the same group of surgeons. We aimed to compare pain management and outcomes in these 2 groups with the purpose of implementing the best practice system-wide.
Methods: Patients who underwent pancreatic surgery between July 2015 and May 2017 on an enhanced recovery pathway were included. Hospital A patients received intrathecal morphine, whereas Hospital B patients received quadratus lumborum/transversus abdominal plane blocks. Data were retrospectively extracted from the electronic medical record and from a prospectively collected institutional database. Patients were analyzed according to the hospital where they received care (Hospital A, n=226, Hospital B, n=45) by univariate analysis. We also performed 2:1 propensity matched analysis (45 Hospital B patients were matched to 90 Hospital A patients) to account for potential confounding factors including comorbidities and at-home prior medications that could affect post-operative experience of pain. Primary outcomes were opioid consumption and average visual analog pain scores. Secondary outcomes were length of hospital and PACU stay, ICU admission, extubation location, ondansetron requirement, time to first bowel movement, local and systemic complications, readmission, and mortality. SPSS version 24 was used for analysis.
Results: Postoperative analgesia was superior on postoperative day 0 in patients who received intrathecal morphine (Hospital A) by both univariate and propensity matched analysis. Among matched groups, Hospital A had a significantly reduced median intravenous morphine equivalent consumption on day 0 [(Hospital A 2.6 mg (0.0-8.5), Hospital B 8.0 mg (0.0-24.4), p=0.002] and median visual analog pain score on days 0 and 5 [Hospital A 4.2 (2.0-5.6) and 4.0 (3.0-5.15), Hospital B 5.7 (2.9-6.9) and 5.7 (3.7-6.2), p=0.01, 0.029]. Although opioid consumption and pain scales did not reach statistical significance on other postoperative days, there was a consistent trend towards superior pain relief for Hospital A patients. Hospital B patients were also significantly less likely to undergo extubation in the operating room (Hospital A 94.4%, Hospital B 62.2%, p=0.006). Wound infection was higher in Hospital B (p=0.02), whereas pancreatic leak was higher in Hospital A (p=0.011). All other variables did not differ significantly.
Conclusion: Intrathecal morphine based enhanced recovery protocols improved postoperative pain relief over nerve block based. The relation between pain management protocols and incidence of wound infection and pancreatic leaks requires further evaluation.