Changes in analgesic strategies for lobectomy from 2009 to 2018

Abstract

Objective: To evaluate trends in the use of epidural analgesia and nonopioid and opioid analgesics for patients undergoing lobectomy from 2009 to 2018.

Methods: We queried the Premier database for adult patients undergoing open, video-assisted, and robotic-assisted lobectomy from 2009 to 2018. The outcome of interest was changes in the receipt of epidural analgesia and nonopioid and opioid analgesics as measured by charges on the day of surgery. We also evaluated postoperative daily opioid use. We used multivariable logistic and linear regression models to examine the association between the utilization of each analgesic modality and year.

Results: We identified 86,308 patients undergoing lobectomy from 2009 to 2018 within the Premier database: 35,818 (41.5%) patients had open lobectomy, 35,951 (41.7%) patients had video-assisted lobectomy, and 14,539 (16.8%) patients had robotic-assisted lobectomy. For all 3 surgical cohorts, epidural analgesia use decreased, and nonopioid analgesics use increased over time, except for intravenous nonsteroidal anti-inflammatory drugs. Use of patient-controlled analgesia decreased, while opioid consumption on the day of surgery increased and postoperative opioid consumption did not decrease over time.

Conclusions: In this large sample of patients undergoing lobectomy, utilization of epidural analgesia declined and use of nonopioid analgesics increased. Despite these changes, opioid consumption on day of surgery increased, and there was no significant reduction in postoperative opioid consumption. Further research is warranted to examine the association of these changes with patient outcomes.

Keywords: COX-2, cyclooxygenase-2; FDA, Food and Drug Administration; ICD, International Classification of Diseases; IV, intravenous; NSAID, nonsteroidal anti-inflammatory drug; PCA, patient-controlled analgesia; PME, parental morphine equivalent; PO, per os, oral; POD, postoperative day; RATS, robotic-assisted thoracoscopic surgery; VATS, video-assisted thoracoscopic surgery; epidural analgesia; lobectomy; multimodal analgesia; nonopioid analgesia; robotic-assisted thoracoscopic surgery; thoracic surgery; thoracotomy; video-assisted thoracoscopic surgery.

Graphical abstract

Opioid consumption on day of surgery increased from 2009 to 2018.

Figure 1

Trend in nonopioid analgesics for open lobectomy on day of surgery. Plot of predicted probabilities of use in nonopioid analgesics for open lobectomy on day of surgery from 2009 to 2018. Use of epidural, PCA, and IV NSAIDs decreased over time (P < .0001). Use of IV and oral acetaminophen, ketamine, gabapentinoids, and liposomal bupivacaine increased over time (P < .0001). PCA, Patient-controlled analgesia; IV, intravenous; NSAID, nonsteroidal anti-inflammatory drug.

Figure 2

Trend in opioid consumption for open lobectomy on POD 0, 1, 2, and 3. Plot of predicted probabilities of values in opioid consumption, expressed in PMEs, on day of surgery and POD 1, 2, and 3 for open lobectomy. Total opioid use on day of surgery went from 17 mg in 2009 to 20 mg in 2018 (P < .0001). POD 1 opioid use increased from 22 mg in 2009 to 31 mg in 2018 (P < .0001). POD 2 opioid use decreased from 27 mg in 2009 to 24 mg in 2012 and then increased to 33 mg in 2018 (P < .0001). POD 3 opioid use decreased from 33 mg in 2009 to 27 mg in 2012 and increased back to 33 mg in 2018 (P = .73). POD, Postoperative day; PME, parenteral morphine equivalents.

Figure 3

Trend in nonopioid analgesics for video-assisted lobectomy on day of surgery. Plot of predicted probabilities of use in nonopioid analgesics for video-assisted lobectomy on day of surgery from 2009 to 2018. Use of epidural, PCA, and IV NSAIDs decreased over time (P < .0001). Use of IV and oral acetaminophen, ketamine, gabapentinoids, and liposomal bupivacaine increased over time (P < .0001). PCA, Patient-controlled analgesia; IV, intravenous; NSAID, nonsteroidal anti-inflammatory drug.

Figure 4

Trend in opioid consumption for video-assisted lobectomy on POD 0, 1, 2, and 3. Plot of predicted probabilities of values in opioid consumption, expressed in PMEs, on day of surgery and POD 1, 2, and 3 for video-assisted lobectomy. Total opioid use on day of surgery went from 17 mg in 2009 to 26 mg in 2018 (P < .0001). POD 1 opioid use decreased from 29 mg in 2009 to 25 mg in 2012 and increased to 36 mg in 2018 (P < .0001). POD 2 opioid use decreased from 31 mg in 2009 to 23 mg in 2012 and increased to 35 mg in 2018 (P < .0001). POD 3 opioid use decreased from 35 mg in 2009 to 24 mg in 2012 and increased to 33 mg in 2018 (P = .005). POD, Postoperative day; PME, parenteral morphine equivalents.

Figure 5

Trend in nonopioid analgesics for robotic-assisted lobectomy on day of surgery. Plot of predicted probabilities of use in nonopioid analgesics for robotic-assisted lobectomy on day of surgery from 2009 to 2018. Use of epidural, PCA, and IV NSAIDs decreased over time (P < .0001). Use of IV and oral acetaminophen, ketamine, gabapentinoids, and liposomal bupivacaine increased over time (P < .0001). PCA, Patient-controlled analgesia; IV, intravenous; NSAID, nonsteroidal anti-inflammatory drug.

Figure 6

Trend in opioid consumption for robotic-assisted lobectomy on POD 0, 1, 2, and 3. Plot of predicted probabilities of values in opioid consumption, expressed in PMEs, on day of surgery and POD 1, 2, and 3 for robotic-assisted lobectomy. Total opioid use on day of surgery went from 24 mg in 2009 to 13 mg in 2011, and then increased to 20 mg in 2018 (P < .0001). POD 1 opioid use decreased from 33 mg in 2009 to 20 mg in 2011, and then increased to 31 mg in 2018 (P < .0001). POD 2 opioid use decreased from 29 mg in 2009 to 21 mg in 2012, and then increased to 26 mg in 2018 (P = .05). POD 3 opioid use decreased from 26 mg in 2009 to 16 mg in 2011, and then increased to 25 mg in 2018 (P = .21). POD, Postoperative day; PME, parenteral morphine equivalents.

Figure 7

Changes in analgesic strategies for lobectomy from 2009 to 2018. A retrospective observational study was conducted using the Premier database for adult patients undergoing open, video-assisted, and robotic-assisted lobectomy from 2009 to 2018. Epidural use declined over time, and nonopioid analgesics use increased. Despite these changes, opioid consumption on day of surgery increased, and there was no significant reduction in postoperative opioid consumption. VATS, Video-assisted thoracoscopic surgery; RATS, robotic-assisted thoracoscopic surgery; POD, postoperative day.

Figure E1

Trend in nonopioid analgesics for open lobectomy on day of surgery. Plot of predicted probabilities of use in other nonopioid analgesics for open lobectomy on day of surgery from 2009 to 2018. Use of COX-2 inhibitors, opioid combination product, dexmedetomidine, and dexamethasone increased over time (P < .0001). Use of oral NSAIDs remained low and did not change significantly over time (P = .45). COX-2, Cyclooxygenase-2; NSAID, nonsteroidal anti-inflammatory drug.

Figure E2

Trend in nonopioid analgesics for video-assisted lobectomy on day of surgery. Plot of predicted probabilities of use in other nonopioid analgesics for video-assisted lobectomy on day of surgery from 2009 to 2018. Use of oral NSAIDs, COX-2 inhibitors, opioid combination product, dexmedetomidine, and dexamethasone increased over time (P < .0001). NSAID, Nonsteroidal anti-inflammatory drug; COX-2, cyclooxygenase-2.

Figure E3

Trend in nonopioid analgesics for robotic-assisted lobectomy on day of surgery. Plot of predicted probabilities of use in other non-opioid analgesics for robotic-assisted lobectomy on day of surgery from 2009 to 2018. Use of oral NSAIDs increased over time (P = .01). Use of COX-2 inhibitors, opioid combination product, and dexamethasone increased over time (P < .0001). Use of dexmedetomidine decreased over time (P < .0001). NSAID, Nonsteroidal anti-inflammatory drug; COX-2, cyclooxygenase-2.