Decreased Opioid Consumption in Bone Marrow Harvest Patients Using Quadratus Lumborum Blocks in a Standardized Protocol

Abstract

Purpose: Bone marrow harvesting is associated with significant postoperative pain that may have potential negative consequences for the patient and health care system. In the current absence of uniform guidelines, there exists considerable variability amongst providers with respect to perioperative analgesia, especially opioid administration. In this initiative, we explored the potential for preoperative bilateral quadratus lumborum blocks in combination with a standardized perioperative analgesic protocol to manage pain with the goal of reducing perioperative narcotic usage and thereby improving opioid stewardship.

Methods: Adults who underwent bone marrow donation from 2018 to 2020 were included in this analysis (n = 32). The pre-implementation group (n = 19) was reviewed retrospectively while the implementation group (n = 13) was evaluated prospectively. Patient demographics, pain scores, and opioid consumption were evaluated.

Results: Patient characteristics were equivalent except for anesthesia type with an increased number of patients in the implementation group undergoing spinal anesthesia. The implementation group showed significantly reduced median intraoperative (20.0 mg vs. 0.0 mg; p < 0.001) and total opioid consumption (20.5 mg vs. 0.0 mg; p < 0.001). The number of patients who received any opioids decreased from 84.2% (16/19) before implementation to 23.1% (3/13) after implementation.

Conclusion: This change in practice suggests that implementation of a standardized perioperative protocol, including bilateral quadratus lumborum blocks, for bone marrow harvest patients leads to reduced perioperative opioid administration without compromising immediate perioperative pain control.

Keywords: bone marrow harvest; local anesthesia; nerve block; opioid analgesics; postoperative pain; quadratus lumborum; regional anesthesia.

FIGURE 1

Run chart for total oral morphine milligram equivalents (MME) in bone marrow donors (N = 32). The line represents median MME. Multiple tests of change over time are noted with arrows. After implementing the protocol and quadratus lumborum (QL) block, administered MMEs significantly decrease. This decrease was maintained over time and through multiple tests of change, supporting the sustainability of the protocol. The tests of change included: (1) instituted QL blocks, (2) created anesthesia quality improvement champion, (3) standardized preoperative multimodal medications, (4) formalized perioperative protocol, (5) added anesthesia attendings to staff cases, (6) standardized intraoperative multimodal medications, (7) reduced postoperative oxycodone prescriptions, and (8) uploaded formal protocol to the anesthesia electronic medical record. BMT, bone marrow transplant.

FIGURE 2

Run charts of opioid consumption before implementation and throughout multiple tests of change. Each data point represents an individual donor. (A) Morphine milligram equivalents (MME) administered in the operating room. (B) MME administered in the post anesthesia care unit (PACU). (C) MME administered in all phases of care.