1
|
Chang JS, Lee DH, Kang MW, Kim JW, Kim CH. Effectiveness of Intravenous Non-Opioid Analgesics for Postoperative Pain Management of in Patients Undergoing Hip Surgery: A Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1904. [PMID: 38003953 PMCID: PMC10673097 DOI: 10.3390/medicina59111904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Intravenous (IV) non-opioid analgesics (NOAs) have been extensively investigated as a multimodal analgesic strategy for the management of acute pain after hip surgery. This pair-wise meta-analysis examined IV NOA effects following hip surgery. Materials and Methods: A systematic search of the MEDLINE (PUBMED), Embase, and Cochrane Library databases was performed for studies investigating the effect of IV NOA for postoperative pain management following hip surgery up to 7 June 2023. We compared in-admission opioid use, postoperative VAS (visual analogue scale) score, hospital stay duration, and opioid-related adverse events between IV NOA and control groups. Results: Seven studies were included with a total of 953 patients who underwent hip surgery. Of these, 478 underwent IV NOA treatment, and 475 did not. The IV NOA groups had lower opioid use within 24-h following hip surgery (SMD, -0.48; 95% CI, -0.66 to -0.30; p < 0.01), lower VAS score (SMD, -0.47; 95% CI, -0.79 to -0.16; p < 0.01), shorter hospital stay (SMD, -0.28; 95% CI, -0.44 to -0.12; p < 0.01), and lower incidence of nausea and vomiting (OR, 0.32; 95% CI, 0.15 to 0.67; p < 0.01) compared with the control groups. Conclusions: This meta-analysis demonstrated that IV NOA administration following hip surgery may have more favorable postoperative outcomes than those in control groups.
Collapse
Affiliation(s)
- Jae Suk Chang
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (D.H.L.); (M.W.K.)
| | - Dong Hwan Lee
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (D.H.L.); (M.W.K.)
| | - Min Wook Kang
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (D.H.L.); (M.W.K.)
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
| | - Chul-Ho Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
| |
Collapse
|
2
|
Di Martino A, Brunello M, Pederiva D, Schilardi F, Rossomando V, Cataldi P, D'Agostino C, Genco R, Faldini C. Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review. Clin Pract 2023; 13:569-582. [PMID: 37218803 DOI: 10.3390/clinpract13030052] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 05/24/2023] Open
Abstract
The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.
Collapse
Affiliation(s)
- Alberto Di Martino
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Matteo Brunello
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Davide Pederiva
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Francesco Schilardi
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Valentino Rossomando
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Piergiorgio Cataldi
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Claudio D'Agostino
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Rossana Genco
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| | - Cesare Faldini
- 1st Orthopedic and Traumatology Clinic, IRCCS Rizzoli Orthopedic Institute, Via G.C. Pupilli 1, 40136 Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136 Bologna, Italy
| |
Collapse
|
3
|
Liposomal Bupivacaine Decreases Intravenous Opioid Use in Patients with Hip Fracture: A Modification to a Novel Pain Protocol. J Am Acad Orthop Surg 2023; 31:e246-e255. [PMID: 36821079 DOI: 10.5435/jaaos-d-22-00493] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/23/2022] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION The aim of this study was to determine whether the administration of liposomal bupivacaine decreased opioid use and delirium in patients sustaining a hip fracture. METHODS A retrospective review of patients with hip fracture from September 2018 to October 2019 was performed through our institution's hip fracture registry. A liposomal bupivacaine cocktail was administered intraoperatively. Opioid requirement was determined for postoperative days 1, 2, and 3. Delirium was identified through chart review. Visual analog scale pain scores were averaged for postoperative days 1, 2, and 3. Four groups were analyzed: patients who received liposomal bupivacaine and IV acetaminophen, patients who only received IV acetaminophen, patients who only received liposomal bupivacaine, and control patients whose data were collected before this intervention. Continuous data were compared using a one-way analysis of variance or Student t-test, as applicable. Categorical data were compared using the Fisher exact test. Significance was set at P < 0.05. RESULTS One hundred nine patients met the inclusion criteria for the study with a mean age of 81.2 years. Eighty-two patients (75.2%) received intraoperative liposomal bupivacaine during the study year. Intravenous opioid requirement was markedly different among all four groups in all postoperative days. Oral opioid requirement and pain scores were not different between groups on any postoperative day. A notable decrease in IV opioid requirement in all postoperative days was seen in the Intervention groups (day 1 P < 0.001, day 2 P = 0.002, and day 3 P = 0.030). There existed a trend toward decreased delirium rates in the Intervention groups compared with the No Intervention group (23.9% vs. 32.8%, P = 0.272). CONCLUSION The inclusion of liposomal bupivacaine in our institution's novel pain protocol led to notable decreases in opioid requirement in all postoperative days studied with a trend toward decreased delirium rates as well.
Collapse
|
4
|
Alsaadi M, Hasan MA, Mehsen J, Aliakbar A. Clinical Evaluation for Effectiveness and Safety of Lidocaine and Bupivacaine Combination Epidural Infusion for the Management of Post-Total Hip Replacement Pain. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background
The management of post-operative pain is critical for both the patient and the surgical outcome. Although epidural analgesia is valuable method, optimal local anesthetic selection and combination could improve its effectiveness. To determine the effectiveness and safety of bupivacaine and lidocaine bolus epidural analgesia in the management of post-total hip arthroplasty.
Methods
65 Records of patients who underwent total hip arthroplasty and received bolus epidural analgesia with bupivacaine and lidocaine were evaluated retrospectively. The numerical pain score for 48 hours, drug adverse effects, hospital stay, and opioid intake were analyzed statistically to determine the effectiveness and safety of epidural analgesia.
Results
The numerical pain score showed mild pain perception through the first 48 hours post operatively. There was no significant difference (p≥ 0.005) between the first score data collected at 6 hours and the last score at 48 hours. Post-operatively, patients had lower incidence of hypotension and headache with acceptable mobility. Opioid rescue analgesia was used for 11(16.9%) of patients.
Conclusions
For patients who have undergone total hip replacement surgery, epidural analgesia with a bolus epidural infusion of lidocaine and bupivacaine delivers an effective and safe pain control method for 48 hours. This method was effective in opioid sparing.
Collapse
|
5
|
Fillingham YA, Hannon CP, Erens GA, Hamilton WG, Della Valle CJ. Acetaminophen in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2020; 35:2697-2699. [PMID: 32571591 DOI: 10.1016/j.arth.2020.05.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Affiliation(s)
- Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Greg A Erens
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
| | | | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| |
Collapse
|
6
|
The Efficacy and Safety of Acetaminophen in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2020; 35:2715-2729. [PMID: 32563592 DOI: 10.1016/j.arth.2020.05.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Oral and intravenous (IV) acetaminophen has become widely used perioperatively as part of a multi-modal pain management protocol for primary total joint arthroplasty (TJA). The purpose of our study is to evaluate the efficacy and safety of acetaminophen in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management. METHODS We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for studies published prior to September 2019 on acetaminophen in primary TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of acetaminophen. RESULTS In total, 1287 publications were critically appraised yielding 17 publications representing the best available evidence for analysis. Oral and IV acetaminophen demonstrates the ability to safely reduce postoperative pain and opioid consumption during the inpatient hospital stay. No evidence was available to assess the efficacy and safety of oral acetaminophen after discharge. CONCLUSION Moderate evidence supports the use of oral and IV acetaminophen as a non-opioid adjunct for pain management during the inpatient hospitalization. Strong evidence supports the safety of oral and IV acetaminophen when appropriately administered to patients undergoing primary TJA. Although there is lack of robust evidence for use of acetaminophen following discharge, it remains a low-cost and low-risk option as part of a multimodal pain regimen.
Collapse
|
7
|
Similar Outcomes After Hospital-Based Same-Day Discharge vs Inpatient Total Hip Arthroplasty. Arthroplast Today 2020; 6:451-456. [PMID: 32637515 PMCID: PMC7327380 DOI: 10.1016/j.artd.2020.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/10/2020] [Accepted: 05/08/2020] [Indexed: 01/03/2023] Open
Abstract
Background There has been increasing interest in performing primary hip and knee replacement with same-day discharge (SDD). The purpose of this study is to compare patient-reported outcome (PRO) scores, pain scores, and readmissions in patients who underwent SDD total hip arthroplasty (THA) with those in patients who underwent traditional inpatient THA. Methods A retrospective study was conducted on 963 patients who underwent primary THA at our institution between September 2016 and December 2018. Two cohorts were established based on whether the patient underwent SDD or traditional inpatient THA. An electronic physical engagement application was used to collect PRO scores (Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, Veterans Rand 12-Item Health Survey Physical Component Score, and Mental Component Score) and pain scores. To control for demographic variables, a multiple regression analysis of PRO scores was conducted. Results Four hundred fifteen (43.1%) patients in this study underwent the SDD protocol. There were significant differences between both cohorts with respect to sex, age, body mass index, American Society of Anesthesiologists score, and smoking status. The bivariate analysis revealed that the SDD cohort had a significantly greater change in the Veterans Rand 12-Item Health Survey Physical Component Score and had fewer readmissions. Both cohorts had equivalent decreases in pain scores. After controlling for demographic variables in a multivariable analysis, the SDD cohort was found to have higher PRO scores at all time points, but there were no significant differences in the change in PRO scores over time between both groups. Conclusion Patients in an SDD THA care pathway experienced similar improvements in PRO scores and clinically equal reduction in pain scores.
Collapse
|
8
|
Bernstein J, Spitzer Y, Ohaegbulam K, Reddy S, Song J, Romanelli E, Nair S. The analgesic efficacy of IV acetaminophen for acute postoperative pain in C-section patients: a randomized, double-blind, placebo-controlled study. J Matern Fetal Neonatal Med 2020; 35:933-940. [PMID: 32156175 DOI: 10.1080/14767058.2020.1735337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: The rate of cesarean delivery is on the rise in the USA. Satisfactory postoperative analgesia remains a top priority for cesarean delivery. Multimodal analgesia with a reduction in opioid consumption and improvement in patient satisfaction is a goal for anesthesiologists caring for this patient population. Our study sought to assess whether IV acetaminophen in four divided doses over 24 h decreased pain scores and opioid requirements in patients undergoing cesarean delivery with neuraxial anesthesia.Methods: 66 patients undergoing elective cesarean delivery under spinal anesthesia with hyperbaric bupivacaine 12 mg, fentanyl 10 µg, and preservative-free morphine 150 µg were randomized to receive either IV acetaminophen or IV placebo for four consecutive doses in the first 24 h postoperatively. The need for rescue medication using morphine equivalence, pain scores, patient satisfaction, and side effects were assessed by a blinded researcher in the first 24 and 48 h postoperatively.Results: There was no difference in opioid requirements in the acetaminophen versus placebo group, 44.32 ± 23 mg versus 47.59 ± 28 mg (p = .607), respectively at 24 h. There was also no difference at 48 h, 57.95 ± 20 mg versus 56.59 ± 22 mg (p = .795). Postoperative pain scores, patient satisfaction, and adverse events were similar in both groups as well.Conclusions: The results of this study failed to demonstrate any additional benefits of administering multiple doses of IV acetaminophen for treating postoperative pain in patients who have undergone CS surgery and receiving intra-thecal morphine as part of their anesthesia and analgesia.Trial Registry number: NCT02069184.
Collapse
Affiliation(s)
- Jeffrey Bernstein
- Department of Anesthesiology, Montefiore Hospital and Medical Center, New York, NY, USA
| | - Yelena Spitzer
- Department of Anesthesiology, Montefiore Hospital and Medical Center, New York, NY, USA
| | | | - Shamantha Reddy
- Department of Anesthesiology, Montefiore Hospital and Medical Center, New York, NY, USA
| | - Jing Song
- Department of Anesthesiology, Montefiore Hospital and Medical Center, New York, NY, USA
| | - Erik Romanelli
- Department of Anesthesiology, Montefiore Hospital and Medical Center, New York, NY, USA
| | - Singh Nair
- Department of Anesthesiology, Montefiore Hospital and Medical Center, New York, NY, USA
| |
Collapse
|
9
|
Yu S, Eftekhary N, Wiznia D, Schwarzkopf R, Long WJ, Bosco JA, Iorio R. Evolution of an Opioid Sparse Pain Management Program for Total Knee Arthroplasty With the Addition of Intravenous Acetaminophen. J Arthroplasty 2020; 35:89-94. [PMID: 31521446 DOI: 10.1016/j.arth.2019.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Perioperative pain management for patients undergoing total knee arthroplasty (TKA) improves patient outcomes and facilitates recovery. In this study, we compared the effects of preoperative oral acetaminophen vs intravenous (IV) acetaminophen administered once intraoperatively and once postoperatively. METHODS Two standardized, multimodal analgesia protocols were compared in patients undergoing primary, unilateral TKA. The oral acetaminophen cohort (OA) received doses of oral acetaminophen preoperatively and an as-needed basis postoperatively (n = 698). The IV acetaminophen cohort (IA) received 2 doses of IV acetaminophen, one intraoperative and one 6 hours postoperatively, with no oral acetaminophen given (n = 318). No other variables were significantly changed during the study period. RESULTS The IV acetaminophen group demonstrated less narcotic usage on postoperative day 0 (OA: 13.3 mme [morphine mg equivalents], IA: 6.2 mme, P < .001) and overall usage (OA: 66.1 mme, IA: 48.5 mme, P < .001). Pain scores were statistically and clinically significantly decreased in the immediate postoperative (the first 8 hours) for the IA group (OA: patient-reported pain scores of 4.0; IA: patient-reported pain scores of 2.0, P < .001). Both groups progressed and completed their physical therapy similarly for each postoperative day. Length of stay and percent discharge home were slightly improved in the IA group as well, however did not reach statistical difference. CONCLUSION An iterative approach to multimodal pain management after TKA led to improvements in narcotic usage, pain scores, and several quality measures. IV acetaminophen is an integral and effective part of our opioid-sparing multimodal pain regimen in TKA.
Collapse
Affiliation(s)
- Stephen Yu
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Nima Eftekhary
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Daniel Wiznia
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - William J Long
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Richard Iorio
- Department of Orthpaedic Surgery, Brigham Health, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
10
|
Padilla JA, Gabor JA, Schwarzkopf R, Davidovitch RI. A Novel Opioid-Sparing Pain Management Protocol Following Total Hip Arthroplasty: Effects on Opioid Consumption, Pain Severity, and Patient-Reported Outcomes. J Arthroplasty 2019; 34:2669-2675. [PMID: 31311667 DOI: 10.1016/j.arth.2019.06.038] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 06/04/2019] [Accepted: 06/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Opioid prescriptions and subsequent opioid-related deaths have increased substantially in the past several decades. Orthopedic surgery ranks among the highest of all specialties with respect to the amount of opioids prescribed. We present here the outcomes of our opioid-sparing pain management pilot protocol for total hip arthroplasty (THA). METHODS A retrospective study was conducted to assess outcomes before and after the implementation of an opioid-sparing pain management protocol for THA. Patients were divided into 2 cohorts for comparison: (1) traditional pain management protocol and (2) opioid-sparing pain management protocol. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, pain severity using a Visual Analog Scale, and inpatient morphine milligram equivalents (MMEs) per day were compared between the 2 cohorts. RESULTS No statistically significant difference was observed in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement between the 2 cohorts at any time point (P > .05). Although there was a significant decrease in pain scores over time (P < .01), there was no statistically significant difference in the rates of change between the 2 pain management protocols at any time point (P = .463). Inpatient opioid consumption was significantly lower for the opioid-sparing cohort in comparison to the traditional cohort (14.6 ± 16.7 vs 25.7 ± 18.8 MME/d, P < .001). Similarly, the opioid-sparing cohort received significantly less opioids than the traditional cohort during the post discharge period (13.9 ± 24.2 vs 80.1 ± 55.9 MME, P < .001). CONCLUSION The results of this study suggest that an opioid-sparing protocol reduces opioid consumption and provides equivalent pain management and patient-reported outcomes during the 90-day THA episode of care relative to a traditional opioid-based regimen. These findings may help decrease the risk of adverse events associated with postoperative opioid use and provide a means of decreasing the opioid footprint in clinical practice.
Collapse
Affiliation(s)
- Jorge A Padilla
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Jonathan A Gabor
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Roy I Davidovitch
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| |
Collapse
|
11
|
White PF. Cost-effective multimodal analgesia in the perioperative period: Use of intravenous vs. oral acetaminophen. J Clin Anesth 2019; 61:109625. [PMID: 31676119 DOI: 10.1016/j.jclinane.2019.109625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Paul F White
- Cedars-Sinai Medical Center, Los Angeles, CA, United States; White Mountain Institute, The Sea Ranch, CA, United States.
| |
Collapse
|
12
|
Zhao J, Davis SP. An integrative review of multimodal pain management on patient recovery after total hip and knee arthroplasty. Int J Nurs Stud 2019; 98:94-106. [DOI: 10.1016/j.ijnurstu.2019.06.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/21/2019] [Accepted: 06/21/2019] [Indexed: 01/25/2023]
|
13
|
Patterson DC, Cagle PJ, Poeran J, Zubizarreta N, Mazumdar M, Galatz LM, Anthony SG. Effectiveness of intravenous acetaminophen for postoperative pain management in shoulder arthroplasties: A population-based study. J Orthop Translat 2019; 18:119-127. [PMID: 31508315 PMCID: PMC6718947 DOI: 10.1016/j.jot.2018.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 10/29/2022] Open
Abstract
Background Intravenous acetaminophen (IV APAP) is an option in multimodal postoperative analgesia. Prior trials focus on hip and knee arthroplasties, whereas large-scale data on utilization and effectiveness in shoulder arthroplasties are lacking. Methods Data on 67,494 (452 hospitals) partial/total shoulder arthroplasties were extracted from the Premier claims database (2011-2016). Patients were categorized by receipt and dosage of IV APAP. Multilevel models measured associations between IV APAP and opioid utilization (in oral morphine equivalents), length/cost of stay and opioid-related complications. Effect estimates (adjusted % change) with 95% confidence intervals (CIs) are reported. Results IV APAP was used in 17.7% (n = 11,949) of patients with an increasing utilization trend. Most patients received only one dose on the day of surgery (69.5%; n = 8308). When adjusting for relevant covariates, IV APAP was not associated with meaningful effects on outcomes. Specifically, its use (versus no use) was not associated with decreased (but rather somewhat increased) opioid utilization: + 5.4% (CI 3.6-7.1%; P < 0.05). Conclusion In this first large-scale study that assesses IV APAP in shoulder arthroplasties, IV APAP use was not associated with decreased opioid utilization or the length/cost of stay. These results do not support routine use of IV APAP in this cohort, especially given its high cost. The translational potential for this article Multimodal pain control to assist in reducing the opioid pain medications are seen as a route to improved postoperative patient outcomes, better pain control and expedited hospital discharge. Acetaminophen plays a significant role in these protocols in many institutions, but it is not established if this expensive IV formulation is superior to the oral formulation. This study evaluates the use and effectiveness of IV acetaminophen following shoulder arthroplasty at a large number of institutions.
Collapse
Affiliation(s)
- Diana C Patterson
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Paul J Cagle
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Zubizarreta
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Shawn G Anthony
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| |
Collapse
|
14
|
Atkins JR, Titch JF, Norcross WP, Thompson JA, Muckler VC. Preemptive Oral Acetaminophen for Women Undergoing Total Laparoscopic Hysterectomy. Nurs Womens Health 2019; 23:105-113. [PMID: 30826322 DOI: 10.1016/j.nwh.2019.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/30/2018] [Accepted: 01/01/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To decrease hospital expenses by administering oral acetaminophen rather than intravenous (IV) acetaminophen to women who undergo laparoscopic hysterectomy. DESIGN A quality improvement project using a between-groups, pre-/postimplementation design for women undergoing total laparoscopic hysterectomy. Retrospective chart review was used to compare data of women who received intraoperative IV acetaminophen before implementation versus women who received oral acetaminophen after implementation. Pain scores and opioid consumption in morphine equivalents were recorded at four time points. SETTING/LOCAL PROBLEM A 369-bed hospital in the southeastern United States, where, in 2016, nearly $260,000 was spent on perioperative IV acetaminophen for all operating room cases. PARTICIPANTS Women between the ages of 18 and 55 years scheduled to have total laparoscopic hysterectomy were included. Excluded were women with a history of chronic pain, opioid use, or liver pathology; women with a contraindication to nonsteroidal anti-inflammatory drugs; and women whose procedures were converted from laparoscopic to open. INTERVENTION/MEASUREMENTS Women were instructed to take oral acetaminophen the day before surgery in divided doses, with 1 g every 6 hours, for a total dose of 3 g. On the day of surgery, women received the final 1-g dose of oral acetaminophen. RESULTS There were no significant differences between groups for pain scores or total opioids received before implementation (mean = 3.28, standard deviation = 2.05) compared with after implementation (mean = 3.65, standard deviation = 1.63; t [18] = -.043, p = .674). The preimplementation cost per individual was $30.03 for 1 g of IV acetaminophen, and the postimplementation cost was $0.36 for 2 500-mg oral acetaminophen tablets, a 98.8% relative cost decrease per woman. CONCLUSION Replacing IV acetaminophen with preemptive oral acetaminophen has the potential to save money without compromising care.
Collapse
|
15
|
Soffin EM, Gibbons MM, Ko CY, Kates SL, Wick EC, Cannesson M, Scott MJ, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 128:454-465. [DOI: 10.1213/ane.0000000000003663] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
16
|
Soffin EM, Wu CL. Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review. HSS J 2019; 15:57-65. [PMID: 30863234 PMCID: PMC6384219 DOI: 10.1007/s11420-018-9652-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Elective total joint arthroplasty may be a gateway to long-term opioid use. QUESTIONS/PURPOSE We sought to review the literature on multimodal and regional analgesia as a strategy to minimize perioperative opioid use and control pain in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS We conducted a narrative review to assess the state of the evidence informing opioid-sparing analgesics for THA and TKA. A PubMed search was conducted for English-language articles published before April 2018. We preferentially included well-designed randomized controlled trials, systematic reviews, and meta-analyses. Where the highest levels of evidence were not yet apparent, we evaluated retrospective and/or observational studies. RESULTS Multimodal analgesia emphasizing nonsteroidal anti-inflammatory agents and acetaminophen is associated with decreases in perioperative opioid use for THA and TKA. Regional analgesia, including peripheral nerve blocks and local infiltration analgesia, is also associated with decreased perioperative opioid use for THA and TKA. Emerging topics in post-arthroplasty analgesia include (1) the value of nonsteroidal anti-inflammatory drugs, (2) the use of peripheral nerve catheters and extended-release local anesthetics to prolong the duration of opioid-free analgesia, and (3) novel peripheral nerve blocks, exemplified by the IPACK (interspace between the popliteal artery and posterior capsule of the knee) block for TKA. CONCLUSIONS The use of multimodal analgesia with regional techniques may decrease perioperative opioid use for patients undergoing THA and TKA. These techniques should be part of a comprehensive perioperative plan to promote adequate analgesia while minimizing overall opioid exposure.
Collapse
Affiliation(s)
- Ellen M. Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD USA
| |
Collapse
|
17
|
Randomized Controlled Trial of Intravenous Acetaminophen Versus Intravenous Hydromorphone for the Treatment of Acute Pain in the Emergency Department. Ann Emerg Med 2019; 73:133-140. [DOI: 10.1016/j.annemergmed.2018.06.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 05/30/2018] [Accepted: 06/11/2018] [Indexed: 12/13/2022]
|
18
|
Guo H, Wang C, He Y. A meta-analysis evaluates the efficacy of intravenous acetaminophen for pain management in knee or hip arthroplasty. J Orthop Sci 2018; 23:793-800. [PMID: 29910098 DOI: 10.1016/j.jos.2018.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/28/2018] [Accepted: 04/22/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The objective of this study was to assess whether intravenous acetaminophen for patients undergoing knee or hip arthroplasty could reduce the opioid consumption and improve pain management. METHOD Eligible studies were searched from electronic databases including PubMed, Web of Science, Embase (Ovid interface) and Cochrane Library (Ovid interface). The quality assessments were performed according to the Cochrane systematic review method. The assessed outcomes were including opioid consumption, pain scores, length of hospital stays and total occurrence of adverse events. RESULTS Among 832 records identified, six randomized controlled trials (RCTs) and five non-RCTs were eligible for data extraction and meta-analysis. According to the outcomes, the patients receive intravenous acetaminophen had less total opioid consumption after knee or hip artroplasty (SMD = -0.66; 95%CI, -1.13 to -0.20), but they did not obtain statistical improvement of postoperative pain control at postoperative day 0 (POD0, SMD = -0,15; 95%CI, -0.36 to 0.07), POD1(SMD = 0,12; 95%CI, -0.13 to 0.36), POD2 (SMD = -0,29; 95%CI, -0.70 to 0.12) and POD3 (SMD = -0,04; 95%CI, -0.49 to 0.41). Meanwhile, there were similar outcomes about the length of hospital stays in patients whether or not receiving intravenous acetaminophen (SMD = -0,05; 95%CI, -0.26 to 0.15). And, the total adverse effects occurrence also didn't show any significant difference between the acetaminophen group and control group (OR = 0.87; 95%CI, 0.57 to 1.33). CONCLUSIONS Perioperative intravenous acetaminophen use in multimodal analgesia could significantly reduce of total opioid consumption, but it did not contribute to decrease the average pain scores and shorten the length of hospital stays in total hip or knee arthroplasty.
Collapse
Affiliation(s)
- Hongzhang Guo
- Department of Orthopaedics, Gansu Provincial Hospital of TCM, 418# GuaZhou Road, Qi Li He Zone, Lanzhou, 730050, People's Republic of China.
| | - Changde Wang
- Department of Orthopaedics, Gansu Provincial Hospital of TCM, 418# GuaZhou Road, Qi Li He Zone, Lanzhou, 730050, People's Republic of China.
| | - Yufang He
- The Third Hospital of Gansu Province, 736# Duan Jia Tan, Cheng Guan Zone, Lanzhou, 730030, People's Republic of China.
| |
Collapse
|
19
|
Bartlett EL, Zavlin D, Friedman JD, Abdollahi A, Rappaport NH. Enhanced Recovery After Surgery: The Plastic Surgery Paradigm Shift. Aesthet Surg J 2018; 38:676-685. [PMID: 29253084 DOI: 10.1093/asj/sjx217] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND With a focus on providing high quality care and reducing facility based expenses there has been an evolution in perioperative care by way of enhanced recovery after surgery (ERAS). ERAS allows for a multidisciplinary and multimodal approach to perioperative care which not only expedites recovery but maximizes patient outcomes. This paradigm shift has been generally accepted by most surgical specialties, including plastic surgery. OBJECTIVES The goal of this study was to evaluate the impact of ERAS on outcomes in cosmetic plastic surgery. METHODS A prospective study consisting of phone call questionnaires was designed where patients from two senior plastic surgeons (N.H.R. and J.D.F.) were followed. The treatment group (n = 10) followed an ERAS protocol while the control group (n = 12) followed the traditional recovery after surgery which included narcotic usage. Patients were contacted on postoperative days (POD) 0 through 7+ and surveyed about a number of outcomes measures. RESULTS The ERAS group demonstrated a significant reduction in postoperative pain on POD 0, 1, 2, and 3 (all P < 0.01). There was also statistically less nausea/vomiting, fatigue/drowsiness, constipation, and hindrance on ambulation compared to the control group (all P < 0.05). Significance was achieved for reduction in fatigue/drowsiness on POD 0 and 1 (P < 0.01), as well as ability to ambulate on POD 0 and 3 (P = 0.044). Lastly, opioid use (P < 0.001) and constipation (P = 0.003) were decreased. CONCLUSIONS ERAS protocols have demonstrated their importance within multiple surgical fields, including cosmetic plastic surgery. The utility lies in the ability to expedite patient's recovery while still providing quality care. This study showed a reduction in postoperative complaints by avoiding narcotics without an increase in complications. Our findings signify the importance of ERAS protocols within cosmetic plastic surgery. LEVEL OF EVIDENCE 4
Collapse
Affiliation(s)
- Erica L Bartlett
- Division of Plastic Surgery, Baylor College of Medicine, Houston, TX
| | - Dmitry Zavlin
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX
| | | | | | | |
Collapse
|
20
|
Randomized Prospective Trial Comparing the Use of Intravenous versus Oral Acetaminophen in Total Joint Arthroplasty. J Arthroplasty 2017; 32:1125-1127. [PMID: 27839957 DOI: 10.1016/j.arth.2016.10.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/20/2016] [Accepted: 10/13/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Multimodal pain management has had a significant effect on improving total joint arthroplasty recovery and patient satisfaction. There is literature supporting that intravenous (IV) acetaminophen reduces postoperative pain and narcotic use in the total joint population. However, there are no studies comparing the effectiveness of IV vs oral (PO) acetaminophen as part of a standard multimodal perioperative pain regimen. METHODS One hundred twenty patients undergoing hip and knee arthroplasty surgeries performed by one joint arthroplasty surgeon were prospectively randomized into 2 groups. Group 1 (63 patients) received IV and group 2 (57 patients) received PO acetaminophen in addition to a standard multimodal perioperative pain regimen. Each group received 1 gram of acetaminophen preoperatively and then every 6 hours for 24 hours. Total narcotic use and visual analog scale (VAS) scores were collected every 4 hours postoperatively. RESULTS The 24-hour average hydromorphone equivalents given were not different between groups (3.71 vs 3.48) at 24 hours (P = .76), or at any of the individual 4-hour intervals. The 24-hour average visual analog scale scores in group 1 (IV) was 3.00 and in group 2 (PO) was 3.40 (P = .06). None of the 4-hour intervals were significantly different except the first interval (0-4 hour postoperatively), which favored the IV group (P = .03). CONCLUSION The use of IV acetaminophen may have a role when given intraoperatively to reduce the immediate pain after surgery. Following that, it does not provide a significant benefit in reducing pain or narcotic use when compared with the much less expensive PO form.
Collapse
|
21
|
Medina-Vera AJ, Novoa LM. Reduced anaesthetic requirements and postoperative analgesics in patients undergoing laparoscopic cholecystectomy: premedication with intravenous paracetamol versus ketorolac, a double blind and randomised clinical trial. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:64-70. [PMID: 27370941 DOI: 10.1016/j.redar.2016.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 05/17/2016] [Accepted: 05/19/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To compare the effects of premedication with intravenous paracetamol versus ketorolac, in decreasing intraoperative anaesthetic and postoperative opioid analgesics requirements in patients undergoing laparoscopic cholecystectomy. METHOD An experimental, prospective, comparative, double blind, and randomised clinical trial was conducted to determine intraoperative opioid requirements, and pain and analgesic requirements in the postoperative period in 100 healthy patients undergoing laparoscopic cholecystectomy. They were randomised into 2 groups: Group 1: pre-medicated with paracetamol 1g, and Group 2: with ketorolac 30mg (both administered intravenously 30minutes prior to surgery). RESULTS There were no statistically significant differences between groups as regards intraoperative remifentanil use (Group 1: 0.0739±0.016μg/kg/min, Group 2: 0.0741±0.018μg/kg/min). The number of patients in Group 2 that had values of VAS>4 points (22.4%) was lower than in Group 1 (28.6%), but with no statistically significant difference. Of the patients who needed postoperative opioid rescue, most required a single rescue and application of analgesics during hospitalisation, that prevailed between 3 and 12hours, without any significant differences between groups. No adverse effects were observed in the study sample. CONCLUSION Paracetamol 1g IV given preoperatively decreased anaesthetic requirements and the need for postoperative analgesics similar to the preoperative administration of ketorolac 30mg IV.
Collapse
MESH Headings
- Acetaminophen/administration & dosage
- Acetaminophen/therapeutic use
- Adult
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Anesthetics, Inhalation/administration & dosage
- Anesthetics, Intravenous/administration & dosage
- Cholecystectomy, Laparoscopic
- Dose-Response Relationship, Drug
- Double-Blind Method
- Female
- Humans
- Infusions, Intravenous
- Intraoperative Complications/drug therapy
- Isoflurane/administration & dosage
- Ketorolac/administration & dosage
- Ketorolac/therapeutic use
- Male
- Middle Aged
- Morphine/administration & dosage
- Morphine/therapeutic use
- Pain, Postoperative/drug therapy
- Pain, Postoperative/prevention & control
- Piperidines/administration & dosage
- Postoperative Period
- Preanesthetic Medication
- Prospective Studies
- Remifentanil
Collapse
Affiliation(s)
- A J Medina-Vera
- Servicio de Anestesiología, Hospital General del Este Dr. Domingo Luciani, Caracas, Venezuela.
| | - L M Novoa
- Servicio de Anestesiología, Hospital General del Este Dr. Domingo Luciani, Caracas, Venezuela
| |
Collapse
|
22
|
Maiese BA, Pham AT, Shah MV, Eaddy MT, Lunacsek OE, Wan GJ. Hospitalization Costs for Patients Undergoing Orthopedic Surgery Treated With Intravenous Acetaminophen (IV-APAP) Plus Other IV Analgesics or IV Opioid Monotherapy for Postoperative Pain. Adv Ther 2017; 34:421-435. [PMID: 27943118 PMCID: PMC5331089 DOI: 10.1007/s12325-016-0449-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Indexed: 12/26/2022]
Abstract
INTRODUCTION To assess the impact on hospitalization costs of multimodal analgesia (MMA), including intravenous acetaminophen (IV-APAP), versus IV opioid monotherapy for postoperative pain management in patients undergoing orthopedic surgery. METHODS Utilizing the Truven Health MarketScan® Hospital Drug Database (HDD), patients undergoing total knee arthroplasty (TKA), total hip arthroplasty (THA), or surgical repair of hip fracture between 1/1/2011 and 8/31/2014 were separated into postoperative pain management groups: MMA with IV-APAP plus other IV analgesics (IV-APAP group) or an IV opioid monotherapy group. All patients could have received oral analgesics. Baseline characteristics and total hospitalization costs were compared. Additionally, an inverse probability treatment weighting [IPTW] with propensity scores analysis further assessed hospitalization cost differences. RESULTS The IV-APAP group (n = 33,954) and IV opioid monotherapy group (n = 110,300) differed significantly (P < 0.0001) across baseline characteristics, though the differences may not have been clinically meaningful. Total hospitalization costs (mean ± standard deviation) were significantly lower for the IV-APAP group than the IV opioid monotherapy group (US$12,540 ± $9564 vs. $13,242 ± $35,825; P < 0.0001). Medical costs accounted for $701 of the $702 between-group difference. Pharmacy costs were similar between groups. Results of the IPTW-adjusted analysis further supported the statistically significant cost difference. CONCLUSIONS Patients undergoing orthopedic surgery who received MMA for postoperative pain management, including IV-APAP, had significantly lower total costs than patients who received IV opioid monotherapy. This difference was driven by medical costs; importantly, there was no difference in pharmacy costs. Generalizability of the results may be limited to patients admitted to hospitals similar to those included in HDD. Dosing could not be determined, so it was not possible to quantify utilization of IV-APAP or ascertain differences in opioid consumption between the 2 groups. This study did not account for healthcare utilization post-discharge.
Collapse
Affiliation(s)
| | - An T Pham
- Health Economics and Outcomes Research Department, Mallinckrodt Pharmaceuticals, Hampton, NJ, USA.
| | - Manasee V Shah
- Xcenda LLC, Palm Harbor, FL, USA
- Mapi Group, Ann Arbor, MI, USA
| | | | | | - George J Wan
- Health Economics and Outcomes Research Department, Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
| |
Collapse
|
23
|
Nwagbologu N, Sarangarm P, D'Angio R. Effect of Intravenous Acetaminophen on Postoperative Opioid Consumption in Adult Orthopedic Surgery Patients. Hosp Pharm 2016; 51:730-737. [PMID: 27803502 DOI: 10.1310/hpj5109-730] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background: Postoperative pain is managed with opioids, which are associated with adverse effects. The efficacy of intravenous (IV) acetaminophen in reducing opioid consumption has been studied with inconsistent results. The primary outcome of this study was to assess the effect of IV acetaminophen on opioid consumption 24 hours postoperatively. Secondary outcomes included the opiate consumption at 48 hours after the operation, opioid-related side effects 72 hours after the operation, discharge disposition, and length of stay. Methods: This was an IRB-approved, retrospective cohort study including adult patients who underwent an elective total knee arthroplasty (TKA). Patients were stratified into IV and no IV acetaminophen groups; patients who had received at least one dose of IV acetaminophen were included in the IV acetaminophen group. Total opioids were collected, converted to morphine equivalents, and compared between groups. Patients were excluded for alcohol abuse, substance abuse treatment, non-elective TKA, or medication mischarting. Results: Of the 161 patients evaluated, 148 patients were included: 86 in the IV acetaminophen and 62 in the no IV acetaminophen group. There were no differences in mean morphine equivalents between groups postoperatively at 24 hours (54.2 ± 35.9 mg vs 45.4 ± 30.2 mg; p = .12) and 48 hours (99.2 ± 68.7 mg vs 79.5 ± 49.1 mg; p = .06). There were no differences in secondary outcomes (administration of bowel regimen medications, antiemetics, naloxone, discharge disposition, or length of stay) between the groups. Conclusion: The use of IV acetaminophen was not associated with a decrease in opiate use, opiate-related side effects, or any secondary outcomes in patients who underwent TKA.
Collapse
|
24
|
Mao Y, Wu L, Ding W. The efficacy of preoperative administration of gabapentin/pregabalin in improving pain after total hip arthroplasty: a meta-analysis. BMC Musculoskelet Disord 2016; 17:373. [PMID: 27577678 PMCID: PMC5004259 DOI: 10.1186/s12891-016-1231-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/23/2016] [Indexed: 11/17/2022] Open
Abstract
Background The purpose of this systematic review and meta-analysis of randomised controlled trials (RCTs) was to evaluate the pain control by gabapentin or pregabalin administration versus placebo after total hip arthroplasty (THA). Methods In January 2016, a systematic computer-based search was conducted in the Medline, Embase, PubMed, CENTRAL (Cochrane Controlled Trials Register), Web of Science and Google databases. This systematic review and meta-analysis were performed according to the PRISMA statement criteria. The primary endpoint was the cumulative morphine consumption and visual analogue scale (VAS) scores at 24 and 48 h with rest or mobilisation. The complications of vomiting, nausea, dizziness and pruritus were also compiled to assess the safety of gabapentin and pregabalin. Stata 12.0 software was used for the meta-analysis. After testing for publication bias and heterogeneity across studies, the data were aggregated for random-effects modelling when necessary. Results Seven studies involving 769 patients met the inclusion criteria. The meta-analysis revealed that treatment with gabapentin or pregabalin can decrease the cumulative morphine consumption at 24 h (mean difference (MD) = −7.82; 95 % CI −0.95 to −0.52; P < 0.001) and 48 h (MD = −6.90; 95 % CI −0.95 to −0.57; P = 0.118). Gabapentin or pregabalin produced no better outcome than placebo in terms of VAS score with rest at 24 h (SMD = 0.15; 95 % CI −0.17 to −0.48; P = 0.360) and with rest at 48 h (SMD = 0.22; 95 % CI −0.25 to 0.69; P = 0.363). There was no statistically significant difference between the groups with respect to the VAS score at 24 h postoperatively (SMD = 0.46; 95 % CI −0.19 to 1.11; P = 0.164) and at 48 h postoperatively (SMD = 1.15; 95 % CI −0.58 to 2.89; P = 0.193). Gabapentin decreased the occurrence of nausea (relative risk (RR), 0.49; 95 % CI 0.27–0.92, P = 0.025), but there was no significant difference in the incidence of vomiting, dizziness and pruritus. Conclusions On the basis of the current meta-analysis, gabapentin or pregabalin can decrease the cumulative morphine consumption and decrease the occurrence of nausea; however, further trials are needed to assess the efficacy of pain control by gabapentin or pregabalin. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1231-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Yingdelong Mao
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, 318 Chaowang Road, Hangzhou, Zhejiang, 310005, People's Republic of China
| | - Lianguo Wu
- Department of Orthopaedics, The Second Affiliated Hospital of Zhejiang Chinese Medical University, 318 Chaowang Road, Hangzhou, Zhejiang, 310005, People's Republic of China
| | - Weiguo Ding
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, Zhejiang, 310012, People's Republic of China.
| |
Collapse
|
25
|
McNicol ED, Ferguson MC, Haroutounian S, Carr DB, Schumann R. Single dose intravenous paracetamol or intravenous propacetamol for postoperative pain. Cochrane Database Syst Rev 2016; 2016:CD007126. [PMID: 27213715 PMCID: PMC6353081 DOI: 10.1002/14651858.cd007126.pub3] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 10, 2011. Paracetamol (acetaminophen) is the most commonly prescribed analgesic for the treatment of acute pain. It may be administered orally, rectally, or intravenously. The efficacy and safety of intravenous (IV) formulations of paracetamol, IV paracetamol, and IV propacetamol (a prodrug that is metabolized to paracetamol), compared with placebo and other analgesics, is unclear. OBJECTIVES To assess the efficacy and safety of IV formulations of paracetamol for the treatment of postoperative pain in both adults and children. SEARCH METHODS We ran the search for the previous review in May 2010. For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE (May 2010 to 16 February 2016), EMBASE (May 2010 to 16 February 2016), LILACS (2010 to 2016), a clinical trials registry, and reference lists of reviews for randomized controlled trials (RCTs) in any language and we retrieved articles. SELECTION CRITERIA Randomized, double-blind, placebo- or active-controlled single dose clinical trials of IV paracetamol or IV propacetamol for acute postoperative pain in adults or children. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, which included demographic variables, type of surgery, interventions, efficacy, and adverse events. We contacted study authors for additional information. We graded each included study for methodological quality by assessing risk of bias and employed the GRADE approach to assess the overall quality of the evidence. MAIN RESULTS We included 75 studies (36 from the original review and 39 from our updated review) enrolling a total of 7200 participants.Among primary outcomes, 36% of participants receiving IV paracetamol/propacetamol experienced at least 50% pain relief over four hours compared with 16% of those receiving placebo (number needed to treat to benefit (NNT) = 5; 95% confidence interval (CI) 3.7 to 5.6, high quality evidence). The proportion of participants in IV paracetamol/propacetamol groups experiencing at least 50% pain relief diminished over six hours, as reflected in a higher NNT of 6 (4.6 to 7.1, moderate quality evidence). Mean pain intensity at four hours was similar when comparing IV paracetamol and placebo, but was seven points lower on a 0 to 100 visual analog scale (0 = no pain, 100 = worst pain imaginable, 95% CI -9 to -6, low quality evidence) in those receiving paracetamol at six hours.For secondary outcomes, participants receiving IV paracetamol/propacetamol required 26% less opioid over four hours and 16% less over six hours (moderate quality evidence) than those receiving placebo. However, this did not translate to a clinically meaningful reduction in opioid-induced adverse events.Meta-analysis of efficacy comparisons between IV paracetamol/propacetamol and active comparators (e.g., opioids or nonsteroidal anti-inflammatory drugs) were either not statistically significant, not clinically significant, or both.Adverse events occurred at similar rates with IV paracetamol or IV propacetamol and placebo. However, pain on infusion occurred more frequently in those receiving IV propacetamol versus placebo (23% versus 1%). Meta-analysis did not demonstrate clinically meaningful differences between IV paracetamol/propacetamol and active comparators for any adverse event. AUTHORS' CONCLUSIONS Since the last version of this review, we have found 39 new studies providing additional information. Most included studies evaluated adults only. We reanalyzed the data but the results did not substantially alter any of our previously published conclusions. This review provides high quality evidence that a single dose of either IV paracetamol or IV propacetamol provides around four hours of effective analgesia for about 36% of patients with acute postoperative pain. Low to very low quality evidence demonstrates that both formulations are associated with few adverse events, although patients receiving IV propacetamol have a higher incidence of pain on infusion than both placebo and IV paracetamol.
Collapse
Affiliation(s)
- Ewan D McNicol
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonMassachusettsUSA
- Tufts Medical CenterDepartment of PharmacyBostonMassachusettsUSA
- Tufts University School of MedicinePain Research, Education and Policy (PREP) Program, Department of Public Health and Community MedicineBostonMassachusettsUSA
| | | | - Simon Haroutounian
- Department of Anesthesiology, Washington University School of MedicineDivision of Clinical and Translational Research and Washington University Pain Center660 S. Euclid AveCampus Box 8054St LouisMOUSA63110
| | - Daniel B Carr
- Tufts University School of MedicinePain Research, Education and Policy (PREP) Program, Department of Public Health and Community MedicineBostonMassachusettsUSA
- Tufts Medical CenterDepartment of AnesthesiologyBostonMassachusettsUSA
| | - Roman Schumann
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonMassachusettsUSA
| | | |
Collapse
|
26
|
Wladis EJ, Kattato DF, De A. Intravenous Acetaminophen in Orbital Surgery. Ophthalmic Plast Reconstr Surg 2016; 32:211-3. [DOI: 10.1097/iop.0000000000000470] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
27
|
Apfel C, Jahr JR, Kelly CL, Ang RY, Oderda GM. Effect of i.v. acetaminophen on total hip or knee replacement surgery: A case-matched evaluation of a national patient database. Am J Health Syst Pharm 2015; 72:1961-8. [DOI: 10.2146/ajhp140179] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Christian Apfel
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Jonathan R. Jahr
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles
| | | | | | - Gary M. Oderda
- Professor and Director, Pharmaceutical Outcomes Research Center, University of Utah College of Pharmacy, Salt Lake City
| |
Collapse
|