1
|
Karam JA, Schwenk ES, Parvizi J. An Update on Multimodal Pain Management After Total Joint Arthroplasty. J Bone Joint Surg Am 2021; 103:1652-1662. [PMID: 34232932 DOI: 10.2106/jbjs.19.01423] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Multimodal analgesia has become the standard of care for total joint arthroplasty as it provides superior analgesia with fewer side effects than opioid-only protocols. ➤ Systemic medications, including nonsteroidal anti-inflammatory drugs, acetaminophen, corticosteroids, and gabapentinoids, and local anesthetics via local infiltration analgesia and peripheral nerve blocks, are the foundation of multimodal analgesia in total joint arthroplasty. ➤ Ideally, multimodal analgesia should begin preoperatively and continue throughout the perioperative period and beyond discharge. ➤ There is insufficient evidence to support the routine use of intravenous acetaminophen or liposomal bupivacaine as part of multimodal analgesia protocols.
Collapse
Affiliation(s)
- Joseph A Karam
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| |
Collapse
|
2
|
Patel MS, Abboud JA, Sethi PM. Perioperative pain management for shoulder surgery: evolving techniques. J Shoulder Elbow Surg 2020; 29:e416-e433. [PMID: 32844751 DOI: 10.1016/j.jse.2020.04.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/13/2020] [Accepted: 04/21/2020] [Indexed: 02/08/2023]
Abstract
Improving management of postoperative pain following shoulder surgery is vital for optimizing patient outcomes, length of stay, and decreasing addiction to narcotic medications. Multimodal analgesia (ie, controlling pain via multiple different analgesic methods with differing mechanisms) is an ever-evolving approach to enhancing pain control perioperatively after shoulder surgery. With a variety of options for the shoulder surgeon to turn to, this article succinctly reviews the pros and cons of each approach and proposes a potential pain management algorithm.
Collapse
Affiliation(s)
- Manan S Patel
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Paul M Sethi
- Orthopaedic & Neurosurgery Specialists, Greenwich, CT, USA
| |
Collapse
|
3
|
Yu S, Eftekhary N, Wiznia D, Schwarzkopf R, Long WJ, Bosco JA, Iorio R. Evolution of an Opioid Sparse Pain Management Program for Total Knee Arthroplasty With the Addition of Intravenous Acetaminophen. J Arthroplasty 2020; 35:89-94. [PMID: 31521446 DOI: 10.1016/j.arth.2019.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Perioperative pain management for patients undergoing total knee arthroplasty (TKA) improves patient outcomes and facilitates recovery. In this study, we compared the effects of preoperative oral acetaminophen vs intravenous (IV) acetaminophen administered once intraoperatively and once postoperatively. METHODS Two standardized, multimodal analgesia protocols were compared in patients undergoing primary, unilateral TKA. The oral acetaminophen cohort (OA) received doses of oral acetaminophen preoperatively and an as-needed basis postoperatively (n = 698). The IV acetaminophen cohort (IA) received 2 doses of IV acetaminophen, one intraoperative and one 6 hours postoperatively, with no oral acetaminophen given (n = 318). No other variables were significantly changed during the study period. RESULTS The IV acetaminophen group demonstrated less narcotic usage on postoperative day 0 (OA: 13.3 mme [morphine mg equivalents], IA: 6.2 mme, P < .001) and overall usage (OA: 66.1 mme, IA: 48.5 mme, P < .001). Pain scores were statistically and clinically significantly decreased in the immediate postoperative (the first 8 hours) for the IA group (OA: patient-reported pain scores of 4.0; IA: patient-reported pain scores of 2.0, P < .001). Both groups progressed and completed their physical therapy similarly for each postoperative day. Length of stay and percent discharge home were slightly improved in the IA group as well, however did not reach statistical difference. CONCLUSION An iterative approach to multimodal pain management after TKA led to improvements in narcotic usage, pain scores, and several quality measures. IV acetaminophen is an integral and effective part of our opioid-sparing multimodal pain regimen in TKA.
Collapse
Affiliation(s)
- Stephen Yu
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Nima Eftekhary
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Daniel Wiznia
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - William J Long
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Richard Iorio
- Department of Orthpaedic Surgery, Brigham Health, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
4
|
Pitchon DN, Dayan AC, Schwenk ES, Baratta JL, Viscusi ER. Updates on Multimodal Analgesia for Orthopedic Surgery. Anesthesiol Clin 2018; 36:361-373. [PMID: 30092934 DOI: 10.1016/j.anclin.2018.05.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Pain control after orthopedic surgery is challenging. A multimodal approach provides superior analgesia with fewer side effects compared with opioids alone. This approach is particularly useful in light of the current opioid epidemic in the United States. Several new nonopioid agents have emerged into the market in recent years. New agents included in this review are intravenous acetaminophen, intranasal ketorolac, and newer nonsteroidal anti-inflammatory drugs, and the established medications ketamine and gabapentinoids. This article evaluates the evidence supporting these drugs in a multimodal context, including a brief discussion of cost.
Collapse
Affiliation(s)
- Darsi N Pitchon
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8290, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA.
| | - Amir C Dayan
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8290, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8290, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA
| | - Jaime L Baratta
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8290, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University, Suite 8290, Gibbon Building, 111 South 11th Street, Philadelphia, PA 19107, USA
| |
Collapse
|
5
|
Guo H, Wang C, He Y. A meta-analysis evaluates the efficacy of intravenous acetaminophen for pain management in knee or hip arthroplasty. J Orthop Sci 2018; 23:793-800. [PMID: 29910098 DOI: 10.1016/j.jos.2018.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/28/2018] [Accepted: 04/22/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The objective of this study was to assess whether intravenous acetaminophen for patients undergoing knee or hip arthroplasty could reduce the opioid consumption and improve pain management. METHOD Eligible studies were searched from electronic databases including PubMed, Web of Science, Embase (Ovid interface) and Cochrane Library (Ovid interface). The quality assessments were performed according to the Cochrane systematic review method. The assessed outcomes were including opioid consumption, pain scores, length of hospital stays and total occurrence of adverse events. RESULTS Among 832 records identified, six randomized controlled trials (RCTs) and five non-RCTs were eligible for data extraction and meta-analysis. According to the outcomes, the patients receive intravenous acetaminophen had less total opioid consumption after knee or hip artroplasty (SMD = -0.66; 95%CI, -1.13 to -0.20), but they did not obtain statistical improvement of postoperative pain control at postoperative day 0 (POD0, SMD = -0,15; 95%CI, -0.36 to 0.07), POD1(SMD = 0,12; 95%CI, -0.13 to 0.36), POD2 (SMD = -0,29; 95%CI, -0.70 to 0.12) and POD3 (SMD = -0,04; 95%CI, -0.49 to 0.41). Meanwhile, there were similar outcomes about the length of hospital stays in patients whether or not receiving intravenous acetaminophen (SMD = -0,05; 95%CI, -0.26 to 0.15). And, the total adverse effects occurrence also didn't show any significant difference between the acetaminophen group and control group (OR = 0.87; 95%CI, 0.57 to 1.33). CONCLUSIONS Perioperative intravenous acetaminophen use in multimodal analgesia could significantly reduce of total opioid consumption, but it did not contribute to decrease the average pain scores and shorten the length of hospital stays in total hip or knee arthroplasty.
Collapse
Affiliation(s)
- Hongzhang Guo
- Department of Orthopaedics, Gansu Provincial Hospital of TCM, 418# GuaZhou Road, Qi Li He Zone, Lanzhou, 730050, People's Republic of China.
| | - Changde Wang
- Department of Orthopaedics, Gansu Provincial Hospital of TCM, 418# GuaZhou Road, Qi Li He Zone, Lanzhou, 730050, People's Republic of China.
| | - Yufang He
- The Third Hospital of Gansu Province, 736# Duan Jia Tan, Cheng Guan Zone, Lanzhou, 730030, People's Republic of China.
| |
Collapse
|
6
|
Ilfeld BM, Ball ST, Gabriel RA, Sztain JF, Monahan AM, Abramson WB, Khatibi B, Said ET, Parekh J, Grant SA, Wongsarnpigoon A, Boggs JW. A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty. Neuromodulation 2018; 22:653-660. [PMID: 30024078 PMCID: PMC6339601 DOI: 10.1111/ner.12790] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/19/2018] [Accepted: 04/09/2018] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA). METHODS For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total. RESULTS In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported. CONCLUSIONS This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.
Collapse
Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Scott T Ball
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Amanda M Monahan
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Jesal Parekh
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Stuart A Grant
- Duke University Medical Center, Duke University, Durham, NC, USA
| | | | | |
Collapse
|
7
|
Sun L, Zhu X, Zou J, Li Y, Han W. Comparison of intravenous and oral acetaminophen for pain control after total knee and hip arthroplasty: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e9751. [PMID: 29419667 PMCID: PMC5944691 DOI: 10.1097/md.0000000000009751] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/24/2017] [Accepted: 01/09/2018] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy between intravenous and oral acetaminophen as adjunct to multimodal analgesia regimens for pain management after total knee and hip arthroplasties. METHODS We conduct electronic searches of Medline (1966-2017.09), PubMed (1966-2017.09), Embase (1980-2017.09), ScienceDirect (1985-2017.09), and the Cochrane Library. Only randomized controlled trials (RCTs) are included. The quality assessment is performed according to the Cochrane systematic review method. Fixed/random effect model is adopted according to the heterogeneity tested by I statistic. Meta-analysis is performed using Stata 11.0 software. RESULTS Two RCTs are included involving 236 patients. The present meta-analysis demonstrated that there were no significant differences between groups regarding pain scores at 12, 24, or 48 hours. No significant differences were observed in terms of opioid consumption at 12, 24, or 48 hours after arthroplasties. CONCLUSION Intravenous acetaminophen to multimodal analgesia dose not demonstrate a significant benefit in reducing pain and opioid consumption compared oral formulation after total knee arthroplasty and total hip arthroplasty. Higher-quality RCTs are required for further research.
Collapse
MESH Headings
- Acetaminophen/pharmacology
- Administration, Intravenous
- Administration, Oral
- Analgesics, Non-Narcotic/pharmacology
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Humans
- Pain Management/methods
- Pain Measurement/methods
- Pain, Postoperative/diagnosis
- Pain, Postoperative/drug therapy
- Treatment Outcome
Collapse
Affiliation(s)
- Lixin Sun
- Department of Anesthesiology, Qingdao Municipal Hospital
| | - Xiaopei Zhu
- Department of Anesthesiology, Qingdao Municipal Hospital
| | - Jianhong Zou
- Department of Lab, Center for Disease Control and Prevention of Shibei District of Qingdao
| | - Yongchun Li
- Department of Pulmonary Medicine, Qingdao Municipal Hospital, Qingdao, China
| | - Wei Han
- Department of Pulmonary Medicine, Qingdao Municipal Hospital, Qingdao, China
| |
Collapse
|
8
|
Liang L, Cai Y, Li A, Ma C. The efficiency of intravenous acetaminophen for pain control following total knee and hip arthroplasty: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e8586. [PMID: 29145272 PMCID: PMC5704817 DOI: 10.1097/md.0000000000008586] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND This meta-analysis aimed to evaluate the efficiency and safety of intravenous acetaminophen as an adjunct to multimodal analgesia for pain control after total joint arthroplasty (TJA). METHODS PubMed, Embase, Web of science, Medline, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) and non-RCTs were included. Fixed/random effect model was used according to the heterogeneity tested by I statistic. Meta-analysis was performed using Stata 11.0 software. RESULTS Four studies including 865 patients met the inclusion criteria. The present meta-analysis indicated that there were significant differences between groups in terms of pain scores at 24 hours (weighted mean difference [WMD] = -0.926, 95% confidence interval [CI]: -1.171 to -0.681, P = .000), 48 hours (WMD = -0.905, 95% CI: -1.198 to -0.612, P = .000), and 72 hours (WMD = -0.279, 95% CI: -0.538 to -0.021, P = .034). Significant differences were found regarding opioid consumption at 24 hours (WMD = -4.043, 95% CI: -5.041 to -3.046, P = .000), 48 hours (WMD = -5.665, 95% CI: -7.383 to -3.947, P = .000), and 72 hours (WMD = -6.338, 95% CI: -7.477 to -5.199, P = .000). CONCLUSION Intravenous acetaminophen was efficacious for reducing postoperative pain and opioid consumption than the placebo following total joint arthroplasty. Due to the limited quality of the evidence currently available, more RCTs are needed.
Collapse
MESH Headings
- Acetaminophen/administration & dosage
- Acetaminophen/therapeutic use
- Administration, Intravenous
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Humans
- Pain Management/methods
- Pain, Postoperative/drug therapy
Collapse
|
9
|
Yang L, Du S, Sun Y. Intravenous acetaminophen as an adjunct to multimodal analgesia after total knee and hip arthroplasty: A systematic review and meta-analysis. Int J Surg 2017; 47:135-146. [PMID: 28919091 DOI: 10.1016/j.ijsu.2017.09.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/08/2017] [Accepted: 09/09/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND This meta-analysis aimed to perform a meta-analysis to investigate the impact of additional intravenous acetaminophen for pain management after total joint arthroplasty (TJA). METHODS We conducted electronic searches of Medline (1966-2017.07), PubMed (1966-2017.07), Embase (1980-2017.07), ScienceDirect (1985-2017.07) and the Cochrane Library. Randomized controlled trials (RCTs) and non-RCTs were included. The quality assessments were performed according to the Cochrane systematic review method. The primary outcomes were postoperative pain scores and opioid consumption. Meta-analysis was performed using Stata 11.0 software. RESULTS A total of four studies were retrieved involving 865 participants. The present meta-analysis indicated that there were significant differences between groups in terms of pain scores at POD 1 (WMD = -0.954, 95% CI: -1.204 to -0.703, P = 0.000), POD 2 (WMD = -1.072, 95% CI: -2.072 to -0.073, P = 0.000), and POD 3 (WMD = -0.883, 95% CI: -1.142 to -0.624, P = 0.000). Significant differences were found regarding opioid consumption at POD 1 (WMD = -3.144, 95% CI: -4.142 to -2.146, P = 0.000), POD 2 (WMD = -5.665, 95% CI: -7.383 to -3.947, P = 0.000), and POD 3 (WMD = -3.563, 95% CI: -6.136 to -0.991, P = 0.007). CONCLUSION Additional intravenous acetaminophen to multimodal analgesia could significantly reduce pain and opioid consumption after total joint arthroplasty with fewer adverse effects. Higher quality RCTs are required for further research.
Collapse
Affiliation(s)
- Liqing Yang
- Department of Orthopedics, Shengjing Hospital of China Medical University, Shenyang 110004, China.
| | - Shuai Du
- Department of Orthopedics, Central Hospital of Shenyang Medical College, Shenyang 110024, China
| | - Yuefeng Sun
- Department of Orthopedics, Shengjing Hospital of China Medical University, Shenyang 110004, China
| |
Collapse
|