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Hatano M, Sasabuchi Y, Ishikura H, Watanabe H, Tanaka T, Tanaka S, Yasunaga H. Outcomes after hip fracture surgery in patients receiving non-steroidal anti-inflammatory drugs alone, acetaminophen alone, or both. Bone Joint J 2024; 106-B:849-857. [PMID: 39084654 DOI: 10.1302/0301-620x.106b8.bjj-2024-0183.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Aims The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone. Methods This nationwide retrospective cohort study used data from the Diagnosis Procedure Combination database. We included patients aged ≥ 18 years who underwent surgery for hip fractures and received acetaminophen combined with NSAIDs (combination group), NSAIDs alone (NSAIDs group), or acetaminophen alone (acetaminophen group) preoperatively, between April 2010 and March 2022. Primary outcomes were in-hospital mortality and complications. Secondary outcomes were opioid use postoperatively; readmission within 90 days, one year, and two years; and total hospitalization costs. We used propensity score overlap weighting models, with the acetaminophen group as the reference group. Results We identified 93,018 eligible patients, including 13,068 in the combination group, 29,203 in the NSAIDs group, and 50,474 in the acetaminophen group. Propensity score overlap weighting successfully balanced patient characteristics among the three groups, with no significant difference in in-hospital mortality rates observed among the groups (combination group risk difference 0.0% (95% CI -0.5 to 0.4%); NSAIDs group risk difference -0.2% (95% CI -0.5 to 0.2%)). However, the combination group exhibited a significantly lower risk of in-hospital complications than the acetaminophen group (risk difference -1.9% (95% CI -3.2 to -0.6%)) as well as a significantly lower risk of deep vein thrombosis (risk difference -1.4% (95% CI -2.2 to -0.7%)). Furthermore, total hospitalization costs were higher in the NSAIDs group than in the acetaminophen group (difference USD $438 (95% CI 249 to 630); p < 0.001). No significant differences in other secondary outcomes were observed among the three groups. Conclusion The combination of acetaminophen with NSAIDs appears to be safe and advantageous in terms of reducing in-hospital complications.
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Affiliation(s)
- Masaki Hatano
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yusuke Sasabuchi
- Department of Real-world Evidence, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hisatoshi Ishikura
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideaki Watanabe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Takeyuki Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Zabawa L, Choubey AS, Drake B, Mayo J, Mejia A. Dementia and Hip Fractures: A Comprehensive Review of Management Approaches. JBJS Rev 2023; 11:01874474-202312000-00002. [PMID: 38079493 DOI: 10.2106/jbjs.rvw.23.00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» The elderly population is the fastest growing demographic, and the number of dementia cases in the United States is expected to double to 10 million by 2050.» Patients with dementia are at 3× higher risk of hip fractures and have higher morbidity and mortality after hip fractures.» Hip fracture patients with dementia benefit from early analgesia and timely surgical fixation of fracture.» Early and intensive inpatient rehabilitation is associated with improved postoperative outcomes in patients with dementia.» Coordination of care within a "orthogeriatric" team decreases mortality, and fracture liaison services show potential for improving long-term outcomes in hip fracture patients with dementia.
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Affiliation(s)
- Luke Zabawa
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Apurva S Choubey
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Brett Drake
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Joel Mayo
- University of Illinois College of Medicine, Chicago, Illinois
| | - Alfonso Mejia
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
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Chang JS, Lee DH, Kang MW, Kim JW, Kim CH. Effectiveness of Intravenous Non-Opioid Analgesics for Postoperative Pain Management of in Patients Undergoing Hip Surgery: A Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1904. [PMID: 38003953 PMCID: PMC10673097 DOI: 10.3390/medicina59111904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Intravenous (IV) non-opioid analgesics (NOAs) have been extensively investigated as a multimodal analgesic strategy for the management of acute pain after hip surgery. This pair-wise meta-analysis examined IV NOA effects following hip surgery. Materials and Methods: A systematic search of the MEDLINE (PUBMED), Embase, and Cochrane Library databases was performed for studies investigating the effect of IV NOA for postoperative pain management following hip surgery up to 7 June 2023. We compared in-admission opioid use, postoperative VAS (visual analogue scale) score, hospital stay duration, and opioid-related adverse events between IV NOA and control groups. Results: Seven studies were included with a total of 953 patients who underwent hip surgery. Of these, 478 underwent IV NOA treatment, and 475 did not. The IV NOA groups had lower opioid use within 24-h following hip surgery (SMD, -0.48; 95% CI, -0.66 to -0.30; p < 0.01), lower VAS score (SMD, -0.47; 95% CI, -0.79 to -0.16; p < 0.01), shorter hospital stay (SMD, -0.28; 95% CI, -0.44 to -0.12; p < 0.01), and lower incidence of nausea and vomiting (OR, 0.32; 95% CI, 0.15 to 0.67; p < 0.01) compared with the control groups. Conclusions: This meta-analysis demonstrated that IV NOA administration following hip surgery may have more favorable postoperative outcomes than those in control groups.
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Affiliation(s)
- Jae Suk Chang
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (D.H.L.); (M.W.K.)
| | - Dong Hwan Lee
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (D.H.L.); (M.W.K.)
| | - Min Wook Kang
- Department of Orthopedic Surgery, National Police Hospital, Seoul 05715, Republic of Korea; (J.S.C.); (D.H.L.); (M.W.K.)
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
| | - Chul-Ho Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
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Stone AB, Iban YC, Zhong H, Poeran J, Liu J, Cozowicz C, Wong J, Illescas A, Memtsoudis SG. Opioid sparing effects of intravenous and oral acetaminophen in hip fracture patients: A population-based study. J Clin Anesth 2023; 86:111074. [PMID: 36758393 DOI: 10.1016/j.jclinane.2023.111074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/13/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023]
Abstract
STUDY OBJECTIVE Acetaminophen (APAP) and intravenous acetaminophen (IVAPAP) has been proposed as a part of many opioid-sparing multimodal analgesic pathways. The aim of this analysis was to compare the effectiveness of IVAPAP with oral APAP on opioid utilization and opioid-related adverse effects. DESIGN Retrospective study of population-based database. PATIENTS The Premier Healthcare database was queried patients undergoing surgery for a primary diagnosis of hip fracture from 2011 to 2019 yielding 245,976 patients. Primary exposure was use of IVAPAP or oral APAP on the day of surgery. INTERVENTIONS None. MEASUREMENTS The primary outcome of interest was opioid utilization over the hospital stay, secondary outcomes included opioid-related adverse effects, length, and costs of hospital stay. Mixed effect models measured the association of IVPAP and APAP and outcomes. MAIN RESULTS In the study population 30.67% (75,445) received at least 1 dose of IVAPAP on the day of surgery. Upon adjusting for relevant covariates, patients who received IVPAP on the day of surgery had slightly higher opioid use standardized by length of hospital stay (2.8% CI: 2%, 3.6%; p < .001), higher hospital cost (2.7% CI: 2.1%, 3.4%), and higher odds of naloxone use (1.18, CI: 1.1, 1.27; p < .001) when compared with patients who received oral APAP. CONCLUSIONS In this population, IVAPAP use on the day of surgery failed to reduce opioid use or associated opioid related adverse effects when compared with oral APAP. IVAPAP was associated with increased overall costs, opioid requirements, and naloxone use. These results do not support the use of IV over oral APAP routinely for hip fracture surgery patients.
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Affiliation(s)
- Alexander B Stone
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Yhan Colon Iban
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy/ Department of Orthopedics / Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy/ Department of Orthopedics / Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Jean Wong
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Alex Illescas
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.; Department of Health Policy and Research, Weill Cornell Medical College, New York, NY, USA.
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Liposomal Bupivacaine Decreases Intravenous Opioid Use in Patients with Hip Fracture: A Modification to a Novel Pain Protocol. J Am Acad Orthop Surg 2023; 31:e246-e255. [PMID: 36821079 DOI: 10.5435/jaaos-d-22-00493] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/23/2022] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION The aim of this study was to determine whether the administration of liposomal bupivacaine decreased opioid use and delirium in patients sustaining a hip fracture. METHODS A retrospective review of patients with hip fracture from September 2018 to October 2019 was performed through our institution's hip fracture registry. A liposomal bupivacaine cocktail was administered intraoperatively. Opioid requirement was determined for postoperative days 1, 2, and 3. Delirium was identified through chart review. Visual analog scale pain scores were averaged for postoperative days 1, 2, and 3. Four groups were analyzed: patients who received liposomal bupivacaine and IV acetaminophen, patients who only received IV acetaminophen, patients who only received liposomal bupivacaine, and control patients whose data were collected before this intervention. Continuous data were compared using a one-way analysis of variance or Student t-test, as applicable. Categorical data were compared using the Fisher exact test. Significance was set at P < 0.05. RESULTS One hundred nine patients met the inclusion criteria for the study with a mean age of 81.2 years. Eighty-two patients (75.2%) received intraoperative liposomal bupivacaine during the study year. Intravenous opioid requirement was markedly different among all four groups in all postoperative days. Oral opioid requirement and pain scores were not different between groups on any postoperative day. A notable decrease in IV opioid requirement in all postoperative days was seen in the Intervention groups (day 1 P < 0.001, day 2 P = 0.002, and day 3 P = 0.030). There existed a trend toward decreased delirium rates in the Intervention groups compared with the No Intervention group (23.9% vs. 32.8%, P = 0.272). CONCLUSION The inclusion of liposomal bupivacaine in our institution's novel pain protocol led to notable decreases in opioid requirement in all postoperative days studied with a trend toward decreased delirium rates as well.
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Chen Y, Liang S, Wu H, Deng S, Wang F, Lunzhu C, Li J. Postoperative delirium in geriatric patients with hip fractures. Front Aging Neurosci 2022; 14:1068278. [PMID: 36620772 PMCID: PMC9813601 DOI: 10.3389/fnagi.2022.1068278] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.
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Affiliation(s)
- Yang Chen
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shuai Liang
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Huiwen Wu
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Shihao Deng
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Fangyuan Wang
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Ciren Lunzhu
- Department of Orthopedics, Shannan City People’s Hospital, Shannan, China
| | - Jun Li
- Department of Orthopedics, The Second Hospital of Anhui Medical University, Hefei, China,Institute of Orthopedics, Research Center for Translational Medicine, The Second Hospital of Anhui Medical University, Hefei, China,*Correspondence: Jun Li,
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7
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Johnson S, Haywood C. Perioperative medication management for older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Samuel Johnson
- Aged Care Services, Austin Health Heidelberg Repatriation Hospital Heidelberg Heights Australia
| | - Cilla Haywood
- Aged Care Services, Austin Health Heidelberg Repatriation Hospital Heidelberg Heights Australia
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8
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Archer V, Cloutier Z, Berg A, McKechnie T, Wiercioch W, Eskicioglu C. Short-stay compared to long-stay admissions for loop ileostomy reversals: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:2113-2124. [PMID: 36151483 DOI: 10.1007/s00384-022-04256-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Short-stay admissions, with lengths of stay less than 24 h, are used for various surgeries without increasing adverse events. However, it is unclear if short-stay admissions would be safe for loop ileostomy reversals. This review aimed to compare outcomes between short (≤24 hours) and long (>24 hours) admissions for adults undergoing loop ileostomy reversals. METHODS Medline, Embase, CINAHL, Web of Science, and the Cochrane Library were systematically searched for studies comparing short- to long-stay admissions in adults undergoing loop ileostomy reversals. Meta-analyses were conducted for mortality, reoperation, readmission, and non-reoperative complications. Quality of evidence was assessed with grading of recommendations, assessment, development, and evaluations (GRADE) guidelines. RESULTS Four observational studies enrolling 24,628 patients were included. Moderate certainty evidence suggests there is no difference in readmissions between short- and long-stay admissions (relative risk (RR) 0.98, 95% CI 0.75 to 1.28, p 0.86). Low certainty evidence demonstrates that short stays may reduce non-reoperative complications (RR 0.44, 95% CI 0.31 to 0.62, p < 0.01). Very low certainty evidence demonstrates that there is no difference in reoperations between short and long stays (RR 1.14, 95% CI 0.26 to 5.04, p 0.87). CONCLUSIONS Moderate certainty evidence demonstrates that there is no difference in readmission rates between short- and long-stay admissions for loop ileostomy reversals. Less robust evidence suggests equivalence in reoperations and a decrease in non-reoperative complications. Future prospective trials are required to evaluate the feasibility and efficacy of short-stay admissions. TRIAL REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=307381 Prospero (CRD42022307381), January 30, 2022.
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Affiliation(s)
- Victoria Archer
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Zacharie Cloutier
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Annie Berg
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tyler McKechnie
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
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Cho JSH, McCarthy K, Schiavo S, Jacob B, Engelsakis M, Zywiel M, Karkouti K, McCluskey S, Clarke H, Wong J. Effect of intravenous acetaminophen on postoperative outcomes in hip fracture patients: a systematic review and narrative synthesis. Can J Anaesth 2022; 69:885-897. [PMID: 35534770 DOI: 10.1007/s12630-022-02257-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/03/2022] [Accepted: 02/23/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Hip fractures are debilitating in older adults because of their impact on quality of life. Opioids are associated with adverse effects in this population, so oral acetaminophen is commonly prescribed to minimize opioid use. Intravenous (iv) acetaminophen has been reported to have superior efficacy and bioavailability than oral acetaminophen. Nevertheless, its effect on postoperative outcomes in emergency hip fractures is unclear. This systematic review assessed the effect of iv acetaminophen on postoperative outcomes in older hip fracture patients. SOURCE We searched multiple databases from inception to June 2021 for studies on adults > 50 yr of age undergoing emergency hip fracture surgery who received iv acetaminophen (or paracetamol) and that reported postoperative outcomes. Relevant titles, abstracts, and full texts were screened based on the eligibility criteria. The Newcastle-Ottawa scale was used to assess the quality of the selected papers. PRINCIPAL FINDINGS Of 3,510 initial studies, four met the inclusion criteria. One was a prospective cohort study and three were retrospective cohort studies. All four studies used historical control groups. Three studies reported a significantly lower mean opioid dose with iv acetaminophen than with oral acetaminophen. Three studies also reported a significantly shorter hospital stay. One study each reported a significant decrease in the number of missed physical therapy sessions, the need for one-to-one supervision, and episodes of delirium. CONCLUSION There is very limited low-level evidence that iv acetaminophen improves preoperative and postoperative analgesia and shortens hospital stay in older hip fracture patients. Nevertheless, our results should be interpreted with caution since there are no prospective randomized trials investigating whether iv acetaminophen improves postoperative outcomes in this patient population. STUDY REGISTRATION PROSPERO (CRD42021198174); registered 15 August 2021.
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Affiliation(s)
| | - Kristian McCarthy
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Simone Schiavo
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Binu Jacob
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Marina Engelsakis
- General Surgery, Anesthesia & Perioperative Care Education Investigator, The Institute of Education Research Library & Information Services, University Health Network, Toronto, ON, Canada
| | - Michael Zywiel
- Division of Orthopedic Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Sinai Health System, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, Women's College Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Stuart McCluskey
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Jean Wong
- Department of Anesthesiology and Pain Management, University Health Network, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, Women's College Hospital, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada.
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10
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Unneby A, Gustafson Y, Olofsson B, Lindgren BM. Between Heaven and Hell: Experiences of Preoperative Pain and Pain Management among Older Patients with Hip Fracture. SAGE Open Nurs 2022; 8:23779608221097450. [PMID: 35558139 PMCID: PMC9087244 DOI: 10.1177/23779608221097450] [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: 12/09/2021] [Revised: 03/30/2022] [Accepted: 04/09/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Among older adults, hip fracture is a common and serious consequence of a fall.
Preoperative pain is common and often severe among patients with hip fracture. Opioids
are usually used but have many side effects. One alternative is a femoral nerve block,
which has been shown to reduce pain and lower the need for opioids. However, to our
knowledge no study has explored qualitatively how patients with hip fracture experience
treatment with femoral nerve block. Objective The aim of this study was to explore experiences of preoperative pain and pain
management among older patients with hip fracture who had received a femoral nerve
block. Method A qualitative design with semi-structured interviews (n = 23) conducted 2–6 days after
surgery. Inclusion criteria were Swedish-speaking patients aged 70 years or older with
hip fracture admitted to the orthopedic ward, treated with femoral nerve block before
nursing actions. Data were analyzed with qualitative content analysis. Results Our result revealed one theme, hovering between heaven and hell, with five subthemes:
how the pain was described – no pain, to worst pain and everything in between; they were
dealing with pain in their own way; felt dependent on staff´s willingness to relieve
pain; pain management could be lifesaving and a near-death experience; and how they
experienced memory loss with respect to the pain and pain management. Conclusion The experience of pain and pain management was described as hovering between heaven and
hell. We conclude that independent of which pain management given, staff should have an
individualized pain mangement approach towards the patient in order to achieve well
managed pain.
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Affiliation(s)
- Anna Unneby
- Department of Nursing and Department of Surgical and Perioperative Science Orthopedics, Umeå University, Umeå, Sweden
| | - Yngve Gustafson
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
| | - Birgitta Olofsson
- Department of Nursing and Department of Surgical and Perioperative Science Orthopedics, Umeå University, Umeå, Sweden
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11
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Tavernier JR. Original Research: Combating the Opioid Epidemic Through Nurse Use of Multimodal Analgesia: An Integrative Literature Review. Am J Nurs 2022; 122:20-32. [PMID: 35394962 DOI: 10.1097/01.naj.0000829772.68328.d5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Opioid misuse and addiction have become a national crisis. New pain management guidelines call for the use of multimodal analgesia to manage acute pain. In hospital settings, a clinical decision aid that emphasizes multimodal analgesia may improve nurses' use of this opioid-sparing strategy. PURPOSE This integrative review was conducted to provide nurses with evidence-based information on the opioid-sparing benefits of multimodal analgesia. METHODS A literature search was conducted using several electronic databases and Google Scholar. These initial searches yielded 136 articles of interest. Twenty-eight were selected for retrieval and in-depth appraisal; of these, 13 met all inclusion criteria. RESULTS Of the 13 reviewed studies, six were randomized controlled trials, six were retrospective cohort or population-based studies, and one was a qualitative study. Overall, the findings provided strong evidence that multimodal analgesia is effective in managing acute pain in surgical patients while reducing opioid requirements. Several studies also found that multimodal analgesia was associated with shorter hospital lengths of stay. CONCLUSIONS With the appropriate tools and education, nurses can make the transition from traditional opioids to multimodal analgesia strategies. In so doing, they can have a significant positive impact on the opioid epidemic. Hospital leaders must address nursing practice regarding the use of opioids alone versus multimodal analgesia for the management of acute pain. Clinical decision tools such as the Michigan Opioid Safety Score may help nurses adopt new acute pain management guidelines. Further research regarding nursing practice and the opioid epidemic is needed.
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Affiliation(s)
- Jennifer René Tavernier
- Jennifer René Tavernier is nursing faculty in the Health Professions Division at Lane Community College, Eugene, OR. Contact author: . The author has disclosed no potential conflicts of interest, financial or otherwise
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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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Wilson SH, Wilson PR, Bridges KH, Bell LH, Clark CA. Nonopioid Analgesics for the Perioperative Geriatric Patient: A Narrative Review. Anesth Analg 2022; 135:290-306. [PMID: 35202007 DOI: 10.1213/ane.0000000000005944] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Management of acute perioperative pain in the geriatric patient can be challenging as the physiologic and pharmacokinetic changes associated with aging may predispose older patients to opioid-related side effects. Furthermore, elderly adults are more susceptible to postoperative delirium and postoperative cognitive dysfunction, which may be exacerbated by both poorly controlled postoperative pain and commonly used pain medications. This narrative review summarizes the literature published in the past 10 years for several nonopioid analgesics commonly prescribed to the geriatric patient in the perioperative period. Nonopioid analgesics are broken down as follows: medications prescribed throughout the perioperative period (acetaminophen and nonsteroidal anti-inflammatory drugs), medications limited to the acute perioperative setting (N-methyl-D-aspartate receptor antagonists, dexmedetomidine, dexamethasone, and local anesthetics), and medications to be used with caution in the geriatric patient population (gabapentinoids and muscle relaxants). Our search identified 1757 citations, but only 33 specifically focused on geriatric analgesia. Of these, only 21 were randomized clinical trials' and 1 was a systematic review. While guidance in tailoring pain regimens that focus on the use of nonopioid medications in the geriatric patient is lacking, we summarize the current literature and highlight that some nonopioid medications may extend benefits to the geriatric patient beyond analgesia.
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Affiliation(s)
- Sylvia H Wilson
- From the Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
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14
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Davies A, Murray J, Zalmay P, Ross E, Dar S, Wilson H. Transdermal Buprenorphine for Pain Management Following a Neck of Femur Fracture. Geriatr Orthop Surg Rehabil 2022; 13:21514593211070260. [PMID: 35070476 PMCID: PMC8777329 DOI: 10.1177/21514593211070260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/08/2021] [Accepted: 12/10/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Pain management in patients with hip fractures can be challenging. Poor pain control is associated with reduced mobility and increased morbidity. Inadequate analgesia in patients with dementia is a concern. After using several different alternatives, transdermal buprenorphine was chosen as a standardised approach for analgesia in patients with fragility fracture in our hospital. There is limited evidence on the use of buprenorphine in this population. Our aim was to investigate the safety and effectiveness of transdermal buprenorphine in patients with hip fractures. Methods A review of consecutive patients presenting with a hip fracture from June 2018 to December 2018 was conducted using medical records. Our primary outcome was the incidence of complications as a consequence of transdermal buprenorphine. Our secondary outcome was adequate analgesia measured by reviewing the requirement for analgesia during the first week following the patient’s admission. Analgesia demands were considered adequate if patients required less than 20 mg of oral morphine in total during the first week following injury. Results In total, 148 patients presented with a hip fracture during the study period. 128 patients had documented evidence of buprenorphine patch application. Complete data was available for the primary outcome of complications in all cases. Data was available for the secondary outcome in 124 patients. Buprenorphine was discontinued in 24 patients (19%), most commonly due to due to concerns about contribution to hypoactive delirium (9%), and when strong analgesia was no longer required (4%). There were no severe complications. Adequate analgesia was achieved using this regime in 68% patients. 38 patients (32%) required more than 20 mg of oral morphine sulphate solution in the first week post-admission. Conclusion This series suggests that transdermal buprenorphine is safe and effective in the management of pain following a neck of femur fragility fracture.
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Affiliation(s)
- Andrew Davies
- Department of Bioengineering, Imperial College London, London, UK
| | - Jane Murray
- Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK
| | - Pardis Zalmay
- Department of Geriatrics, Royal Surrey Hospital NHS Trust, Guildford, Surrey, UK
| | - Ewan Ross
- Department of Geriatrics, Royal Surrey Hospital NHS Trust, Guildford, Surrey, UK
| | - Shumaila Dar
- Department of Geriatrics, Royal Surrey Hospital NHS Trust, Guildford, Surrey, UK
| | - Helen Wilson
- Department of Geriatrics, Royal Surrey Hospital NHS Trust, Guildford, Surrey, UK
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15
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De Vincentis A, Behr AU, Bellelli G, Bravi M, Castaldo A, Galluzzo L, Iolascon G, Maggi S, Martini E, Momoli A, Onder G, Paoletta M, Pietrogrande L, Roselli M, Ruggeri M, Ruggiero C, Santacaterina F, Tritapepe L, Zurlo A, Antonelli Incalzi R. Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus. Aging Clin Exp Res 2021; 33:2405-2443. [PMID: 34287785 DOI: 10.1007/s40520-021-01898-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues. AIM To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF. METHODS A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence. RESULTS A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics). CONCLUSION These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.
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Aches and Pain in the Geriatric Trauma Patient. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00202-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Carter JA, Black LK, Sharma D, Bhagnani T, Jahr JS. Efficacy of non-opioid analgesics to control postoperative pain: a network meta-analysis. BMC Anesthesiol 2020; 20:272. [PMID: 33109098 PMCID: PMC7592505 DOI: 10.1186/s12871-020-01147-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/03/2020] [Indexed: 12/19/2022] Open
Abstract
Background The aim of this network meta-analysis (NMA) was to evaluate the safety and efficacy of intravenous (IV) Meloxicam 30 mg (MIV), an investigational non-steroidal anti-inflammatory drug (NSAID), and certain other IV non-opioid analgesics for moderate-severe acute postoperative pain. Methods We searched PubMed and CENTRAL for Randomized Controlled Trials (RCT) (years 2000–2019, adult human subjects) of IV non-opioid analgesics (IV NSAIDs or IV Acetaminophen) used to treat acute pain after abdominal, hysterectomy, bunionectomy or orthopedic procedures. A Bayesian NMA was conducted in R to rank treatments based on the standardized mean differences in sum of pain intensity difference from baseline up to 24 h postoperatively (sum of pain intensity difference: SPID 24). The probability and the cumulative probability of rank for each treatment were calculated, and the surface under the cumulative ranking curve (SUCRA) was applied to distinguish treatments on the basis of their outcomes such that higher SUCRA values indicate better outcomes. The study protocol was prospectively registered with by PROSPERO (CRD42019117360). Results Out of 2313 screened studies, 27 studies with 36 comparative observations were included, producing a treatment network that included the four non-opioid IV pain medications of interest (MIV, ketorolac, acetaminophen, and ibuprofen). MIV was associated with the largest SPID 24 for all procedure categories and comparators. The SUCRA ranking table indicated that MIV had the highest probability for the most effective treatment for abdominal (89.5%), bunionectomy (100%), and hysterectomy (99.8%). MIV was associated with significantly less MME utilization versus all comparators for abdominal procedures, hysterectomy, and versus acetaminophen in orthopedic procedures. Elsewhere MME utilization outcomes for MIV were largely equivalent or nominally better than other comparators. Odds of ORADEs were significantly higher for all comparators vs MIV for orthopedic (gastrointestinal) and hysterectomy (respiratory). Conclusions MIV 30 mg may provide better pain reduction with similar or better safety compared to other approved IV non-opioid analgesics. Caution is warranted in interpreting these results as all comparisons involving MIV were indirect.
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Affiliation(s)
- John A Carter
- Blue Point LLC, 711 Warrenville Road, Wheaton, IL, 60189, USA.
| | | | | | | | - Jonathan S Jahr
- Department of Anesthesiology and Perioperative Medicine, UCLA, Los Angeles, CA, USA
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Shikatani Y, Soh J, Shien K, Kurosaki T, Ohtani S, Yamamoto H, Taniguchi A, Okazaki M, Sugimoto S, Yamane M, Oto T, Morimatsu H, Toyooka S. Effectiveness of scheduled intravenous acetaminophen in the postoperative pain management of video-assisted thoracic surgery. Surg Today 2020; 51:589-594. [PMID: 32880060 DOI: 10.1007/s00595-020-02127-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The scheduled administration of intravenous acetaminophen (scheduled-IV-AcA) is one of the more effective multimodal analgesic approaches for postoperative pain in abdominal/orthopedic surgeries. However, there is little evidence concerning scheduled-IV-AcA after general thoracic surgery, especially when limited to video-assisted thoracoscopic surgery (VATS). We investigated the efficacy of scheduled-IV-AcA administration in patients after undergoing VATS. METHODS Ninety-nine patients who underwent VATS lobectomy or segmentectomy via an 8-cm access window and 1 camera port were retrospectively reviewed by categorizing them into groups either with scheduled-IV-AcA (Group AcA: n = 29) or without it (Group non-AcA: n = 70). Group AcA received 1 g of IV-AcA every 6 h from the end of the operation until the end of POD2. Postoperative pain was measured using a numeric rating scale (NRS) three times per day until discharge. RESULTS NRS scores were significantly lower in Group AcA with motion (on POD1 to the first point of POD2) than in Group non-AcA. Group non-AcA was also more likely to use additional analgesics than Group AcA (39% vs. 17%, p = 0.058). CONCLUSIONS Scheduled-IV-AcA administration is a safe and effective multimodal analgesic approach in patients undergoing VATS pulmonary resection via an 8-cm access window.
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Affiliation(s)
- Yoshinobu Shikatani
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Junichi Soh
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan.
| | - Kazuhiko Shien
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Takeshi Kurosaki
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Shinji Ohtani
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Hiromasa Yamamoto
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Arata Taniguchi
- Anesthesiology and Resuscitology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, Japan
| | - Mikio Okazaki
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Seiichiro Sugimoto
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Masaomi Yamane
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Takahiro Oto
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
| | - Hiroshi Morimatsu
- Anesthesiology and Resuscitology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, Japan
| | - Shinichi Toyooka
- Department of General Thoracic, Breast and Endocrine Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Okayama, 700-8558, Japan
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Effectiveness of Multimodal Pain Therapy on Reducing Opioid Use in Surgical Geriatric Hip Fracture Patients. J Trauma Nurs 2020; 27:207-215. [PMID: 32658061 DOI: 10.1097/jtn.0000000000000516] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is a need for appropriate pain control in the geriatric hip fracture population to prevent diminished function, increased mortality, and opioid dependence. Multimodal pain therapy is one method for reducing pain postoperatively while also decreasing opioid use in the geriatric hip fracture patient. This study aimed to determine whether multimodal pain therapy could decrease opioid use without increasing pain scores in surgical geriatric hip fracture patients. METHODS This was a before-and-after cohort study. The hospital implemented multimodal pain control order sets with a standardized pain regimen and performed retrospective chart review pre- and postorder set implementation for analysis. RESULTS A total of 248 patients were enrolled in the study: 131 in the preorder set group and 117 in the postorder set group. The mean postoperative oral morphine equivalent (OME) was significantly lower in the postorder set group than in the preorder set group (45.1 mg vs. 63.4 mg, respectively, p = .03). Compared with the preorder set group, total OME and postoperative OME were decreased by 22.6% (95% confidence interval [CI] -44.9, -3.8), 1-tailed p < .01, and 53.6% (95% CI -103.4, -16.1), 1-tailed p <.01 respectively, in the postorder set group. There was not a statistically significant difference in mean pain scores at 6, 24, and 48 hr postoperatively (p = .53, .10, and .99), respectively. CONCLUSION Implementing a multimodal approach to pain management may help reduce opioid use and may be a critical maneuver in averting the national opioid epidemic.
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Charlton K, Limmer M, Moore H. Intravenous versus oral paracetamol in a UK ambulance service: a case control study. Br Paramed J 2020; 5:1-6. [PMID: 33456379 PMCID: PMC7783910 DOI: 10.29045/14784726.2020.06.5.1.1] [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] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To determine the effectiveness of intravenous versus oral paracetamol (acetaminophen) in the management of acute pain in the out-of-hospital setting. METHODS We extracted ambulance electronic patient care records for all patients who received 1 g intravenous paracetamol throughout January 2019, and case matched these by sex and age with consecutive patients who received 1 g oral paracetamol over the same time period. Eligible for inclusion were all patients aged ≥ 18 who received 1 g paracetamol for acute pain and who were transported to the emergency department (ED). The primary outcome was the mean reduction in pain score using the numeric rating scale (NRS), with a reduction of 2 or more accepted as clinically significant. RESULTS 80 care records were eligible for analysis; 40 patients received intravenous and 40 patients received oral paracetamol. The mean age of both groups was 54 years (± 3 years) and 67.5% (n = 54) were female. Patients receiving intravenous paracetamol had a clinically significant mean (SD) improved pain score compared to those receiving oral paracetamol, 2.02 (1.64) versus 0.75 (1.76), respectively [p = 0.0013]. 13/40 (32.5%) patients who received intravenous paracetamol saw an improved pain score of ≥ 2 compared to 8/40 (20%) who received oral paracetamol. No patients received additional analgesia or reported any adverse symptoms. Abdominal pain, infection and trauma were the most common causes of pain in both groups. CONCLUSION Our study suggests that intravenous paracetamol is more effective than oral paracetamol when managing acute pain in the out-of-hospital setting. Our findings support further investigation of the role of paracetamol in paramedic practice using more robust methods.
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Affiliation(s)
- Karl Charlton
- North East Ambulance Service NHS Foundation Trust: ORCID iD: https://orcid.org/0000-0002-9601-1083
| | | | - Hayley Moore
- North East Ambulance Service NHS Foundation Trust
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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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Romanenko A, Кучин Ю, Бєлка К, Токар І. Perioperative pain management in elderly patients with а proximal femoral fracture: evidence review. PAIN MEDICINE 2020. [DOI: 10.31636/pmjua.v4i4.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The purpose of this article is to compare different methods of analgesia during perioperative period in elderly patients with а proximal femoral fracture. The incidence of hip fracture is high and also rises with the age, for example, In Great Britain, number of patients with a hip fracture will be approximately 100 000 in 2033, and it’s also associated with significant healthcare financing. Nevertheless, effective pain management is a big challenge for clinicians because of considerable problems in geriatric patients, including age, physiological changes in the elderly, preexisting comorbidities, cognitive impairment, high risk of delirium, problems with rehabilitation and probability of an independent life [12]. Opioids are still the main option for hip fracture pain management, despite differences in pharmacokinetics and pharmacodynamics in elderly patients, which are correlated with high frequency of side effects. Opioid-related adverse drug events are associated with worse patient outcomes such as morbidity, mortality and length of stay increase. Therefore, peripheral nerve blocks as part of multimodal analgesic technique can provide more effective pain control after hip fracture. Comprehensive literature searches focus on the use of peripheral nerves blocks as preoperative analgesia, as postoperative analgesia or as a supplement to general anesthesia for hip fracture surgery.
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23
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Factors that influence the quality of pain management in patients with skin traction. Int J Orthop Trauma Nurs 2020; 36:100713. [DOI: 10.1016/j.ijotn.2019.100713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/30/2019] [Accepted: 08/18/2019] [Indexed: 11/20/2022]
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Yamamoto N, Sakura S, Noda T, Nishiyama A, Dan'ura T, Matsui Y, Ozaki T. Comparison of the postoperative analgesic efficacies of intravenous acetaminophen and fascia iliaca compartment block in hip fracture surgery: A randomised controlled trial. Injury 2019; 50:1689-1693. [PMID: 30904248 DOI: 10.1016/j.injury.2019.03.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/07/2019] [Accepted: 03/09/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Managing pain during movement after hip fracture surgery is important for achieving earlier hip mobilisation and for preventing postoperative complications. In the present study, we tested the hypothesis that the fascia iliaca compartment block (FICB) would improve postoperative pain on movement compared with intravenous acetaminophen. METHODS In this prospective, randomised, controlled, parallel trial, patients were assigned to either the intravenous acetaminophen or the ultrasound-guided FICB group. Visual analog scale (VAS) pain scores were evaluated at 6, 9, 12, 18, 24 h, 2 days, and 7 days postoperatively. The primary outcome was VAS scores on movement at 24 h after surgery. The secondary outcomes were VAS scores on movement at the other time points, VAS scores at rest, the total number of rescue analgesics required and incidence of delirium during the first 24 h postoperatively, potential drug or block-related complications, and the time to first standing. RESULTS VAS scores on movement at 24 h after surgery were significantly lower in the FICB group than in the intravenous acetaminophen group [median (the 25th to 75th percentiles), 20 (10-30) vs 40 (30-53); P < 0.01]. The VAS scores on movement at any other time point and the scores at rest at 12 h after surgery were also significantly lower in the FICB group than in the intravenous acetaminophen group. The two groups did not differ in terms of the total number of rescue analgesics required or the incidence of delirium during the first 24 h postoperatively; complications; or the time to first standing. CONCLUSIONS FICB improved postoperative pain on movement compared with intravenous acetaminophen without increasing the complication rate. However, the total number of rescue analgesics required and the time to first standing were not significantly different between the two groups.
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Affiliation(s)
- Norio Yamamoto
- Department of Orthopaedic Surgery, Unnan City Hospital, Shimane, Japan.
| | - Shinichi Sakura
- Department of Anaesthesiology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Tomoyuki Noda
- Department of Musculoskeletal Traumatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akihiro Nishiyama
- Department of Orthopaedic Surgery, Unnan City Hospital, Shimane, Japan
| | - Tomoyuki Dan'ura
- Department of Orthopaedic Surgery, Unnan City Hospital, Shimane, Japan
| | - Yuzuru Matsui
- Department of Orthopaedic Surgery, Unnan City Hospital, Shimane, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
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Patterson DC, Cagle PJ, Poeran J, Zubizarreta N, Mazumdar M, Galatz LM, Anthony SG. Effectiveness of intravenous acetaminophen for postoperative pain management in shoulder arthroplasties: A population-based study. J Orthop Translat 2019; 18:119-127. [PMID: 31508315 PMCID: PMC6718947 DOI: 10.1016/j.jot.2018.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 10/29/2022] Open
Abstract
Background Intravenous acetaminophen (IV APAP) is an option in multimodal postoperative analgesia. Prior trials focus on hip and knee arthroplasties, whereas large-scale data on utilization and effectiveness in shoulder arthroplasties are lacking. Methods Data on 67,494 (452 hospitals) partial/total shoulder arthroplasties were extracted from the Premier claims database (2011-2016). Patients were categorized by receipt and dosage of IV APAP. Multilevel models measured associations between IV APAP and opioid utilization (in oral morphine equivalents), length/cost of stay and opioid-related complications. Effect estimates (adjusted % change) with 95% confidence intervals (CIs) are reported. Results IV APAP was used in 17.7% (n = 11,949) of patients with an increasing utilization trend. Most patients received only one dose on the day of surgery (69.5%; n = 8308). When adjusting for relevant covariates, IV APAP was not associated with meaningful effects on outcomes. Specifically, its use (versus no use) was not associated with decreased (but rather somewhat increased) opioid utilization: + 5.4% (CI 3.6-7.1%; P < 0.05). Conclusion In this first large-scale study that assesses IV APAP in shoulder arthroplasties, IV APAP use was not associated with decreased opioid utilization or the length/cost of stay. These results do not support routine use of IV APAP in this cohort, especially given its high cost. The translational potential for this article Multimodal pain control to assist in reducing the opioid pain medications are seen as a route to improved postoperative patient outcomes, better pain control and expedited hospital discharge. Acetaminophen plays a significant role in these protocols in many institutions, but it is not established if this expensive IV formulation is superior to the oral formulation. This study evaluates the use and effectiveness of IV acetaminophen following shoulder arthroplasty at a large number of institutions.
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Affiliation(s)
- Diana C Patterson
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Paul J Cagle
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Zubizarreta
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leesa M Galatz
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
| | - Shawn G Anthony
- Department of Orthopaedic Surgery, Mount Sinai Health System, New York, NY, USA
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26
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Weingarten TN, Taenzer AH, Elkassabany NM, Le Wendling L, Nin O, Kent ML. Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps. PAIN MEDICINE 2019; 19:2296-2315. [PMID: 29727003 DOI: 10.1093/pm/pny079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting Expert commentary. Methods Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andreas H Taenzer
- Departments of Anesthesiology.,Pediatrics, The Dartmouth Institute, Dartmouth Hitchcock Medical Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda Le Wendling
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Olga Nin
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Michael L Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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Soffin EM, Gibbons MM, Wick EC, Kates SL, Cannesson M, Scott MJ, Grant MC, Ko SS, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery. Anesth Analg 2019; 128:1107-1117. [PMID: 31094775 DOI: 10.1213/ane.0000000000003925] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.
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Affiliation(s)
- Ellen M Soffin
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maxime Cannesson
- Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Samantha S Ko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher L Wu
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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Talan DA, Saltzman DJ, DeUgarte DA, Moran GJ. Methods of conservative antibiotic treatment of acute uncomplicated appendicitis: A systematic review. J Trauma Acute Care Surg 2019; 86:722-736. [PMID: 30516592 PMCID: PMC6437084 DOI: 10.1097/ta.0000000000002137] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/09/2018] [Accepted: 10/29/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Meta-analyses and a recent guideline acknowledge that conservative management of uncomplicated appendicitis with antibiotics can be successful for patients who wish to avoid surgery. However, guidance as to specific management does not exist. METHODS PUBMED and EMBASE search of trials describing methods of conservative treatment was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS Thirty-four studies involving 2,944 antibiotic-treated participants were identified. The greatest experience with conservative treatment is in persons 5 to 50 years of age. In most trials, imaging was used to confirm localized appendicitis without evidence of abscess, phlegmon, or tumor. Antibiotics regimens were generally consistent with intra-abdominal infection treatment guidelines and used for a total of 7 to 10 days. Approaches ranged from 3-day hospitalization on parenteral agents to same-day hospital or ED discharge of stable patients with outpatient oral antibiotics. Minimum time allowed before response was evaluated varied from 8 to 72 hours. Although pain was a common criterion for nonresponse and appendectomy, analgesic regimens were poorly described. Trials differed in use of other response indicators, that is, white blood cell count, C-reactive protein, and reimaging. Diet ranged from restriction for 48 hours to as tolerated. Initial response rates were generally greater than 90% and most participants improved by 24 to 48 hours, with no related severe sepsis or deaths. In most studies, appendectomy was recommended for recurrence; however, in several, patients had antibiotic retreatment with success. CONCLUSION While further investigation of conservative treatment is ongoing, patients considering this approach should be advised and managed according to study methods and related guidelines to promote informed shared decision-making and optimize their chance of similar outcomes as described in published trials. Future studies that address biases associated with enrollment and response evaluation, employ best-practice pain control and antibiotic selection, better define cancer risk, and explore longer time thresholds for response, minimized diet restriction and hospital stays, and antibiotic re-treatment will further our understanding of the potential effectiveness of conservative management. LEVEL OF EVIDENCE Systematic review, level II.
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Affiliation(s)
- David A Talan
- From the Department of Emergency Medicine (D.A.T., G.J.M.); Division of Infectious Diseases (D.A.T., G.J.M.), Department of Medicine; Department of Surgery (D.J.S.), Olive View-UCLA Medical Center, Sylmar; and Department of Surgery (D.A.D.), Division of Pediatric Surgery, Harbor-UCLA Medical Center, Torrance, California
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Marcantonio AJ, Pace M, Brabeck D, Nault KM, Trzaskos A, Anderson R. Team Approach: Management of Postoperative Delirium in the Elderly Patient with Femoral-Neck Fracture. JBJS Rev 2019; 5:e8. [PMID: 29064845 DOI: 10.2106/jbjs.rvw.17.00026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Andrew J Marcantonio
- Departments of Orthopaedics (A.J.M.), Anesthesiology (M.P.), Hospital Medicine (D.B.), and Rehabilitation Services (A.T.), and Surgical Critical Care Clinical Pharmacy (K.M.N. and R.A.), Lahey Hospital and Medical Center, Burlington, Massachusetts
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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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White SM, Foss NB, Griffiths R. Anaesthetic aspects in the treatment of fragility fracture patients. Injury 2018; 49:1403-1408. [PMID: 29958684 DOI: 10.1016/j.injury.2018.06.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 06/21/2018] [Indexed: 02/02/2023]
Abstract
As longevity increases globally, the number of older, frailer, comorbid patients requiring fragility fracture surgery will increase. Fundamentally, anaesthesia should aim to maintain these patients' pre-fracture cognitive and physiological trajectories and facilitate early (ie day 1) postoperative recovery. This review describes the 10 general principles of anaesthesia for fragility fracture surgery that best achieve these aims: multidisciplinary care, 'getting it right first time', timely surgery, standardisation, sympathetic anaesthesia, avoiding ischaemia, sympathetic analgesia, re-enablement, data collection and training.
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Affiliation(s)
- S M White
- FRCA, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, East Sussex, BN2 5BE, United Kingdom.
| | - N B Foss
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegård Allé 30, Hvidovre, Denmark
| | - R Griffiths
- North West Anglia Hospitals NHS FT, Bretton Gate, Peterborough, PE3 9GZ, United Kingdom
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Infiltration Techniques for Local Infiltration Analgesia With Liposomal Bupivacaine in Extracapsular and Intracapsular Hip Fracture Surgery: Expert Panel Opinion. J Orthop Trauma 2018; 32 Suppl 2:S5-S10. [PMID: 30028758 DOI: 10.1097/bot.0000000000001227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Liposomal bupivacaine (LB) has demonstrated efficacy in improving pain scores and reducing opioid consumption across a variety of surgical settings, including orthopaedic surgery. However, meticulous infiltration techniques combined with a multimodal approach are important to optimizing outcomes. METHODS A panel of 4 orthopaedic surgeons and 3 anesthesiologists convened on April 1, 2017, to discuss current practices and develop a consensus statement regarding local infiltration analgesia with LB for extracapsular and intracapsular hip fracture surgery, including LB infiltration techniques. RESULTS Optimizing surgical outcomes with LB in hip fracture surgery requires an understanding of the neuroanatomy of the surgical site and the pharmacology of the drug. Meticulous infiltration technique is critical to achieve optimal results with LB given its viscosity and reduced diffusion compared with bupivacaine HCl. For extracapsular procedures, a total injection volume of 120 mL is recommended, whereas intracapsular procedures typically require a lower volume (∼80 mL). In both cases, infiltration is best achieved using a 22-gauge needle and applying a tracking and/or fanning technique. To ensure optimal placement, LB should be infiltrated using multiple, small-volume (1- to 5-mL) injections spaced at 1.0-cm intervals. CONCLUSIONS These consensus recommendations regarding LB infiltration techniques can serve as a resource for designing clinical studies to evaluate outcomes using periarticular infiltration of LB in extracapsular and intracapsular hip fracture surgery as part of a multimodal pain management approach. LEVEL OF EVIDENCE Level V.
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33
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Suarez JC, Al-Mansoori AA, Kanwar S, Semien GA, Villa JM, McNamara CA, Patel PD. Effectiveness of Novel Adjuncts in Pain Management Following Total Knee Arthroplasty: A Randomized Clinical Trial. J Arthroplasty 2018; 33:S136-S141. [PMID: 29628196 DOI: 10.1016/j.arth.2018.02.088] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/20/2018] [Accepted: 02/22/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) can be associated with significant pain which can negatively impact outcomes. Multiple strategies have been employed to reduce pain. The aim of this study is to compare the effectiveness of 3 different pain management modalities after TKA that included (1) our standardized knee injection cocktail and oral acetaminophen, (2) liposomal bupivacaine periarticular injection and oral acetaminophen, and (3) our standardized knee injection cocktail and intravenous (IV) acetaminophen. METHODS A prospective randomized clinical trial was conducted with 3 perioperative pain management regimes: oral acetaminophen and our standardized knee injection cocktail (standard group), oral acetaminophen and liposomal bupivacaine periarticular injection (LB group), and IV acetaminophen and our standardized knee injection cocktail (IVA group). Primary outcome measures included visual analog scale, total morphine equivalents, and the opioid-related symptoms distress scale at 24 and 48 hours postoperatively. RESULTS There were no significant differences on visual analog scale/opioid-related symptoms distress scale scores 24 hours after surgery. The LB group required significantly more narcotics (total morphine equivalents) than the standard (P = .025) and IVA groups (P = .032). No significant differences were observed on any of the outcomes measured at 48 hours after surgery. CONCLUSION Our data suggest that there is no added benefit in the routine use of IV acetaminophen or liposomal bupivacaine after TKA.
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Affiliation(s)
- Juan C Suarez
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Ahmed A Al-Mansoori
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Sumit Kanwar
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | | | - Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Colin A McNamara
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Preetesh D Patel
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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White SM, Altermatt F, Barry J, Ben-David B, Coburn M, Coluzzi F, Degoli M, Dillane D, Foss NB, Gelmanas A, Griffiths R, Karpetas G, Kim JH, Kluger M, Lau PW, Matot I, McBrien M, McManus S, Montoya-Pelaez LF, Moppett IK, Parker M, Porrill O, Sanders RD, Shelton C, Sieber F, Trikha A, Xuebing X. International Fragility Fracture Network Delphi consensus statement on the principles of anaesthesia for patients with hip fracture. Anaesthesia 2018; 73:863-874. [DOI: 10.1111/anae.14225] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2018] [Indexed: 01/16/2023]
Affiliation(s)
- S. M. White
- Brighton and Sussex University Hospitals NHS Trust; Brighton East Sussex UK
| | - F. Altermatt
- División de Anestesiología; Escuela de Medicina; Pontificia Universidad Católica de Chile; Santiago Chile
| | - J. Barry
- Cairns Hospital; Queensland Australia
| | - B. Ben-David
- University of Pittsburgh Medical Centre; Pittsburgh PA USA
| | - M. Coburn
- Medical Faculty; RWTH Aachen University; Aachen Germany
| | - F. Coluzzi
- Department Medical and Surgical Sciences and Biotechnologies; Sapienza University of Rome; Latina Italy
| | - M. Degoli
- Ospedale Civile di Baggiovara; Azienda Ospedaliero Universitaria di Modena; Modena Italy
| | - D. Dillane
- Anesthesiology and Pain Medicine; University of Alberta; Canada
| | - N. B. Foss
- Department of Anaesthesiology and Intensive Care Medicine; Hvidovre University Hospital; Hvidovre Denmark
| | - A. Gelmanas
- Hospital of Lithuanian University of Health Sciences Kauno klinikos; Lithuania
| | - R. Griffiths
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - G. Karpetas
- General University Hospital of Patras; Rio Greece
| | - J.-H. Kim
- Korea University College of Medicine; Seoul South Korea
| | | | - P.-W. Lau
- University of Hong Kong; Hong Kong China
| | - I. Matot
- Critical Care and Pain; Tel Aviv Medical Center; Sackeler School of Medicine; Tel Aviv Israel
| | | | | | - L. F. Montoya-Pelaez
- Department of Anaesthesia and Perioperative Medicine; Groote Schuur Hospital; University of Cape Town; Cape Town South Africa
| | - I. K. Moppett
- Anaesthesia and Critical Care Section; Division of Clinical Neuroscience; Queen's Medical Centre Campus; Nottingham University Hospitals NHS Trust; University of Nottingham; Nottingham UK
| | - M. Parker
- Peterborough and Stamford Hospitals NHS Trust; Peterborough UK
| | - O. Porrill
- New Somerset Hospital; University of Cape Town; South Africa
| | | | - C. Shelton
- Lancaster Medical School and Wythenshawe Hospital; Manchester UK
| | - F. Sieber
- Johns Hopkins Bayview Medical Center; Baltimore MD USA
| | - A. Trikha
- All India Institute of Medical Sciences; New Delhi India
| | - X. Xuebing
- University of Hong Kong-Shenzhen Hospital; Shenzhen China
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Likar R, Jaksch W, Aigmüller T, Brunner M, Cohnert T, Dieber J, Eisner W, Geyrhofer S, Grögl G, Herbst F, Hetterle R, Javorsky F, Kress HG, Kwasny O, Madersbacher S, Mächler H, Mittermair R, Osterbrink J, Stöckl B, Sulzbacher M, Taxer B, Todoroff B, Tuchmann A, Wicker A, Sandner-Kiesling A. Interdisziplinäres Positionspapier „Perioperatives Schmerzmanagement“. Schmerz 2017; 31:463-482. [DOI: 10.1007/s00482-017-0217-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Management of Postoperative Pain in Opioid-Tolerant Patients. J Perianesth Nurs 2017; 30:436-43. [PMID: 26408520 DOI: 10.1016/j.jopan.2015.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 08/14/2015] [Indexed: 11/24/2022]
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Cowan R, Lim JH, Ong T, Kumar A, Sahota O. The Challenges of Anaesthesia and Pain Relief in Hip Fracture Care. Drugs Aging 2017; 34:1-11. [PMID: 27913981 DOI: 10.1007/s40266-016-0427-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The care of the older person with hip fracture is complicated by their comorbid condition, limited physiological reserve, cognitive impairment and frailty. Two aspects of hip fracture management that have received considerable attention are how best to manage the pain associated with it and the ideal mode of anaesthesia. Existing literature has reported on the suboptimal treatment of pain in this orthogeriatric cohort. With recent advancements in medical care, a number of options have emerged as alternatives to conservative systemic analgesia. Systemic analgesia, such as opioids, can lead to untoward side effects, especially in this particular group of patients. Hence, peripheral nerve blocks, epidural analgesia and regional anaesthesia have emerged as options in the delivery of adequate pain relief in hip fractures. Besides that, there is ongoing debate regarding the appropriate anaesthesia technique for surgical repair of the fractured hip. The benefits and risks related to either spinal anaesthesia or general anaesthesia have been subject to studies determining which method is associated with better short- and long-term outcomes. In this review, we aim to examine the evidence behind the different analgesia options available, compare spinal and general anaesthesia, and discuss the importance of the multidisciplinary orthogeriatric model of care in hip fracture and its potential role in other fragility fractures.
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MESH Headings
- Aged
- Aged, 80 and over
- Analgesia, Epidural/methods
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anesthesia, Conduction/methods
- Anesthesia, General/methods
- Anesthesia, Spinal/methods
- Female
- Hip Fractures/drug therapy
- Hip Fractures/surgery
- Humans
- Male
- Nerve Block/methods
- Pain/prevention & control
- Pain Management/methods
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Affiliation(s)
- Rachel Cowan
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Jun Hao Lim
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Terence Ong
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK.
- School of Medicine, University of Nottingham, Medical School, Nottingham, UK.
| | - Ashok Kumar
- School of Medicine, University of Nottingham, Medical School, Nottingham, UK
| | - Opinder Sahota
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
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Yasuhara T, Hishikawa T, Agari T, Kurozumi K, Ichikawa T, Kameda M, Shinko A, Ishida J, Hiramatsu M, Kobayashi M, Matsuoka Y, Sasaki T, Soga Y, Yamanaka R, Ashiwa T, Arioka A, Hashimoto Y, Misaki A, Ishihara Y, Sato M, Morimatsu H, Date I. Perioperative Management Center (PERIO) for Neurosurgical Patients. Neurol Med Chir (Tokyo) 2016; 56:574-9. [PMID: 27396396 PMCID: PMC5027240 DOI: 10.2176/nmc.oa.2016-0085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Perioperative management is critical for positive neurosurgical outcomes. In order to maintain safe and authentic perioperative management, a perioperative management center (PERIO) was introduced to patients of our Neurosurgery Department beginning in June 2014. PERIO involves a multidisciplinary team consisting of anesthesiologists, dentists/dental hygienists/technicians, nurses, physical therapists, pharmacists, and nutritionists. After neurosurgeons decide on the course of surgery, a preoperative evaluation consisting of blood sampling, electrocardiogram, chest X-ray, and lung function test was performed. The patients then visited the PERIO clinic 7–14 days before surgery. One or two days before surgery, the patients without particular issues enter the hospital and receive a mouth cleaning one day before surgery. After surgery, postoperative support involving eating/swallowing evaluation, rehabilitation, and pain control is provided. The differences in duration from admission to surgery, cancellation of surgery, and postoperative complications between PERIO and non-PERIO groups were examined. Eighty-five patients were enrolled in the PERIO group and 131 patients in the non-PERIO group. The duration from admission to surgery was significantly decreased in the PERIO group (3.6 ± 0.3 days), compared to that in the non-PERIO group (4.7 ± 0.2 days). There was one cancelled surgery in the PERIO group and six in the non-PERIO group. Postoperative complications and the overall hospital stay did not differ between the two groups. The PERIO system decreased the duration from admission to surgery, and it is useful in providing high-quality medical service, although the system should be improved so as not to increase the burden on medical staff.
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Affiliation(s)
- Takao Yasuhara
- Department of Neurological Surgery, Okayama University Graduate School of Medicine
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Abstract
Although opioids are widely used for the management of pain in patients with hip fracture, these medications are known to have a wide range of adverse effects that can result in suboptimal outcomes or serious life-threatening complications. Common opioid-related adverse events include gastrointestinal effects, central nervous system effects, and respiratory depression. Hip fractures occur most frequently among the elderly-the very population that is most susceptible to the adverse effects of opioids and the risks of serious physiological complications. There has been much interest during recent years in identifying alternative analgesic approaches that are less opioid-dependent. There is good evidence to show that nerve blocks can be effective in managing the acute pain associated with hip fracture. However, sciatic and femoral nerve blocks seem to increase the risk of several clinically significant adverse events. A retrospective cohort study that examined the effectiveness of scheduled intravenous acetaminophen as part of the pain management protocol for hip fracture patients revealed significant improvement in pain scores, narcotic use, length of stay, and missed physical therapy sessions. Limited data exist in patients with hip fracture on the effects of infiltration of the surgical site with the local anesthetic agent, bupivacaine. However, extensive use of bupivacaine in hip arthroplasty surgery suggests that it may be highly beneficial in the patient with hip fracture.
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