Decreased Postoperative Opiate Use Following Implementation of a Multimodal Perioperative Medication Pathway [12Q]

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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.


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.


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.


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.

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