Eliminating Opioids from Breast Conserving Surgery: A Perioperative Pain Management Pathway
*Ravinder Kang1, *Jackson T. Read2, *Adam C. Glaser2, *Richard J. Barth Jr,1
1Dartmouth Hitchcock Medical Center, Lebanon, NH;2Geisel School of Medicine at Dartmouth, Hanover, NH
Objective: Current opioid prescribing guidelines for partial mastectomy (PM) and PM with sentinel lymph node biopsy (PM-SLNB) recommend 10-15 oxycodone pills for postoperative pain. At our institution, we prescribed opioids to 74% of PM and 95% of PM-SLNB patients between 2015-2016. In January 2017, we sought to eliminate opioids following breast conserving surgery by implementing a perioperative pathway.
Design: Retrospective review.
Setting: Academic medical center.
Participants: Patients who underwent a PM or PM-SLNB between 01/2017-12/2018.
Interventions: The pathway consisted of (1)preoperative acetaminophen, (2)pre-excisional administration of local anesthetic, (3)wound infiltration with bupivacaine, and (4)perioperative ketorolac. All patients were given the expectation that opioids would not be required and were counseled to manage their postoperative pain with a combination of acetaminophen and ibuprofen.
Main Outcome Measure:The percentage of patients whose postoperative pain was managed without opioids.
Results: 265 patients (mean age: 62±13 years) underwent surgery: 48% underwent PM alone and 52% underwent PM-SLNB. We excluded 8 patients with postoperative complications leaving 257 for analysis. 90% of these patients received at least 3 elements of the pathway. Thirty-five patients (14%) required opioids in the PACU; 9 of these were discharged with an opioid prescription. Overall, 28/257 (11%) patients were discharged with an opioid prescription (9% of PM and 13% of PM-SLNB patients). Yet, 35% did not fill their prescription. Therefore, 93% of all patients (95% of PM and 91% of PM-SLNB) were managed without opioids. Two patients (1%) who were discharged without a prescription called within 7 days with pain and were prescribed opioids.
Conclusion: When a multimodal non-opioid pain pathway was implemented, more than 90% of patients undergoing breast conserving surgery did not require postoperative opioids.
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