2026 Proffered Presentations
S277: A NOVEL COMPREHENSIVE, GENERALIZABLE AND MULTI-MODAL PROTOCOL TO REDUCE OPIOID UTILIZATION FOLLOWING ENDOSCOPIC ENDONASAL SURGERY - A SINGLE INSTITUTION PILOT STUDY
Walavan Sivakumar; Matthew Pelletier, BS; Jian Guan, MD; Jean-Philippe Langevin, MD; Marcus Mazur, MD; Garni Barkhoudarian, MD; Neil Martin, MD; Daniel F Kelly, MD; Michael Yong, MD; Chester Griffiths, MD; Pacific Neuroscience Insitute
Introduction: Pain control remains a challenge for many patients undergoing endoscopic skull base surgery. Despite its untoward effects, opioid analgesia is a mainstay of post-operative treatment. Additionally, no single intervention has resulted in a significant decrease in post-endonasal intracranial surgery narcotic requirement. While enhanced recovery after surgery (ERAS) and multimodal pain protocols have been studied in other neurosurgical populations, no comprehensive ERAS-style protocol has been evaluated specifically in patients undergoing endoscopic endonasal surgery. We present the results of the first study, to the author's knowledge, utilizing a comprehensive, generalizable and multi-modal protocol focused on non-narcotic analgesia to reduce opioid utilization following endoscopic endonasal surgery.
Methods: We conducted a prospective multi-cohort pilot study evaluating post-operative opioid utilization throughout hospitalization in patients undergoing endoscopic endonasal surgery in both urgent and elective cases. Patients in the historic cohort (January 2019 - December 2021) received the traditional pain control algorithm. A comprehensive, multi-modal protocol spanning the patient’s surgical continuum (including pre-operative counseling, total-Intravenous-anesthesia (TIVA), multimodal opioid-sparing analgesia, early mobilization and closely monitored post-operative convalescence) was implemented in January 2022 and administered to all patients undergoing endoscopic endonasal surgery through December 2024.
Results: There were 112 patients included for review. Average morphine milligram equivalents (MME) administered to patients in the historic cohort was 33.93 versus 2.62 for patients in the implementation cohort (p=0.023). Total MME administered for patients in the historic cohort was 712.6 versus 238.6 in the implementation cohort. 91% of patients in the implementation cohort did not require a single opioid following endonasal surgery, versus 52% in the historic cohort. No post-surgical intracranial hemorrhage related to peri-operative NSAIDs was noted. No patients returned to the emergency department within 30 days of surgery for pain crisis in the historic or implementation cohort. Average length of stay for patients in the historic cohort was 3.62 days versus 2.88 days in the implementation cohort (p=0.167).
Conclusions: Utilization of a comprehensive, generalizable and multi-modal pain protocol was feasible and resulted in significant reductions in postoperative opioid consumption amongst patients undergoing endoscopic endonasal surgery. There was no increase in NSAID-related intracranial hemorrhage. Additionally, there was a trend towards improvement in length of stay in these patient cohorts. These findings support the efficacy of ERAS protocols in this population and warrant further investigation in larger studies.