Perioperative Opioid and Non Opioid Prescribing Patterns in AVF/AVG Creation.

OBJECTIVE To evaluate post-operative opioid prescribing patterns in patients undergoing hemodialysis (HD) access creation. METHODS Operative logs were reviewed to identify patients undergoing creation of arteriovenous fistula (AVF) or graft (AVG) from September 2016 through January 2018. Immediate post-operative opioid prescriptions were compared for ambulatory patients versus inpatients. Opioid prescriptions at the time of discharge for inpatients were recorded. Rates of opioid prescribing were standardized by conversion to morphine milligram equivalents (MME). Opioid use post-operatively and at time of discharge based on anesthetic technique, general anesthesia (GA) versus regional or local anesthesia with sedation (LRAS) were compared. Alternative pain medications administered and pain scores were recorded. Comparisons were made between the percentage of opioid use and doses administered between AVF and AVG patients, ambulatory and inpatients, and type of anesthetic technique used. Statistical analysis was performed with chi square and t-tests. RESULTS We identified 164 patients undergoing arteriovenous (AV) access creation but not receiving chronic opioid therapy. A significantly higher percentage of inpatients received opioids in the immediate postoperative period than ambulatory patients (arteriovenous fistula (AVF): 72% vs 19%, p<0.001; arteriovenous graft (AVG): 62% vs 25%, p=0.001). Overall, all AVG patients were more likely to be discharged with an opioid prescription than all AVF patients (37% vs 8%, p<0.001). Of AVG patients managed in the ambulatory setting, 48% were discharged with an opioid prescription. The mean total opioid post-operative dose prescribed to inpatients was significantly higher than that prescribed to ambulatory patients for both fistulas (28.73 MME vs 1.27 MME, p<0.001) and grafts (22.11 MME vs 2.16 MME, p=0.005). GA patients were more likely to receive opioids post-operatively than LRAS patients for both AVF (54% vs 24%, p=0.027) and AVG creation (61% vs 17% p<0.001). Post-operative alternative medication use in the hospital was low with 18% acetaminophen and 1% non-steroidal anti-inflammatory drug(NSAID) use for AVF patients and 24% acetaminophen and 0% NSAID use for AVG patients. The percentage of patients reporting post-operative pain in the recovery room and on the inpatient units was comparable between ambulatory and inpatient settings (AVF: 21% vs 28%, p=0.534; AVG: 23% vs 44%, p=0.061). CONCLUSION A higher percentage of inpatients undergoing HD access received opioids when compared with ambulatory patients in the immediate post-operative period. Inpatients were prescribed higher mean doses than ambulatory patients. AVG patients were prescribed more opioids than AVF patients. Alternative analgesic agent use was low, suggesting an opportunity for improved pain control and opioid reduction.. Dialysis access creation represents an opportunity to improve upon opioid prescribing patterns .