Reduced post-operative pain after laparoscopic hysterectomy is an advantage of the minimally invasive approach, but there is still room for improvement. We adapted a standardized multimodal peri-operative pathway to reduce postoperative pain and nausea.METHODS:
Retrospective chart review of post-anesthesia care unit (PACU) opiate use in patients undergoing a laparoscopic hysterectomy (total and supracervical; robotic and traditional) before and after the institution of a multimodal pathway at Virginia Mason Medical Center in Seattle WA. Thirty randomly selected control patients were compared with thirty-one patients from the first five weeks of pathway use. The same seven surgeons performed all operations. Peri-operative administration of dexamethasone, acetaminophen 975 mg, celecoxib 400 mg and gabapentin 600 mg was documented. PACU administration of opiates (IV fentanyl, IV hydromorphone, PO hydromorphone, PO oxycodone, PO acetaminophen/hydrocodone) was compared. PASW software was employed for data analysis.RESULTS:
Mean PACU fentanyl dose fell from 49.17 mcg to 24.19 mcg with use of the pathway, median went from 25 to 0 mcg. Total opiate doses were converted to morphine equivalents, with mean pre-pathway total 10 mg and 5.8 mg on the pathway. Median morphine equivalent was 4.8 mg before and 3.3 mg on the pathway.CONCLUSION:
The total dose of opiates administered in PACU was lower in patients on the standardized laparoscopic hysterectomy multimodal pathway, demonstrating better post-operative pain control. Multiple aspects of the multimodal pathway will be examined.