P073: THORACIC EPIDURAL AND MULTIMODAL OPIOID-SPARING PAIN MODALITIES IN SURGICAL ONCOLOGY: A PERIOPERATIVE QUALITY IMPROVEMENT INITIATIVE
Jacquelin Peck, MD, Bryan Kerner, MD, Pedro Garcia, MD, Roy Williams, MD, Hector Davila, MD, Guillermo Garcia, MD; Mount Sinai Medical Center
INTRODUCTION: A growing body of evidence suggests that the choice of anesthetic and analgesic agents within the perioperative period of surgical oncology may have important implications for cancer metastasis and recurrence. Many commonly used agents such as volatile anesthetics, narcotics, ketamine, thiopental and alpha-2 agonists may be linked to increased risk for metastasis and/or recurrence.1,2 Other agents, such as propofol, NSAIDs, midazolam, and local anesthetics have been associated with cancer suppression.1,2 To avoid potentially risk-enhancing agents, thoracic epidurals are increasingly used within this patient population. However, our institution, like many others does not currently have the resources to maintain a thoracic epidural for post-operative pain outside of the ICU.
To benefit patients undergoing video-assisted thoracoscopic surgery (VATS) for cancers of the thoracic cavity, our institution implemented a quality-improvement-driven change in practice to provide anesthesia and analgesia while avoiding potentially risk-enhancing medications. This change was accomplished with the addition of perioperative thoracic epidural anesthesia for qualifying patients. Due to present facility limitations, all epidurals were removed upon discharge from PACU following redosing. This study evaluates the analgesic benefit and opioid-sparing capabilities of short-term perioperative thoracic epidural.
METHODS: This study was a retrospective cohort study comparing patient outcomes following a change in practice. After obtaining approval from the Internal Review Board, patient outcomes following administration of a thoracic epidural (TEA) vs. traditional pain management with narcotics were recorded. Operating surgeon, surgical technique, anesthesia providers, and PACU/ICU staff remained consistent throughout the study.
The primary objective of the study is to evaluate analgesia and narcotic administration. Secondary outcomes include patient complication rates (respiratory compromise, need for CPAP, BiPAP, or reintubation; rates of pneumonia, need for rescue medication including naloxone, flumazenil, and intralipids; rates of urologic, gastrointestinal, and cardiac complications; among others), assessment of perioperative delays, delayed mobility, ICU stay, hospital 30-day all-cause readmission rates, and overall hospital length of stay.
All patients >18.0 years of age who underwent thoracoscopy with cancerous, non-cancerous, or pre-cancerous diagnoses from Oct 15, 2016 to Dec 10, 2018 were included in this study. Exclusion criteria included age <18.0 years.
RESULTS: Ten patients receiving TEA and ten patients receiving narcotic pain management were randomly selected to assess statistical differences in primary and secondary outcomes prior to determining sample size requirements for adequate study power. Preliminary results were abstracted from these charts. Both cohorts had similar gender distribution (30% female vs 40% female) and mean ASA class (3.0 vs 3.1), but TEA patients were on average younger (65 vs 72). TEA patients received fewer intra-operative, post-operative, and total narcotics (10mg vs 14.75mg; 0.96mg vs 3.16mg; 18mg vs 34mg morphine equivalents), and experienced shorter PACU length of stay (1.6 vs 2.6 hrs). There were no 30-day readmissions for either cohort.
CONCLUSION: Patients receiving TE had lower average opioid requirements and shorter recovery times, while maintaining equivalent 30-day all-cause readmission rates. Additional research is needed to determine the feasibility of total narcotic and avoidance as well as a regimen devoid of potentially risk-enhancing agents for oncology patients.