Nonsteroidal antiinflammatory drugs, perioperative blood loss, and transfusion requirements in elective hip arthroplasty

Evolution of Perioperative Pain Management in Shoulder Arthroplasty

Historically, opioids have been used as a primary conservative treatment for pain related to glenohumeral osteoarthritis (GHOA). However, this practice is concerning as it often leads to overuse, which has contributed to the current epidemic of addiction and overdoses in the United States. Studies have shown that preoperative opioid use is associated with higher complication rates and worse outcomes following surgery, particularly for shoulder arthroplasty. To address these concerns, perioperative pain management for shoulder arthroplasty has evolved over the years to the use of multimodal analgesia.

Preoperative Management of Medications for Rheumatologic and HIV Diseases: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement

Perioperative medical management is challenging because of the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources use recommendations derived from individual studies and do not include a multidisciplinary focus on formal consensus. The Society for Perioperative Assessment and Quality Improvement identified a lack of authoritative clinical guidance as an opportunity to use its multidisciplinary membership to improve evidence-based perioperative care. The Society for Perioperative Assessment and Quality Improvement seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of immunosuppressive, biologic, antiretroviral, and anti-inflammatory medications. A panel of experts including hospitalists, anesthesiologists, internal medicine physicians, infectious disease specialists, and rheumatologists was appointed to identify the common medications in each of these categories. The authors then used a modified Delphi process to critically review the literature and to generate consensus recommendations.

Perioperative pain management for shoulder surgery: evolving techniques

Improving management of postoperative pain following shoulder surgery is vital for optimizing patient outcomes, length of stay, and decreasing addiction to narcotic medications. Multimodal analgesia (ie, controlling pain via multiple different analgesic methods with differing mechanisms) is an ever-evolving approach to enhancing pain control perioperatively after shoulder surgery. With a variety of options for the shoulder surgeon to turn to, this article succinctly reviews the pros and cons of each approach and proposes a potential pain management algorithm.

The Impact of Nonsteroidal Anti-inflammatory Drugs on Older Adult Trauma Patients With Hip Fractures

BACKGROUND

Nonsteroidal anti-inflammatory drug (NSAID) use is frequently recommended for multimodal analgesia to reduce opioid use. We hypothesized that increased NSAID utilization will decrease opioid requirements without leading to significant complications in older adult trauma patients undergoing hip fracture repair.

METHODS

An observational cross-sectional cohort study of 190,057 adult trauma patients over a 6-y period (2008-2014) in the national Premier Healthcare Database was performed. Patients aged 65 or older undergoing femur repair and hip arthroplasty following fractures due to falls were analyzed. Primary outcome was opioid use, and secondary outcomes included transfusion requirements, length of stay (LOS), and organ system dysfunction. Continuous outcomes were analyzed using mixed-effect linear regression models to assess the effect of NSAIDs on the day of surgery. Fixed effects were included for patient and hospital characteristics, comorbidities, co-treatments, and surgery. Random intercepts for each hospital were included to control for clustering. Categorical outcomes were similarly analyzed using mixed-effect logistic regression models.

RESULTS

NSAIDs decreased opioids prescribed (12.01 versus 11.43 morphine milligram equivalents) (odds ratio [OR], -0.23; confidence interval [CI] = -0.41, -0.06) without overall increased bleeding (40.83% versus 43.18%; OR, 1.02; CI = 0.99, 1.05). NSAIDs were associated with reduced LOS (5.61 versus 5.96 d; CI = -0.24, -0.12), intensive care unit admissions (9.73% versus 10.59%; OR, 0.91; CI = 0.86, 0.96), and pulmonary complications (OR, 0.88; CI = 0.83, 0.93). Additionally, there was a 21% prescribing variability based solely on hospital.

CONCLUSIONS

NSAIDs were associated with decreased opioid requirements, hospital LOS, and intensive care unit admissions in older adult trauma patients without overall increase in bleeding. NSAIDs should be considered in multimodal pain regimens, moreover, given prescribing variability guidelines are needed.

LEVEL OF EVIDENCE

Level III, Prognostic.

Preoperative multimodal analgesia decreases 24-hour postoperative narcotic consumption in elective spinal fusion patients

BACKGROUND CONTEXT

Effective postoperative pain management in patients undergoing elective spinal fusion surgery has been associated with shorter hospital stays, reduced rates of hospital readmissions due to pain, and decreased cost of care. Furthermore, preoperative multimodal analgesia regimens have been shown to decrease postoperative subjective pain measurements and narcotic consumption in patients undergoing spinal fusion and total arthroplasty surgeries.

PURPOSE

Compare the difference in effects on 24-hour postoperative narcotic consumption, reported pain, and early mobility with administration of preoperative celecoxib plus gabapentin, gabapentin alone, and a nonstandardized analgesia regimen in patients undergoing elective spinal fusion surgery involving ≤5 levels.

STUDY DESIGN

Retrospective review, Level of Evidence III.

PATIENT SAMPLE

A total of 185 adult patients undergoing elective spinal fusion surgery involving ≤5 levels from 2013 to 2017 at one academic institution. Patients were excluded if the surgery was nonelective, for oncological purposes, or the patient was younger than 17 years old.

OUTCOME MEASURES

Twenty-four-hour postoperative morphine equivalent consumption, 24-hour postoperative visual analogue scale (VAS) pain scores, postoperative day to ambulate, and postoperative day to clear physical therapy.

METHODS

A single-institution retrospective chart review was conducted. Patients meeting inclusion criteria were grouped by whether they had received preoperative celecoxib plus gabapentin, gabapentin alone, or neither of these medications. Opioid medication intake for the first 24 hours after the surgery end time was tabulated and converted to morphine equivalents. Visual analogue scale (VAS) pain scores were also averaged over the first 24 hours. Finally, physical therapy notes were reviewed to determine the time taken for the patient to first ambulate and to clear physical therapy. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work.

RESULTS

Twenty-four-hour postoperative morphine equivalent consumption was significantly lower in the celecoxib plus gabapentin group compared with control (p=.004). Patients in the celecoxib plus gabapentin group had significantly lower mean VAS scores (p=.002) and had earlier mobility postoperatively (p=.012) than those in the control group. Early mobility and time to physical therapy clearance did differ between the celecoxib + gabapentin group compared with the gabapentin alone group. The gabapentin group had a significantly higher 24-hour morphine dose equivalent (p=.013) and a significantly higher VAS average (p=.009) compared with the celecoxib + gabapentin group. Gabapentin given alone compared with control did not show statistically significant improved outcomes in postoperative morphine equivalent consumption, pain scores or physical therapy goals.

CONCLUSIONS

This study demonstrates that administering a selective COX-2 inhibitor and GABA-analogue preoperatively can significantly decrease 24-hour postoperative opioid consumption, VAS pain scores, and elapsed time to postoperative mobility in patients undergoing elective spine fusion surgery of ≤5 levels. Optimal standardized dosing and drug combination for preoperative multimodal analgesia remains to be elucidated.

Perioperative Pain Management in Hip and Knee Arthroplasty

Total hip and knee arthroplasty is associated with significant perioperative pain, which can adversely affect recovery by increasing risk of complications, length of stay, and cost. Historically, opioids were the mainstay of perioperative pain control. However, opioids are associated with significant downsides. Preemptive use of a multimodal pain management approach has become the standard of care to manage pain after hip and knee arthroplasty. Multimodal pain management uses oral medicines, peripheral nerve blocks, intra-articular injections, and other tools to reduce the need for opioids. Use of a multimodal approach promises to decrease complications, improve outcomes, and increase patient satisfaction after hip and knee arthroplasty.

Aspirin mono-therapy continuation does not result in more bleeding after knee arthroplasty

PURPOSE

Current clinical practice guidelines sometimes still recommend stopping aspirin five to seven days before knee arthroplasty surgery. Literature regarding multimodal blood management and continuation of anti-platelet therapy in this type of surgery is scant. The study hypothesis was that knee arthroplasty under low-dose aspirin mono-therapy continuation does not cause more total blood loss than knee arthroplasty performed without aspirin. Blood loss would be measured by haemoglobin (Hb) and haematocrit (HTC) levels drop at day 2 or day 4 for patients who benefit from multimodal bleeding control measures.

METHODS

A database of all patients undergoing knee arthroplasty between 2006 and 2014 was analysed. Demographic, surgical and complete blood workup data were collected. A retrospective comparison study analysed both groups in terms of blood loss, by mean calculated blood loss as haemoglobin or haematocrit drop between the preoperative Nadir value and the postoperative day 2 and 4 value. A group of 198 (44 UKA and 154 TKA) patients underwent surgery without interrupting their aspirin therapy for cardiovascular prevention. Mean (SD) age was 71 (8) and the mean (SD) BMI was 29 (5.5) kg/m². The control group consisted of 403 (102 UKA and 301 TKA) patients who were not under aspirin, or any other anti-platelet agent. Mean (SD) age was 65 (10) (p < 0.05) and the mean (SD) BMI was 29 (5.0) kg/m² (n.s.). All patients in the control group were randomly selected.

RESULTS

There were no differences in terms of visible (early) or hidden (late) blood loss as measured by Hb drop in between both groups. There is no difference in transfusion rates.

CONCLUSIONS

Modern multimodal blood management provides sufficient blood loss prevention during and after knee arthroplasty to allow physicians to continue low-dose aspirin mono-therapy for cardiovascular prevention.

LEVEL OF EVIDENCE

III.

Efficacy and safety of Postoperative Intravenous Parecoxib sodium Followed by ORal CElecoxib (PIPFORCE) post-total knee arthroplasty in patients with osteoarthritis: a study protocol for a multicentre, double-blind, parallel-group trial

INTRODUCTION

Total knee arthroplasty (TKA) has been regarded as a most painful orthopaedic surgery. Although many surgeons sequentially use parecoxib and celecoxib as a routine strategy for postoperative pain control after TKA, high quality evidence is still lacking to prove the effect of this sequential regimen, especially at the medium-term follow-up. The purpose of this study, therefore, is to evaluate efficacy and safety of postoperative intravenous parecoxib sodium followed by oral celecoxib in patients with osteoarthritis (OA) undergoing TKA. The hypothesis is that compared to placebo with opioids as rescue treatment, sequential use of parecoxib and celecoxib can achieve less morphine consumption over the postoperative 2 weeks, as well as better pain control, quicker functional recovery in the postoperative 6 weeks and less opioid-related adverse events during the 12-week recovery phase.

METHODS AND ANALYSIS

This study is designed as a multicentre, randomised, double-blind, parallel-group and placebo-controlled trial. The target sample size is 246. All participants who meet the study inclusion and exclusion criteria will be randomly assigned in a 1:1 ratio to either the parecoxib/celecoxib group or placebo group. The randomisation and allocation will be study site based. The study will consist of three phases: an initial screening phase; a 6-week double-blind treatment phase; and a 6-week follow-up phase. The primary end point is cumulative opioid consumption during 2 weeks postoperation. Secondary end points consist of the postoperative visual analogue scale score, knee joint function, quality of life, local skin temperature, erythrocyte sedimentation rate, C reactive protein, cytokines and blood coagulation parameters. Safety end points will be monitored too.

ETHICS AND DISSEMINATION

Ethics approval for this study has been obtained from the Ethics Committee, Peking Union Medical College Hospital, China (Protocol number: S-572) Study results will be available as published manuscripts and presentations at national and international meetings.

TRIAL REGISTRATION NUMBER

NCT02198924.

Use of a haemostatic matrix (Floseal®) does not reduce blood loss in minimally invasive total knee arthroplasty performed under continued aspirin

BACKGROUND

Aspirin is being used for primary and secondary cardiovascular prevention. It has been proposed that aspirin should be discontinued 5 to 7 days before surgery. However, discontinuation might increase the risk of cardiac and thrombo-embolic co-morbidity. Aspirin also increases the risk of bleeding during and after total knee arthroplasty. This study evaluated if the intra-articular use of a haemostatic matrix (Floseal®) might decrease blood loss in total knee arthroplasty performed under continued aspirin use.

MATERIALS AND METHODS

We retrospectively compared matched pairs in two groups (80 patients in each group). Patients in both groups were taking aspirin: one group was managed with conventional haemostasis (with bovie electrocoagulation), while the other group was treated with an intra-articular haemostatic matrix as an adjunct to electrocoagulation. The outcomes compared were haemoglobin and haematocrit levels at days 2 and 4 after surgery as surrogates for blood loss, transfusion rate, surgical time, and length of stay in the hospital.

RESULTS

No differences were observed between the two groups for haemoglobin and haematocrit levels on days 2 and 4. There were no differences in transfusion rate, surgical time or length of stay in hospital between the two groups.

DISCUSSION

The present study shows that the use of Floseal® has no effect on reducing either visible or hidden blood loss after total knee arthroplasty with peri-operative continuation of aspirin use, as assessed by a drop in haemoglobin or haematocrit.

Perioperative celecoxib decreases opioid use in patients undergoing testicular surgery: a randomized, double-blind, placebo controlled trial

PURPOSE

We evaluated the effect of daily perioperative celecoxib on patient reported pain control and opioid use after testicular surgery.

MATERIALS AND METHODS

Men scheduled to undergo elective outpatient microsurgical testicular sperm extraction were prospectively randomized to receive 200 mg celecoxib or placebo twice daily, which was initiated the night before surgery and continued for 6 days thereafter. Using an 11-point visual analog scale, participants self-reported the postoperative pain level and acetaminophen/hydrocodone use for supplemental pain control. We compared differences in pain scores and opioid use between the 2 patient groups using the Student t test with p<0.05 considered significant.

RESULTS

At 1-year interim analysis 35 of 78 eligible participants (45%) had returned the study questionnaire, of whom 34 were included in the final analysis. Of the 34 patients the 16 who received celecoxib had significantly lower postoperative opioid use than those on placebo (6 vs 16 pills, p=0.02). We noted a statistically significant difference in postoperative day 1 and 2 patient reported pain scores (4 vs 6, p<0.05 and 3 vs 5, p=0.03) and opioid use (1 vs 5 pills, p<0.01 and 2 vs 4, p=0.02) seen between the celecoxib and placebo groups, respectively. No study complications were identified. The trial was terminated early based on the results of interim analysis.

CONCLUSIONS

Twice daily celecoxib use started preoperatively significantly decreased patient reported postoperative pain and opioid use, especially in the early postoperative period. A short course of celecoxib is well tolerated and may be effective as part of multimodal postoperative analgesia in patients who undergo testicular surgery for sperm retrieval.

Perioperative administration of selective cyclooxygenase-2 inhibitors for postoperative pain management in patients after total knee arthroplasty

Total knee arthroplasty (TKA) is associated with considerable postoperative pain. The relative analgesic efficacy and adverse effect profile of perioperative use of selective cyclooxygenase-2 (COX-2) inhibitors for patients undergoing TKA are unclear. This is a systematic review and meta-analysis of all randomized controlled trials evaluating perioperative administration of COX-2 inhibitors for TKA. Eight studies that had enrolled a total of 571 patients were identified. There was a statistical significance in postoperative pain scores (0-24 hours: P = .0007, 24-48 hours: P = .01, 48-72 hours: P < .0001), opioid consumption (P = .006), active range of motion (P = .002), itching (P = .005), and postoperative nausea/vomiting (P = .003) between groups. There was no difference in blood loss during the first 24 hours after operation between groups. The efficacy of perioperative administration of selective COX-2 inhibitors to reduce postoperative pain and opioid consumption after TKA is validated. Furthermore, it has important outcome benefits after TKA.

Safety of peri-operative low-dose aspirin as a part of multimodal venous thromboembolic prophylaxis for total knee and hip arthroplasty

PURPOSE

To examine whether it is safe to continue low-dose (100 mg/day) aspirin perioperatively as a part of standard multimodal venous thromboembolic prophylaxis for total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

79 women and 60 men aged 52 to 91 years who underwent THA (n=50) or TKA (n=89) were prospectively studied. Preoperatively, 63 of the patients were on 100 mg of aspirin every morning for various medical reasons and continued in the perioperative period, except for the operation day. The remaining 76 patients were controls. Pre- and post-operative haemoglobin levels, postoperative blood drainage, and the amount of reinfused drained blood were recorded. Intra-operative blood loss and operative times were recorded for THA only. These parameters for the aspirin and control groups were compared.

RESULTS

All the parameters, namely blood loss (intraoperative and postoperative), operative time, surgical wound healing, and drop in the haemoglobin level (determined on day 3) did not differ significantly between the 2 groups.

CONCLUSION

It is safe to continue low-dose (100 mg/day) aspirin in the perioperative period as a part of multimodal prophylaxis against deep vein thrombosis.

Dabigatran etexilate and concomitant use of non-steroidal anti-inflammatory drugs or acetylsalicylic acid in patients undergoing total hip and total knee arthroplasty: no increased risk of bleeding

Patients undergoing total hip or knee arthroplasty should receive anticoagulant therapy because of the high risk of venous thromboembolism. However, many are already taking non-steroidal anti-inflammatory drugs (NSAIDs) or acetylsalicylic acid (ASA) that can have antihaemostatic effects. We assessed the bleeding risk in patients treated with thromboprophylactic dabigatran etexilate, with and without concomitant NSAID or ASA. A post-hoc analysis was undertaken of the pooled data from trials comparing dabigatran etexilate (220 mg and 150 mg once daily) and enoxaparin. Major bleeding event (MBE) rates were determined and odds ratios (ORs) generated for patients who received study treatment plus NSAID (half-life ≤12 hours) or ASA (≤160 mg/day) versus study treatment alone. Relative risks were calculated for comparisons between treatments. Overall, 4,405/8,135 patients (54.1%) received concomitant NSAID and 386/8,135 (4.7%) received ASA.ORs for the comparison with/without concomitant NSAID were 1.05 (95% confidence interval [CI] 0.55-2.01) for 220 mg dabigatran etexilate; 1.19 (0.55-2.55) for 150 mg; and 1.32 (0.67-2.57) for enoxaparin. ORs for the comparison with/without ASA were 1.14 (0.26-5.03); 1.64 (0.36-7.49); and 2.57 (0.83-7.94), respectively. For both NSAIDs and ASA there was no significant difference in bleeding between patients with and without concomitant therapy in any treatment arm. Patients concomitantly taking NSAIDs or ASA have a similar risk of MBE to those taking dabigatran etexilate alone. No significant differences in MBE were detected between dabigatran etexilate and enoxaparin within co-medication subgroups, suggesting that no increased major bleeding risk exists when dabigatran etexilate is administered with NSAID or ASA.

Benefits of prolonged postoperative cyclooxygenase-2 inhibitor administration on total knee arthroplasty recovery: a double-blind, placebo-controlled study

A double-blind, placebo-controlled study of a selective cyclooxygenase (COX)-2 inhibitor administered in 107 patients for 6 weeks after total knee arthroplasty was done to determine any benefits. All patients received celecoxib preoperatively and during hospitalization. At hospital discharge, patients were randomized to receive celecoxib or placebo for 6 weeks. Narcotic use, knee flexion, Knee Society Score, Oxford Knee Score, and Short-Form 12 scores were determined preoperatively and at postoperative intervals to 1 year. Visual analog scale scores documented pain at rest, at night, and with activities. The celecoxib group used fewer narcotics and had significantly better visual analog scale scores, knee flexion, Knee Society Score scores, Oxford Knee Score scores, and Short-Form 12 physical composite scores than the placebo group. Knee flexion remained significantly improved through 1 year. These results demonstrate that patients who took celecoxib for 6 weeks after total knee arthroplasty had a less painful and more rapid recovery.

Multimodal pain management after total joint arthroplasty

Adequate postoperative pain control in patients who have undergone total joint arthroplasty allows faster rehabilitation and reduces the rate of postoperative complications. Multimodal pain management involves the introduction of adjunctive pain control methods in an attempt to control pain with less reliance on opioids and fewer side effects. Current research suggests that traditional nonsteroidal anti-inflammatory drugs (NSAIDs) and the associated cyclooxygenase type-2 (COX-2) inhibitors improve pain control in most cases. Nearly all multimodal pain management modalities have a safe side-effect profile when they are added to existing methods. The exception is the administration of DepoDur (extended-release epidural morphine) to elderly or respiratory-compromised patients because of a potential for hypoxia and cardiopulmonary events.

Does low-dose aspirin increase blood loss after spinal fusion surgery?

BACKGROUND CONTEXT

Low-dose aspirin for the prevention of cardiovascular disease is recommended to be discontinued at least 7 days before spinal surgery.

PURPOSE

To determine the effect of stopping low-dose aspirin at least 7 days before surgery on the level of the perioperative blood loss or complications related to hemorrhage.

STUDY DESIGN

Retrospective case study.

PATIENT SAMPLE

Patients who underwent spinal fusion surgery for degenerative lumbar disease.

OUTCOME MEASURE

Clinical outcome was measured by the Oswestry Disability Index.

METHODS

The aspirin group included 38 patients who had taken 100 mg aspirin for an average of 40.3 months. They stopped aspirin for at least 7 days before surgery (mean, 9.0 days). The control group included 38 patients who had not taken aspirin. Both groups were matched in terms of age, gender, number of fused segments, and surgical procedures. The diagnosis in all patients was degenerative spinal disease.

RESULTS

The mean age in the aspirin and control groups was 68.5 and 69.1 years, respectively. The mean number of levels fused was 2.0 segments in both groups. During surgery, the estimated blood loss was 855.3 cc in the aspirin group and 840.8 cc in the control group with no significant difference (p=.84). However, there was a significant difference in blood drainage after surgery. The hemovac blood drainage after surgery was 864.4 cc in the aspirin group but only 458.4 cc in the control group (p<.001). Therefore, the transfusion requirement after surgery was significantly greater in the aspirin group than in the control group (p=.03). The rate of complications related to hemorrhage was higher in the aspirin group than in the control group.

CONCLUSIONS

The intraoperative blood loss during spinal fusion surgery was similar in both groups. However, the blood drainage after surgery was significantly higher in the aspirin group despite stopping aspirin 7 days before surgery. Hence, surgeons should pay careful attention to postoperative blood loss and complications related to hemorrhage in patients who have been taking low-dose aspirin.

Perioperative management of the patient with rheumatoid arthritis

Familiarity with the systemic manifestations of rheumatoid arthritis as well as familiarity with drug therapy used for the management of rheumatoid arthritis may be helpful in the avoidance of some postoperative complications. Drug effects on soft tissues and bone may complicate reduction, stabilization, and fixation of deformities. Evaluation of the patient with rheumatoid arthritis for extraarticular disease may also explain symptomatology, and reduce the incidence of complications by unrecognized contributions of soft tissue pathology of osseous and articular disorders.

Blood management for hip reconstruction surgery

Blood conservation techniques are well established and have significant benefits. We review the current literature on these techniques and their applicability to hip reconstruction surgery and offer a suitable strategy to minimize allogeneic red cell transfusion.

Strategies for blood management in orthopaedic and trauma surgery

Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.

Comprehensive preoperative evaluation of platelet function in total knee arthroplasty patients taking diclofenac

The severity and variability of platelet dysfunction in preoperative arthritic patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) have not been well studied previously. We evaluate 30 preoperative patients taking diclofenac (group D) by routine coagulation screen, platelet count, fibrinogen concentration, thrombelastography, and PFA-100 (Dade Behring, Inc, Deerfield, IL)) platelet function analyzer. Ten patients (group P) and 30 healthy volunteers (group N) not taking NSAIDs serve as control. Diclofenac causes significant prolongation of mean PFA-100 closure times (P < .0001). However, the prolongation is highly variable; and up to 33% of patients are still having normal platelet function despite diclofenac consumption. Low body weight is a significant predictor of more severe platelet dysfunction (P < .01). Other tests are not useful. We conclude that not all patients taking NSAIDs have similar platelet dysfunction and that preoperative monitoring with PFA-100 is preferable.

Update on the role of nonsteroidal anti-inflammatory drugs and coxibs in the management of acute pain

PURPOSE OF REVIEW

Although NSAIDs have been shown to reduce postoperative analgesics, their ability to reduce opioid-related adverse effects and improve functional outcomes is questioned. Further, perioperative NSAID use may contribute to cardiovascular toxicity and impaired bone healing. This review highlights recent advances in our understanding of the role perioperative NSAIDs have on modulating nociception, their benefits when utilized as components of a multimodal analgesic regimen, and potential deleterious cardiovascular and osteogenic effects.

RECENT FINDINGS

Recent research indicates that, in addition to peripheral blockade of prostaglandin synthesis, central inhibition of cyclooxygenase-2 may play an important role in modulating nociception. Although nonspecific NSAIDs provide analgesic efficacy similar to coxibs, their use has been limited in the perioperative setting because of platelet dysfunction and gastrointestinal toxicity. Coxibs may be a safer alternative in that setting. Both coxibs and traditional NSAIDs may contribute to a dose-dependent increase in cardiovascular toxicity and impaired osteogenesis. When used short term at the lowest effective dose, however, NSAIDs may provide for analgesic benefit without significant toxicity.

SUMMARY

When utilized as a component of a multimodal analgesic regimen for acute pain, short-term NSAID administration reduces opioid-related side effects and may contribute to improved functional outcomes without significant adverse effects.

Assessment of bleeding after concomitant administration of antiplatelet and anticoagulant agents in lower limb arthroplasty

In an analysis of the Melagatran Thrombosis Prophylaxis in Orthopedic Surgery (METHRO) III study, we evaluated whether concomitant administration of aspirin (ASA) and non-steroidal anti-inflammatory drugs (NSAIDs) with the direct thrombin inhibitor melagatran/ximelagatran or the low-molecular-weight heparin enoxaparin increased bleeding in patients undergoing major joint surgery. Further objectives were to compare the influence of the timing of initial postoperative administration of melagatran/ximelagatran on bleeding in orthopedic patients receiving ASA/NSAIDs and in comparison with the preoperative administration of enoxaparin. ASA or NSAIDs in conjunction with melagatran/ximelagatran or enoxaparin did not increase bleeding. Bleeding rates were not significantly different, irrespective of the timing of the initial postoperative dose of melagatran/ximelagatran (4-8 vs. 4-12 h) when compared with preoperative (12 h) administration of enoxaparin. Transfusion rates were significantly lower with administration of melagatran/ximelagatran compared with enoxaparin.

Is clopidogrel stopped prior to hip fracture surgery--A survey of current practice in the United Kingdom

BACKGROUND

Clopidogrel is an anti-platelet agent which causes an increase in bleeding time. An increasing number of patients presenting with an acute femoral neck fracture take clopidogrel in combination with other anti-platelet agents as regular prescription medication. Such patients may be at higher risk of increased peri-operative bleeding. No guidelines or recommendations currently exist regarding the routine discontinuation of clopidogrel in patients with fracture of the femoral neck awaiting surgery.

METHODS

A telephone questionnaire was undertaken to examine the current practice amongst 110 orthopaedic departments in the UK regarding the discontinuation of clopidogrel prior to trauma surgery for femoral neck fractures. This was compared to the practice of discontinuing aspirin and warfarin in the same patient groups in these departments.

RESULTS

There appears to be significant variation in practice amongst orthopaedic departments with 43.6% having a policy of discontinuing clopidogrel. This compares to 37.3% of trusts having a policy of stopping aspirin and 97.3% stopping warfarin.

CONCLUSION

There is wide variation in practice regarding the discontinuation of clopidogrel preoperatively in patients due to undergo surgery for femoral neck fractures. These findings highlight the need to develop guidelines for the preoperative management of these patients.

Patients with rheumatoid arthritis undergoing surgery: how should we deal with antirheumatic treatment?

OBJECTIVES

To review published data on the perioperative management of antirheumatic treatment and perioperative outcome in patients with rheumatoid arthritis (RA).

METHODS

The review is based on a MEDLINE (PubMed) search of the English-language literature from 1965 to 2005, using the index keywords "rheumatoid arthritis" and "surgery". As co-indexing terms the different disease-modifying antirheumatic drugs (DMARDs) as well as nonsteroidal anti-inflammatory drugs (NSAIDs) and "glucocorticoids" were used. In addition, citations from retrieved articles were scanned for additional references. Furthermore, because the number of published articles is so limited, relevant abstracts presented at congresses were included in the analysis.

RESULTS

Continuation of methotrexate (MTX) appears to be safe in the perioperative period. Only a limited number of studies address the use of leflunomide and the results are conflicting. Because of the very long drug half-life, its discontinuation would need to be of long duration and is probably not necessary. Data on hydroxychloroquine do not show increased risks of infection. Regarding sulfasalazine, there are no studies from which definite answers could be drawn on whether it should be withheld perioperatively. Preliminary data show that the risk of infections during treatment with TNF-blocking agents may be lower than initially expected. The only available recommendation (Club Rhumatismes et Inflammation, CRI) suggests discontinuing the drugs before surgery for several weeks, depending on the risk of infection and the drug used. They should not be restarted until wound healing is complete. To avoid the antiplatelet effect during surgery, NSAIDs other than aspirin should be withheld for a duration of 4 to 5 times the drug half-life. Patients with chronic glucocorticoid therapy and suppressed hypothalamic-pituitary-adrenal (HPA) axis need perioperative supplementation.

CONCLUSIONS

While continuation of MTX likely is safe, data on other DMARDs are sparse. In particular, more data on the perioperative use of the biologic agents are needed.

Perioperative medication management for the patient with rheumatoid arthritis

The treatment of rheumatoid arthritis has improved dramatically in recent years with the advent of the latest generation of disease-modifying antirheumatic drugs. Despite these advances, in some patients inflammation is not diminished sufficiently to prevent irreversible musculoskeletal damage, thus requiring surgical intervention to reduce pain and improve function. In these cases, the orthopaedic surgeon frequently encounters patients on a drug regimen consisting of nonsteroidal anti-inflammatory drugs, glucocorticoids, methotrexate, and biologic agents (disease-modifying antirheumatic drugs). Consultation with a rheumatologist is recommended, but the surgeon also should be aware of these medications that could potentially affect surgical outcome. Prudent perioperative management of these drugs is required to optimize surgical outcome. A balance must be struck between minimizing potential surgical complications and maintaining disease control to facilitate postoperative rehabilitation of patients with rheumatoid arthritis.

Analgesic efficacy of perioperative celecoxib in ambulatory arthroscopic knee surgery: a double-blind, placebo-controlled study

PURPOSE

To examine whether celecoxib, administered perioperatively, reduces opioid consumption and opioid-related adverse effects, and provides effective analgesia, in patients undergoing ambulatory arthroscopic knee meniscectomy.

METHODS

Patients (> or = 18 years) with diagnosed knee meniscus disease were given celecoxib (400 mg; n = 99) or placebo (n = 101) 1 hour before they underwent arthroscopic knee surgery; this was followed by celecoxib (200 mg) or placebo given postoperatively at their first request for pain medication. Surgery was performed with patients under general anesthesia (fentanyl, 1 to 3 microg/kg plus 0.25% intra-articular bupivacaine, 10 to 20 mL) administered at the index joint. Every 4 to 6 hours, patients were allowed 1 to 2 tablets of hydrocodone bitartrate 5 mg/acetaminophen 500 mg (and optional opioids as needed). All efficacy analyses were conducted in the modified intent-to-treat population.

RESULTS

In the 24 hours following surgery, total opioid consumption was significantly reduced in the celecoxib group (3.6 tablets) compared with the placebo group (4.6 tablets; P = .009). Celecoxib was associated with significant reductions in opioid consumption compared with placebo at 10 to 12 hours (P = .005) and at 12 to 24 hours (P = .012). The percentage of placebo-treated patients (41%) who required opioid analgesics was significantly greater than the percentage of celecoxib-treated patients who required opioids (22%; P = .008) at 10 to 12 hours. Adverse events (AEs) were experienced by more patients in the placebo group (37%) than in the celecoxib group (18%). Incidences of opioid-related events, such as central nervous system disorders (12% v 3%, respectively) and constipation (5% v 1%, respectively), were higher in placebo-treated patients than in those given celecoxib.

CONCLUSIONS

Perioperative administration of celecoxib plus optional opioids reduces the use of opioids and the occurrence of opioid-related AEs compared with treatment with placebo plus optional opioids given to patients undergoing arthroscopic knee meniscectomy.

LEVEL OF EVIDENCE

Level I, randomized, double-blind, placebo-controlled, parallel-group study.

Perioperative Schmerztherapie in der Kniegelenkendoprothetik

Total knee arthroplasty (TKA) is associated with significant postoperative pain. Adequate analgesics and techniques are required for early mobilization, continuous passive motion and intensified physical therapy as well as for high-quality postoperative analgesia.However, in the immediate postoperative setting the excessive nociceptive input can be blocked by using doses which are most frequently associated with adverse effects like dizziness, nausea and vomiting, sedation and risk of respiratory depression. The use of peripheral nerve blocks is recommended after orthopaedic surgery. After TKA, the continuous "3 in 1 nerve block" has been proven to be more effective than conventional patient controlled intravenous opioid therapy as well as than epidural analgesia accompanied by side effects. Postoperative analgesic techniques influence surgical outcome, duration of hospitalization and re-convalescence. The use of regional analgesia after TKA may initially lead to higher costs but it is counterbalanced by a reduction in morbidity and mortality, decrease in hospitalization, improved re-convalescence and a better functional outcome.

A procedure-specific systematic review and consensus recommendations for analgesia after total hip replacement

Total hip replacement is a major surgical procedure usually associated with significant pain in the early postoperative period. Several anaesthetic and analgesic techniques are in common clinical use for this procedure but, to date, clinical studies of pain after total hip replacement have not been systematically assessed. Using the Cochrane protocol, we have conducted a systematic review of analgesic, anaesthetic and surgical interventions affecting postoperative pain after total hip replacement. In addition to the review, transferable evidence from other relevant procedures and clinical practice observations collated by the Delphi method were used to develop evidence-based recommendations for the treatment of postoperative pain. For primary total hip replacement, PROSPECT recommends either general anaesthesia combined with a peripheral nerve block that is continued after surgery or an intrathecal (spinal) injection of local anaesthetic and opioid. The primary analgesic technique should be combined with a step-down approach using paracetamol plus conventional non-steroidal anti-inflammatory drugs, with strong or weak opioids as required.

Blood management: issues and options

Blood management in the perioperative period of the total joint arthroplasty procedure has evolved over the last 3 decades. Strategies have changed and are changing based on a better understanding of blood loss and blood replacement options in this patient population. Patient-specific options based on preoperative hemoglobin levels and patient comorbidities as well as anticipated blood loss have been developed and studied. Patient-specific blood management programs have provided cost-efficient care with low morbidity.

Cerebrospinal Fluid and Plasma Pharmacokinetics of the Cyclooxygenase 2 Inhibitor Rofecoxib in Humans: Single and Multiple Oral Drug Administration

Cerebrospinal fluid (CSF) pharmacokinetics of orally administered cyclooxygenase 2 inhibitors, with single or multiple dosing, is of clinical relevance because it may relate to the analgesic efficacy of these drugs. We enrolled 9 subjects with implanted intrathecal catheters in the study. After 50-mg oral rofecoxib administration, the CSF drug concentration lagged slightly behind the plasma drug concentration. The ratio of the 24-h area under the drug-concentration curve (AUC) in CSF to plasma was 0.142. After daily dosing of rofecoxib 50 mg/d for 9 days, rofecoxib concentrations in plasma and CSF were larger on Day 9 than on Day 1, with the 24-h AUC on Day 9 more than twice the Day 1 AUC for both plasma and CSF. After nine consecutive daily doses of rofecoxib, the AUC(CSF)/AUC(plasma) ratio was 0.159. The important findings of this study are that CSF rofecoxib levels are approximately 15% of plasma levels and that repeated daily dosing more than doubles the AUC in CSF.

The effect of cyclooxygenase-2 inhibition on analgesia and spinal fusion

BACKGROUND

Cyclooxygenase (COX)-2-specific inhibitors demonstrate analgesic efficacy comparable with that of conventional nonsteroidal anti-inflammatory drugs but are associated with reduced gastrointestinal side effects and an absence of antiplatelet activity. Thus, they can be administered to patients undergoing spinal fusion surgery without an added risk of bleeding. However, concerns regarding a possible deleterious effect on bone-healing have limited their routine use. Celecoxib, a COX-2 inhibitor, recently was approved for the treatment of acute pain. The goals of the present study were to examine the analgesic efficacy of celecoxib and to determine the incidence of nonunion at one year following spinal fusion surgery.

METHODS

Eighty patients who were scheduled to undergo spinal fusion received either celecoxib or placebo one hour before the induction of anesthesia and every twelve hours after surgery for the first five postoperative days. Pain scores and morphine use were recorded one hour after arrival in the post-anesthesia care unit and at four, eight, twelve, sixteen, twenty, and twenty-four hours later. Intraoperative blood loss was recorded. The status of the fusion was determined radiographically at the time of the one-year follow-up.

RESULTS

There were no differences in demographic data or blood loss between the two groups. Pain scores were lower in the celecoxib group at one, four, eight, sixteen, and twenty hours postoperatively. There were no differences between the two groups with regard to the pain scores at twelve and twenty-four hours postoperatively. Morphine use was lower in the celecoxib group at all postoperative time-intervals. There was no difference between the celecoxib group and the placebo group with regard to the incidence of nonunion at the time of the one-year follow-up (7.5% [three of forty] compared with 10% [four of forty]).

CONCLUSIONS

The perioperative administration of celecoxib resulted in a significant reduction in postoperative pain and opioid use following spinal fusion surgery. In addition, the short-term administration of this COX-2-specific non-steroidal anti-inflammatory drug had no apparent effect on the rate of nonunion at the time of the one-year follow-up.

The effect of iron supplementation on the level of haemoglobin after lower limb arthroplasty

We randomised 120 patients who were undergoing either primary total hip or knee arthroplasty to receive either ferrous sulphate or a placebo for three weeks after surgery. The level of haemoglobin and absolute reticulocyte count were measured at one and five days, and three and six weeks after operation. Ninety-nine patients (ferrous sulphate 50, placebo 49) completed the study. The two groups differed only in the treatment administered.

Recovery of level of haemoglobin was similar at five days and three weeks and returned to 85% of the pre-operative level, irrespective of the treatment group. A small, albeit greater recovery in the level of haemoglobin was identified at six weeks in the ferrous sulphate group in both men (ferrous sulphate 5%, placebo 1.5%) and women (ferrous sulphate 6%, placebo 3%). The clinical significance of this is questionable and may be outweighed by the high incidence of reported side effects of oral iron and the cost of the medication. Administration of iron supplements after elective total hip or total knee arthroplasty does not appear to be worthwhile.

Preoperative rofecoxib oral suspension as an analgesic adjunct after lower abdominal surgery: the effects on effort-dependent pain and pulmonary function

Rofecoxib is a selective cyclooxygenase-2 inhibitor that reduces pain and inflammation without inhibiting platelet function. We examined its effects on effort-dependent pain, postoperative morphine requirements, and pulmonary function in 48 patients recovering from open abdominal surgery. Spirometric measurement of forced expiratory volume(1) and vital capacity (FVC) were assessed preoperatively. One hour before the induction of a standardized general anesthetic, patients were given either placebo oral suspension (Group A), or rofecoxib oral suspension (25 mg [Group B] or 50 mg [Group C]) in a double-blinded manner. Postoperative pain control was provided with IV morphine in the postanesthesia care unit and IV-patient-controlled analgesia morphine on the patient care unit. Morphine dose, pain intensity at rest, and pain after respiratory effort (postoperative spirometry) were assessed at 12 and 24 h after study drug administration. The patient-controlled analgesia morphine dose at 24 h was reduced 44% in Group B (30.3 +/- 17.5 mg) and 59% in Group C (22.1 +/- 16.5 mg) versus Group A (53.7 +/- 31.1 mg); P < 0.01 (A versus B). At 12 h, pain scores at rest and after spirometry were lower in Groups B and C than in A (P < 0.05). At 24 h, resting pain scores were lowest in Group C (P < 0.05). Twelve-hour FVC was best preserved in Group C (P < 0.03). There were no inter-group differences in adverse effects or perioperative blood loss. Rofecoxib oral suspension provided a morphine-sparing effect, as well as improvements in pain control and 12-h FVC in patients recovering from open abdominal surgery.

IMPLICATIONS

Rofecoxib belongs to class of analgesics known as cyclooxygenase-2 inhibitors that reduce pain and inflammation with less risk of bleeding than standard nonsteroidal antiinflammatory drugs. We found that patients treated with rofecoxib 25 or 50 mg before open abdominal surgery required less IV morphine during the first day of recovery. Despite reductions in morphine requirements, rofecoxib-treated patients reported lower pain intensity scores at rest and after a vigorous cough. In the 50-mg group, improvements in pain control correlated with greater preservation of baseline cough effectiveness (vital capacity) at 12 h. These findings may offer clinical advantages in patients with preexisting pulmonary disease.

Perioperative pain control

There are many options for perioperative pain control available to surgeons. Given these options, adequate levels of analgesia should be achieved and maintained in all surgical patients. Data suggest that analgesia may be improved by combining different analgesic approaches. To avoid high-dose requirements, dose-dependent adverse effects, and potential toxicity associated with reliance on one agent or technique, "balanced" or multimodal analgesic regimens have been advocated. A multimodal recovery program consists of three major components: (1) early mobilization, (2) complete perioperative analgesia, and (3) early oral nutrition. The goal of multimodal programs is to accelerate patient rehabilitation and reduce hospital stays. Balanced multimodal programs are the present and future of perioperative pain control and will enhance patient care.

Role of COX-2 inhibitors in the evolution of acute pain management

Management of acute postoperative pain remains suboptimal: nearly 80% of patients report moderate to extreme pain following surgery. New pain management paradigms incorporate multimodal analgesia, using a combination of analgesics throughout the perioperative period to control nociceptive and centrally-stimulated pain. Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) have a role in postoperative pain management, but concerns about increased bleeding and inhibited wound healing and bone fusion have limited their use. Cyclooxygenase (COX)-2-selective inhibitors (coxibs) offer the peripheral pain-relieving benefits of nonselective NSAIDs but with fewer adverse GI effects; they also may have a role in central sensitization. Clinical trials have demonstrated the efficacy and safety of celecoxib and rofecoxib for postoperative pain and for preemptive analgesia, and newer agents such as valdecoxib and etoricoxib also have demonstrated efficacy in these settings. In addition to their selectivity for the COX-2 isozyme overall, unique differences among the coxibs, such as in plasma half-life, may impart certain clinical advantages.

The perioperative complication rate of orthopedic surgery in sickle cell disease: report of the National Sickle Cell Surgery Study Group

Orthopedic disease affects the majority of sickle cell anemia patients of which aseptic necrosis of the hip is the most common, occurring in up to 50% of patients. We conducted a multicentered study to determine the perioperative complications among sickle cell patients assigned to different transfusion regimens prior to orthopedic procedures: 118 patients underwent 138 surgeries. The overall serious complication rate was 67%. The most common of these were excessive intraoperative blood loss, defined as in excess of 10% of blood volume. The next most common complication was sickle cell-related events (acute chest syndrome or vaso-occlusive crisis), which occurred in 17% of cases. While preoperative transfusion group assignment did not predict overall complication rates, higher risk procedures were associated with significantly higher rates of overall complications. Transfusion complications were experienced by 12% of the patients. Two patients died following surgery. Both deaths were associated with an acute pulmonary event. The 52 patients undergoing hip replacements experienced the highest rate of complications with excessive intraoperative blood loss occurring in the majority of patients. Sickle cell-related events occurred in 19% of patients, and surgical complications occurred after 15% of hip replacements and included postoperative hemorrhage, dislocated prosthesis, wound abscess, and rupture of the femoral prosthesis. There were twenty-two hip coring procedures. Acute chest syndrome occurred in 14% of the patients. Overall, decompression coring was a safer, shorter operation. A randomized prospective trial to determine the perioperative and long-term efficacy of core decompression for avascular necrosis of the hip in sickle cell disease is needed. In conclusion, this study demonstrates a high rate of perioperative complications despite compliance with sickle cell perioperative care guidelines. Pulmonary complications and transfusion reactions were common. This study supports the results previously published by the National Preoperative Transfusion in Sickle Cell Disease Group. These results stated that a conservative preoperative transfusion regimen to bring hemoglobin concentration to between 9 and 11 g/dl was as effective as an aggressive transfusion regimen in which the hemoglobin S level was lowered to 30%.

Perioperative management of selected problems in patients with rheumatic diseases

Patients undergoing surgery are subject to multiple perioperative problems. This article reviews several issues that occur in surgical patients with rheumatic diseases, including management of medications, diagnosis of fat embolism syndrome, prophylaxis against endocarditis, postoperative fever, and perioperative myocardial infarction.