Opioid-sparing protocols have become increasingly desired and commonplace in outpatient surgery, as heightened surgical volumes and patient preferences increase the demand for swifter recoveries.
“Especially in ASCs … they don’t want prolonged recovery,” Gavin Baker, CRNA, CEO of New Orleans-based Krewe Anesthesia, recently told Becker’s. “They don’’t want post-op nausea. So [enhanced recovery after surgery protocols], opioid-sparing protocols and increased reliance on peripheral nerve blocks, neuraxial blocks to where you can spare those narcotics and you can get patients in and out and with less pain and complications associated with narcotics.”
Armen Voskeridjian, MD, the director of anesthesia services at Jefferson Surgery Center at the Navy Yard in Philadelphia, is on the cutting edge of opioid-sparing techniques.
Dr. Voskeridjian has extensive experience using ultrasound-guided nerve blocks, which lent itself to his interest in liposomal bupivacaine, a local anesthetic. Liposomal bupivacaine has been touted for its ability to deliver three days’ worth of pain relief for patients recovering from surgery.
However, he said that he wasn’t noticing a full 72-hour response from liposomal bupivacaine alone.
“So, I started thinking about what ways we have to prolong it,” Dr. Voskeridjian said. “We know that if you add a steroid, dexamethasone, to aqueous local anesthetic, it can double the length of time the local anesthetic works in the body. If you do a nerve block with straight bupivacaine, you can probably get nine to 15 hours out of that block. If you add dexamethasone to it, you can easily get 18 to 30 hours out of it. And we even have studies that show that. So I started wondering, what if we were to add a steroid to the liposomal bupivacaine?”
Technically, he added, the manufacturer states that nothing should be added to liposomal bupivacaine other than aqueous local anesthetic.
“I did. I took a leap of faith, I did a couple of small experiments on my own, but I felt confident that the addition of dexamethasone to the liposomal bupivacaine was not changing or altering [it], so I went ahead and started using this.”
Dr. Voskeridjian has since conducted two studies on the effectiveness of liposomal bupivacaine in combination with dexamethasone in blocking pain after ACL, ankle and foot procedures. He added that a third study, focusing on shoulder procedures, is in progress.
In the study focused on ACL surgeries, which included 131 patients, 77% of the patients took zero narcotics after surgery. Of the 23% who did take narcotics, the average number of pills they took was two 5-milligram tablets of oxycodone.
“This is an incredible result,” Dr. Voskeridjian said. “Considering most patients would finish their narcotic prescription of 20 pills, sometimes calling the surgeon’s office for a refill.”
The study is being prepared for publication in The Online Journal of Sports Medicine, he added. Results from the study focusing on recovery from foot and ankle procedures were even more promising.
“[Patients in the study] with the nerve blocks with dexamethasone and the liposomal bupivacaine were getting, on average, about eight days of pain relief. Those without [dexamethasone] were getting about five-and-a-half days. But regardless, both groups showed an near elimination of narcotic use in ankle cases,” Dr. Voskeridjian said.
Of the 129 patients in the treatment group in that study, less than 1% used oxycodone after surgery — less than 1 pill per 100 patients.
“It’s truly remarkable,” he said. “Being able to reduce narcotic use, or eliminate narcotic use in these types of surgeries, is a huge leap in outpatient orthopedic ambulatory surgery.”
Dr. Voskeridjian said that widespread adoption of this technique will depend on support from orthopedic surgeons, as well as anesthesia professionals, but has the potential to revolutionize orthopedics and, eventually, other outpatient surgical specialties.
“The formulation will work regardless of where you’re using it,” he said. “So if you are an OB-GYN, or you’re doing abdominal surgery and you want to use it on a [transabdominal plane] block [or erector spinae plane] blocks, this formulation is not limited. … You can use it anywhere, and it will cause a prolongation of the block.”
“But I have no qualms about the fact that it’s going to make a difference,” he said.
In addition to its potential to revolutionize patient care, this method of pain management may also prove to be a financial gamechanger for ASCs facing years of diminishing reimbursement rates and a strained anesthesia workforce.
“ASCs are finding themselves being asked to subsidize the anesthesia group, and this becomes a very raw point of contention,” Dr. Voskeridjian said. “But if the anesthesia group says, ‘Look, this is what I’m bringing to the ASC. I’m bringing a zero to no narcotic use experience,’ patient satisfaction scores go up. And now that we know that reimbursements are going to be related to patient satisfaction, this becomes an imperative that I think all anesthesiologists should adopt that are doing regional anesthesia.”
