MULTIMODAL ANALGESIA

Drahos AL, Scott AM, Johns TJ, Ashley DW. Multimodal analgesia and decreased opioid use in adult trauma patients. Am Surg 2020 Aug 7. DOI: 10.1177/0003134820942177 

Introduction

Because of the ongoing opioid epidemic it is feasible to examine pain management strategies in order to decrease opioid administration in patients with pain. Multimodal analgesia (MMA) is the administration of several different analgesics with different pharmacologic actions providing analgesia through distinct mechanisms. MMA has been associated with decreased opioid usage in the peri-operative setting.

Objective

To review the impact of the implementation of an multimodal analgesia pain management guideline on opioid usage in trauma patients. Besides the development of the MMA guideline, there was an education period for health care staff including feed-back at monthly trauma conferences and pocket cards for residents.

 

Setting

High volume level 1 trauma center in the USA

Population

All patients admitted in trauma services, excluding patients 15 years and younger.

Methods

Retrospective comparative before-and-after implementation study using data from a trauma registry.

Patients data from 2016 served as control group. In 2017 the MMA guideline was implemented and patients data from 2018 served as intervention group.

 

Outcomes

1. Differences in usage of opioids and Morphine Milligram Equivalents (MME)

2. - Patient pain satisfaction

    - Rates of acute kidney injury (AKI)

Results

A total of 3013 (2016) and 3249 (2018) patients were eligible for inclusion.

Baseline: majority male with mean age 47.7 (2016) and 50.1 (2018) years.

ISS scores 9.2 (2016) and 9.6 (2018) and most had blunt trauma (85% and 88%). LOS was longer in 2018 (5.6) versus 5.1 days in 2016 (p<0.05). No difference in ICU / mortality.

The total MME was 2402329 in 2016 and 1975935 in 2018 and this was a 17.8% decrease in all opioids (p=0.009). Per patient this was 797 MME in 2016 versus 608 MME in 2018, a 24% decrease per patient.

Regarding analgesics used as MMA, there was an increase in use of:

- acetaminophen 34% (p<0.001)

- ibuprofen 143% (p<0.001)

- baclofen 705% (p<0.01)

- methocarbamol 72% (p<0.001)

- gabapentin 161% (p<0.001)

- local analgesic (catheter) infusions 147% (p<0.001)

- lidocaine patches 437% (p<0.001)

Mean pain scores during the first 24 hours of admission were 4.8 in 2016 and 4.3 in 2018 (p<0.001) and during the second 24 hours 3.9 and 3.1 (p<0.001), respectively.

There was a non-significant increase in AKI: 0.56% (2016) versus 0.68% (2018).

Conclusion

Implementation of the MMA guideline resulted in a statistically significant 17.8% decrease in opioid administration and non-opoid usage increased concurrently. This resulted in more effective pain treatment and lower pain scores with a non-significant increase in acute kidney injury.

 

Limitations

This was a retrospective study, therefore prone to potential and unknown confounders and documentation bias, especially as data were extracted from a registry and outcomes such as pain scores are known to be documented poorly.

No sample size calculation was performed beforehand.

The secondary endpoint of patient satisfaction was not presented in the results.

Level of evidence 4

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