1
|
Tse G, Algaze C, Pageler N, Wood M, Chadwick W. Using Clinical Decision Support Systems to Decrease Intravenous Acetaminophen Use: Implementation and Lessons Learned. Appl Clin Inform 2024; 15:64-74. [PMID: 37995743 PMCID: PMC10807987 DOI: 10.1055/a-2216-5775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/22/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Clinical decision support systems (CDSS) can enhance medical decision-making by providing targeted information to providers. While they have the potential to improve quality of care and reduce costs, they are not universally effective and can lead to unintended harm. OBJECTIVES To describe the implementation of an unsuccessful interruptive CDSS that aimed to promote appropriate use of intravenous (IV) acetaminophen at an academic pediatric hospital, with an emphasis on lessons learned. METHODS Quality improvement methodology was used to study the effect of an interruptive CDSS, which set a mandatory expiry time of 24 hours for all IV acetaminophen orders. This CDSS was implemented on April 5, 2021. The primary outcome measure was number of IV acetaminophen administrations per 1,000 patient days, measured pre- and postimplementation. Process measures were the number of IV acetaminophen orders placed per 1,000 patient days. Balancing measures were collected via survey data and included provider and nursing acceptability and unintended consequences of the CDSS. RESULTS There was no special cause variation in hospital-wide IV acetaminophen administrations and orders after CDSS implementation, nor when the CDSS was removed. A total of 88 participants completed the survey. Nearly half (40/88) of respondents reported negative issues with the CDSS, with the majority stating that this affected patient care (39/40). Respondents cited delays in patient care and reduced efficiency as the most common negative effects. CONCLUSION This study underscores the significance of monitoring CDSS implementations and including end user acceptability as an outcome measure. Teams should be prepared to modify or remove CDSS that do not achieve their intended goal or are associated with low end user acceptability. CDSS holds promise for improving clinical practice, but careful implementation and ongoing evaluation are crucial for maximizing their benefits and minimizing potential harm.
Collapse
Affiliation(s)
- Gabriel Tse
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Claudia Algaze
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, California, United States
| | - Natalie Pageler
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Matthew Wood
- Center for Pediatric and Maternal Value, Lucile Packard Children's Hospital, Palo Alto, California, United States
| | - Whitney Chadwick
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Stanford, California, United States
| |
Collapse
|
2
|
Grant MC, Chappell D, Gan TJ, Manning MW, Miller TE, Brodt JL. Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society. J Thorac Cardiovasc Surg 2023; 166:1695-1706.e2. [PMID: 36868931 DOI: 10.1016/j.jtcvs.2023.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/07/2023] [Accepted: 01/19/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND Opioid-based anesthesia and analgesia is a traditional component of perioperative care for the cardiac surgery patient. Growing enthusiasm for Enhanced Recovery Programs (ERPs) coupled with evidence of potential harm associated with high-dose opioids suggests that we reconsider the role of opioids in cardiac surgery. METHODS An interdisciplinary North American panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus recommendations for optimal pain management and opioid stewardship for cardiac surgery patients. Individual recommendations are graded based on the strength and level of evidence. RESULTS The panel addressed 4 main topics: the harms associated with historical opioid use, the benefits of more targeted opioid administration, the use of nonopioid medications and techniques, and patient and provider education. A key principle that emerged is that opioid stewardship should apply to all cardiac surgery patients, entailing judicious and targeted use of opioids to achieve optimal analgesia with the fewest potential side effects. The process resulted in the promulgation of 6 recommendations regarding pain management and opioid stewardship in cardiac surgery, focused on avoiding the use of high-dose opioids, as well as encouraging more widespread application of foundational aspects of ERPs, such as the use of multimodal nonopioid medications and regional anesthesia techniques, formal patient and provider education, and structured system-level opioid prescription practices. CONCLUSIONS Based on the available literature and expert consensus, there is an opportunity to optimize anesthesia and analgesia for cardiac surgery patients. Although additional research is needed to establish specific strategies, core principles of pain management and opioid stewardship apply to the cardiac surgery population.
Collapse
Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
| | - Michael W Manning
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Timothy E Miller
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Jessica L Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, Calif.
| |
Collapse
|
3
|
Myler CS, Chapman MR, Eden BD, Lehman EB, Karamchandani K. Oral versus intravenous acetaminophen for perioperative pain management in adult patients undergoing non-cardiac surgery: A quantile segmented regression analysis. J Clin Anesth 2023; 90:111220. [PMID: 37499316 DOI: 10.1016/j.jclinane.2023.111220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
STUDY OBJECTIVE Determine whether preferential use of perioperative enteral acetaminophen is associated with changes in perioperative pain, narcotic administration, or time to meeting criteria for post anesthesia care unit (PACU) discharge, compared to preferential parenteral administration. DESIGN Retrospective Cohort with quantile segmented regression analysis. Groups determined by date of surgery, one year pre-initiative and one year post-initiative. SETTING Operating room and PACU of a tertiary academic medical center. PATIENTS Adult (age > 18 years), ASA status 1-5, non-pregnant patients undergoing non-cardiac surgery of less than six hours duration admitted to the PACU postoperatively. INTERVENTIONS A multidisciplinary initiative to preferentially utilize enteral over parenteral acetaminophen. MEASUREMENTS The primary outcome was narcotic consumption in the PACU. Secondary outcomes were intraoperative narcotic administration, pain score on PACU admission and discharge, and time to meeting criteria for PACU discharge. RESULTS 24,701 patients were included in the analysis; 12,379 had surgery prior to the initiative and 12,322 after. Enteral acetaminophen administration increased preoperatively from 13.49% to 26.84%, and postoperatively from 43.16% to 51.45%, while intraoperative parenteral APAP use dropped from 43.23% to 6.81%. Quantile Segmented regression analysis after adjusting for period (pre versus postintervention), day, age, gender, inpatient status, and ASA class demonstrated a decrease in adjusted median perioperative acetaminophen dose (-175 mg P < 0.001), with no significant difference in level change of intraoperative or PACU narcotic administration. There was no significant difference in median time to meet criteria for PACU discharge, though there was a significant change in the slope, (-0.36, p = 0.007.) Median pain scores measured on a standard 0-10 numeric rating scale at PACU admission did not change, while median pain scores at PACU discharge decreased slightly (-0.24 p < 0.001). There was no change in the probability of PONV. CONCLUSION In adult patients undergoing non-cardiac surgery of <6 h duration, preferential use of enteral rather than parenteral acetaminophen is associated with non-inferior outcomes in narcotic requirements, pain scores, time to PACU discharge, and probability of PONV when compared with routine parenteral administration. Further studies are needed to validate these findings.
Collapse
Affiliation(s)
- Conrad S Myler
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.
| | | | | | - Erik B Lehman
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| |
Collapse
|
4
|
Sandhu MRS, Tickoo M, Bardia A. Data Science and Geriatric Anesthesia Research: Opportunity and Challenges. Anesthesiol Clin 2023; 41:631-646. [PMID: 37516499 DOI: 10.1016/j.anclin.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
With an increase in geriatric population undergoing surgical procedures, research focused on enhancing their perioperative outcomes is of paramount importance. Currently, most of the evidence-based medicine protocols are driven by studies concentrating on adults encompassing all adult age groups. Given the alterations in physiology with aging, geriatric patients respond differently to anesthetics and, therefore, require specific research initiatives to further expound on the same. Large databases and the development of sophisticated analytic tools can provide meaningful insights into this. Here, we discuss a few research opportunities and challenges that data scientists face when focusing on geriatric perioperative research.
Collapse
Affiliation(s)
- Mani Ratnesh S Sandhu
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mayanka Tickoo
- Division of Pulmonary, Department of Medicine, Critical Care and Sleep Medicine, Tufts Medical Center, Biewend Building, 3Road Floor, 260 Tremont Street, Boston, MA 02118, USA
| | - Amit Bardia
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 06520, USA.
| |
Collapse
|
5
|
Semyonov M, Bartulovic A, Cohen N, Berzon B, Fedorina E, Lerman S, Semionov A, Friger M, Acker A, Geftler A, Zlotnik A, Brotfain E. The effect of timing of intravenous paracetamol on perioperative pain and cytokine levels following laparoscopic bariatric surgery, a randomized controlled trial. Obesity (Silver Spring) 2022; 30:2185-2193. [PMID: 36161276 DOI: 10.1002/oby.23545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Bariatric surgeries involve manipulation of the viscera and are associated with significant postoperative pain. Paracetamol is a nonopioid analgesic with a rapid onset, and it is effective and safe. The study compared the effects of pre- and postincisional intravenous paracetamol administration for optimal postoperative pain management in patients undergoing bariatric surgeries. METHODS This is a prospective, double-blinded, placebo-controlled randomized clinical trial of adult patients, admitted electively for laparoscopic bariatric surgery. The patients were randomly divided into two groups. One group of patients was given paracetamol at the beginning of the operation, prior to the surgical incision, the other group of patients received the same treatment at the end of the operation. RESULTS Patients who were given preincisional intravenous paracetamol presented significantly lower visual analog scale (VAS) scores following the surgery compared with patients who were given intravenous paracetamol in the last 30 minutes of the operation (VAS, median [IQR] = 2 [2-3] vs. 5 [3-6]; p < 0.001). They also required fewer postoperative opioids and tramadol (in milligrams, respectively, 1 [0-5] vs. 7.5 [5-10] and 300 [100-400] vs. 400 [200-500]) compared with later analgesia administration (p < 0.001 and p = 0.03). The levels of inflammatory markers measured at fixed intervals from paracetamol administration were not statistically different between the study groups. CONCLUSION Early analgesia with intravenous paracetamol, given before the surgical incision, may result in lower VAS scores postoperatively compared with the same treatment administered toward the end of the operation.
Collapse
Affiliation(s)
- Michael Semyonov
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Anastasiya Bartulovic
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Nir Cohen
- Department of General Surgery B, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Baruch Berzon
- Department of Emergency Medicine, Shamir Assaf Harofeh, Tzrifin, Israel
| | - Ekaterina Fedorina
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Sofia Lerman
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Anastasia Semionov
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Michael Friger
- Department of Public Health, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Asaf Acker
- Department of Orthopedic Surgery, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Alexander Geftler
- Department of Orthopedic Surgery, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Alexander Zlotnik
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Evgeni Brotfain
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| |
Collapse
|
6
|
Cho JSH, McCarthy K, Schiavo S, Jacob B, Engelsakis M, Zywiel M, Karkouti K, McCluskey S, Clarke H, Wong J. Effect of intravenous acetaminophen on postoperative outcomes in hip fracture patients: a systematic review and narrative synthesis. Can J Anaesth 2022; 69:885-897. [PMID: 35534770 DOI: 10.1007/s12630-022-02257-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/03/2022] [Accepted: 02/23/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Hip fractures are debilitating in older adults because of their impact on quality of life. Opioids are associated with adverse effects in this population, so oral acetaminophen is commonly prescribed to minimize opioid use. Intravenous (iv) acetaminophen has been reported to have superior efficacy and bioavailability than oral acetaminophen. Nevertheless, its effect on postoperative outcomes in emergency hip fractures is unclear. This systematic review assessed the effect of iv acetaminophen on postoperative outcomes in older hip fracture patients. SOURCE We searched multiple databases from inception to June 2021 for studies on adults > 50 yr of age undergoing emergency hip fracture surgery who received iv acetaminophen (or paracetamol) and that reported postoperative outcomes. Relevant titles, abstracts, and full texts were screened based on the eligibility criteria. The Newcastle-Ottawa scale was used to assess the quality of the selected papers. PRINCIPAL FINDINGS Of 3,510 initial studies, four met the inclusion criteria. One was a prospective cohort study and three were retrospective cohort studies. All four studies used historical control groups. Three studies reported a significantly lower mean opioid dose with iv acetaminophen than with oral acetaminophen. Three studies also reported a significantly shorter hospital stay. One study each reported a significant decrease in the number of missed physical therapy sessions, the need for one-to-one supervision, and episodes of delirium. CONCLUSION There is very limited low-level evidence that iv acetaminophen improves preoperative and postoperative analgesia and shortens hospital stay in older hip fracture patients. Nevertheless, our results should be interpreted with caution since there are no prospective randomized trials investigating whether iv acetaminophen improves postoperative outcomes in this patient population. STUDY REGISTRATION PROSPERO (CRD42021198174); registered 15 August 2021.
Collapse
Affiliation(s)
| | - Kristian McCarthy
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Simone Schiavo
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Binu Jacob
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Marina Engelsakis
- General Surgery, Anesthesia & Perioperative Care Education Investigator, The Institute of Education Research Library & Information Services, University Health Network, Toronto, ON, Canada
| | - Michael Zywiel
- Division of Orthopedic Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Sinai Health System, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Women's College Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Stuart McCluskey
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Jean Wong
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, Women's College Hospital, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada.
| |
Collapse
|
7
|
Patel AK, Gai J, Trujillo-Rivera E, Faruqe F, Kim D, Bost JE, Pollack MM. National Intravenous Acetaminophen Use in Pediatric Inpatients From 2011–2016. J Pediatr Pharmacol Ther 2022; 27:358-365. [DOI: 10.5863/1551-6776-27.4.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
To 1) determine current intravenous (IV) acetaminophen use in pediatric inpatients; and 2) determine the association between opioid medication duration when used with or without IV acetaminophen.
METHODS
A retrospective analysis of pediatric inpatients exposed to IV acetaminophen from January 2011 to June 2016, using the national database Health Facts.
RESULTS
Eighteen thousand one hundred ninety-seven (2.0%) of 893,293 pediatric inpatients received IV acetaminophen for a median of 14 doses per patient (IQR, 8–56). A greater proportion of IV acetaminophen patients were admitted to the intensive care unit (ICU) (14.8% vs 5.1%, p < 0.0001), received positive pressure ventilation (2.0% vs 1.5%, p < 0.0001), had a higher hospital mortality rate (0.9% vs 0.3%, p < 0.0001), and were operative (35.5% vs 12.8%, p < 0.001) than those not receiving IV acetaminophen. The most common operations associated with IV acetaminophen use were musculoskeletal and digestive system operations. Prescription of IV acetaminophen increased over time, both in prescription rates and number of per patient doses. Of the 18,197 patients prescribed IV acetaminophen, 16,241 (89.2%) also were prescribed opioids during their hospitalization. A multivariate analysis revealed patients prescribed both IV acetaminophen and opioids had a 54.8% increase in opioid duration as compared with patients who received opioids alone.
CONCLUSIONS
This is the first study to assess IV acetaminophen prescription practices for pediatric inpatients. Intravenous acetaminophen prescription was greater in the non-operative pediatric inpatient population than operative patients. Intravenous acetaminophen prescription was associated with an increase in opioid duration as compared with patients who received opioids alone, suggesting that it is commonly used to supplement opioids for pain relief.
Collapse
Affiliation(s)
- Anita K. Patel
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Jiaxiang Gai
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Eduardo Trujillo-Rivera
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Farhana Faruqe
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
| | - Dongkyu Kim
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - James E. Bost
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Murray M. Pollack
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| |
Collapse
|
8
|
Abstract
Pain and related disability remain a major social and therapeutic problem. Comorbidities and therapies increase drug interactions and side effects making pain management more compounded especially in the elderly who are the fastest-growing pain population. Multimodal analgesia consists of using two or more drugs and/or techniques that target different sites of pain, increasing the level of analgesia and decreasing adverse events from treatment. Paracetamol enhances multimodal analgesia in experimental and clinical pain states. Strong preclinical evidence supports that paracetamol has additive and synergistic interactions with anti-inflammatory, opioid and anti-neuropathic drugs in rodent models of nociceptive and neuropathic pain. Clinical studies in young and adult elderly patients confirm the utility of paracetamol in multimodal, non-opioid or opioid-sparing, therapies for the treatment of acute and chronic pain.
Collapse
Affiliation(s)
- Ulderico Freo
- Anesthesiology & Intensive Medicine, Department of Medicine - DIMED, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
| |
Collapse
|
9
|
Patel AK, Gai J, Trujillo-Rivera E, Faruqe F, Kim D, Bost JE, Pollack MM. Association of Intravenous Acetaminophen Administration With the Duration of Intravenous Opioid Use Among Hospitalized Pediatric Patients. JAMA Netw Open 2021; 4:e2138420. [PMID: 34932106 PMCID: PMC8693214 DOI: 10.1001/jamanetworkopen.2021.38420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/17/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Adoption of multimodal pain regimens that incorporate nonopioid analgesic medications to reduce inpatient opioid administration can prevent serious opioid-related adverse effects in children, including tolerance, withdrawal, delirium, and respiratory depression. Intravenous (IV) acetaminophen is in widespread pediatric use; however, its effectiveness as an opioid-sparing agent has not been evaluated in general pediatric inpatients. Objective To determine if IV acetaminophen administered prior to IV opioids is associated with a reduction in the total duration of IV opioids administered compared with IV opioids administered without IV acetaminophen in general pediatric inpatients. Design, Setting, and Participants This comparative effectiveness research study included data on pediatric inpatients from 274 US hospitals between January 2011 and June 2016 collected from a national database. Outcomes were compared with a propensity score-matched analysis of pediatric inpatients administered IV opioids without IV acetaminophen (control) and those administered IV acetaminophen prior to IV opioids (intervention). Data were analyzed from January 2020 through October 2021. Exposures Patients in the intervention group received IV acetaminophen prior to IV opioids. Patients in the control group received IV opioids without IV acetaminophen. Main Outcomes and Measures Total duration of all IV opioids administered during a patient's hospitalization. Results Of 893 293 pediatric inpatients, a total of 104 579 were included in analysis (median [IQR] age, 1.3 [0-14.7] years; 59 806 [57.2%] female; 21 485 [21.5%] African American, 56 309 [53.8%] White), of whom 18 197 (2.0%) received IV acetaminophen, and 287 504 (34.0%) received IV opioids. After applying exclusion criteria, among patients who received IV acetaminophen, 1739 (10.8%) received IV acetaminophen prior to IV opioids within a median (IQR) treatment time of 1.5 (0.02-7.3) hours. After propensity score matching produced comparable groups in the control and intervention groups (with 839 patients in each group), the multivariable model estimated a 15.5% shorter duration of IV opioid use in the intervention group, with an absolute IV opioid reduction of 7.5 hours (95% CI, 0.7-15.8 hours). Conclusions and Relevance In this comparative effectiveness study, IV acetaminophen administered prior to IV opioids was associated with a reduction in IV opioid duration by 15.5%. Multimodal pain regimens that use IV acetaminophen prior to IV opioids could reduce IV opioid duration.
Collapse
Affiliation(s)
- Anita K. Patel
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jiaxiang Gai
- Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | | | - Dongkyu Kim
- Department of Pediatrics, Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James E. Bost
- Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Murray M. Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| |
Collapse
|
10
|
Wallskog KE, Lauderdale S, Peppard WJ, Kirkwood C, Taylor S, Johnston S. Inpatient Perioperative Formulary Restriction of Intravenous Acetaminophen at Vizient Partner Hospitals: A National Survey of Pharmacists. Hosp Pharm 2021; 56:650-659. [PMID: 34732917 DOI: 10.1177/0018578720931751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: Despite potential benefits of intravenous (i.v.) administration of acetaminophen (APAP), consistent outcome data are lacking. This, combined with the higher acquisition cost of the drug, has led to variation in i.v. APAP management strategies. This project evaluated the contemporary formulary status and restrictions of i.v. APAP in the perioperative setting. Methods: A survey focusing on i.v. APAP formulary restriction in the perioperative setting was developed by the Vizient Pharmacy Research Committee and distributed to Vizient Pharmacy Program participant listservs for Pharmacy Directors or Drug Information Pharmacists. The four survey domains included hospital characteristics, perioperative i.v. APAP formulary status and prescribing restrictions, perioperative i.v. APAP use, and perioperative i.v. APAP medication use evaluation (MUE) results. Responses were collected and summarized, and primary outcomes were evaluated using Fisher's exact test. Results: A total of 1195 surveys were distributed with a response rate of 19%. Respondents were equally distributed between academic medical centers (AMC) and non-academic medical centers (non-AMC). Two cohorts were examined: those with i.v. APAP on formulary and those without. The non-AMCs showed a larger proportion of hospitals with the medication on formulary (P = .041). Regarding formulary decision-making, the AMCs were more considerate of value. Several different practices were employed to limit or restrict i.v. APAP. Conclusion: A survey of directors of pharmacy and drug information specialists revealed that the majority of hospitals have i.v. APAP on formulary for perioperative use, but use is restricted. Differences in i.v. APAP formulary practices between AMCs and non-AMCs warrant further consideration.
Collapse
Affiliation(s)
| | | | | | | | - Stacy Taylor
- College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | | |
Collapse
|
11
|
Phillips SJ, Peck CJ, Pourtaheri N, Reategui A, Carney M, Dinis J, Park KE, Maniskas S, Lopez J, Steinbacher DM. Decreasing Inpatient Opioid Use Following Orthognathic Surgery. J Craniofac Surg 2021; 32:2808-2811. [PMID: 34727482 DOI: 10.1097/scs.0000000000008001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Strategies to decrease postoperative opioid use are important for mitigating the immediate and long-term risks associated with their use. We aimed to investigate the impact of perioperative various factors on inpatient opioid needs for patients undergoing orthognathic surgery. METHODS This was a retrospective cohort study of all patients who underwent orthognathic surgery performed by the senior author from 2012 to 2018. Patients were grouped into intravenous (IV) acetaminophen and no-IV acetaminophen cohorts. Opioid medications received by patients during hospital stay were converted to mean morphine equivalents (MME) for comparison. Additional factors that influenced opioid consumption, such as transexamic acid (TXA) and postoperative nausea and vomiting (PONV), were identified using univariate analysis. Factors found to have statistical significance were added to a multivariate linear regression model. RESULTS 319 patients were included. Those who received IV acetaminophen had lower rates of total opioid use (57.3 versus 74.8 MME; P = 0.002) and postoperative opioid use (24.0 versus 37.7 MME; P < 0.001). Perioperative prothrombotic agents, such as TXA, were associated with lower total and postoperative MME (P = 0.005, P = 0.002). Multivariate regression analysis showed that increased PONV resulted in increased postoperative opioid use, whereas perioperative acetaminophen lowered total and postoperative quantities. CONCLUSIONS Perioperative IV acetaminophen is an effective method for decreasing inpatient opioid analgesia after orthognathic surgery. Intravenous TXA and PONV control may provide additional benefit to decreasing inpatient opioid consumption. More research as to the mechanisms and ideal clinical applications for both IV acetaminophen and TXA are warranted.
Collapse
Affiliation(s)
- Sarah J Phillips
- Plastic and Oral and Maxillofacial SUrgery, Yale New Haven Health, New Haven CT
| | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Subramaniam K, Esper SA, Mallikarjun K, Dickson A, Ruppert K, Drabek T, Wong H, Murray JH. The Effect of Scheduled Intravenous Acetaminophen in an Enhanced Recovery Protocol Pathway in Patients Undergoing Major Abdominal Procedures: A Prospective, Randomized, and Placebo-Controlled Clinical Trial. PAIN MEDICINE 2021; 23:10-18. [PMID: 34498068 DOI: 10.1093/pm/pnab272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 06/30/2021] [Accepted: 09/01/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Enhanced recovery protocols (ERPs) utilize multi-modal analgesia regimens. Individual regimen components should be evaluated for their analgesic efficacy. We evaluated the effect of scheduled intravenous (IV) acetaminophen within an ERP on analgesia and recovery after a major abdominal surgery. DESIGN This study is a prospective, randomized, double-blinded clinical trial. SETTING The study setting was a tertiary care, academic medical center. SUBJECTS Adult patients scheduled for elective major abdominal surgical procedures. METHODS Patients in group A received 1g IV acetaminophen, while patients in group P received IV placebo every six hours for 48 hours postoperatively within an ERP. Pain scores, opioid requirements, nausea and vomiting, time to oral intake and mobilization, length of stay, and patient satisfaction scores were measured and compared. RESULTS From 412 patients screened, 154 patients completed the study (Group A: 76, Group P: 78). Primary outcome was the number of patients with unsatisfactory pain relief, defined as a composite of average Numeric Rating Scale (NRS) scores above 5 and requirement of IV patient-controlled analgesia for pain relief during the first 48 hours postoperatively, and was not significantly different between the two groups (33 (43.4%) in group A versus 42 (53.8%) patients in group P, p=0.20). Opioid consumption was comparable between two groups. Group A utilized significantly less postoperative rescue antiemetics compared to group P (41% vs. 58%, p= 0.02). CONCLUSIONS Scheduled administration of IV acetaminophen did not improve postoperative analgesia or characteristics of postoperative recovery in patients undergoing major abdominal surgery within an ERP pathway.
Collapse
Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Kushanth Mallikarjun
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Alec Dickson
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Kristin Ruppert
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh PA
| | - Tomas Drabek
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Hesper Wong
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA
| | - Jennifer Holder Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh PA
| |
Collapse
|
13
|
Haines KL, Fuller M, Antonescu I, Vaughan JG, Raghunathan K, Cox CE, Bartz RR, Ohnuma T, Agarwal S, Krishnamoorthy V. Underutilization of Acetaminophen in Older Adult Trauma Patients. Am Surg 2021; 88:2003-2010. [PMID: 34049451 DOI: 10.1177/00031348211023397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Older adults are more vulnerable to opioid-associated morbidity. The purpose of this study was to determine the frequency and timing of acetaminophen and opioid use in the postoperative period. METHODS Older adult trauma patients (≥65 years) with hip fractures requiring femur or hip fixation were reviewed (Premier Database 2008-2014). We examined rates of acetaminophen use on the day of surgery and prior to receipt of oral opioids. Mixed-effects linear regression models were used to examine the effects of an acetaminophen-first approach on opioid use the day prior to and on the day of discharge. RESULTS Of the 192 768 patients, 81.6% were Caucasian; 74.0% were female; and the mean age was 82.0 years [± 7.0]. Only 16.8% (32 291) of patients received acetaminophen prior to being prescribed opioids. 27.4% (52 779) received an acetaminophen-opioid combination, and 9.2% (17 730) received opioids without acetaminophen first. Acetaminophen first was associated with reduced opioid use on the day prior to and on the day of discharge (3.52 parenteral morphine equivalent doses (PMEs) less [95% CI: 3.33, 3.70]; P < .0001). A statistically but not clinically significant reduction in length of stay was observed in the acetaminophen-first group. CONCLUSION Nearly 37% of older adult patients did not receive acetaminophen as first-line analgesia after hip surgery. Multimodal analgesia, including non-opioid medications as first-line, should be encouraged.
Collapse
Affiliation(s)
- Krista L Haines
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Matthew Fuller
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Ioana Antonescu
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Justin G Vaughan
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Christopher E Cox
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Raquel R Bartz
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Tetsu Ohnuma
- The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| | - Suresh Agarwal
- Division of Trauma and Critical Care and Acute Care Surgery, Department of Surgery, 22957Duke University Medical Center, Durham, NC, USA.,The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, 22957Duke University Medical Center, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, 22957Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
14
|
Abstract
This article addresses the importance of anesthesiologists providing regional anesthesia techniques that are beneficial to the care of trauma patients in the field. It also discusses the advantages and risks associated with regional anesthesia in the field along with how to avoid those risks. In addition, it describes some of the benefits of modern ultrasound techniques compared with landmark techniques with stimulation and other important considerations when performing regional anesthesia in the field. The article gives the unique indications, risks, and key points of the most useful regional techniques for anesthesiologists operating in field environments.
Collapse
Affiliation(s)
- Robert Vietor
- Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Chester Buckenmaier
- Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| |
Collapse
|
15
|
Abstract
Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms.
Collapse
|
16
|
Tirotta CF, Lin JH, Tran MH. Effectiveness of Liposomal Bupivacaine Compared With Standard- of-Care Measures in Pediatric Cardiothoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:3681-3687. [PMID: 33975790 DOI: 10.1053/j.jvca.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/22/2021] [Accepted: 04/02/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Effective postsurgical pain management is important for pediatric patients to improve outcomes while reducing resource use and waste. The authors examined opioid consumption and economic outcomes associated with liposomal bupivacaine (LB) or non-LB analgesia use in pediatric patients undergoing cardiothoracic surgery. DESIGN The authors retrospectively analyzed Premier Healthcare Database records. SETTING The data extracted from the database included patient records from hospitals across the United States in both rural and urban locations. PARTICIPANTS The records included data from patients aged 12-to-<18 years. INTERVENTIONS The records belonged to patients undergoing video-assisted thoracoscopic procedures (VATS) who received LB or non-LB analgesia after surgery. MEASUREMENTS AND MAIN RESULTS Outcomes included in-hospital postsurgical opioid consumption in morphine milligram equivalents (MMEs), hospital length of stay (LOS), and total hospital costs; the LB and non-LB cohorts were compared using a generalized linear model with inverse probability of treatment weighting to balance the cohorts. For VATS procedures, pediatric patients receiving LB had significant reductions in in-hospital opioid consumption (632 v 991 MMEs; p < 0.0001), shorter LOS (5.1 v 5.6 days; p = 0.0023), and lower total hospital costs ($18,084 v $21,962; p < 0.0001) compared with those receiving non-LB analgesia. CONCLUSIONS These results support use of LB in multimodal analgesia regimens for managing pain in pediatric patients after cardiothoracic surgery.
Collapse
|
17
|
Pelzer D, Burgess E, Cox J, Baker R. Preoperative Intravenous Versus Oral Acetaminophen in Outpatient Surgery: A Double-Blinded, Randomized Control Trial. J Perianesth Nurs 2020; 36:162-166. [PMID: 33262012 DOI: 10.1016/j.jopan.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Preoperative acetaminophen is recognized as an effective part of the multimodal approach to perioperative pain management. The present study, conducted between April 12, 2018 and February 14, 2019, examined whether there are differences in patient-reported pain, postoperative opioid consumption, negative opioid effects, length of postanesthesia care unit stay, and patient satisfaction with pain control between patients who receive intravenous (IV) acetaminophen and patients who receive oral acetaminophen. DESIGN This double-blinded, randomized controlled trial was conducted among 120 patients undergoing outpatient surgery. METHODS Patients were randomized to receive preoperatively either intravenous (IV) acetaminophen (and oral placebo) or oral acetaminophen (and IV placebo). Results were analyzed using SPSS statistical software; statistical analyses consisted of Mann-Whitney U test, independent samples t test, and χ2 test. In all analyses, a P value less than .05 was considered significant. FINDINGS There were no significant differences in any outcome measures based on the route of acetaminophen administration. CONCLUSIONS The findings of the present study support the practice of administering oral acetaminophen, as opposed to IV acetaminophen, preoperatively as part of the multimodal approach to manage postoperative pain in patients able to tolerate preoperative oral medications.
Collapse
Affiliation(s)
- Diana Pelzer
- TriHealth Bethesda Butler Hospital, Hamilton, OH.
| | | | - Jennifer Cox
- TriHealth Bethesda Butler Hospital, Hamilton, OH
| | | |
Collapse
|
18
|
Mazumdar M, Poeran JV, Ferket BS, Zubizarreta N, Agarwal P, Gorbenko K, Craven CK, Zhong XT, Moskowitz AJ, Gelijns AC, Reich DL. Developing an Institute for Health Care Delivery Science: successes, challenges, and solutions in the first five years. Health Care Manag Sci 2020; 24:234-243. [PMID: 33161511 DOI: 10.1007/s10729-020-09521-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
Medical knowledge is increasing at an exponential rate. At the same time, unexplained variations in practice and patient outcomes and unacceptable rates of medical errors and inefficiencies in health care delivery have emerged. Our Institute for Health Care Delivery Science (I-HDS) began in 2014 as a novel platform to conduct multidisciplinary healthcare delivery research. We followed ten strategies to develop a successful institute with excellence in methodology and strong understanding of the value of team science. Our work was organized around five hubs: 1) Quality/Process Improvement and Systematic Review, 2) Comparative Effectiveness Research, Pragmatic Clinical Trials, and Predictive Analytics, 3) Health Economics and Decision Modeling, 4) Qualitative, Survey, and Mixed Methods, and 5) Training and Mentoring. In the first 5 years of the I-HDS, we have identified opportunities for change in clinical practice through research using our health system's electronic health record (EHR) data, and designed programs to educate clinicians in the value of research to improve patient care and recognize efficiencies in processes. Testing the value of several model interventions has guided prioritization of evidence-based quality improvements. Some of the changes in practice have already been embedded in the EHR workflow successfully. Development and sustainability of the I-HDS has been fostered by a mix of internal and external funding, including philanthropic foundations. Challenges remain due to the highly competitive funding environment and changes needed to adapt the EHR to healthcare delivery research. Further stakeholder engagement and culture change working with hospital leadership and I-HDS core and affiliate members continues.
Collapse
Affiliation(s)
- Madhu Mazumdar
- Institute for Health Care Delivery Science, Center for Biostatistics, Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA.
| | - Jashvant V Poeran
- Institute for Health Care Delivery Science, Departments of Population Health Science and Policy, Medicine, and Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bart S Ferket
- Institute for Health Care Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Zubizarreta
- Institute for Health Care Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parul Agarwal
- Institute for Health Care Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ksenia Gorbenko
- Institute for Health Care Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Catherine K Craven
- Institute for Health Care Delivery Science, Department of Population Health Science and Policy, Clinical Informatics Group, Information Technology, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Xiaobo Tony Zhong
- Institute for Health Care Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alan J Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David L Reich
- Mount Sinai Hospital, Mount Sinai Queens, New York, NY, USA
| |
Collapse
|
19
|
Chemoselective vinylation of aminophenols with acetylene catalyzed by sodium aminophenolates in aqueous DMSO. MENDELEEV COMMUNICATIONS 2020. [DOI: 10.1016/j.mencom.2020.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
20
|
Turan A, Essber H, Saasouh W, Hovsepyan K, Makarova N, Ayad S, Cohen B, Ruetzler K, Soliman LM, Maheshwari K, Yang D, Mascha EJ, Ali Sakr Esa W, Kessler H, Delaney CP, Sessler DI. Effect of Intravenous Acetaminophen on Postoperative Hypoxemia After Abdominal Surgery: The FACTOR Randomized Clinical Trial. JAMA 2020; 324:350-358. [PMID: 32721009 PMCID: PMC7388016 DOI: 10.1001/jama.2020.10009] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Opioid-induced ventilatory depression and hypoxemia is common, severe, and often unrecognized in postoperative patients. To the extent that nonopioid analgesics reduce opioid consumption, they may decrease postoperative hypoxemia. OBJECTIVE To test the hypothesis that duration of hypoxemia is less in patients given intravenous acetaminophen than those given placebo. DESIGN, SETTING, AND PARTICIPANTS Randomized, placebo-controlled, double-blind trial conducted at 2 US academic hospitals among 570 patients who were undergoing abdominal surgery, enrolled from February 2015 through October 2018 and followed up until February 2019. INTERVENTIONS Participants were randomized to receive either intravenous acetaminophen, 1 g (n = 289), or normal saline placebo (n = 291) starting at the beginning of surgery and repeated every 6 hours until 48 postoperative hours or hospital discharge, whichever occurred first. MAIN OUTCOMES AND MEASURES The primary outcome was the total duration of hypoxemia (hemoglobin oxygen saturation [Spo2] <90%) per hour, with oxygen saturation measured continuously for 48 postoperative hours. Secondary outcomes were postoperative opioid consumption, pain (0- 10-point scale; 0: no pain; 10: the most pain imaginable), nausea and vomiting, sedation, minimal alveolar concentration of volatile anesthetic, fatigue, active time, and respiratory function. RESULTS Among 580 patients randomized (mean age, 49 years; 48% women), 570 (98%) completed the trial. The primary outcome, median duration with Spo2 of less than 90%, was 0.7 (interquartile range [IQR], 0.1-5.1) minutes per hour among patients in the acetaminophen group and 1.1 (IQR, 0.1-6.6) minutes per hour among patients in the placebo group (P = .29), with an estimated median difference of -0.04 (95% CI,-0.18 to 0.11) minutes per hour. None of the 8 secondary end points differed significantly between the acetaminophen and placebo groups. Mean pain scores within initial 48 postoperative hours were 4.2 (SD, 1.8) in the acetaminophen group and 4.4 (SD, 1.8) in the placebo group (difference, -0.28; 95% CI, -0.71 to 0.15); median opioid use in morphine equivalents was 50 mg (IQR, 18-122 mg) and 58 mg (IQR, 24-151 mg) , respectively, with a ratio of geometric means of 0.86 (95% CI, 0.61-1.21). CONCLUSIONS AND RELEVANCE Among patients who underwent abdominal surgery, use of postoperative intravenous acetaminophen, compared with placebo, did not significantly reduce the duration of postoperative hypoxemia over 48 hours. The study findings do not support the use of intravenous acetaminophen for this purpose. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02156154.
Collapse
Affiliation(s)
- Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Hani Essber
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Wael Saasouh
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Karen Hovsepyan
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Natalya Makarova
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Sabry Ayad
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of Regional Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Barak Cohen
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Division of Anesthesiology, Intensive Care, and Pain Management, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kurt Ruetzler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | | | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Dongsheng Yang
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Edward J. Mascha
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Wael Ali Sakr Esa
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Herman Kessler
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Conor P. Delaney
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | | |
Collapse
|
21
|
Lee Y, Yu J, Doumouras AG, Ashoorion V, Gmora S, Anvari M, Hong D. Intravenous Acetaminophen Versus Placebo in Post-bariatric Surgery Multimodal Pain Management: a Meta-analysis of Randomized Controlled Trials. Obes Surg 2020; 29:1420-1428. [PMID: 30726545 DOI: 10.1007/s11695-019-03732-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pain management after bariatric surgery is challenging. Recent trials have been exploring the role of intravenous (IV) acetaminophen in multimodal analgesic therapy. This systematic review and meta-analysis assessed the effect of IV acetaminophen compared to placebo for pain management after bariatric surgery. METHODS A comprehensive search of MEDLINE, Embase, CENTRAL, and PubMed databases were performed. Randomized controlled trials (RCTs) comparing IV acetaminophen to placebo as part of multimodal pain management after bariatric surgery in patients with obesity were included. Key outcomes were analyzed using random-effects meta-analysis, and the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). RESULTS Four RCTs including 349 patients met the inclusion criteria, of whom 175 were provided IV acetaminophen and 174 were provided placebo. Patients given IV acetaminophen demonstrated a lower postoperative pain score (mean difference (MD) - 0.66, 95% CI - 1.03 to - 0.28, P < 0.001) 24 h after surgery and lower postoperative opioid use (MD - 6.44, 95% CI - 9.26 to - 3.61, P < 0.001; I2 = 0%) in morphine equivalent doses (MED) within 24 h compared with the placebo group. There was no significant difference in length of stay between groups (MD - 0.26, 95% CI - 0.55 to 0.03, P = 0.08). CONCLUSIONS The use of IV acetaminophen after bariatric surgery is effective in reducing pain score after 24 h and postoperative opioid doses, but not length of stay. Provided the benefits of IV acetaminophen, its addition to postoperative care and enhanced recovery programs may be warranted.
Collapse
Affiliation(s)
- Yung Lee
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James Yu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aristithes G Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada
| | - Vahid Ashoorion
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Scott Gmora
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada
| | - Mehran Anvari
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada.
| |
Collapse
|
22
|
American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Advancing Sedation and Respiratory Depression: Revisions. Pain Manag Nurs 2020; 21:7-25. [DOI: 10.1016/j.pmn.2019.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/25/2019] [Accepted: 06/14/2019] [Indexed: 01/12/2023]
|
23
|
Scholzen E, Zeng AM, Schroeder KM. Perioperative Management and Analgesia for Patients Taking Buprenorphine and Other Forms of Medication-Assisted Treatment for Substance Abuse Disorders. Adv Anesth 2019; 37:65-86. [PMID: 31677660 DOI: 10.1016/j.aan.2019.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Elizabeth Scholzen
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, B6/319 CSC, Madison, WI 53792, USA
| | - Angela M Zeng
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, B6/319 CSC, Madison, WI 53792, USA
| | - Kristopher M Schroeder
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, University of Wisconsin, 600 Highland Avenue, B6/319 CSC, Madison, WI 53792, USA.
| |
Collapse
|
24
|
Wanek MR. Intravenous Acetaminophen for Postoperative Delirium. JAMA 2019; 322:271-272. [PMID: 31310289 DOI: 10.1001/jama.2019.6130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|
25
|
Johnson RJ, Nguyen DK, Acosta JM, O'Brien AL, Doyle PD, Medina-Rivera G. Intravenous Versus Oral Acetaminophen in Ambulatory Surgical Center Laparoscopic Cholecystectomies: A Retrospective Analysis. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2019; 44:359-363. [PMID: 31160871 PMCID: PMC6534170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
STUDY OBJECTIVE The primary aim was to compare postoperative pain scores in patients undergoing laparoscopic cholecystectomy and receiving intravenous (IV) or oral (PO) acetaminophen (APAP) as part of a multimodal analgesic regimen to examine whether PO APAP is non-inferior to IV APAP. DESIGN Retrospective analysis. SETTING Ambulatory surgical center (ASC) in an academic setting. PATIENTS 579 patients (18-70 years old), American Society of Anesthesiologists physical status I-III, undergoing laparoscopic cholecystectomy. INTERVENTIONS Patients received 1,000 mg IV APAP intraoperatively (n = 319) or 1,000 mg PO APAP preoperatively (n = 260). MEASUREMENTS The primary outcome was the median difference in post-anesthesia care unit (PACU) end-pain scores between the groups. Median pain scores were also compared on PACU admission, and at 15, 30, 45, and 60 minutes. Additional measures include PACU rescue-analgesia consumption, time to first PACU rescue analgesia, intraoperative use of opioid and nonopioid analgesics, PACU length of stay, and PACU rescue nausea and vomiting therapy. MAIN RESULTS In both groups, the PACU median end-pain score was 2. The 90% confidence interval (CI) for difference in median pain scores between groups was [0, 0]; the CI upper limit was below the non-inferior margin of 1 pain-score point, indicating PO APAP's non-inferiority to IV APAP. There were no statistically significant differences in the percentages of patients receiving PACU hydromorphone equivalents between the IV and PO groups (75% vs. 77%, P = 0.72) or in the mean dose received (0.5 mg vs. 0.5 mg, P = 0.66). CONCLUSION Single-dose PO APAP is non-inferior to IV APAP for postoperative analgesia in ASC laparoscopic cholecystectomy patients. The value of single-dose IV APAP in this population should be further explored.
Collapse
|
26
|
Stundner O, Poeran J, Ladenhauf HN, Berger MM, Levy SB, Zubizarreta N, Mazumdar M, Bekeris J, Liu J, Galatz LM, Moucha CS, Memtsoudis S. Effectiveness of intravenous acetaminophen for postoperative pain management in hip and knee arthroplasties: a population-based study. Reg Anesth Pain Med 2019; 44:565-572. [PMID: 30867279 DOI: 10.1136/rapm-2018-100145] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/21/2019] [Accepted: 02/01/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES The significance of intravenous over oral acetaminophen (APAP) as part of multimodal analgesic protocols is contested, particularly when considering its relatively high price and use in a surgical cohort such as total hip or knee arthroplasty (THA/TKA), which generally tolerates oral medications. This study aims to elucidate APAP's effectiveness in a large, population-based patient sample. METHODS 1 039 647 THA/TKA procedures were sampled from the Premier Healthcare claims database 2011-2016. APAP use was categorized by intravenous/oral and use on the day of surgery, postoperative day 1 and thereafter. Outcomes were opioid utilization (in oral morphine equivalents), length and cost of hospitalization, and opioid-related adverse effects (respiratory, gastrointestinal, and naloxone use as a proxy). Mixed-effects models measured the associations between intravenous/oral APAP use and outcomes. Percent (%) change and 95% CIs are reported. RESULTS Overall, 23.6% (n=245 454) of patients received intravenous APAP; of these, 56.3% (n=138 180) received just one dose on the day of surgery. After adjustment for relevant covariates, particularly use of >1 dose of intravenous APAP (compared with no use) on postoperative day 1 was associated with -6.0% (CI -7.2% to -4.7%) reduced opioid utilization; this was -10.7% (CI -11.4% to -9.9%) for use of > 1 dose oral APAP on postoperative day 1. Further comparisons regarding other outcomes also favored oral (over intravenous) APAP. CONCLUSIONS These results do not support the routine use of intravenous APAP in patients undergoing lower joint arthroplasty, especially since oral APAP shows more beneficial outcome patterns.
Collapse
Affiliation(s)
- Ottokar Stundner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
| | - Jashvant Poeran
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA .,Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hannah Noemi Ladenhauf
- Department of Pediatric and Adolescent Surgery, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
| | - Marc Moritz Berger
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
| | - Steven B Levy
- Department of Pharmacy, Mount Sinai St Luke's, Mount Sinai Health System, New York, New York, USA
| | - Nicole Zubizarreta
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Janis Bekeris
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria.,Department of Anesthesiology, Hospital for Special Surgery, New York, New York, USA
| | - Jiabin Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, USA
| | - Leesa M Galatz
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Calin S Moucha
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stavros Memtsoudis
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria.,Department of Anesthesiology, Hospital for Special Surgery, New York, New York, USA.,Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| |
Collapse
|
27
|
Opiates and IV Acetaminophen. Anesthesiology 2019; 130:513-514. [PMID: 30762643 DOI: 10.1097/aln.0000000000002568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
28
|
When Large Administrative Databases Provide Less Relevant Information than Randomized Studies. Anesthesiology 2019; 130:514-515. [PMID: 30762644 DOI: 10.1097/aln.0000000000002569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
29
|
In Reply. Anesthesiology 2019; 130:515-516. [PMID: 30762645 DOI: 10.1097/aln.0000000000002570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
30
|
Nelson AM, Wu CL. “Randomization at the Expense of Relevance.” L. J. Cronbach and Intravenous Acetaminophen as an Opioid-Sparing Adjuvant. Anesth Analg 2018; 127:1099-1100. [DOI: 10.1213/ane.0000000000003577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|