HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Otolaryngology–Head and Neck Surgery 158(5)

Table 3. Relevant Resources on Opioid Use for Acute Postoperative Pain.

Source

Content

Website

Centers for Disease Control and Prevention: Opioid Overdose

Collection of resources for providers on the opioid epidemic Includes mobile phone app on opioid guidelines with morphine-equivalent dose calculator Patient summary of risks of opioids

https://www.cdc.gov/drugoverdose/opioids/index.html

Centers for Disease Control and Prevention: Prescription Opioids: What You Need to Know American Pain Society Guideline on the Management of Postoperative Pain American Society of Anesthesiologists: Practice Guidelines for Acute Pain

https:/www.cdc.gov/drugoverdose/pdf/aha-patient-opioid-factsheet-a.pdf

Guideline on acute postoperative pain management Guideline on acute postoperative pain management

http://www.jpain.org/article/S1526-5900(15)00995-5/pdf

http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1933589

Management in the Perioperative Setting

Enhanced Recovery after Surgery Society Consensus

Guideline outlining enhanced recovery adapted to head and neck surgery with free flap reconstruction

http://erassociety.org/specialties/head-and-neck/

Review and Recommendations on Optimal Perioperative Care in Major Head and Neck Cancer Care with Free Flap Reconstruction

strategies has identified that patients experience a significant reduction in postoperative pain medication requirements. 63 Local and Regional Anesthesia Head and neck surgery provides several unique challenges in regards to use of local and regional anesthetics. Local anesthetics have been used safely for decades but require consideration of proximity to cranial nerves in surgery on the head and neck to avoid inadvertent paresis complicating identification or postoperative assessment. Preincisional infiltration of tissues with local anesthesia pro- vides preventive analgesia and reduces analgesic consumption postoperatively without an increase in postoperative pain. 63 However, use of local anesthetics as a mainstay of postopera- tive analgesia is limited by the brief duration of most tradi- tional local anesthetics ( \ 8 hours). Newer options for administration of local anesthesia allow for a longer duration of action with the prospect of improved pain control. Liposomal bupivacaine was approved by the FDA in 2011 and provides pain control for up to 96 hours after surgery. 64 Pooled analysis of 9 studies shows that injectable liposomal bupivacaine is associated with lower pain scores, reduced con- sumption of opioids, and fewer opioid-related adverse events compared with conventional local anesthetics. 64

Pain pumps are another strategy to provide long-duration pain control by infusing local anesthesia via a catheter into the surgical wound bed continuously, bolused, or via a patient-controlled system for up to 5 days postoperatively. There are several on the market, including ON-Q PainBuster (Halyard Health, Alpharetta, Georgia), Stryker Pain Pump 2 (Stryker Corporation, Kalamazoo, Michigan), and Accufuser disposable silicone balloon infuser (Woo Young Medical, Seoul, Korea). Meta-analysis of 44 rando- mized controlled trials of pain pumps in general surgery, cardiothoracic surgery, orthopedic surgery, and urology found that continuous infusion lowers both pain scores and the need for supplemental opioids. 65 Small series in thyroid and parathyroid surgery have found the ON-Q pain pump to have similar efficacy and be safe without cranial nerve par- esis from infusion of local anesthesia. 47 In this series, the ON-Q catheter was placed superficial to the platysma in conjunction with use of surgical drains in the deeper aspect of the wounds. 47 There is no definitive evidence on whether drains interfere with pain pumps. Regional nerve blocks using long-acting local anesthetics can enhance anesthesia in the head and neck. For example, for facial surgery, external branches of the trigeminal nerve can be blocked. For neck surgery, superficial and deep

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