Current practice on perioperative opioid titration and clinician-perceived predictors for dose escalation in adults, a Danish nation-wide survey
Trang XM Tran1, BSc Med., BA Psych. (project manager/driver)
Mik Wetterslev2, MD, PhD (conceptualisation, survey setup in RedCap)
Ole Mathiesen3,4, MD, PhD, Representing Chair Professor (pain expert opinion)
Anders K Nørskov3,4, MD, PhD, Ass. Professor (identification of site investigators via CEPRA)
Christian S Meyhoff1, MD, PhD, Professor (co-supervisor)
Theis Itenov1, MD, PhD, Associate Professor (formal supervisor)
Anders PH Karlsen1, MD, PhD (conceptualisation, primary supervisor)
1 Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, Copenhagen.
2 Department of Intensive Care 4131, Rigshospitalet, Copenhagen.
3 Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital Koege.
4 The Collaboration for Evidence-based Practice & Research in Anaesthesia (CEPRA)
Introduction
Opioids hold a fundamental role in perioperative pain management, both as part of multimodal analgesia and as first line treatment in patients who experience breakthrough pain after surgery.1,2 Their use must be balanced to provide sufficient analgesia while avoiding opioid-related adverse events.3–7 While equipotent doses of some opioids provide comparable analgesia and adverse event profiles, each opioid possesses distinct pharmacodynamic properties, rendering them more or less suitable for different surgical populations or phases in the perioperative course.8,9 The evidence on how demographic and surgical factors impact individual opioid needs in the perioperative setting is very limited.10,11 Currently, no evidence-based guidelines exist on how to titrate opioids for the surgical patient during the intra- and postoperative phase based on easily obtainable factors such as: age, gender, weight, perioperative anxiety, type of surgery, and surgical complications.11–16 Therefore, clinicians must resort to their own clinical experience, local guidelines and expert-opinion guidelines, when choosing intra- and postoperative opioid doses.10,11,17
We have reason to believe that local guidelines differ between hospitals - and when this is combined with clinicians dosing based on their prior experiences and/or expert-opinions – there occurs a variability in opioid-dosages administered to the same type of patients. An explorative survey of current practice in opioid dosing strategies will provide important information on variability in opioid dosing in relation to patient predictors. These insights can be used to template future clinical trials with the aim of streamlining and optimising opioid dosing.19
Aim
We aim to assess clinician-perceived predictors for escalating intra- and postoperative use of opioids in adults among anesthesia nurses, PACU nurses and anesthesiologists. We hypothesize that there is a significant inter-clinician, inter-personnel group, and inter-hospital heterogeneity concerning the selection of opioids and dosages.
Methods
Design: We plan to perform a nation-wide online survey. Participation is voluntary without financial compensation, which will be stated in the invitation. We will consider activation and completion of the survey link as informed consent. The survey will be distributed and collected in the period from 01.02.24 to 31.04.24. The protocol and manuscript will be prepared according to the Consensus-Based Checklist for Reporting of Survey Studies (CROSS).21
Population: Anesthesiologists, anesthesia nurses and PACU nurses in Danish public hospitals.
Survey details: The survey will address current practice in perioperative opioid administration at participating sites, i.e., 1) opioids administered intraoperatively to prevent postoperative pain and 2) opioids administered in PACU for patients who have developed pain despite receiving preventive multimodal analgesia. The survey will consist of 8 questions regarding intraoperative opioid dosing and 8 questions regarding postoperative opioid titration – completable within 7-8 minutes for nurses and slightly longer for anaesthesiologists who have to answer both intra- and postoperative questions. Participants will be requested to describe their typical selection of opioids (e.g., first choice drug, second choice etc., and specific choice of opioids for specific patient co-morbidities or types of surgery). We will create a list of potential predictors for escalation of dose titration. Participants will be asked to rate how they perceive the influence of these potential predictors on required opioid doses. Participants will be able to add other potential predictors not listed by the authors. The survey will include a clinical case designed to assess how various patient characteristics and surgical factors impact participant’s dose administration. Data will be transferred directly into REDcap.
The survey will be pilot-tested and revised in three independent rounds by two anesthesia nurses, two PACU nurses and two anesthesiologists – different persons and hospitals each time. The second and third pilot-round and the final survey will be designed in the secure web application Research Electronic Data Capture (REDCap)20
Population and recruitment: We will include participants from all 40 public departments of anesthesia at Danish hospitals. We aim to recruit all anesthesia nurses, PACU nurses and anesthesiologists working with perioperative pain management. We aim to reach a response rate of 70% of identified potential participants.23
Identification of eligible participants, survey distribution and optimised response rates: From each department, we will recruit a local site investigator, preferably anesthesiologists participating in the perioperative research network Collaboration for Evidence-based Practice and Research in Anesthesia (CEPRA).22 Site investigators will be responsible for identifying all eligible participants at their department and distribute the survey via a standardized email with an online link. Site investigators will be asked to send a minimum of three e-mail reminders to all participating sites with low participation rates (<70%). Site investigators will receive an acknowledgement in the scientific publication.
Statistics: We will present data descriptively. Continuous data will be presented as medians with interquartile ranges (IQRs); and categorical data presented as numbers and percentages.
The proportion of missing data will be reported, and all analyses will be conducted as complete-case analyses. In four clinical cases, the survey will provide answers regarding clinician’s specific choice of opioid drugs and dosages. All statistical analyses will be performed in the statistical software R.24 As we use a convenience sample, no formal sample size estimation will be performed. We will explore local response rates to ensure the surveys representativity.
Ethical considerations: Participants are anonymous and data are secured by using REDCap. Participants will be asked for consent in the first survey question. The research project has been locally approved by the The Legal Section, Bispebjerg and Frederiksberg University Hospital.
References
