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Meier KM, Zheng A, Rollins ZH, Asantey KA, Shah MD, Banooni AB, Liss ZJ. Elimination of postoperative narcotics in infant robotic pyeloplasty using caudal anesthesia and a non-narcotic pain pathway. J Endourol 2022; 36:1431-1435. [PMID: 35850585 DOI: 10.1089/end.2022.0263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary for post-operative pain control in most infants undergoing robotic pyeloplasty. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of eliminating postoperative narcotics following infant robotic pyeloplasty. METHODS We reviewed 24 consecutive patients who underwent robotic pyeloplasty by a single surgeon treated with an end-procedure caudal block followed by a non-narcotic postoperative pain pathway treated between May 2017 and May 2021. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating intravenous acetaminophen and ketorolac. We reviewed demographics, outcomes and unscheduled healthcare encounters within 30 postoperative days. RESULTS 63% (15/24) patients were male and average age was 12.1 months (range 4-34 months). 58% (9/15) underwent surgery on the left. 16.7% (4/24) of patients received a single postoperative dose of narcotics in the PACU. No patient required narcotic prescriptions at discharge or anytime thereafter. The average length of stay was 1.13 days. There was no pain-related, unscheduled visits or phone calls after discharge. CONCLUSIONS This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. Post procedure caudal block is a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use.
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Affiliation(s)
- Kristen M Meier
- Beaumont Health System, 7005, Department of Urology, Royal Oak, Michigan, United States;
| | - Anna Zheng
- Michigan Institute of Urology, 20952 Twelve Mile Road, Suite #200, St. Clair Shores , Michigan, United States, 48081;
| | - Zach H Rollins
- Oakland University William Beaumont School of Medicine, 159878, Rochester, Michigan, United States;
| | - Kwesi A Asantey
- Oakland University William Beaumont School of Medicine, 159878, Rochester, Michigan, United States;
| | - Mit D Shah
- Beaumont Health System, 7005, Department of Urology, Royal Oak, Michigan, United States;
| | - Andrew B Banooni
- Beaumont Health System, 7005, Department of Anesthesia, Royal Oak, Michigan, United States;
| | - Zachary J Liss
- Beaumont Health System, 7005, Department of Urology, Royal Oak, Michigan, United States.,Oakland University William Beaumont School of Medicine, 159878, Rochester, Michigan, United States.,Michigan Institute of Urology, St. Clair Shores , United States;
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2
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Ludwig K, Wexelman B, Chen S, Cheng G, DeSnyder S, Golesorkhi N, Greenup R, James T, Lee B, Pockaj B, Vuong B, Fluharty S, Fuentes E, Rao R. Home Recovery After Mastectomy: Review of Literature and Strategies for Implementation American Society of Breast Surgeons Working Group. Ann Surg Oncol 2022; 29:5799-5808. [PMID: 35503389 DOI: 10.1245/s10434-022-11799-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/07/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Practices regarding recovery after mastectomy vary significantly, including overnight stay versus discharge same day. Expanded use of Enhanced Recovery After Surgery (ERAS) algorithms and the recent COVID pandemic have led to increased number of patients who undergo home recovery after mastectomy (HRAM). METHODS The Patient Safety Quality Committee of the American Society of Breast Surgeons created a multispecialty working group to review the literature evaluating HRAM after mastectomy with and without implant-based reconstruction. A literature review was performed regarding this topic; the group then developed guidance for patient selection and tools for implementation. RESULTS Multiple, retrospective series have reported that patients discharged day of mastectomy have similar risk of complications compared with those kept overnight, including risk of hematoma (0-5.1%). Multimodal strategies that improve nausea and analgesia improve likelihood of HRAM. Patients who undergo surgery in ambulatory surgery centers and by high-volume breast surgeons are more likely to be discharged day of surgery. When evaluating unplanned return to care, the only significant factors are African American race and increased comorbidities. CONCLUSIONS Review of current literature demonstrates that HRAM is a safe option in appropriate patients. Choice of method of recovery should consider patient factors, such as comorbidities and social situation, and requires input from the multidisciplinary team. Preoperative education regarding pain management, drain care, and after-hour access to medical care are crucial components to a successful program. Additional investigation is needed as these programs become more prevalent to assess quality measures such as unplanned return to care, complications, and patient satisfaction.
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Affiliation(s)
- Kandice Ludwig
- Indiana University School of Medicine, Indianapolis, IN, USA.
| | | | | | - Gloria Cheng
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Ted James
- Harvard Medical School, Boston, MA, USA
| | | | | | - Brooke Vuong
- Kaiser Permanente Medical Center, Sacramento, CA, USA
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3
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Use of Intravenous Paracetamol Preoperatively Favors Lower Risk of Delirium and Functional Recovery in Elderly Patients with Hip Fracture: A Propensity Score-Matched Analysis. Pain Res Manag 2022; 2022:1582727. [PMID: 35463628 PMCID: PMC9020999 DOI: 10.1155/2022/1582727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/12/2022] [Accepted: 03/18/2022] [Indexed: 11/17/2022]
Abstract
We aimed to investigate whether the use of intravenous paracetamol (IVP) preoperatively in intertrochanteric fracture (IF) patients aged 65 years or over receiving intramedullary fixation had significantly benefits on the pain score at discharge, delirium incidence, length of hospital stay (LOS), functional outcomes, and mortality. A retrospective analysis of all surgically treated patients presenting with IF was conducted at a single Level I trauma center in China between Jan. 2016 and Jan. 2020. The data concerning patients' demographics, injury-related data, surgery-related data, operation-related data, in-hospital data, and postoperative outcomes were extracted. To minimize potential confounding and selection bias, the propensity score matching (PSM) method was performed via the caliper matching method by using a 1 : 1 ratio. After PSM, McNemar's chi-square tests were used to examine the association of using IVP with outcome analyses. The Spearman correlations of IVP using, pain scores, and the factors which may influence them were also computed. After screening 2963 consecutive patients, 2166 were included finally, including 1576 in the non-IVP group and 590 in the IVP group. After PSM, 531 remained in each group. The pain scores at discharge were significantly between the two groups before and after matching (all p < 0.001). The differences of delirium rate and functional outcomes became significant after propensity score-based matching (p=0.001 and 0.033, respectively), although they were not significant before matching. No significant difference was observed in other operation-related data, LOS, and crude mortality rates at 30-day, 90-day, and 12-month before and after PSM. In conclusion, this study highlights the need for preoperative IVP use to optimize pain control, postoperative functional recovery, and minimize pain-related comorbidities such as delirium in elderly patients with hip fracture.
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4
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Son J, Tran T, Yao M, Michener CM. Factors Associated With Unplanned Admission in Patients Intended for Same Day Discharge After Minimally Invasive Hysterectomy for Endometrial Cancer. Surg Innov 2021; 29:336-342. [PMID: 34470516 DOI: 10.1177/15533506211041882] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives. To identify factors that lead to successful same-day discharge compared with unplanned and planned admission after minimally invasive hysterectomy for endometrial cancer. Methods. Patients undergoing laparoscopic or robotic hysterectomy for endometrial cancer between 2016 and 2019 were retrospectively reviewed. 3 groups were created: same-day discarge (SDD), unplanned admission (UA), and planned admission(PA). Demographic/perioperative factors and encounters after discharge were compared. A multivariable logistic regression was performed. Results. 262 patients were included. By year, the success of SDD increased from 59.1% to 82.5%. Patients who underwent SDD compared with admission were younger (62.2 vs 66.2, P = .003) and had a lower Charlson Comorbidity Index (4 vs 5, P < .001). BMI was not significant. Comparing SDD and UA, shorter operative time (100.3 min vs 130.6 min, P = .037) was associated with SDD. Postoperative pain scores were not significant (3.8 vs 4.7, P = .086). The rate of unscheduled encounters within 30 days of discharge was not significantly different. On multivariable analysis, the odds of SDD decreased by 4% with each 1-year increase in age (OR .96, P = .017). Each 1-minute increase in operative time decreased the odds of SDD by 2% (OR .98, P < .001). Intraoperative acetaminophen (OR 2.78, P = .003) and ketorolac (OR 2.27, P = .031) were predictive of SDD. Conclusion. SDD can be safely incorporated into clinical practice in gynecologic oncology patients undergoing minimally invasive hysterectomy, even for patients older than previously reported. Shorter operative time was associated with SDD. The role of perioperative acetaminophen and ketorolac should be further investigated.
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Affiliation(s)
- Ji Son
- Department of OBGYN, Women's Health Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Thang Tran
- 12304Case Western University School of Medicine, Cleveland, OH, USA
| | - Meng Yao
- Section of Biostatistics, Quantitative Health Sciences, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Chad M Michener
- Division of Gynecologic Oncology, Women's Health Institute, 2569Cleveland Clinic, Cleveland, OH, USA
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5
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Turan A, Sessler DI. Intravenous Acetaminophen in Postoperative Patients-Reply. JAMA 2020; 324:2327. [PMID: 33289821 DOI: 10.1001/jama.2020.21470] [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]
Affiliation(s)
- Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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6
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Brenin DR, Dietz JR, Baima J, Cheng G, Froman J, Laronga C, Ma A, Manahan MA, Mariano ER, Rojas K, Schroen AT, Tiouririne NAD, Wiechmann LS, Rao R. Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons. Ann Surg Oncol 2020; 27:4588-4602. [PMID: 32783121 DOI: 10.1245/s10434-020-08892-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.
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Affiliation(s)
- David R Brenin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Baima
- Department of Physical Medicine and Rehabilitation, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gloria Cheng
- Department of Anesthesia, University of Texas Southwestern, Dallas, TX, USA
| | - Joshua Froman
- Department of Surgery, Mayo Clinic, Owatonna, MN, USA
| | | | - Ayemoethu Ma
- Surgery and Integrative Medicine, Scripps Health, La Jolla, CA, USA
| | - Michele A Manahan
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward R Mariano
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Anneke T Schroen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Lisa S Wiechmann
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshni Rao
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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7
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Antill AC, Frye SW, McMillen JC, Haynes JC, Ford BR, Bollig RW, Daley BJ. Treatment With Oral Versus Intravenous Acetaminophen in Elderly Trauma Patients With Rib Fractures: A Prospective Randomized Trial. Am Surg 2020; 86:926-932. [PMID: 32749863 DOI: 10.1177/0003134820940268] [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: 11/17/2022]
Abstract
BACKGROUND Rib fractures are common injuries among traumatically injured patients, and elderly patients with rib fractures are at increased risk for adverse events and death. The purpose of this study was to determine if oral Per os (PO) acetaminophen is as effective as intravenous (IV) acetaminophen in treating the pain associated with rib fractures. METHODS We performed a single-center, randomized, placebo-controlled, double-blinded study. Trauma patients who were ≥65 years old and had ≥1 rib fracture were included in this study. Patients were randomized into IV acetaminophen and oral placebo (n = 63) or IV placebo and oral solution acetaminophen (n = 75) groups. The primary outcome was a mean reduction in pain score at 24 hours, and secondary outcomes included opioid use, intensive care unit (ICU) length of stay (LOS), hospital LOS, hospital mortality, the difference in incentive spirometry, and development of pneumonia. RESULTS Among the 138 patients included, there was no statistically significant difference between the 2 study groups in a mean reduction in pain score at 24 hours after injury (PO: 3.24, IV: 2.49; P = .230). Opioid pain medication use was equivalent between groups (P = .212), and there was no significant difference in hospital mortality rate between groups (P = .827). There was no statistically significant difference in ICU LOS, hospital LOS, or development of pneumonia. DISCUSSION In elderly trauma patients (age ≥65 years) with 1 or more rib fractures, PO acetaminophen is equivalent to IV acetaminophen for pain control, with no difference in morbidity or mortality. Oral acetaminophen should be preferentially used over IV acetaminophen when treating the elderly trauma patient with rib fractures.
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Affiliation(s)
- Andrew C Antill
- 21823 Department of Surgery, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Sarah W Frye
- Department of Pharmacy, Spartanburg Medical Center, SC, USA
| | - James C McMillen
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA
| | - James C Haynes
- Department of Surgery, WellStar North Fulton Hospital, Roswell, GA, USA
| | - Benjamin R Ford
- Department of Surgery, Roper Saint Francis Healthcare, Charleston, SC, USA
| | - Reagan W Bollig
- 21823 Department of Surgery, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Brian J Daley
- 21823 Department of Surgery, University of Tennessee Medical Center, Knoxville, TN, USA
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8
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Mallama M, Valencia A, Rijs K, Rietdijk WJR, Klimek M, Calvache JA. A systematic review and trial sequential analysis of intravenous vs. oral peri-operative paracetamol. Anaesthesia 2020; 76:270-276. [PMID: 32557588 PMCID: PMC7818191 DOI: 10.1111/anae.15163] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2020] [Indexed: 12/13/2022]
Abstract
Postoperative pain might be different after intravenous vs. oral paracetamol. We systematically reviewed randomised controlled trials in patients >15 years that compared intravenous with oral paracetamol for postoperative pain. We identified 14 trials with 1695 participants. There was inconclusive evidence for an effect of route of paracetamol administration on postoperative pain at 0–2 h (734 participants), 2–6 h (766 participants), 6–24 h (1115 participants) and >24 h (248 participants), with differences in standardised mean (95%CI) pain scores for intravenous vs. oral of −0.17 (−0.45 to 0.10), −0.09 (−0.24 to 0.06), 0.06 (−0.12 to 0.23) and 0.03 (−0.22 to 0.28), respectively. Trial sequential analyses suggested that a total of 3948 participants would be needed to demonstrate a meaningful difference in pain or its absence at 0–2 h. There were no differences in secondary outcomes. Intravenous paracetamol is more expensive than oral paracetamol. Substitution of oral paracetamol in half the patients given intravenous paracetamol in our hospital would save around £ 38,711 (€ 43,960 or US$ 47,498) per annum.
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Affiliation(s)
- M Mallama
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia
| | - A Valencia
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia
| | - K Rijs
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - W J R Rietdijk
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J A Calvache
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia.,Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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9
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Effect of scheduled intravenous acetaminophen on postoperative nausea and vomiting in patients undergoing laparoscopic gynecologic surgery. J Anesth 2020; 34:502-511. [PMID: 32303883 DOI: 10.1007/s00540-020-02777-9] [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: 01/16/2020] [Accepted: 04/04/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study was to assess the effect of scheduled intravenous acetaminophen (SIVA) on the incidence of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic gynecologic surgery (LGS). METHODS This retrospective observational study identified consecutive patients who underwent LGS at our institution from January to November of 2017 and were managed with either our hospital's old protocol (Group H) or a new protocol using SIVA (Group S). Primary outcomes included the incidences of PONV and the amount of additional antiemetic required in the postoperative period. The secondary outcomes included the pain score on postoperative day 1, the requirement for additional analgesic medications, and the length of hospitalization (LOH). RESULTS Patients in Group S had significantly lower incidences of PONV from postoperative days 0 to 1 and required significantly less antiemetics or tramadol than those in Group H (P = 0.0085). Patients at a low risk for PONV in Group S had significantly lower incidences of PONV than those in Group H (P = 0.0129). Further, the amount of additional tramadol required was lower in Group S than in Group H (P = 0.0021). CONCLUSION Introduction of SIVA into the postoperative pain management protocol of LGS may reduce the incidence of PONV and the amount of adjunctive antiemetic medication required from postoperative days 0 to 1. In patients undergoing LGS, PONV prophylaxis using antiemetics should be prescribed depending on PONV risk profile; however, SIVA prophylaxis can be used in all patients regardless of PONV risk profile.
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10
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Abstract
INTRODUCTION Postoperative delirium is associated with opioid use in the elderly and is a common complication of geriatric hip fractures, with reported incidences from 16% to 70%. Intravenous (IV) acetaminophen is a safe and efficacious medication in elderly patients and has been shown to reduce use of opioids after hip fracture. At our institution, IV acetaminophen was implemented for the first 24 hours postoperatively as part of a multimodal pain control regimen for geriatric hip fracture patients. METHODS A retrospective review of 123 hip fragility fracture patients older than 60 years from January 2016 to December 2016 was performed. Delirium was identified using a validated chart-based review tool. The rate of delirium, as well as length of stay, pain scores, opioid administration, need for one-to-one supervision, and readmissions were analyzed. RESULTS Sixty-five patients (52.8%) received IV acetaminophen during this period. No notable differences were found in baseline characteristics between groups. Ten of 65 patients receiving IV acetaminophen postoperatively experienced delirium compared with 19 of 58 who did not receive the medication (15.4% versus 32.8%, P = 0.024). The IV acetaminophen group also required fewer doses of IV opioids on postoperative day 1 (0.37 versus 1.19 doses, P = 0.008), were less likely to require one-to-one supervision (9.2% versus 24.1%, P = 0.025), and had shorter lengths of hospital stay (6.37 versus 8.47 days, P = 0.037). Readmission rates and discharge dispositions did not vary with significance between the two groups. CONCLUSION The inclusion of IV acetaminophen as part of a multimodal pain regimen led to fewer episodes of delirium in this study. The reduced use of opioids immediately after surgery may have been a large factor in this outcome. Lower delirium rates may reduce the utilization of inpatient resources for direct patient supervision and provide for shorter hospital stays.
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11
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George NE, Gurk-Turner C, Mohamed NS, Wilkie WA, Remily EA, Dávila Castrodad IM, Roadcloud E, Delanois R. Diclofenac Versus Ketorolac for Pain Control After Primary Total Joint Arthroplasty: A Comparative Analysis. Cureus 2020; 12:e7310. [PMID: 32313751 PMCID: PMC7164553 DOI: 10.7759/cureus.7310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/17/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction As total hip arthroplasty (THA) and total knee arthroplasty (TKA) transition to outpatient settings, appropriate pain management remains a challenge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may subvert the need for postoperative opioids. This study evaluated: 1) total opioid consumption; 2) postoperative pain intensity; 3) discharge destination; 4) length of stay (LOS); and 5) THA and TKA patients' satisfaction in receiving adjunctive intravenous (IV) diclofenac or ketorolac. Methods In this retrospective cohort study, patients scheduled to undergo primary THA or TKA by a single surgeon between March 2017 and April 2018 were identified. Patients were stratified based on the receipt of IV diclofenac (THA: n = 25; TKA: n = 51) or IV ketorolac (THA: n = 28; TKA: n = 32) in addition to the standard pain management regimen. Student's t-testing and Chi-square were used to analyze continuous and categorical variables, respectively. Results TKA diclofenac patients had lower opioid consumption 12 hours postoperatively (p: 0.037). TKA patients in the diclofenac cohort were discharged to home less often (p: 0.025). Both diclofenac cohorts had greater patient satisfaction than the ketorolac cohorts (p: <0.05). There was no significant difference between groups in postoperative pain intensity at 24 or 48 hours or in the length of stay (p: >0.05 for all). Conclusion This study demonstrated that both TKA and THA patients treated with IV diclofenac had no difference in postoperative pain intensity while THA patients had no difference in opioid consumption relative to those treated with IV ketorolac. Further comparison of IV NSAIDs with other IV pain medications may provide broader insight into the ideal management for postoperative pain for this widening patient population.
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Affiliation(s)
| | - Cheryle Gurk-Turner
- Pain Management, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
| | - Nequesha S Mohamed
- Orthopedics, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
| | - Wayne A Wilkie
- Orthopedics, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
| | - Ethan A Remily
- Orthopedics, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
| | - Iciar M Dávila Castrodad
- Orthopedic Surgery, Hackensack Meridian School of Medicine at Seton Hall University, Nutley, USA
| | - Elana Roadcloud
- Orthopedics, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
| | - Ronald Delanois
- Orthopedics, Lifebridge Health-Rubin Institute for Advanced Orthopedics, Baltimore, USA
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12
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Purnomo E, Nugrahaningsih DAA, Agustriani N, Gunadi. Comparison of metamizole and paracetamol effects on colonic anastomosis and fibroblast activities in Wistar rats. BMC Pharmacol Toxicol 2020; 21:6. [PMID: 31931882 PMCID: PMC6958591 DOI: 10.1186/s40360-020-0383-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/31/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Leakage following colorectal anastomosis surgery causes various complications associated with high morbidity and mortality, especially in pediatric patients. It might be caused by the use of non-steroidal anti-inflammatory drugs (NSAIDs) as postoperative analgesics. This study aimed to compare the effect of metamizole and paracetamol on colonic anastomosis and fibroblast activities, including proliferation, migration, and collagen synthesis, in Wistar rats. METHODS Rats were divided into control, paracetamol and metamizole groups. The colonic anastomosis was evaluated by determining the integrity of the muscle layers, the formation of granulation tissue, and mucosal anastomosis. Fibroblast activities were analyzed by measuring the proliferation, migration, and collagen synthesis. RESULTS Metamizole caused more damage to muscle layer integrity, more inhibition of granulation tissue formation in the anastomosis area and lower mucosal anastomosis compared with paracetamol and control groups. Metamizole had a higher cytotoxic effect than paracetamol, which suppressed the proliferation and migration of fibroblasts. Furthermore, both drugs did not affect the synthesis of collagen. CONCLUSION Metamizole shows worse effects on the integrity of muscle layers, inhibition of granulation tissue formation, mucosal anastomosis, fibroblast proliferation, and migration, but not collagen synthesis, than paracetamol in Wistar rat intestines following colonic anastomosis. These findings might indicate that paracetamol is safer than metamizole as analgesic following colonic anastomosis.
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Affiliation(s)
- Eko Purnomo
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/UGM Academic Hospital, Yogyakarta, 55291, Indonesia
| | - Dwi Aris Agung Nugrahaningsih
- Department of Pharmacology and Therapy, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia.
| | - Nunik Agustriani
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
| | - Gunadi
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
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13
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Intravenous Acetaminophen Reduces Length of Stay Via Mediation of Postoperative Opioid Consumption After Posterior Spinal Fusion in a Pediatric Cohort. Clin J Pain 2019; 34:593-599. [PMID: 29200016 DOI: 10.1097/ajp.0000000000000576] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Since approval of intravenous acetaminophen (IV APAP), its use has become quite common without strong positive evidence. Our goal was to determine the effect of IV APAP on length of hospital stay (LOS) via mediation of opioid-related side effects in pediatric patients. MATERIALS AND METHODS After Institutional Review Board approval, 114 adolescents undergoing posterior spinal fusion were prospectively recruited and managed postoperatively with patient-controlled analgesia and adjuvant therapy. Patients were divided into 2 groups based on the use of IV APAP: control (n=70) and treatment (n=44). Association of IV APAP use with opioid outcomes was analyzed using inverse probability of treatment weighting (IPTW)-adjusted propensity scores to balance the 2 groups for all significant covariates except postoperative opioid consumption. Mediation analysis was carried out for LOS with IV APAP as the independent variable and morphine consumption as the mediator. RESULTS Oral intake was delayed by ∼1 day (P<0.001) and LOS was 0.6 days longer in the control group (P=0.044). After IPTW, time to oral intake remained significantly longer in the control group (P=0.014). The mediation model with IPTW revealed a significant negative association between IV APAP and morphine consumption (P<0.001), which significantly increased LOS (P<0.003). IV APAP had a significant opioid-sparing effect associated with shorter LOS. DISCUSSION IV APAP hastens oral intake and is associated with decreased LOS in an adolescent surgery population likely through decreased opioid consumption. Through addition of IV APAP in this population, LOS may be decreased, an important implication in the setting of escalating health care costs.
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Moulder JK, Boone JD, Buehler JM, Louie M. Opioid Use in the Postoperative Arena: Global Reduction in Opioids After Surgery Through Enhanced Recovery and Gynecologic Surgery. Clin Obstet Gynecol 2019; 62:67-86. [PMID: 30407228 DOI: 10.1097/grf.0000000000000410] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Enhanced recovery programs aim to reduce surgical stress to improve the patient perioperative experience. Through a combination of multimodal analgesia and maintaining a physiological state, postoperative recovery is improved. Many analgesic adjuncts are available that improve postoperative pain control and limit opioid analgesia requirements. Adjuncts are often used in combination, but different interventions may be incorporated for patient-specific and procedure-specific needs. Postoperative pain control can be optimized by continuing nonopioid adjuncts, and prescribing opioid analgesia to address breakthrough pain. Prescribing practices should balance optimizing pain relief, minimizing the risk of chronic pain, while limiting the potential for opioid misuse.
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Affiliation(s)
| | | | - Jason M Buehler
- Anesthesiology, University of Tennessee Medical Center Knoxville, Graduate School of Medicine, Knoxville, Tennessee
| | - Michelle Louie
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
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Dixon J, Ashton F, Baker P, Charlton K, Bates C, Eardley W. Assessment and Early Management of Pain in Hip Fractures: The Impact of Paracetamol. Geriatr Orthop Surg Rehabil 2018; 9:2151459318806443. [PMID: 30377550 PMCID: PMC6202735 DOI: 10.1177/2151459318806443] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/06/2018] [Accepted: 09/19/2018] [Indexed: 11/15/2022] Open
Abstract
Introduction As the number of patients sustaining hip fractures increases, interventions aimed at improving patient comfort and reducing complication burden acquire increased importance. Frailty, cognitive impairment, and difficulty in assessing pain control characterize this population. In order to inform future care, a review of pain assessment and the use of preoperative intravenous paracetamol (IVP) is presented. Materials and Methods Systematic review of preoperative IVP administration in patients presenting with a hip fracture. Results Intravenous paracetamol is effective in the early management of pain control in the hip fracture population. There is a considerable decrease in use of breakthrough pain medications when compared with other pain relief modalities. Additionally, IVP reduces the incidence of opioid-induced complications, reduces length of stay, and lowers mean pain scores. Another significant finding of this study is the poor administration of all analgesics to patients with hip fracture with up to 72% receiving no prehospital analgesia. Discussion The potential benefits of IVP as routine in the early management of hip fracture-related pain are clear. Studies of direct comparison between analgesia regimes to inform optimum bundles of analgesic care are sparse. This study highlights the need for properly constructed pathway-driven comparator studies of contemporary analgesia regimes, with IVP as a central feature to optimize pain control and minimize analgesia-related morbidity in this vulnerable population.
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Affiliation(s)
- Ján Dixon
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Fiona Ashton
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Paul Baker
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Karl Charlton
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - Charlotte Bates
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
| | - William Eardley
- Department of Trauma & Orthopaedics, James Cook University Hospital, Middlesbrough, England
- William Eardley, Department of Trauma & Orthopaedics, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, England, United Kingdom.
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Hansen RN, Pham AT, Boing EA, Lovelace B, Wan GJ, Urman RD. Reduced length of stay and hospitalization costs among inpatient hysterectomy patients with postoperative pain management including IV versus oral acetaminophen. PLoS One 2018; 13:e0203746. [PMID: 30212524 PMCID: PMC6136753 DOI: 10.1371/journal.pone.0203746] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 08/27/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To compare the outcomes of hysterectomy patients who received standard pain management including IV acetaminophen (IV APAP) versus oral APAP. METHODS We performed a retrospective analysis of the Premier Database (January 2012 to September 2015) comparing hysterectomy patients who received postoperative pain management including IV APAP to those who received oral APAP starting on the day of surgery and continuing up to the third post-operative day, with no exclusions based on additional pain management. We compared the groups on length of stay (LOS), hospitalization costs, and average daily morphine equivalent dose (MED). The quarterly rate of IV APAP use for all hospitalizations by hospital was used as an instrumental variable in two-stage least squares regressions also adjusting for patient demographics, clinical risk factors, and hospital characteristics. RESULTS We identified 22,828 hysterectomy patients including 14,811 (65%) who had received IV APAP. Study subjects averaged 50 and 52 years of age, respectively in the IV APAP and oral APAP cohorts and were predominantly non-Hispanic Caucasians (≥60% in both cohorts). Instrumental variable models found IV APAP associated with 0.8 days shorter hospitalization (95% CI: -0.92 to -0.68, p<0.0001) and $2,449 lower hospitalization costs (95% CI: -$2,902 to -$1,996, p<0.0001). Average daily MED trended lower without statistical significance (-1.41 mg, 95% CI: -3.43 mg to 0.61 mg, p = 0.17). CONCLUSIONS Compared to oral APAP, managing post-hysterectomy pain with IV APAP is associated with shorter LOS and lower total hospitalization costs.
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Affiliation(s)
- Ryan N. Hansen
- University of Washington, School of Pharmacy, Seattle, Washington, United States of America
- * E-mail:
| | - An T. Pham
- Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department, Hampton, New Jersey, United States of America
- University of California San Francisco, School of Pharmacy, San Francisco, California, United States of America
| | - Elaine A. Boing
- Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department, Hampton, New Jersey, United States of America
| | - Belinda Lovelace
- Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department, Hampton, New Jersey, United States of America
| | - George J. Wan
- Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department, Hampton, New Jersey, United States of America
| | - Richard D. Urman
- Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Plunkett A, Haley C, McCoart A, Beltran T, Highland KB, Berry-Caban C, Lamberth S, Bartoszek M. A Preliminary Examination of the Comparative Efficacy of Intravenous vs Oral Acetaminophen in the Treatment of Perioperative Pain. PAIN MEDICINE 2018; 18:2466-2473. [PMID: 28034981 DOI: 10.1093/pm/pnw273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective The management of postoperative pain is a major health care issue. While the cost of intravenous acetaminophen (IVA) is significantly greater than its oral acetaminophen (OA) counterpart, less is known regarding comparative effectiveness of these routes. The purpose of this study was to determine whether perioperative IVA is equivalent in reducing postoperative pain compared with perioperative OA for laparoscopic cholecystectomy (LapChole). Design Double-blinded, prospective, randomized placebo-controlled trial. Setting Womack Army Medical Center, Fort Bragg, North Carolina. Subjects Adults (age > 18 years) active duty military, veterans, and beneficiaries receiving a laparoscopic cholecystectomy. Methods This study was conducted at Womack Army Medical Center (WAMC), Fort Bragg, North Carolina, between January 2013 and June 2015. Sixty-seven subjects with symptomatic cholelithiasis were randomly assigned to receive two doses (1,000 mg each) of either IVA or OA. A numerical rating scale (NRS) score of pain was obtained preoperatively and every six hours for 24 hours postoperation. The primary objective was to assess whether treatment groups had significantly different 24-hour postoperative sum of pain intensity differences (SPID24) using an analysis of covariance test. Results Sixty subjects completed the study and were included in the analysis. Treatment groups did not differ in SPID24, even when controlling for age, gender, and preoperative pain levels (F(1,55) = 0.39, P = 0.54, partial η2 = 0.007), nor did 24-hour opioid consumption when controlling for age, gender, and operation time (F(1, 46) = 0.47, P = 0.50, partial η2 = 0.01). Furthermore, treatment groups were equally as likely to report average postoperative NRS scores of 4 or higher (β = 0.24, Exp(B) = 1.28, P = 0.68). Conclusions The results show no evidence of differences between IVA or OA in pain or opioid consumption among a sample of patients undergoing LapChole. Due to low sample size, these descriptive findings warrant larger studies, which may have a significant economic impact.
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Affiliation(s)
| | - Chelsey Haley
- Defense and Veterans Center for Integrative Pain Management, Henry M. Jackson Foundation, Womack Army Medical Center, Fort Bragg, North Carolina
| | - Amy McCoart
- Defense and Veterans Center for Integrative Pain Management, Henry M. Jackson Foundation, Womack Army Medical Center, Fort Bragg, North Carolina
| | | | - Krista Beth Highland
- Defense and Veterans Center for Integrative Pain Management, Henry M. Jackson Foundation, Uniformed Services University of the Health Sciences, Rockville, Maryland, USA
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Perioperative Management of Patients with Addiction to Opioid and Non-opioid Medications. Curr Pain Headache Rep 2018; 22:52. [PMID: 29904819 DOI: 10.1007/s11916-018-0704-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW With the rise of the opioid epidemic, anesthesiologists will find themselves faced with opioid-addicted patients more frequently. Addiction to opioids may also occur concurrently with abuse of other non-opioid medications. Our review article seeks to outline an armamentarium of pain management strategies in the perioperative period for these patients with addiction to opioid and non-opioid medications. RECENT FINDINGS Statistics from the CDC demonstrate a shocking increase in opioid prescription rates and opioid-related deaths. Furthermore, opioid-addicted patients have notoriously undertreated pain in the perioperative period. A multitude of strategies are available in the perioperative period to treat pain in these patients. Formulating treatment plans for opioid and non-opioid-addicted patients undergoing surgery should include considerations in the pre-, intra-, and post-operative period. Our review article outlines several non-opioid modalities which may be employed to treat pain in these patients; however, particularly in the opioid-addicted population, the practitioner must be aware that non-opioids alone may not suffice to treat post-surgical pain. Consultation with pain management may be warranted to optimize opioid and non-opioid treatment for these patients.
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Raffa RB, Pawasauskas J, Pergolizzi JV, Lu L, Chen Y, Wu S, Jarrett B, Fain R, Hill L, Devarakonda K. Pharmacokinetics of Oral and Intravenous Paracetamol (Acetaminophen) When Co-Administered with Intravenous Morphine in Healthy Adult Subjects. Clin Drug Investig 2018; 38:259-268. [PMID: 29214506 PMCID: PMC5834589 DOI: 10.1007/s40261-017-0610-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Several features favor paracetamol (acetaminophen) administration by the intravenous rather than the oral route in the postoperative setting. This study compared the pharmacokinetics and bioavailability of oral and intravenous paracetamol when given with or without an opioid, morphine. METHODS In this randomized, single-blind, parallel, repeat-dose study in healthy adults, subjects received four repeat doses of oral or intravenous 1000 mg paracetamol at 6-h intervals, and morphine infusions (0.125 mg/kg) at the 2nd and 3rd intervals. Comparisons of plasma pharmacokinetic profiles were conducted before, during, and after opioid co-administrations. RESULTS Twenty-two subjects were included in the pharmacokinetic analysis. Observed paracetamol peak concentration (C max) and area under the plasma concentration-time curve over the dosing interval (AUC0-6) were reduced when oral paracetamol was co-administered with morphine (reduced from 11.6 to 7.25 µg/mL and from 31.00 to 25.51 µg·h/mL, respectively), followed by an abruptly increased C max and AUC0-6 upon discontinuation of morphine (to 13.5 µg/mL and 52.38 µg·h/mL, respectively). There was also a significantly prolonged mean time to peak plasma concentration (T max) after the 4th dose of oral paracetamol (2.84 h) compared to the 1st dose (1.48 h). However, pharmacokinetic parameters of paracetamol were not impacted when intravenous paracetamol was co-administered with morphine. CONCLUSIONS Morphine co-administration significantly impacted the pharmacokinetics of oral but not intravenous paracetamol. The abrupt release of accumulated paracetamol at the end of morphine-mediated gastrointestinal inhibition following oral but not intravenous administration of paracetamol suggests that intravenous paracetamol provides a better option for the management of postoperative pain. CLINICALTRIALS. GOV IDENTIFIER NCT02848729.
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Affiliation(s)
- Robert B Raffa
- University of Arizona College of Pharmacy, Tucson, AZ, 85718, USA
| | - Jayne Pawasauskas
- The University of Rhode Island College of Pharmacy, Kingston, RI, 02881, USA
| | | | - Luke Lu
- Mallinckrodt Pharmaceuticals, Perryville III Corporate Park, 53 Frontage Road Third Floor, P.O. Box 9001, Hampton, NJ, 08827-9001, USA
| | - Yin Chen
- Mallinckrodt Pharmaceuticals, Hazelwood, MO, 63042, USA
| | - Sutan Wu
- Mallinckrodt Pharmaceuticals, Hazelwood, MO, 63042, USA
| | - Brant Jarrett
- Mallinckrodt Pharmaceuticals, Perryville III Corporate Park, 53 Frontage Road Third Floor, P.O. Box 9001, Hampton, NJ, 08827-9001, USA
| | - Randi Fain
- Mallinckrodt Pharmaceuticals, Perryville III Corporate Park, 53 Frontage Road Third Floor, P.O. Box 9001, Hampton, NJ, 08827-9001, USA
| | - Lawrence Hill
- Mallinckrodt Pharmaceuticals, Perryville III Corporate Park, 53 Frontage Road Third Floor, P.O. Box 9001, Hampton, NJ, 08827-9001, USA
| | - Krishna Devarakonda
- Mallinckrodt Pharmaceuticals, Perryville III Corporate Park, 53 Frontage Road Third Floor, P.O. Box 9001, Hampton, NJ, 08827-9001, USA.
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Chidambaran V, Subramanyam R, Ding L, Sadhasivam S, Geisler K, Stubbeman B, Sturm P, Jain V, Eckman MH. Cost-effectiveness of intravenous acetaminophen and ketorolac in adolescents undergoing idiopathic scoliosis surgery. Paediatr Anaesth 2018; 28:237-248. [PMID: 29377376 PMCID: PMC6004284 DOI: 10.1111/pan.13329] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Enhanced recovery after surgery protocols increasingly use multimodal analgesia after major surgeries with intravenous acetaminophen and ketorolac, despite no documented cost-effectiveness of these strategies. AIMS The goal of this prospective cohort study was to model cost-effectiveness of adding acetaminophen or acetaminophen + ketorolac to opioids for postoperative outcomes in children having scoliosis surgery. METHODS Of 106 postsurgical children, 36 received only opioids, 26 received intravenous acetaminophen, and 44 received acetaminophen + ketorolac as analgesia adjuncts. Costs were calculated in 2015 US $. Decision analytic model was constructed with Decision Maker® software. Base-case and sensitivity analyses were performed with effectiveness defined as avoidance of opioid adverse effects. RESULTS The groups were comparable demographically. Compared with opioids-only strategy, subjects in the intravenous acetaminophen + ketorolac strategy consumed less opioids (P = .002; difference in mean morphine consumption on postoperative days 1 and 2 was -0.44 mg/kg (95% CI -0.72 to -0.16); tolerated meals earlier (P < .001; RR 0.250 (0.112-0.556)) and had less constipation (P < .001; RR 0.226 (0.094-0.546)). Base-case analysis showed that of the 3 strategies, use of opioids alone is both most costly and least effective, opioids + intravenous acetaminophen is intermediate in both cost and effectiveness; and opioids + intravenous acetaminophen and ketorolac is the least expensive and most effective strategy. The addition of intravenous acetaminophen with or without ketorolac to an opioid-only strategy saves $510-$947 per patient undergoing spine surgery and decreases opioid side effects. CONCLUSION Intravenous acetaminophen with or without ketorolac reduced opioid consumption, opioid-related adverse effects, length of stay, and thereby cost of care following idiopathic scoliosis in adolescents compared with opioids-alone postoperative analgesia strategy.
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Rajeev Subramanyam
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Lili Ding
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kristie Geisler
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Bobbie Stubbeman
- Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Sturm
- Division of Orthopedic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Viral Jain
- Division of Orthopedic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Mark H. Eckman
- Department of Internal Medicine, Division of General Internal Medicine, and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, USA
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Procter NJ, Lamacraft G, Joubert G. Intravenous paracetamol — waste not, want not: a retrospective audit on the appropriate use of intravenous paracetamol at Universitas Academic Hospital Complex—Bloemfontein. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1426208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- NJ Procter
- Department of Anaesthesiology, University of the Free State, Bloemfontein, South Africa
| | - G Lamacraft
- Department of Anaesthesiology, University of the Free State, Bloemfontein, South Africa
| | - G Joubert
- Department of Biostatistics, University of the Free State, Bloemfontein, South Africa
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Decreased opioid consumption and enhance recovery with the addition of IV Acetaminophen in colorectal patients: a prospective, multi-institutional, randomized, double-blinded, placebo-controlled study (DOCIVA study). Surg Endosc 2018; 32:3432-3438. [DOI: 10.1007/s00464-018-6062-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/11/2018] [Indexed: 10/18/2022]
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Bauchat JR, Milad MP, Kolb S, Hilao J, McCarthy RJ. Effects of Preoperatively Administered Oral Gabapentin and Acetaminophen on Opioid Consumption When Added to an Analgesic Regimen Containing Dexamethasone for Abdominal and Vaginal Hysterectomies. J Gynecol Surg 2017. [DOI: 10.1089/gyn.2017.0052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jeanette R. Bauchat
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Magdy P. Milad
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Stephen Kolb
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jay Hilao
- Department of Pharmacy, Northwestern Medicine, Chicago, IL
| | - Robert J. McCarthy
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Langford RA, Hogg M, Bjorksten AR, Williams DL, Leslie K, Jamsen K, Kirkpatrick C. Comparative Plasma and Cerebrospinal Fluid Pharmacokinetics of Paracetamol After Intravenous and Oral Administration. Anesth Analg 2017; 123:610-5. [PMID: 27537754 DOI: 10.1213/ane.0000000000001463] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We compared plasma and cerebrospinal fluid (CSF) pharmacokinetics of paracetamol after intravenous (IV) and oral administration to determine dosing regimens that optimize CSF concentrations. METHODS Twenty-one adult patients were assigned randomly to 1 g IV, 1 g oral or 1.5 g oral paracetamol. An IV cannula and lumbar intrathecal catheter were used to sample venous blood and CSF, respectively, over 6 hours. The plasma and CSF maximum concentrations (Cmax), times to maximum concentrations (Tmax), and area under the plasma and CSF concentration-time curves (AUCs) were calculated using noncompartmental techniques. Significance was defined by P < .0167 (Bonferroni correction for 3 comparisons for each parameter). Probability (X < Y) (p″) with Bonferroni corrected 95% confidence intervals (CIs) were calculated (CIs including 0.5 meet the null hypothesis). Results are presented as median (range) or p″ (CI). P values are listed as 1 g IV vs 1 g orally, 1 g IV vs 1.5 g orally and 1 g orally vs 1.5 g orally, respectively. RESULTS Wide variation in measured paracetamol concentrations was observed, especially in the oral groups. The median plasma Cmax in the 1 g IV group was significantly greater than the oral groups. In contrast, the median CSF Cmax was not different between groups. The median plasma Tmax in the 1 g IV group was 105 and 75 minutes earlier than in the 1 and 1.5 g oral groups. The median CSF Tmax was not significantly different between groups. The median plasma AUC (total) was not significantly different between groups; however, in the first hour, the median plasma AUC was significantly greater in the IV group than in the oral groups. In the second hour, there was no difference between groups. The median CSF AUC (total) did not significantly differ between groups; however, in the first hour, the median CSF AUC was significantly greater in the IV compared with the orally groups. In the second hour, there was no difference between groups. Our analysis indicated that the median Cmax, Tmax, and AUC values lacked precision because of small sample sizes. CONCLUSIONS Peak plasma concentrations were greater and reached earlier after IV than oral dosing. Evidence for differences in CSF Cmax and Tmax was lacking because of the small size of this study.
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Affiliation(s)
- Roger A Langford
- From the *Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Victoria, Australia; †Anaesthesia, Perioperative and Pain Medicine Unit, ‡Department of Pharmacology and Therapeutics, §Department of Medicine, and ∥Department of Pharmacology, University of Melbourne, Melbourne, Victoria, Australia; ¶Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; and #Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
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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.
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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
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Kelly SJ, Moran JL, Williams PJ, Burns K, Rowland A, Miners JO, Peake SL. Haemodynamic effects of parenteral vs. enteral paracetamol in critically ill patients: a randomised controlled trial. Anaesthesia 2016; 71:1153-62. [DOI: 10.1111/anae.13562] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 11/30/2022]
Affiliation(s)
- S. J. Kelly
- Department of Intensive Medicine; The Queen Elizabeth Hospital; Woodville South South Australia Australia
| | - J. L. Moran
- Department of Intensive Medicine; The Queen Elizabeth Hospital; Woodville South South Australia Australia
- School of Medicine; University of Adelaide; Adelaide South Australia Australia
| | - P. J. Williams
- Department of Intensive Medicine; The Queen Elizabeth Hospital; Woodville South South Australia Australia
- School of Medicine; University of Adelaide; Adelaide South Australia Australia
- School of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - K. Burns
- Department of Clinical Pharmacology; Flinders University; School of Medicine; Bedford Park South Australia Australia
| | - A. Rowland
- Department of Clinical Pharmacology; Flinders University; School of Medicine; Bedford Park South Australia Australia
| | - J. O. Miners
- Department of Clinical Pharmacology; Flinders University; School of Medicine; Bedford Park South Australia Australia
| | - S. L. Peake
- Department of Intensive Medicine; The Queen Elizabeth Hospital; Woodville South South Australia Australia
- School of Medicine; University of Adelaide; Adelaide South Australia Australia
- School of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
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Atkinson HC, Stanescu I, Frampton C, Salem II, Beasley CPH, Robson R. Pharmacokinetics and Bioavailability of a Fixed-Dose Combination of Ibuprofen and Paracetamol after Intravenous and Oral Administration. Clin Drug Investig 2016; 35:625-32. [PMID: 26334726 PMCID: PMC4579261 DOI: 10.1007/s40261-015-0320-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background and Objectives Previously published studies have suggested the lack of a
pharmacokinetic interaction between ibuprofen and paracetamol when they are delivered as a fixed-dose oral combination. The aim of this study was to determine the pharmacokinetic profile and safety of a fixed-dose intravenous (IV) combination, containing 3 mg/mL ibuprofen and 10 mg/mL paracetamol, in comparison with its individual components. The study also assessed the relative bioavailability of the same doses of the active ingredients when they were administered as an oral formulation. Methods A single-dose, open-label, randomized, five-period cross-over sequence pharmacokinetic study was undertaken in 30 healthy volunteers. Serial plasma samples were assayed for both paracetamol and ibuprofen concentrations, using validated liquid chromatography–tandem mass spectrometry methods. Pharmacokinetic parameters were computed using standard non-compartmental analyses. Adverse events were also assessed. The ratios of the maximum measured plasma concentration (Cmax), the area under the plasma concentration–time curve (AUC) from time zero to the time of the last measurable plasma concentration (AUCt) and AUC from time zero to infinity (AUC∞) were analysed for bioequivalence as determined by 90 % confidence intervals. Results The pharmacokinetic parameters of ibuprofen and paracetamol were very similar for the combination and monotherapy IV preparations; the ratios of the Cmax, AUCt and AUC∞ values fell within the 80–125 % acceptable bioequivalence range. Precise dose proportionality for both compounds was also determined for the half dose of the IV formulation in comparison with the full dose. The relative bioavailability of paracetamol (93.78 %) and ibuprofen (96.45 %) confirmed the pharmacokinetic equivalence of the oral and IV formulations of the fixed-dose combination. Conclusion Concomitant administration of 3 mg/mL ibuprofen and 10 mg/mL paracetamol in a fixed-dose IV combination does not alter the pharmacokinetic profiles of either drug. The IV and oral dose forms of such a combination are pharmacokinetically equivalent.
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Affiliation(s)
- Hartley C Atkinson
- AFT Pharmaceuticals Ltd, PO Box 33203, Takapuna, Auckland, 0740, New Zealand
| | - Ioana Stanescu
- AFT Pharmaceuticals Ltd, PO Box 33203, Takapuna, Auckland, 0740, New Zealand
| | - Chris Frampton
- University of Otago, PO Box 4345, Christchurch, 8140, New Zealand
| | - Isam I Salem
- International Pharmaceutical Research Centre, 1 Queen Rania Street-Sport City Circle, Amman, 11196, Jordan
| | - Charles P H Beasley
- AFT Pharmaceuticals Ltd, PO Box 33203, Takapuna, Auckland, 0740, New Zealand.
| | - Richard Robson
- Christchurch Clinical Studies Trust Ltd, PO Box 2856, Christchurch, 8140, New Zealand.
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30
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A Retrospective Analysis to Compare the Effects of Intravenous Acetaminophen Administered Intraoperatively. J Gynecol Surg 2016. [DOI: 10.1089/gyn.2015.0066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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31
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Acetaminophen, nonsteroidal anti-inflammatory drugs, and cyclooxygenase-2 selective inhibitors: an update. Plast Reconstr Surg 2016; 134:24S-31S. [PMID: 25255003 DOI: 10.1097/prs.0000000000000672] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
SUMMARY Plastic and cosmetic surgery is often performed as an ambulatory procedure, and pain is often mild to moderate. Good pain relief is central to patient comfort and satisfaction. Analgesics used should ensure rapid onset and adequate pain relief lasting a sufficiently long duration with minimal or no side effects. Acetaminophen is well tolerated by patients, efficacious, and associated with only minor side effects, when used in the minimal effective doses. Nonsteroidal anti-inflammatory drugs (NSAIDs) are more efficacious, having lower numbers needed to treat compared with acetaminophen, but have several side effects and contraindications. However, when used in the correct doses in healthy patients, NSAIDs are excellent for pain management with one caveat that there is an increased risk for oozing or bleeding. In contrast, cyclooxygenase inhibitors (Coxibs) are equally efficacious as NSAIDs but have the added advantage that they have minimal or no effect on platelet function, and therefore, the risk for bleeding complications is minimal. However, there has been some concern about the risk of vascular events in patients with ischemic heart disease, specifically when using Coxibs, but even some NSAIDs, for example, diclofenac. In conclusion, acetaminophen should be given postoperatively to all patients undergoing plastic surgical procedures. For patients undergoing moderately invasive surgery, the addition of Coxibs to acetaminophen would be an advantage except in the patient with ischemic heart disease where NSAIDs could have a place in management of pain. Side effects and contraindications of NSAIDs, however, restrict their use to the healthy patient with mild comorbidities.
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Bollinger AJ, Butler PD, Nies MS, Sietsema DL, Jones CB, Endres TJ. Is Scheduled Intravenous Acetaminophen Effective in the Pain Management Protocol of Geriatric Hip Fractures? Geriatr Orthop Surg Rehabil 2015; 6:202-8. [PMID: 26328237 PMCID: PMC4536513 DOI: 10.1177/2151458515588560] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hip fractures have significant effects on the geriatric population and the health care system. Prior studies have demonstrated both the safety of intravenous (IV) acetaminophen and its efficacy in decreasing perioperative narcotic consumption. The purpose of this study is to evaluate the effect of scheduled IV acetaminophen for perioperative pain control on length of hospital stay, pain level, narcotic use, rate of missed physical therapy (PT) sessions, adverse effects, and discharge disposition in geriatric patients with hip fractures. METHODS A retrospective review was performed of all patients 65 years and older admitted to a level I trauma center, who received operative treatment for a hip fracture over a 2-year period. Demographic data, in-hospital variables, and outcome measures were analyzed. Three hundred thirty-six consecutive fractures in 332 patients met inclusion criteria. These patients were divided into 2 cohorts. Group 1 (169 fractures) consisted of patients treated before the initiation of a standardized IV acetaminophen perioperative pain control protocol, and group 2 (167 fractures) consisted of those treated after the protocol was initiated. RESULTS Group 2 had a statistically significant shorter mean length of hospital stay (4.4 vs 3.8 days), lower mean pain score (4.2 vs 2.8), lower mean narcotic usage (41.3 vs 28.3 mg), lower rate of PT sessions missed (21.8% vs 10.4%), and higher likelihood of discharge home (7% vs 19%; P ≤ .001). Use of IV acetaminophen was also consistently and independently predictive of the same variables (P < .01). CONCLUSION The utilization of scheduled IV acetaminophen as part of a standardized pain management protocol for geriatric hip fractures resulted in shortened length of hospital stay, decreased pain levels and narcotic use, fewer missed PT sessions, and higher rate of discharge to home. LEVEL OF EVIDENCE Therapeutic level III.
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Affiliation(s)
- Alexander J. Bollinger
- Grand Rapids Medical Education Partners, Department of Orthopaedic Surgery, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Paul D. Butler
- Grand Rapids Medical Education Partners, Department of Orthopaedic Surgery, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Matthew S. Nies
- Department of Orthopaedic Surgery, University of Wisconsin, Madison, WI, USA
| | - Debra L. Sietsema
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
| | - Clifford B. Jones
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
| | - Terrence J. Endres
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Orthopaedic Associates of Michigan, Grand Rapids, MI, USA
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Hamer M, Suarez SA, Neuman NI, Alvarez L, Muñoz M, Marti MA, Doctorovich F. Discussing Endogenous NO•/HNO Interconversion Aided by Phenolic Drugs and Vitamins. Inorg Chem 2015; 54:9342-50. [DOI: 10.1021/acs.inorgchem.5b01347] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Mariana Hamer
- Departamento
de Química Analítica y Fisicoquímica, Facultad
de Farmacia y Bioquímica (IQUIFIB-CONICET), Universidad de Buenos Aires, Junin 956, Buenos Aires, Argentina
| | - Sebastian A. Suarez
- Gerencia
de Investigación y Aplicaciones, Centro Atómico Constituyentes, Comisión Nacional de Energía Atómica, Buenos Aires, Argentina
- Departamento
de Química Inorgánica, Analítica y Química
Física, Facultad de Ciencias Exactas y Naturales (INQUIMAE-CONICET), Universidad de Buenos Aires, Ciudad Universitaria, Buenos
Aires, Argentina
| | - Nicolás I. Neuman
- Departamento
de Química Inorgánica, Analítica y Química
Física, Facultad de Ciencias Exactas y Naturales (INQUIMAE-CONICET), Universidad de Buenos Aires, Ciudad Universitaria, Buenos
Aires, Argentina
- Departamento
de Física, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Ciudad Universitaria, Paraje El Pozo, Santa Fe, Argentina
| | - Lucía Alvarez
- Departamento
de Química Inorgánica, Analítica y Química
Física, Facultad de Ciencias Exactas y Naturales (INQUIMAE-CONICET), Universidad de Buenos Aires, Ciudad Universitaria, Buenos
Aires, Argentina
| | - Martina Muñoz
- Departamento
de Química Inorgánica, Analítica y Química
Física, Facultad de Ciencias Exactas y Naturales (INQUIMAE-CONICET), Universidad de Buenos Aires, Ciudad Universitaria, Buenos
Aires, Argentina
| | - Marcelo A. Marti
- Departamento
de Química Biológica, Facultad de Ciencias Exactas y
Naturales, Universidad de Buenos Aires, Ciudad Universitaria, Pab. II, Buenos Aires, Argentina
| | - Fabio Doctorovich
- Departamento
de Química Inorgánica, Analítica y Química
Física, Facultad de Ciencias Exactas y Naturales (INQUIMAE-CONICET), Universidad de Buenos Aires, Ciudad Universitaria, Buenos
Aires, Argentina
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Jibril F, Sharaby S, Mohamed A, Wilby KJ. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making. Can J Hosp Pharm 2015; 68:238-47. [PMID: 26157186 DOI: 10.4212/cjhp.v68i3.1458] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intravenous (IV) acetaminophen is increasingly used around the world for pain control for a variety of indications. However, it is unclear whether IV administration offers advantages over oral administration. OBJECTIVE To identify, summarize, and critically evaluate the literature comparing analgesic efficacy, safety, and pharmacokinetics for IV and oral dosage forms of acetaminophen. DATA SOURCES A literature search of the PubMed, Embase, and International Pharmaceutical Abstracts databases was supplemented with keyword searches of Science Direct, Wiley Library Online, and Springer Link databases for the period 1948 to November 2014. The reference lists of identified studies were searched manually. STUDY SELECTION AND DATA EXTRACTION Randomized controlled trials comparing IV and oral dosage forms of acetaminophen were included if they assessed an efficacy, safety, or pharmacokinetic outcome. For each study, 2 investigators independently extracted data (study design, population, interventions, follow-up, efficacy outcomes, safety outcomes, pharmacokinetic outcomes, and any other pertinent information) and completed risk-of-bias assessments. DATA SYNTHESIS Six randomized clinical trials were included. Three of the studies reported outcomes pertaining to efficacy, 4 to safety, and 4 to pharmacokinetics. No clinically significant differences in efficacy were found between the 2 dosage forms. Safety outcomes were not reported consistently enough to allow adequate assessment. No evidence was found to suggest that increased bioavailability of the IV formulation enhances efficacy outcomes. For studies reporting clinical outcomes, the results of risk-of-bias assessments were largely unclear. CONCLUSIONS For patients who can take an oral dosage form, no clear indication exists for preferential prescribing of IV acetaminophen. Decision-making must take into account the known adverse effects of each dosage form and other considerations such as convenience and cost. Future studies should assess multiple-dose regimens over longer periods for patients with common pain indications such as cancer, trauma, and surgery.
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Affiliation(s)
- Farah Jibril
- BSc(Pharm), PharmD, is a Clinical Pharmacist at the National Center for Cancer Care and Research, Doha, Qatar
| | - Sherif Sharaby
- Sherif Sharaby, BSc(Pharm), is a Pharmacist with the San Joaquin Valley Rehabilitation Hospital, Fresno, California
| | - Ahmed Mohamed
- BSc(Pharm), PhD, is an Assistant Professor with the College of Pharmacy, Qatar University, Doha, Qatar
| | - Kyle J Wilby
- BSP, ACPR, PharmD, is an Assistant Professor - Clinical Pharmacy and Practice, College of Pharmacy, Qatar University, Doha, Qatar
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Abstract
This was judged to be the first place winning submission for the American Dental Society of Anesthesiology Student Essay Award. Acetaminophen is an old drug that is now available in an intravenous formulation. Its advantages and disadvantages are reviewed, including its potential role in multimodal postoperative pain therapy.
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36
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Smith AN, Hoefling VC. A retrospective analysis of intravenous acetaminophen use in spinal surgery patients. Pharm Pract (Granada) 2014; 12:417. [PMID: 25243029 PMCID: PMC4161406 DOI: 10.4321/s1886-36552014000300004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 07/14/2014] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE This study aimed to determine if intravenous acetaminophen [paracetamol] (IV APAP) could decrease visual analog pain scores (VAS), opioid exposure and subsequent opioid related adverse effects (nausea, vomiting, constipation) in spinal surgery patients. METHODS Thirty four spinal surgery patients to date have received IV APAP since its addition to the formulary at our institution. The electronic medical record was accessed on all patients who received at least one dose pre or post operatively to collect postoperative opioid consumption (in morphine equivalents), number of antiemetic and laxative doses, use of naloxone, and VAS pain scores from arrival to surgical unit through postop day two. An equivalent number of patients who did not receive any IV APAP were selected and matched on the basis of opioid use prior to admission, surgery type, surgeon, age, and sex to constitute the control group. RESULTS The IV APAP group used significantly less opioids than the control group (p=0.015). Frequency of antiemetic and laxative use and VAS pain scores did not differ significantly between the two groups. CONCLUSIONS It appears IV APAP can be used effectively as an adjuvant pain management therapy in spinal surgery patients to decrease opioid exposure, but does not necessarily reduce the incidence of opioid related adverse effects or VAS pain scores.
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Affiliation(s)
- April N Smith
- Department of Pharmacy Practice, School of Pharmacy & Health Professions, Creighton University . Omaha, NE ( United States ).
| | - Vie C Hoefling
- School of Pharmacy & Health Professions, Creighton University . Omaha, NE ( United States )
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Gibbs NM, Weightman WM. An Audit of the Statistical Validity of Conclusions of Clinical Superiority in Anaesthesia Journals. Anaesth Intensive Care 2014; 42:599-607. [DOI: 10.1177/0310057x1404200509] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Making a statistically valid conclusion of the superiority of a clinical intervention in a clinical trial requires not only a statistically significant P value, but also adequate a priori power and an observed effect size larger than the clinically important value specified in the sample size calculation. We scrutinised the five most highly cited clinical trials reporting one or more conclusions of clinical superiority published in Anesthesiology, the British Journal of Anaesthesia, Anaesthesia, Anesthesia and Analgesia and Anaesthesia and Intensive Care in 2011 or 2012 to determine how many met all three requisite criteria. In the 25 articles, there were a total of 36 unconditional conclusions of the superiority of a clinical intervention. All were supported by a statistically significant P value. However, only 15 (41.6%) met all three requisite statistical criteria to support clinical superiority. The remainder included secondary outcomes without specific reference to their observational nature, and primary outcomes whose observed effect size was smaller than the clinically important value specified in the sample size calculation. These findings indicate that clinicians should closely scrutinise conclusions of clinical superiority in anaesthesia journals. Many will be ‘hypothesis-generating observations’ without adequate statistical support for a conclusion of clinical superiority in their own right.
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Affiliation(s)
- N. M. Gibbs
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia
| | - W. M. Weightman
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia
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38
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.
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39
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Mahgoobifard M, Mirmesdagh Y, Imani F, Najafi A, Nataj-Majd M. The analgesic efficacy of preoperative oral Ibuprofen and acetaminophen in children undergoing adenotonsillectomy: a randomized clinical trial. Anesth Pain Med 2014; 4:e15049. [PMID: 24660156 PMCID: PMC3961035 DOI: 10.5812/aapm.15049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/25/2013] [Accepted: 11/30/2013] [Indexed: 01/07/2023] Open
Abstract
Background: Adenotonsillectomy is one of the most common surgical procedures in children. Several complications and morbidities are common after nasal surgeries and the most common is pain. Several techniques have been employed to reduce the severity of postoperative pain. One of the preoperative techniques is pre-emptive analgesia through preventive central hypersensitization. This technique is performed by applying analgesic methods before the onset of nociceptive stimuli, consequently decreasing postoperative analgesics requirements. Objectives: Preoperative oral drug administration for pain analgesia is performed in several methods. The aim of this study was to compare the analgesic effects of preoperatively administration of oral acetaminophen and ibuprofen. Patients and Methods: In a double-blinded, randomized placebo-controlled study, sixty 4-12 years old ASA I or II children scheduled for elective adenotonsillectomy, were assigned to receive either acetaminophen 15 mg/kg, ibuprofen 10 mg/kg or placebo 30 minutes before the operation. Postoperative pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), upon arrival to the post anesthetic care unit (PACU) and ward. Findings were analyzed by SPSS version 17 using variance analysis and Tukey’s test. Results: The average pain intensities were significantly lower in acetaminophen group based on the CHEOPS in both PACU and ward compared to ibuprofen or placebo groups; but there was no difference in pain intensity between the ibuprofen and placebo groups. Pain intensity in PACU in Acetaminophen group was 7.05 ± 0.64 vs. 8.38 ± 1.20 in placebo group and 8.14 ± 0.85 in ibuprofen group, pain intensity in ward in the acetaminophen group was 6.0.87 ± 0.85in the acetaminophen group, vs. 8.04 ± 1.02 in placebo group, and 7.78 ± 0.78 in ibuprofen group. Conclusions: This study showed that administration of oral acetaminophen 30 minutes preoperatively, resulted in significantly lower pain intensity in children undergoing adenotonsillectomy in PACU and ward, compared to ibuprofen and placebo.
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Affiliation(s)
- Maziar Mahgoobifard
- Department of Anesthesiology and Children and Adolescent Health Research Center, Ali-Ebne Abitaleeb Hospital, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Yalda Mirmesdagh
- Heart Value Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farsad Imani
- Department of Anesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabak Najafi
- Department of Anesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoomeh Nataj-Majd
- Research Development Center of Arash Woman's Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Masoomeh Nataj-Majd, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran. Tel: +98-2177883283, Fax: +98-2177883196, E-mail:
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Terrin G, Conte F, Scipione A, Bacchio E, Conti MG, Ferro R, Ventriglia F, De Curtis M. Efficacy of paracetamol for the treatment of patent ductus arteriosus in preterm neonates. Ital J Pediatr 2014; 40:21. [PMID: 24555510 PMCID: PMC3940001 DOI: 10.1186/1824-7288-40-21] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 02/16/2014] [Indexed: 02/06/2023] Open
Abstract
Inhibitors of the cyclo-oxygenase component of prostaglandin-H2 synthetase, namely indomethacin and ibuprofen, are commonly used in the treatment of hemodynamically significant patent ductus arteriosus. These drugs are associated with serious adverse events, including gastrointestinal perforation, renal failure and bleeding. The role of paracetamol, an inhibitor of the peroxidase component of prostaglandin-H2 synthetase, has been proposed for the treatment of patent ductus arteriosus. We report a series of 8 neonates (birth weight: 724 ± 173 g; gestational age: 26 ± 2 weeks) treated with paracetamol for a hemodynamically significant patent ductus arteriosus, because of contraindications to ibuprofen or indomethacin. Successful closure was achieved in 6 out of 8 babies (75%). Median ductal diameter was significantly reduced after treatment (from 1.2 mm, range 1.0-2.5 mm to 0.6 mm, range 0.0-2.5 mm, p = 0.038). No adverse or side effects were observed during treatment. On the basis of these results, paracetamol could be considered a promising and safe therapy for the treatment of patent ductus arteriosus in neonates.
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Affiliation(s)
- Gianluca Terrin
- Department of Gynecology-Obstetrics and Perinatal Medicine, University "La Sapienza", Viale del Policlinico 155, 00161 Rome, Italy.
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Breivik H, Romundstad L. Intravenous non-opioids for immediate postop pain relief in day-case programmes: Paracetamol (acetaminophen) and ketorolac are good choices reducing opioid needs and opioid side-effects. Scand J Pain 2013; 4:247-248. [PMID: 29913627 DOI: 10.1016/j.sjpain.2013.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Harald Breivik
- Department of Pain Management and Research, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Department of Anaesthesiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Luis Romundstad
- Department of Pain Management and Research, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,Department of Anaesthesiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
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Lachiewicz PF. The role of intravenous acetaminophen in multimodal pain protocols for perioperative orthopedic patients. Orthopedics 2013; 36:15-9. [PMID: 23379571 DOI: 10.3928/01477447-20130122-52] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Multimodal pain management should be considered for all perioperative orthopedic patients. The goal of reducing the amount of perioperative opioid medication given may be achieved by using nonopioid medications, including intravenous acetaminophen. The site of action of acetaminophen is a variety of receptors in the central nervous system. When given intravenously, acetaminophen produces a much higher plasma concentration, which then leads to higher levels in the cerebrospinal fluid. The safety profile and relative lack of systemic adverse reactions make this an attractive analgesic for a wide variety of orthopedic surgical patients. Clinical studies have demonstrated the efficacy and safety of intravenous acetaminophen in elective total hip and knee arthroplasty, knee arthroscopy, lumbar spine surgery, and for acute traumatic limb pain.
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Affiliation(s)
- Paul F Lachiewicz
- Chapel Hill Orthopedics Surgery and Sports Medicine, 101 Conner Drive, Chapel Hill, NC 27514, USA.
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43
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Tsang KS, Page J, Mackenney P. Can intravenous paracetamol reduce opioid use in preoperative hip fracture patients? Orthopedics 2013; 36:20-4. [PMID: 23379572 DOI: 10.3928/01477447-20130122-53] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pain due to intra- and extracapsular hip fractures is usually treated with opioid medication. Paracetamol (acetaminophen in North America) has better bioavailability when given intravenously than orally and has been successfully used in the postoperative care of orthopedic patients. However, no study has evaluated its use in the preoperative trauma patient. Our unit conducted a prospective, consecutive cohort study to investigate the opioid-sparing effect of regularly administered intravenous paracetamol compared with oral paracetamol in preoperative hip fracture patients. The total opioid dose given, based on conversion to intravenous morphine, and the reported pain score were evaluated in 75 patients. There were 28 patients in the control group who were give routine oral paracetamol and oral opioids, with morphine for breakthrough pain. There were 47 patients in the study group who received only routine intravenous paracetamol, with opioids reserved for breakthrough pain. The patients in the 2 groups had similar characteristics. The mean preoperative oral paracetamol dose for the control group was 7.2 g compared with 6.3 g in the study group. There was a significant reduction (P<.005) in the mean total intravenous morphine with intravenous paracetamol (6.5 mg) compared with oral paracetamol (21.8 mg). There was no difference in the mean pain score between the groups, 2.1 vs 1.8 (P=.3). Intravenous paracetamol had a significant opioid-sparing effect and satisfactory pain relief in preoperative hip fracture patients.
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Affiliation(s)
- Kai S Tsang
- Trauma and Orthopaedic Department, James Cook University Hospital, Marton Rd., Middlesbrough, UK.
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44
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Gillogly A, Kilbourn C, Waldvogel J, Martin J, Annich G, Wagner D. In vitro clearance of intravenous acetaminophen in extracorporeal membrane oxygenation. Perfusion 2012. [PMID: 23201817 DOI: 10.1177/0267659112467825] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life support system used as a bridge to transplantation in critically ill patients who suffer from acute respiratory or cardiac failure with resultant hypoxemia and tissue hypoxia. This is not amendable to conventional support intervention. Previous studies have shown significant drug losses in the components of an ECMO circuit, leading to decreased plasma drug levels. An in vitro study was conducted to determine: (1) changes in intravenous acetaminophen levels over time and (2) changes in concentration observed between different sites of the ECMO circuit. A single bolus dose of intravenous (IV) acetaminophen was injected into a standard blood-primed ECMO circuit. Plasma drug concentrations in the circuit were then measured at specific time points at three different locations to determine concentrations of the drug at time 0, 15, 30, 60, 240 and 360 minutes. The three samples were drawn pre- and post-membrane oxygenator and the polyvinyl chloride (PVC) tubing. A second bolus dose was administered 24 hours after the first in order to compare "new" and "old" circuits. This entire process was repeated a total of three times. The results show that acetaminophen concentrations do not change significantly over time, with consistent levels seen in both new and old circuits (N=9). Average old circuit concentrations were approximately two times greater than the average new circuit concentrations after the circuit was re-dosed at 24 hours. Drug sequestration in the circuit was not significant in any of the three sites measured. It appears that, while acetaminophen levels remain relatively constant over a six hour period, dosing adjustments may be required for use in a circuit beyond the initial 24 hour period, depending on physiologic clearance of the drug. Assuming a six-hour dosing interval, levels should remain constant.
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Affiliation(s)
- A Gillogly
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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Singla NK, Parulan C, Samson R, Hutchinson J, Bushnell R, Beja EG, Ang R, Royal MA. Plasma and Cerebrospinal Fluid Pharmacokinetic Parameters After Single-Dose Administration of Intravenous, Oral, or Rectal Acetaminophen. Pain Pract 2012; 12:523-32. [DOI: 10.1111/j.1533-2500.2012.00556.x] [Citation(s) in RCA: 169] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Brett CN, Barnett SG, Pearson J. Postoperative plasma paracetamol levels following oral or intravenous paracetamol administration: a double-blind randomised controlled trial. Anaesth Intensive Care 2012; 40:166-71. [PMID: 22313079 DOI: 10.1177/0310057x1204000121] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In day-case surgery paracetamol is commonly given orally preoperatively, or intravenously intraoperatively. In this double-blind randomised controlled trial we investigated which of these methods of administration achieved therapeutic plasma levels most effectively in the early postoperative period. Thirty patients undergoing day case arthroscopy of the knee were randomised to receive either 1.0 g oral paracetamol 30 to 60 minutes preoperatively (20 patients) or 1.0 g intravenous paracetamol intraoperatively (10 patients). Plasma paracetamol levels were measured 30 minutes after arrival in the recovery room. Secondary outcomes included postoperative pain scores, rescue analgesia requirements and duration of stay in the recovery room. All patients receiving the intravenous preparation had plasma levels above the analgesic level compared to less than half (7/20) in the oral group. Mean plasma paracetamol levels were 88.6 µmol/l for the intravenous group and 53.2 µmol/l for the oral group (P=0.0005). There were trends towards reduced rescue analgesia and duration of stay in the recovery room for the intravenous group although not reaching statistical significance. There was no difference in pain scores between groups. Intraoperative administration of 1.0 g of intravenous paracetamol more reliably achieved effective paracetamol levels in the early postoperative period compared to an equal dose given orally preoperatively. Only a minority of patients receiving the 1.0 g oral dose preoperatively had plasma levels in the therapeutic analgesic range.
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Affiliation(s)
- Christian N Brett
- Department of Anaesthesia, Christchurch Hospital, Christchurch, New Zealand.
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