Abstract
Outcome objectives
1) Analyze differences in healthcare usage between subjects receiving different perioperative analgesic medications after uvulopalatopharyngoplasty (UPPP) surgery. 2) Comment on the impact of perioperative analgesic medication on length of hospital stay and complications after UPPP.
Methods
A retrospective cohort study of 120 UPPPs conducted by a single surgeon in the past 5 years was conducted. Subjects were grouped based on perioperative pain medication regimen into three groups; narcotics alone ( n = 83), narcotics with gabapentin ( n = 27), or narcotics with ketorolac tromethamine ( n = 10). The primary outcome variable was total number of clinic/emergency room and/or telephone encounters related to post-UPPP pain. Secondary outcomes included length of post-operative hospital stay, number of telephone and/or clinical encounters in which the patient complained specifically of pain or requested a refill for analgesics, and post-operative complications.
Results
No significant difference was found between the three analgesic regimens in post-operative hospital stay length ( p = 0.28, median stay 23.5 h), number of clinic or telephone encounters related to pain ( p = 0.26, mean value 0.71 encounters), or post-operative complication rate ( p = 0.82, 5.9% complication rate).
Conclusion
This study shows no significant difference in post-operative healthcare usage between patients with peri-operative analgesic regimens including narcotics alone, gabapentin with narcotics, or ketorolac with narcotics. Post-operative complication rate and length of stay did not differ between groups. These data suggest that these three medication regimens have similar impact on post-operative course for UPPP patients. Therefore, the most affordable or simplest options have equivalent effects on post-operative healthcare usage.
1
Introduction
Obstructive sleep apnea (OSA) affects 2–4% of the adult population in the United States and is associated with increased risk of cardiovascular disease . OSA has been shown to increase hypoxia, intrathoracic pressure, and inflammatory markers and is associated with increased rates of hypertension, congestive heart failure, and cardiac arrhythmias . It has been estimated that untreated OSA costs billions of dollars annually in the American Medical System . Recommended therapy for OSA begins with patient education and lifestyle counseling and a trial of continuous positive airway pressure (CPAP) devices . While CPAP has been shown to significantly improve symptoms of OSA as well as physiologic measures of the disease , patient compliance with CPAP therapy is variable. Some trials with optimized patient education and rigorous follow-up have shown compliance rates approaching 90% while others have observed compliance after months of therapy to reduce to closer to 50% of patients . If patients fail to improve with CPAP therapy or are unable to comply with this primary intervention, they should be counseled on alternative therapeutic options including oral appliances, lifestyle interventions, and surgical procedures .
Several surgical options exist for the treatment of OSA including maxillo-mandibular advancement, laser assisted uvulopalatoplasty, uvulopalatopharyngoplasty (UPPP), palatal implants, and tracheostomy. In contrast to the robust research investigating the use of CPAP in OSA, systematic research of surgical options for the treatment of OSA remains poorly represented in the scientific literature . Each surgical procedure has unique advantages and disadvantages and no clear guidelines for procedure selection have been established. At our center, UPPP is one favored surgical intervention based on patient experience and previous successes of this procedure. This research does not strive to establish recommendations for surgical treatment of OSA but instead examines the patient experience and complication profile of UPPP.
UPPP was described in the 1980s as a treatment for obstructive upper airway disease . It has since been shown to be relatively safe, with mortality reported at 0.02–0.043% in the literature . The principle peri-operative complications of this surgery are post-operative bleeding, which has been reported in 3.7% of patients in one large case series , and post-operative pain. No standardized peri-operative regimens have been described to maximize pain-control or to minimize bleeding complications. Analgesic medication choice intuitively impacts the post-operative pain in UPPP patients and has been proposed to also impact the risk of post-surgical bleeding . As such, many surgeons have altered their preferred peri-operative analgesic regimens based on the evolving literature in this area, patient preferences, and personal experience. Recognizing that a paucity of evidence to support one peri-UPPP analgesic regimen when compared to others, we conducted the following study to examine the effects of three different analgesic regimens on safety and healthcare usage by examining three regiments implemented by a single surgeon at our institution over five years of practice.
2
Materials and methods
The study was approved by the Cleveland Clinic Institutional Review Board prior to initiating the research. 120 adult patients who had undergone UPPP between 1/1/2010 and 1/1/2015 were identified and included in this study. Data was gathered using the electronic medical records from our institution. Demographic and morphometric data were gathered. Patients were grouped based on analgesic regimen prescribed. The analgesic regimen chosen was determined based on provider preference, patient preference based on prior medication experiences, and co-morbid conditions. Three different regimens were prescribed during the study period. “Opioids alone” which consisted of hydrocodone and oxycodone only, “opioids with gabapentin” which consisted of gabapentin in addition to hydrocodone and/or oxycodone, or “opioids with ketorolac tromethamine” which used ketorolac tromethamine in addition to opioid medications. In the later two cases a reduced schedule of opioids was given, but this was titrated to patient requirements during the perioperative period and doses varied within the labeled usage for each drug. Gabapentin was begun approximately 1 h before surgery to activate the descending noradrenergic analgesic pathway while all other medications being started during the post-surgical stay. All patients stayed overnight following their surgery and were discharged the following day after meeting analgesic and par-oral dietary requirements for outpatient follow-up.
Healthcare usage was assessed via several values. The total time spent as an inpatient post-operatively was calculated to compare the effect of analgesic choice on hospital stay. This value in hours was calculated from the beginning of the UPPP operation until the time of discharge. The number of visits to the emergency room and/or clinic with complaints of post-operative pain, discomfort, or bleeding was also recorded. The number of telephone encounters in which patients complained of post-operative pain or discomfort was also recorded to assess this modality of healthcare service utilization and as a surrogate variable to represent patient pain. Any re-admission or post-operative intervention for bleeding complications was also recorded. Complete medication records were assessed for each patient and prescribed analgesics, peri-operative steroids, and post-operative antibiotic prescriptions were recorded. Post-operative bleeding concerns were defined as any instance when a subject initiated an encounter complaining of bleeding in the oropharynx within a 3-week post-operative period. All of these encounters were assessed in the Emergency Department and were further described as requiring assessment/observation, bedside intervention such as silver nitrate cautery, or operative intervention.
Statistical analyses were conducted using SAS 9.4 and JMP 10.0 (SAS Institute Inc., Cary, NC, USA). Descriptive statistics were calculated for each variable. Wilcoxon Rank-Sum testing was conducted to compare between analgesic groups for continuous variables and Fisher’s Exact Test was used to compare categorical variables. Student t -test was used to assess the impact of steroid and antibiotic medications on continuous outcome variables. An alpha level of 0.05 was used to determine statistical significance for all testing.
2
Materials and methods
The study was approved by the Cleveland Clinic Institutional Review Board prior to initiating the research. 120 adult patients who had undergone UPPP between 1/1/2010 and 1/1/2015 were identified and included in this study. Data was gathered using the electronic medical records from our institution. Demographic and morphometric data were gathered. Patients were grouped based on analgesic regimen prescribed. The analgesic regimen chosen was determined based on provider preference, patient preference based on prior medication experiences, and co-morbid conditions. Three different regimens were prescribed during the study period. “Opioids alone” which consisted of hydrocodone and oxycodone only, “opioids with gabapentin” which consisted of gabapentin in addition to hydrocodone and/or oxycodone, or “opioids with ketorolac tromethamine” which used ketorolac tromethamine in addition to opioid medications. In the later two cases a reduced schedule of opioids was given, but this was titrated to patient requirements during the perioperative period and doses varied within the labeled usage for each drug. Gabapentin was begun approximately 1 h before surgery to activate the descending noradrenergic analgesic pathway while all other medications being started during the post-surgical stay. All patients stayed overnight following their surgery and were discharged the following day after meeting analgesic and par-oral dietary requirements for outpatient follow-up.
Healthcare usage was assessed via several values. The total time spent as an inpatient post-operatively was calculated to compare the effect of analgesic choice on hospital stay. This value in hours was calculated from the beginning of the UPPP operation until the time of discharge. The number of visits to the emergency room and/or clinic with complaints of post-operative pain, discomfort, or bleeding was also recorded. The number of telephone encounters in which patients complained of post-operative pain or discomfort was also recorded to assess this modality of healthcare service utilization and as a surrogate variable to represent patient pain. Any re-admission or post-operative intervention for bleeding complications was also recorded. Complete medication records were assessed for each patient and prescribed analgesics, peri-operative steroids, and post-operative antibiotic prescriptions were recorded. Post-operative bleeding concerns were defined as any instance when a subject initiated an encounter complaining of bleeding in the oropharynx within a 3-week post-operative period. All of these encounters were assessed in the Emergency Department and were further described as requiring assessment/observation, bedside intervention such as silver nitrate cautery, or operative intervention.
Statistical analyses were conducted using SAS 9.4 and JMP 10.0 (SAS Institute Inc., Cary, NC, USA). Descriptive statistics were calculated for each variable. Wilcoxon Rank-Sum testing was conducted to compare between analgesic groups for continuous variables and Fisher’s Exact Test was used to compare categorical variables. Student t -test was used to assess the impact of steroid and antibiotic medications on continuous outcome variables. An alpha level of 0.05 was used to determine statistical significance for all testing.
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