SAFETY PROFILE AND ECONOMICS WITH THE USE OF FENTAYL AND HYDROMORPHONE AS POSTOPERATIVE EPIDURAL ANALGESICS

Senthilkumar Sadhasivam , Balachundhar Subramaniam, Vimal Akhouri, Carolyn Debeauport, Thomas Simopoulos, Christine Peeters‐Asdourian, Robert I. Cohen. Arnold Pain Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA A nation‐wide shortage of fentanyl increased the use of epidural hydromorphone for postoperative analgesia in our hospital. Compared to fentanyl, the more hydrophilic hydromorphone is expected to spread cephalad in CSF and achieve widespread analgesia with an increased risk of respiratory depression. We aimed to evaluate the safety, side effect profile and costs to manage postoperative pain and associated side effects with epidural fentanyl and hydromorphone. With institutional approval, 1002 adult surgical in‐patients who required postoperative epidural analgesia were studied retrospectively based on postoperative pain consultation and daily pain team follow‐up reports, and chart review. The demographic data and the distribution of catheter placements at upper and lower thoracic and at lumbar levels were comparable. 525 patients received epidural fentanyl 4μg/cc with 0.1% bupivacaine (F‐group) and 477 patients received epidural hydromorphone 20μg/cc with 0.1% bupivacaine (H‐group). The epidural analgesic efficacy and the number of effective epidural analgesic days were comparable in both the groups. The incidences of side effects including respiratory depression, drowsiness, hypotension, nausea/vomiting, pruritus, confusion, motor weakness and ileus were comparable in the F‐ and the H‐groups, but the cumulative incidence of all the side effects was significantly less in the H‐group (34%) than the F‐group (42%, p=0.0016) (Table 1). Urinary retention was not compared as>50% of patients had a urinary catheter as part of routine postoperative care. The direct cost of epidural analgesic solution, calculated by multiplying mean epidural analgesic days, mean epidural rate, and cost per unit of epidural analgesic solution was $23.4 in the F‐group and $22.5 in the H‐group. Epidural hydromorphone has successfully taken over the place of epidural fentanyl in the postoperative pain management at our institution with comparable efficacy, safety and costs for analgesia. With the fentanyl shortage over, hydromorphone has remained the preferred epidural analgesic as the patients in the H‐group had less overall incidence of side effects and less severe nausea and vomiting (reflected by decreased antiemetic intervention). Though the cost to treat PONV per patient was comparable (F‐group $4.3 vs. H‐group $4.8), less frequent need for antiemetics in the H‐group has a cost saving potential. 1 Epidural opioid associated side effectsAssociated Effect Fentanyl Hydro‐morphone P‐ValueTotal side effects (%) 219 (41.7) 162 (33.9) 0.01 * Respiratory depression (%) 9 (1.7) 10 (2.1) 0.66 Drowsiness (%) 40 (7.6) 48 (10.1) 0.19 Hypotension (%) 52 (9.9) 36 (7.6) 0.18 Pruritus (%) 57 (10.9) 62 (12.9) 0.33 Nausea/Vomiting (%) 81 (15.4) 56 (11.7) 0.08 Ileus (%) 6 (1.1) 3 (0.6) 0.38 Motor weakness (%) 22 (4.2) 12 (2.5) 0.14 Confusion (%) 9 (1.7) 6 (1.3) 0.55 Dizziness (%) 7 (1.3) 4 (0.8) 0.20 Inflamed site (%) 6 (1.1) 2 (0.4) 0.35 Spinal migration (%) 1 (0.2) 2 (0.4) 0.93 Catheter shear (%) 2 (0.4) 0 (0) 0.69 Cardiac event (%) 6 (1.1) 1 (0.2) 0.16 Respiratory distress/OSA (%) 2 (0.4) 1 (0.2) >0.99 SE of treatment for NV (%) 0 (0) 2 (0.4) 0.55 Side effects requiring treatment Respiratory depression (%) 9 (1.71) 10 (2.1) 0.66  Hypotension (%) 28 (5.3) 21 (4.4) 0.50  Pruritus (%) 21 (4.0) 18 (3.8) 0.85  Nausea/Vomiting (%) 38 (7.2) 18 (3.8) 0.02 **Statistically significant for p<0.05