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Multimodal Pain Prophylaxis Reduces Length of Stay in Bariatric Surgical Patients
*Jennifer L Salluzzo1, *Danielle Massee2, *James M Healy1, *Donna-Ann Thomas1, *Geoffrey S Nadzam1, Kurt E Roberts1, Andrew J Duffy1
1Yale School of Medicine, New Haven, CT;2Yale-New Haven Hospital, New Haven, CT

OBJECTIVE An Enhanced Recovery Protocol(ERP) was established for bariatric surgical patients at our institution in June 2014. This standardized, multimodal approach to perioperative pain management, early ambulation, and diet advancement was designed to enhance the patient experience and reduce length of stay(LOS). This includes combination non-narcotic pain prophylaxis with IVacetaminophen(OFIRMEV) and IVketorolac(Toradol) during surgery, unless contraindicated. In November 2014, IV acetaminophen became non-formulary at our institution and was eliminated from the protocol. We hypothesize that combination pain prophylaxis with IVacetaminophen and IVketorolac, as part of our ERP, reduces the LOS in bariatric surgical patients when compared to other regimens. DESIGN Retrospective chart review. SETTING Institutional Practice. Tertiary Care Center. PATIENTS OR OTHER PARTICIPANTS Seventy-two consecutive morbidly obese(BMI 34.8-93.1) patients (Females= 60, Males=12), aged 18-72, underwent a stapled bariatric surgical procedure from June 2014-January 2015 by a single surgeon(AJD). INTERVENTION(S) All patients were treated per the ERP. Intra-operatively, patients received either IVacetaminophen or IVketorolac (n= 33), both agents(n=34), or neither agent (n=5), based on contraindications and formulary availability of IVacetaminophen. LOS was compared across these groups. MAIN OUTCOME MEASURE(S) LOS RESULTS LOS for patients who received combination therapy with both IVacetaminophen and IVketorolac was 45.4 hours(h)(95% CI 40.5-50.2h). LOS for patients who received single agent or no pain prophylaxis was 58.3h(95%CI
47.1-69.6h). The difference of 12.9h was statistically significant (p=0.041). No significant difference was detected in postoperative narcotic administration. CONCLUSIONS An institutional ERP combining IVacetaminophen and IVketorolac in bariatric surgical patients reduces LOS. The clinical value of this combination therapy should be considered in the formulary review of the components of the ERP.


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