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Seki K, Seki T, Imagama T, Matsuki Y, Kawakami T, Sakai T. Efficacy of repeated administration of intravenous acetaminophen for pain management after total knee arthroplasty. Acta Orthop Belg 2023; 89:469-475. [PMID: 37935231 DOI: 10.52628/89.3.10347] [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: 11/09/2023]
Abstract
Intravenous acetaminophen is an integral component of multimodal postoperative pain management. This prospective study aims to assess the efficacy of the repeated administration of intravenous acetaminophen and the impact on postoperative patient satisfaction with postoperative pain management after total knee arthroplasty (TKA). We enrolled 98 patients scheduled for unilateral TKA. Patients were randomly assigned to receive either 1000 mg of intravenous acetaminophen at 6-hour intervals (AAP group) or not to receive intravenous acetaminophen (control group). All patients underwent single-shot femoral nerve block after general anesthesia, as well as intraoperative periarticular infiltration of analgesia prior to implantation. The primary outcome was the postoperative numerical rating scale (NRS) pain score at rest. The NRS score was measured just before the administration of study drugs, immediately after arrival in the ward (time 0), and at 6, 12, 18, 24, and 48 h (time 1 to time 5, respectively) postoperatively. We also evaluated the mean doses of rescue opioid use for 24 h postoperatively. At time 5, the AAP group had significantly improved mean NRS score than controls (3.0 vs. 4.0; P < 0.01). Rescue opioid use was significantly lower in the AAP group for 24 hours compared to controls (0.3 μg vs. 0.9 μg; P < 0.01). Repeated intravenous acetaminophen administration after TKA may provide better analgesia and reduce opioid use.
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Phillips SJ, Peck CJ, Pourtaheri N, Reategui A, Carney M, Dinis J, Park KE, Maniskas S, Lopez J, Steinbacher DM. Decreasing Inpatient Opioid Use Following Orthognathic Surgery. J Craniofac Surg 2021; 32:2808-2811. [PMID: 34727482 DOI: 10.1097/scs.0000000000008001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Strategies to decrease postoperative opioid use are important for mitigating the immediate and long-term risks associated with their use. We aimed to investigate the impact of perioperative various factors on inpatient opioid needs for patients undergoing orthognathic surgery. METHODS This was a retrospective cohort study of all patients who underwent orthognathic surgery performed by the senior author from 2012 to 2018. Patients were grouped into intravenous (IV) acetaminophen and no-IV acetaminophen cohorts. Opioid medications received by patients during hospital stay were converted to mean morphine equivalents (MME) for comparison. Additional factors that influenced opioid consumption, such as transexamic acid (TXA) and postoperative nausea and vomiting (PONV), were identified using univariate analysis. Factors found to have statistical significance were added to a multivariate linear regression model. RESULTS 319 patients were included. Those who received IV acetaminophen had lower rates of total opioid use (57.3 versus 74.8 MME; P = 0.002) and postoperative opioid use (24.0 versus 37.7 MME; P < 0.001). Perioperative prothrombotic agents, such as TXA, were associated with lower total and postoperative MME (P = 0.005, P = 0.002). Multivariate regression analysis showed that increased PONV resulted in increased postoperative opioid use, whereas perioperative acetaminophen lowered total and postoperative quantities. CONCLUSIONS Perioperative IV acetaminophen is an effective method for decreasing inpatient opioid analgesia after orthognathic surgery. Intravenous TXA and PONV control may provide additional benefit to decreasing inpatient opioid consumption. More research as to the mechanisms and ideal clinical applications for both IV acetaminophen and TXA are warranted.
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Affiliation(s)
- Sarah J Phillips
- Plastic and Oral and Maxillofacial SUrgery, Yale New Haven Health, New Haven CT
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Altshuler D, Yu K, Papadopoulos J, Dabestani A. Is P&T Ready to Add Rapid Cycle Analytics to Formulary? Hosp Pharm 2021; 56:430-435. [PMID: 34720142 DOI: 10.1177/0018578720918341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: The intent of this article is to evaluate a novel approach, using rapid cycle analytics and real world evidence, to optimize and improve the medication evaluation process to help the formulary decision making process, while reducing time for clinicians. Summary: The Pharmacy and Therapeutics (P&T) Committee within each health system is responsible for evaluating medication requests for formulary addition. Members of the pharmacy staff prepare the drug monograph or a medication use evaluation (MUE) and allocate precious clinical resources to review patient charts to assess efficacy and value. We explored a novel approach to evaluate the value of our intravenous acetaminophen (IV APAP) formulary admittance. This new methodology, called rapid cycle analytics, can assist hospitals in meeting and/or exceeding the minimum criteria of formulary maintenance as defined by the Joint Commission Standards. In this particular study, we assessed the effectiveness of IV APAP in total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures. We assessed the correlation to same-stay opioid utilization, average length of inpatient stay and post anesthesia care unit (PACU) time. Conclusion: We were able to explore and improve our organization's approach in evaluating medications by partnering with an external analytics expert to help organize and normalize our data in a more robust, yet time efficient manner. Additionally, we were able to use a significantly larger external data set as a point of reference. Being able to perform this detailed analytical exercise for thousands of encounters internally and using a data warehouse of over 130 million patients as a point of reference in a short time has improved the depth of our assessment, as well as reducing valuable clinical resources allocated to MUEs to allow for more direct patient care. This clinically real-world and data-rich analytics model is the necessary foundation for using Artificial or Augmented Intelligence (AI) to make real-time formulary and drug selection decisions.
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Affiliation(s)
| | - Kenny Yu
- NYU Langone Health, New York City, NY, USA
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Yu S, Eftekhary N, Wiznia D, Schwarzkopf R, Long WJ, Bosco JA, Iorio R. Evolution of an Opioid Sparse Pain Management Program for Total Knee Arthroplasty With the Addition of Intravenous Acetaminophen. J Arthroplasty 2020; 35:89-94. [PMID: 31521446 DOI: 10.1016/j.arth.2019.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Perioperative pain management for patients undergoing total knee arthroplasty (TKA) improves patient outcomes and facilitates recovery. In this study, we compared the effects of preoperative oral acetaminophen vs intravenous (IV) acetaminophen administered once intraoperatively and once postoperatively. METHODS Two standardized, multimodal analgesia protocols were compared in patients undergoing primary, unilateral TKA. The oral acetaminophen cohort (OA) received doses of oral acetaminophen preoperatively and an as-needed basis postoperatively (n = 698). The IV acetaminophen cohort (IA) received 2 doses of IV acetaminophen, one intraoperative and one 6 hours postoperatively, with no oral acetaminophen given (n = 318). No other variables were significantly changed during the study period. RESULTS The IV acetaminophen group demonstrated less narcotic usage on postoperative day 0 (OA: 13.3 mme [morphine mg equivalents], IA: 6.2 mme, P < .001) and overall usage (OA: 66.1 mme, IA: 48.5 mme, P < .001). Pain scores were statistically and clinically significantly decreased in the immediate postoperative (the first 8 hours) for the IA group (OA: patient-reported pain scores of 4.0; IA: patient-reported pain scores of 2.0, P < .001). Both groups progressed and completed their physical therapy similarly for each postoperative day. Length of stay and percent discharge home were slightly improved in the IA group as well, however did not reach statistical difference. CONCLUSION An iterative approach to multimodal pain management after TKA led to improvements in narcotic usage, pain scores, and several quality measures. IV acetaminophen is an integral and effective part of our opioid-sparing multimodal pain regimen in TKA.
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Affiliation(s)
- Stephen Yu
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Nima Eftekhary
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Daniel Wiznia
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - William J Long
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Richard Iorio
- Department of Orthpaedic Surgery, Brigham Health, Brigham and Women's Hospital, Boston, MA
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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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Soffin EM, Gibbons MM, Ko CY, Kates SL, Wick E, Cannesson M, Scott MJ, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 128:441-453. [DOI: 10.1213/ane.0000000000003564] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Soffin EM, Wu CL. Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review. HSS J 2019; 15:57-65. [PMID: 30863234 PMCID: PMC6384219 DOI: 10.1007/s11420-018-9652-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Elective total joint arthroplasty may be a gateway to long-term opioid use. QUESTIONS/PURPOSE We sought to review the literature on multimodal and regional analgesia as a strategy to minimize perioperative opioid use and control pain in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS We conducted a narrative review to assess the state of the evidence informing opioid-sparing analgesics for THA and TKA. A PubMed search was conducted for English-language articles published before April 2018. We preferentially included well-designed randomized controlled trials, systematic reviews, and meta-analyses. Where the highest levels of evidence were not yet apparent, we evaluated retrospective and/or observational studies. RESULTS Multimodal analgesia emphasizing nonsteroidal anti-inflammatory agents and acetaminophen is associated with decreases in perioperative opioid use for THA and TKA. Regional analgesia, including peripheral nerve blocks and local infiltration analgesia, is also associated with decreased perioperative opioid use for THA and TKA. Emerging topics in post-arthroplasty analgesia include (1) the value of nonsteroidal anti-inflammatory drugs, (2) the use of peripheral nerve catheters and extended-release local anesthetics to prolong the duration of opioid-free analgesia, and (3) novel peripheral nerve blocks, exemplified by the IPACK (interspace between the popliteal artery and posterior capsule of the knee) block for TKA. CONCLUSIONS The use of multimodal analgesia with regional techniques may decrease perioperative opioid use for patients undergoing THA and TKA. These techniques should be part of a comprehensive perioperative plan to promote adequate analgesia while minimizing overall opioid exposure.
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Affiliation(s)
- Ellen M. Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD USA
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Nelson AM, Wu CL. “Randomization at the Expense of Relevance.” L. J. Cronbach and Intravenous Acetaminophen as an Opioid-Sparing Adjuvant. Anesth Analg 2018; 127:1099-1100. [DOI: 10.1213/ane.0000000000003577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Shi SB, Wang XB, Song JM, Guo SF, Chen ZX, Wang Y. Efficacy of intravenous acetaminophen in multimodal management for pain relief following total knee arthroplasty: a meta-analysis. J Orthop Surg Res 2018; 13:250. [PMID: 30305124 PMCID: PMC6180443 DOI: 10.1186/s13018-018-0950-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/19/2018] [Indexed: 01/08/2023] Open
Abstract
Background The efficacy of intravenous acetaminophen in multimodal pain management in patients undergoing total knee arthroplasty (TKA) is controversial. The purpose of this meta-analysis was to compare the efficacy of intravenous acetaminophen versus placebo in TKA. Methods Randomized controlled trials (RCTs) or retrospective cohort studies (RCSs) concerning related topics were retrieved from PubMed (1996–June 2018), Embase (1980–June 2018), and the Cochrane Library (CENTRAL June 2018). Any studies comparing intravenous acetaminophen with a placebo were included in this meta-analysis. Meta-analysis results were collected and analyzed by Stata 12.0. Subgroup analysis was performed according to the general characteristics of the patients. Results In total, the patients from six studies met the inclusion criteria. Our meta-analysis results indicated that compared with a control group, intravenous acetaminophen was associated with reductions in total morphine consumption and visual analogue scale (VAS) score at postoperative day (POD) 3. However, there was no significant difference in morphine consumption at POD 1 or in VAS at POD 1 or POD 2. Moreover, there was no significant difference in the length of hospital stay. Conclusions Based on our results, intravenous acetaminophen in multimodal management has shown better efficacy in pain relief at POD 3 and has morphine-sparing effects. High-quality studies with more patients are needed in the future. Electronic supplementary material The online version of this article (10.1186/s13018-018-0950-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Song-Bo Shi
- Orthopaedics Department, Gansu Provincial Hospital, Lanzhou, 730000, Gansu, China
| | - Xing-Bo Wang
- Orthopaedics Department, Gansu Provincial Hospital, Lanzhou, 730000, Gansu, China
| | - Jian-Min Song
- Orthopaedics Department, Gansu Provincial Hospital, Lanzhou, 730000, Gansu, China
| | - Shi-Fang Guo
- Orthopaedics Department, Gansu Provincial Hospital, Lanzhou, 730000, Gansu, China
| | - Zhi-Xin Chen
- Orthopaedics Department, Gansu Provincial Hospital, Lanzhou, 730000, Gansu, China
| | - Yin Wang
- Orthopaedics Department, Gansu Provincial Hospital, Lanzhou, 730000, Gansu, China.
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