A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
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A9 [MAY 2014, SUPPLEMENT A] Bariatric Times HOT TOPICS IN SURGICAL PAIN MANAGEMENT analgesia with OFIRMEV preoperatively with the aim of improving pain relief and significantly reducing opioid use. OFIRMEV is the first and only agent in the class of IV non-opioid, non-NSAID analgesics approved in the United States. As a foundational agent within a perioperative multimodal analgesic regimen, OFIRMEV improves pain relief, reduces opioid consumption, and increases patient satisfaction with pain treatment in the perioperative setting. CASE STUDY 1: SLEEVE GASTRECTOMY by Anthony Gonzalez, MD A 34-year-old female presented with a long history of morbid obesity. She had failed multiple medical attempts at weight loss, including diet, exercise, pharmacological therapy, and holistic measures. She presented to the bariatric surgeon for evaluation for weight-loss surgery, specifically sleeve gastrectomy. On evaluation by the bariatric surgeon, she was found to have a past medical history of obstructive sleep apnea (OSA), treated with a continuous positive airway pressure (CPAP) mask during sleep, and fibrocystic breast disease. Her social history consisted of rare tobacco use and social alcohol consumption. Her weight at the time of the office visit was 298 pounds and her height was 66 inches; this calculated to a BMI of 48kg/m 2 . After discussing the diagnosis of morbid obesity and its implications medically, socially, and psychologically to the patient, the options for weight loss surgery were reviewed. The patient was offered three bariatric procedure options: adjustable gastric band, gastric sleeve, and gastric bypass. After careful discussion, both the patient and the surgeon agreed that the best bariatric procedure would be a robotic sleeve gastrectomy, along with a robotic hiatal hernia repair and upper endoscopy. Prior to procedure, patient was given DVT prophylaxis, preoperative antibiotics, and 1g of OFIRMEV. Via four laparoscopic incisions 5 to 12mm in size, a robotic sleeve gastrectomy was created over a 36 French bougie. The staple line was oversewn. The hiatal hernia was repaired with nonabsorbable sutures. The upper endoscopy was completed at the end of the procedure. The duration of the procedure was 1 hour and 23 minutes. The patient was transferred to the recovery room and the postoperative orders were initiated. They included 1g of OFIRMEV every six hours, 30mg of ketorolac every eight hours, and 0.5 to 1.0mg of hydromorphone every three hours as needed by the patient. The initial pain assessment score in the recovery room was a 7/10 (based on a 10-point visual analog scale). The patient received 2mg of IV hydromorphone during the night after surgery. Later that night the patient received her second dose of OFIRMEV (1g); the pain score 32 minutes after that dose was 4/10. On the first postoperative day after surgery, the patient received her third dose of 1g of OFIRMEV and the pain score was measured 30 minutes later and found to be 0/10. The last dose of OFIRMEV was given later that first postoperative day, as was 30mg of ketorolac. A total of 2mg of IV hydromorphone was given to the patient on the first postoperative day. The patient ambulated 50 yards on the surgical day and more than 200 yards postoperative days 1 and 2. She was discharged home on postoperative day 2. CASE STUDY 2: ROUX-EN-Y GASTRIC BYPASS by Patrick Ziemann-Gimmel, MD A 46-year-old male was suffering from morbid obesity. He failed multiple attempts with various different diets and continued to gain weight. He suffered from diseases related to morbid obesity, including diabetes, TABLE 3. Dosing of OFIRMEV for adults, adolescents, and children ≥2 years old AGE GROUP DOSE GIVEN EVERY 4 HOURS DOSE GIVEN EVERY 6 HOURS MAXIMUM SINGLE DOSE MAXIMUM TOTAL DAILY DOSE OF ACETAMINOPHEN ( BY ALL ROUTES) A dults and adolescents (13 years and older) weighing ≥50kg 650mg 1,000mg 1,000mg 4,000mg i n 24 hours Adults and adolescents (13 years and older) weighing <50kg 12.5mg/kg 15mg/kg 15mg/kg (up to 750mg) 75mg/kg in 24 hours (up to 3,750mg) Children 2 to 12 years of age EDITED-Cadence Ofirmez Suppl copy 2_Layout 1 4/14/14 10:14 AM Page A9