David Kahn, DO
Assistant Professor of Neurology
NYU Langone Brooklyn Hospital
Brooklyn, NY
Disclosure information not submitted.
Aaron Lord, MD, MSc
Chief of Neurology, NYU Langone Brooklyn, Associate Professor of Neurology,
NYU Langone Medical Center and School of Medicine
Brooklyn, New York, United States
Disclosure information not submitted.
Ting Zhou, MD
Assistant Professor of Neurology
NYU School of Medicine Brooklyn
Brooklyn, New York, United States
Disclosure information not submitted.
Erica Scher, NP, MPH
Nurse Practitioner
NYU
Brooklyn, New York, United States
Disclosure information not submitted.
Jennifer Frontera, MD
Professor of Neurology
New York University School of Medicine
Brooklyn, New York, United States
Disclosure information not submitted.
Prachi Bhatt, BCCCP, BCPS, PharmD
Pharmacist
NYU Langone Health - Brooklyn
Brooklyn, New York, United States
Disclosure information not submitted.
Shashank Agarwal, MD
Stroke fellow
NYU Langone School of Medicine
Brooklyn, New York, United States
Disclosure information not submitted.
Title: Use of an Opioid-Sparing Headache Protocol for Treating Low Grade Subarachnoid Hemorrhage Patients.
Introduction: Subarachnoid Hemorrhage (SAH) associated headaches are severe and challenging to manage. The use of sedating, high-dose opioids can cloud neurological assessments, leading to unnecessary testing and potentially increase the risk of dependence. We hypothesized that a tiered opioid sparing pain management protocol favoring NSAIDs and gabapentin for low grade SAH patients would decrease opioid use without adversely affecting headache severity scores.
Methods: We performed a retrospective cohort study pre- and post-implementation of the opioid sparing protocol. Inclusion criteria included admission to NYU Langone-Brooklyn Hospital with Hunt Hess Grade 1 or 2 aneurysmal SAH on Day 3 of hospital admission as most patients received peri-procedural sedation and analgesia during the first 2 days. The pre-implementation group (pre) was admitted from 8/2016 to 8/2017 and the post-implementation group (post) was admitted from 4/2019 to 4/2020. The two-year washout period was included because newly hired intensivists integrated elements of opioid-sparing protocols as part of their practice prior to the go-live date. We collected demographics, baseline admission characteristics, hospital complications, and past history of headaches and opioid use. From day 3-7, we tracked total use of morphine milligram equivalents (MME) of all opioids, acetaminophen, NSAIDS, barbiturates, and gabapentin. We recorded the highest (HP) and lowest (LP) visual analogue pain assessment scores in daily quartiles. Data analysis was completed with SPSS.
Results: 55 patients (n=24 pre and n=31 post) were eligible and enrolled in the study. 85 patients were excluded. Aneurysm location, surgical method, symptomatic vasospasm, and EVD placement were similar between groups. Hydrocephalus was more common in pre; EVD complications were more common in post. There were no documented stress ulcers nor re-hemorrhage attributed to medications. The protocol resulted in a 19% decrease in total average MME compared to baseline use ((21.7 vs 26.9, p=0.77), a 12% decrease in average HP (2.60 vs. 2.96, p=0.41), and a 30% decrease in average LP (0.63 vs. 0.90, p=0.16), although not statistically significant. 14 pre received barbiturates; 0 post.
Conclusions: Pain control with reduced opioid usage can be achieved with a tiered opioid sparing pain protocol.