Impact of Replacing Fentanyl With Hydromorphone as the First-Line Postoperative Opioid Among Patients Undergoing Outpatient Cancer Surgery.
Jennifer R Majumdar, John Grbic, Sigrid Carlsson and 5 others
PMID 38493405WHAT IT FOUND
Replacing first-line postoperative fentanyl with hydromorphone did not cause clinically meaningful recovery delays.
Overnight recovery patients had unchanged recovery time; outpatient PACU stays increased by 8.5 minutes, still below the 20-minute threshold.
Key findings
01In AXR patients, median time from PACU arrival to transition to phase 2 was 116 minutes in the fentanyl-standard period and 115 minutes in the hydromorphone-standard period; the adjusted difference was 0.56 minutes shorter in the hydromorphone-standard period and was not significant (p=0.9).
02In the outpatient analysis of 13,286 procedures, median postoperative PACU stay was 188 minutes with fentanyl and 201 minutes with hydromorphone; adjusted analysis showed an 8.5-minute longer stay with hydromorphone (95% CI 3.7 to 13), still below the 20-minute clinically meaningful threshold.
03In the outpatient comparison, hydromorphone was associated with 4.0% more rescue medication for postoperative nausea and vomiting and 3.1 fewer morphine milliequivalents of total postoperative narcotics than fentanyl.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
Retrospective, single-centre, quality improvement design, not a randomised trial. Clinician discretion decided whether a postoperative IV opioid was given, so the comparison is not fully controlled. The study changed the first-line postoperative IV opioid within a multimodal pain protocol, so it does not isolate the opioid from other analgesic components. Outpatient case mix differed by period and by medication received, especially robotic surgery, so the primary comparison was redefined. Re-surgery events were too few for full adjustment, and multiple testing was not formally adjusted. The study cannot prove hydromorphone caused the observed differences.
Declared interests
The article is marked as supported by NIH extramural research. S.V.C. received lecture honorarium and travel reimbursement from Ipsen, unrelated to this study; no other conflicts were reported.
The easy way to misread this
Do not conclude hydromorphone causes longer recovery or more re-surgery. The outpatient 8.5-minute stay increase was statistically significant but below the 20-minute clinically meaningful threshold, and the re-surgery signal was based on very few events, could not be fully adjusted, and was not seen in AXR patients.