title: Multimodal analgesia reduces narcotic requirements and antiemetic rescue medication in laparoscopic Roux-en-Y gastric bypass surgery.
abstract: BACKGROUND
  After bariatric surgery, patients are at risk for narcotic-related side effects. Multimodal pain management strategies should be used when possible to reduce the consumption of narcotic medication. The purpose of this study was to investigate whether multimodal analgesia reduces narcotic consumption and may have an influence on opioid-related side effects in patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB).
  
  
  METHODS
  In this retrospective data analysis, we examined the data of a total of 181 consecutive patients undergoing LRYGB. In January 2011, i.v. acetaminophen became clinically available. Hydromorphone patient controlled analgesia (PCA) was replaced by i.v. acetaminophen and i.v. ketorolac (TNT-Tylenol and Toradol). The first 89 patients received postoperative hydromorphone PCA (PCA group). The next 92 patients received i.v. acetaminophen and i.v. ketorolac every 6 hours for the first 24 hours (TNT group). In the TNT group, 8 patients were excluded in the analysis.
  
  
  RESULTS
  There were no differences in clinical characteristics between the groups except for smoking history. Patients treated with PCA required 4.2 mg hydromorphone in the postoperative period. Patients in the TNT group required 1.1 mg hydromorphone. This was a statistically significant reduction of opioids by 73.8%. After discharge from postanesthesia care unit, 34.8% of patients required antiemetic rescue medication (AERM) compared with 20.2% in the TNT group (P<.001). The relative risk (AERM/no AERM) in the postoperative period after postanesthesia care unit discharge is 1.75 (95% CI, 1.05-2.92).
  
  
  CONCLUSIONS
  This study suggests that a multimodal analgesic regimen (TNT) can reduce postoperative narcotic consumption, which may lead to a reduction in the number of patients requiring AERM.
authors.affiliation: Coastal Anesthesiology Consultants, US Bariatrics, Flagler Hospital, St. Augustine, Florida. Electronic address: pziemann@yahoo.com.
authors.forename: Patrick
authors.initials: P
authors.lastname: Ziemann-Gimmel
authors.forename: Priscilla
authors.initials: P
authors.lastname: Hensel
authors.forename: John
authors.initials: J
authors.lastname: Koppman
authors.forename: Robert
authors.initials: R
authors.lastname: Marema
mesh_terms: D000082:Acetaminophen / Q000008:administration & dosage; D000328:Adult; D016058:Analgesia, Patient-Controlled / Q000379:methods; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D000713:Anastomosis, Roux-en-Y / Q000009:adverse effects / Q000379:methods; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D007262:Infusions, Intravenous; D020910:Ketorolac / Q000008:administration & dosage; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000175:diagnosis / Q000601:surgery*; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000188:drug therapy*; D020250:Postoperative Nausea and Vomiting / Q000188:drug therapy*; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid; D000082:Acetaminophen; D020910:Ketorolac
keywords: IV acetaminophen; Laparoscopic Roux-en-Y gastric bypass; Multimodal analgesia; Postoperative nausea and vomiting (PONV); Tylenol and Toradol (TNT)