Improved Patient Experience and Opioid Minimalization in Outpatient Plastic Surgery Procedures Using a Sufentanil Sublingual Tablet

Goals/Purpose: As the number of outpatient plastic surgeries continues to rise, it is important to optimize perioperative pain management to enhance the patient experience. Emphasis on better pain control with less narcotic usage represents an ongoing challenge. The usual practice of intravenous bolus pain medication leads to short term relief but an increased need for antiemetic drugs and prolonged recovery time. Commonly used oral analgesics may not be adequate for awake procedures, resulting in moderate to severe pain and sometimes, inability to complete the procedure. Sufentanil sublingual tablet 30 mcg (SST) is equi-analgesic to 5 mg IV morphine and has a unique pharmacokinetic profile achieving analgesic plasma concentrations within 15 minutes, a peak plasma concentration by 60 minutes, a duration of action of 3 hours following a single dose and a mean elimination half-life of 13 hours. Two recently published studies have shown SST to be associated with reduced overall opioid use and postsurgical recovery time.

The intent of this investigation was to examine the impact of SST in an outpatient plastic surgery population, both in aesthetic surgery under general anesthesia as well as awake surgery with minimal sedation.

Methods/Technique: A prospective evaluation of the aesthetic surgery patients under general anesthesia receiving a single SST was compared to a historical, non-SST treated control group (Controls). The Controls, 32 consecutive patients between January 2020 and June 2020, were compared with recently managed, consecutive SST patients (n=61) undergoing similar surgical procedures. All patients received intravenous Propofol and fentanyl for induction of anesthesia. Depending on length of surgery, SST patients received a single SST thirty minutes prior to surgery for short procedures less than an hour or 45 min prior to surgical extubation for procedures of 60 minutes or longer.

The awake surgery analysis was a prospective single-group cohort study conducted at the same plastic surgery practice (n = 31). SST was administered approximately 30 minutes prior to the procedure.

For the general anesthesia population, a comparison of the amount of opioid administered was performed, using Morphine Milligram Equivalents (MME), as calculated by the online Practical Pain Management Opioid Calculator. For both groups, outcome measures included the number of patients with adverse events, the number of patients requiring medications in the post-anesthesia care unit (PACU), and recovery time.

Results/Complications: In the general anesthesia population, patients were largely females (95%) mid-40’s years in age. Procedures ranged from 22 min to 7+ hours. Controls received significantly more IV MME in recovery than SST patients. The average dose of opioids administered in the PACU was more than fivefold higher, with controls receiving MME 3.6 ± 2.65 and SST patients 0.64 ± 2.31 (p <.001).

Nearly all patients received antiemetic medications during surgery (Controls=31/32) (SST=55/61). Protocol dictated that Controls receive 1 dose of an antiemetic drug at the start of recovery. Among Controls, 3 patients (9.7%) required additional antiemetic drugs whereas only one SST patient (3.2%) required an antiemetic in the PACU. There was no difference in recovery time between the two groups (Controls = 59 mins, SST = 57 mins) due to our standard recovery protocols.

For the awake surgery study, the most common procedures were liposuction (71%), facelift (10%), and blepharoplasty (6%). The mean (± standard error) procedural duration was 81 ± 9 min. No vital sign instability or oxygen desaturation was observed. Three patients experienced mild side effects that did not require treatment (2 nausea, 1 dizziness), and one additional patient received oral ondansetron 4 mg in the PACU for nausea. No patients required opioids or other analgesics in the PACU for pain. The mean (± standard error) recovery time was 15 ± 4 minutes.

Conclusion: s: In this analysis, we examined the impact of SST in an outpatient plastic surgery population, both in aesthetic surgery under general anesthesia as well as awake surgery with minimal sedation. SST reduced MME during recovery for patients undergoing short and long duration outpatient procedures under general anesthesia and reduced the need for additional antiemetics.

Awake surgery was performed using SST 30 mcg with minimal side effects and a rapid recovery time. The absence of cognitive impairment after awake surgery allowed a easier discharge.

In all patients, SST was well tolerated, with no significant adverse events. Implementing the use of SST in our practice and outpatient surgical center, has resulted in increased patient satisfaction and an increase in patients requesting awake surgery as well as a smoother recovery for the patient after general anesthesia.