Development of a postoperative ileus risk assessment scale: identification of intraoperative opioid exposure as a significant predictor after spinal surgery

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OBJECTIVE

Postoperative ileus (POI) is associated with abdominal pain, nausea, vomiting, and delayed mobilization that in turn lead to diminished patient satisfaction, increased hospital length of stay (LOS), and increased healthcare costs. In this study, the authors developed a risk assessment scale to predict the likelihood of developing POI following spinal surgery.

METHODS

The authors undertook a retrospective review of a prospectively maintained registry of consecutive patients who underwent arthrodesis/fusion surgeries between May 2013 and December 2017. They extracted clinical information, including cumulative intraoperative and postoperative opioid doses using standardized converted morphine milligram equivalent (MME) values. Univariate and multivariate analyses were performed and several categorical and continuous variables were evaluated in a binary logistic regression model built with backward elimination to assess for independent predictors. A points-based prediction model was developed and validated to determine the risk of POI.

RESULTS

A total of 334 patients who underwent spinal fusion surgeries were included. Fifty-six patients (16.8%) developed POI, more frequently in those who underwent long-segment surgeries compared to short-segment surgeries (33.3% vs 10.4%; p < 0.001). POI was associated with an increased LOS when compared with patients who did not develop POI (8.0 ± 4.5 days vs 4.4 ± 2.4 days; p < 0.01). The incidences of liver disease (16% vs 3.7%; p = 0.01) and substance abuse history (12.0% vs 3.2%; p = 0.04) were higher in POI patients than non-POI patients undergoing short-segment surgeries. While the incidences of preoperative opioid intake (p = 0.23) and cumulative 24-hour (87.7 MME vs 73.2 MME; p = 0.08) and 72-hour (225.6 MME vs 221.4 MME; p = 0.87) postoperative opioid administration were not different, remifentanil (3059.3 µg vs 1821.5 µg; p < 0.01) and overall intraoperative opioid (326.7 MME vs 201.7 MME; p < 0.01) dosing were increased in the POI group. The authors derived a multivariate model based on the 5 most significant factors predictive of POI (number of surgical levels, intraoperative MME, liver disease, age, and history of substance abuse) and calculated relative POI risks using a derived 32-point system.

CONCLUSIONS

Intraoperative opioid administration, incorporated in a comprehensive risk assessment scale, represents an early and potentially modifiable predictor of POI. These data indicate that potential preventive strategies, implemented as part of enhanced recovery after surgery protocols, could be instituted in the preoperative phase of care to reduce POI incidence.

ABBREVIATIONS BMI = body mass index; EBL = estimated blood loss; ERAS = enhanced recovery after surgery; GERD = gastroesophageal reflux disease; GI = gastrointestinal; LOS = length of stay; MME = morphine milligram equivalent; MNTX = methylnaltrexone; POI = postoperative ileus; ROC = receiver operating characteristic.

Article Information

Correspondence H. Francis Farhadi: The Ohio State University Wexner Medical Center, Columbus, OH. francis.farhadi@osumc.edu.

INCLUDE WHEN CITING Published online July 19, 2019; DOI: 10.3171/2019.5.SPINE19365.

Disclosures Dr. Farhadi reports receiving non–study-related support for research efforts that he oversees from DePuy Synthes, Implanet America, and Nexxt Spine.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Dot plot showing significant variation (p < 0.001) in intraoperative opioid doses (y axis: MMEs) administered to 167 patients who underwent surgeries spanning ≤ 3 levels managed by 10 different anesthesiologists (x axis: A to J). Bars represent median opioid administration grouped by anesthesiologist. Gray and black dots represent individual patients without and with POI, respectively.

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