Multi-agent Preemptive Analgesia Reduces Pain and Shortens Hospital Stay After Mastectomy with Reconstruction.

BACKGROUND: A cornerstone of enhanced recovery after surgery (ERAS) pathways is preemptive analgesia-the administration of analgesic medications prior to incision to blunt central sensitization and postoperative pain. We now evaluate the efficacy of different preoperative analgesia regimens for reducing patient-reported pain, opioid consumption, and postoperative length of stay (LOS). METHODS: We performed a retrospective review of consecutive women undergoing mastectomy with immediate implant/tissue-expander reconstruction from January 2023 through June 2024. Preoperative analgesia regimens were acetaminophen only (A-only); acetaminophen and gabapentin (A+G); acetaminophen, gabapentin, and celecoxib (A+G+C); or no analgesics (no meds). RESULTS: Mean postoperative LOS for 537 mastectomy with reconstruction patients was 6.2 hours (range 0.9-75), median 3.9 hours. 98.5% of patients received a paravertebral block. The distribution of preoperative oral analgesics was no meds, 70 (13.0%); A-only, 298 (55.5%); A+G, 125 (23.3%); and A+G+C, 44 patients (8.2%). Same-day discharge was highest with A+G+C (100%) versus A+G (90%), A-only (89%), and no preoperative medications (77%) (p < 0.001). On multivariable analysis, compared with a 9.0 hour mean LOS with no medications, A-only reduced LOS by 2.9 hours (p = 0.004), A+G by 3.0 hours (p = 0.007), and A+G+C by 4.5 hours (p = 0.023). On multivariable analysis, A+G+C was also independently associated with lower maximum pain scores (β = - 2.24, p < 0.001) compared with patients receiving no preoperative analgesic medications. DISCUSSION: Our findings demonstrate that even with a preoperative paravertebral block, preemptive oral analgesics reduce pain, and LOS after mastectomy with reconstruction. These data support the routine use of a standardized multi-agent oral analgesia regimen in mastectomy and reconstruction procedures.