Impact of intraoperative acetaminophen administration on postoperative opioid consumption in patients undergoing hip or knee replacement

The effect of timing of intravenous paracetamol on perioperative pain and cytokine levels following laparoscopic bariatric surgery, a randomized controlled trial

OBJECTIVE

Bariatric surgeries involve manipulation of the viscera and are associated with significant postoperative pain. Paracetamol is a nonopioid analgesic with a rapid onset, and it is effective and safe. The study compared the effects of pre- and postincisional intravenous paracetamol administration for optimal postoperative pain management in patients undergoing bariatric surgeries.

METHODS

This is a prospective, double-blinded, placebo-controlled randomized clinical trial of adult patients, admitted electively for laparoscopic bariatric surgery. The patients were randomly divided into two groups. One group of patients was given paracetamol at the beginning of the operation, prior to the surgical incision, the other group of patients received the same treatment at the end of the operation.

RESULTS

Patients who were given preincisional intravenous paracetamol presented significantly lower visual analog scale (VAS) scores following the surgery compared with patients who were given intravenous paracetamol in the last 30 minutes of the operation (VAS, median [IQR] = 2 [2-3] vs. 5 [3-6]; p < 0.001). They also required fewer postoperative opioids and tramadol (in milligrams, respectively, 1 [0-5] vs. 7.5 [5-10] and 300 [100-400] vs. 400 [200-500]) compared with later analgesia administration (p < 0.001 and p = 0.03). The levels of inflammatory markers measured at fixed intervals from paracetamol administration were not statistically different between the study groups.

CONCLUSION

Early analgesia with intravenous paracetamol, given before the surgical incision, may result in lower VAS scores postoperatively compared with the same treatment administered toward the end of the operation.

Is P&T Ready to Add Rapid Cycle Analytics to Formulary?

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.

Comparison of the Effect of Dexamethasone and Ketorolac on Pain Control in Elective Foot Surgery

Objectives: This study aimed to compare the effect of dexamethasone and ketorolac on pain control in elective foot surgery. Methods: Forty patients visiting Akhtar and Imam Hossein Hospital for lower limb orthopedic surgery were selected. They were randomly divided into two groups: (1) dexamethasone, and (2) ketorolac. The dexamethasone group received eight mg dexamethasone intravenously. Also, 90 mg ketorolac was infused in one liter of normal saline serum for 24 hours for the ketorolac group. Before injection and 2, 4, and 6 hours after the injection, pain control was measured employing the Visual Analog Scale (VAS) score. Corresponding data were then analyzed using the independent t-test. Results: The conclusions revealed that in two and four hours after injection, there was a significant difference between the two groups in the amount of VAS score. That is, the pain was weaker in the ketorolac group than in the dexamethasone group. The findings additionally proved that there was no statistically important difference in pain levels between the two groups six hours after injection. Conclusions: Overall, according to the results of the research, it can be settled that ketorolac is a better drug in foot surgery pain control than dexamethasone.

Machine learning approach to predict postoperative opioid requirements in ambulatory surgery patients

Opioids play a critical role in acute postoperative pain management. Our objective was to develop machine learning models to predict postoperative opioid requirements in patients undergoing ambulatory surgery. To develop the models, we used a perioperative dataset of 13,700 patients (≥ 18 years) undergoing ambulatory surgery between the years 2016–2018. The data, comprising of patient, procedure and provider factors that could influence postoperative pain and opioid requirements, was randomly split into training (80%) and validation (20%) datasets. Machine learning models of different classes were developed to predict categorized levels of postoperative opioid requirements using the training dataset and then evaluated on the validation dataset. Prediction accuracy was used to differentiate model performances. The five types of models that were developed returned the following accuracies at two different stages of surgery: 1) Prior to surgery—Multinomial Logistic Regression: 71%, Naïve Bayes: 67%, Neural Network: 30%, Random Forest: 72%, Extreme Gradient Boost: 71% and 2) End of surgery—Multinomial Logistic Regression: 71%, Naïve Bayes: 63%, Neural Network: 32%, Random Forest: 72%, Extreme Gradient Boost: 70%. Analyzing the sensitivities of the best performing Random Forest model showed that the lower opioid requirements are predicted with better accuracy (89%) as compared with higher opioid requirements (43%). Feature importance (% relative importance) of model predictions showed that the type of procedure (15.4%), medical history (12.9%) and procedure duration (12.0%) were the top three features contributing to model predictions. Overall, the contribution of patient and procedure features towards model predictions were 65% and 35% respectively. Machine learning models could be used to predict postoperative opioid requirements in ambulatory surgery patients and could potentially assist in better management of their postoperative acute pain.

Comparison of clinical outcomes of acetaminophen IV vs PO in the peri-operative setting for laparoscopic inguinal hernia repair surgeries: A triple-blinded, randomized controlled trial

BACKGROUND

Acetaminophen is available in a variety of modalities but there is conflicting evidence as to whether intravenous provides superior analgesia than oral formulations METHODS: A prospective, randomized, triple-blinded clinical trial was conducted in which 100 participants, scheduled for any laparoscopic unilateral hernia repair surgery in the ambulatory setting, were computer randomized to receive either 975 mg oral acetaminophen or 1000 mg of intravenous acetaminophen. The primary outcomes evaluated were post-anesthesia care unit (PACU) pain scores at arrival, 1 hour discharge, 6 hour post-op as well as total opioid use intraoperatively and in PACU. Secondary outcomes were PACU length of stay, patient reported total opioid use in the first 24 h, pain scores 24 hour post-op and patient satisfaction.

RESULTS

We found that no significant difference was appreciated between the oral and intravenous acetaminophen groups in any of the primary or secondary outcomes with the p-value of the pain score on arrival of 0.173, pain score at 1 h 0.544, pain score on discharge from PACU 0.586, pain score at 6 h 0.234, pain score at 24 h 0.133, total morphine milligram equivalents (MME) intraoperatively 0.096, total MME in PACU 0.960, time in PACU 0.15, home opioid MME 0.336, and overall patient satisfaction 0.067.

CONCLUSIONS

We concluded that in the ambulatory surgery population the efficacy of oral and intravenous acetaminophen is equivalent.

Effectiveness of intravenous acetaminophen for postoperative pain management in shoulder arthroplasties: A population-based study

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.

Liposomal Bupivacaine Does Not Reduce Inpatient Opioid Prescription or Related Complications after Knee Arthroplasty: A Database Analysis

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS MANUSCRIPT TELLS US THAT IS NEW: BACKGROUND:: Although some trials suggest benefits of liposomal bupivacaine, data on real-world use and effectiveness is lacking. This study analyzed the impact of liposomal bupivacaine use (regardless of administration route) on inpatient opioid prescription, resource utilization, and opioid-related complications among patients undergoing total knee arthroplasties with a peripheral nerve block. It was hypothesized that liposomal bupivacaine has limited clinical influence on the studied outcomes.

METHODS

The study included data on 88,830 total knee arthroplasties performed with a peripheral nerve block (Premier Healthcare Database 2013 to 2016). Multilevel multivariable regressions measured associations between use of liposomal bupivacaine and (1) inpatient opioid prescription (extracted from billing) and (2) length of stay, cost of hospitalization, as well as opioid-related complications. To reflect the difference between statistical and clinical significance, a relative change of -15% in outcomes was assumed to be clinically important.

RESULTS

Overall, liposomal bupivacaine was used in 21.2% (n = 18,817) of patients that underwent a total knee arthroplasty with a peripheral nerve block. Liposomal bupivacaine use was not associated with a clinically meaningful reduction in inpatient opioid prescription (group median, 253 mg of oral morphine equivalents, adjusted effect -9.3% CI -11.1%, -7.5%; P < 0.0001) and length of stay (group median, 3 days, adjusted effect -8.8% CI -10.1%, -7.5%; P < 0.0001) with no effect on cost of hospitalization. Most importantly, liposomal bupivacaine use was not associated with decreased odds for opioid-related complications.

CONCLUSIONS

Liposomal bupivacaine was not associated with a clinically relevant improvement in inpatient opioid prescription, resource utilization, or opioid-related complications in patients who received modern pain management including a peripheral nerve block.

A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty

INTRODUCTION

The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA).

METHODS

For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total.

RESULTS

In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported.

CONCLUSIONS

This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.

Multimodal Pain Management for Enhanced Recovery: Reinforcing the Shift From Traditional Pathways Through Nurse-Led Interventions

Despite recent advances in perioperative patient care, postsurgical pain continues to be undermanaged. There is increasing acceptance of the concept that effective postsurgical pain management is best achieved through combined use of more than one analgesic agent or technique, and overreliance on opioids produces unwanted side effects limiting their utility. Accordingly, a balanced, multimodal approach to pain management within the larger framework of an Enhanced Recovery After Surgery (ERAS) pathway has become standard at many institutions for perioperative care, to control postsurgical pain, reduce opioid-related adverse events, hasten postsurgical recovery, and shorten length of hospital stay. The success of ERAS is dependent on nurses and the multidisciplinary team to execute its standardized processes across the care continuum, including patient education, perioperative care, and postsurgical evaluation. Here, we review current concepts related to multimodal analgesia and ERAS regarding care of adult surgical patients and discuss the perioperative nurse's role within this paradigm.

Local infiltration for postsurgical analgesia following total hip arthroplasty: a comparison of liposomal bupivacaine to traditional bupivacaine

OBJECTIVE

To assess postsurgical clinical and economic outcomes of patients who received local infiltration containing liposomal bupivacaine versus traditional bupivacaine for pain management following total hip arthroplasty (THA).

METHODS

This retrospective study included two groups of consecutive patients undergoing THA. The experimental group received local infiltration with a combination of liposomal bupivacaine, bupivacaine HCl 0.25% with epinephrine 1:200,000, and ketorolac for postsurgical analgesia. The historical control group received the previous standard of care: local infiltration with a combination of bupivacaine HCl 0.25% with epinephrine 1:200,000 and ketorolac. Key outcomes included distance walked, length of stay (LOS), opioid medication use, numeric pain scores, hospital charges, hospital costs, all-cause 30 day readmission rate, and adverse events (AEs). Both unadjusted and adjusted (i.e. age, sex, insurance type, living situation, body mass index, procedure side, and comorbidity) outcomes were compared between the two groups.

RESULTS

The experimental group (n = 64) demonstrated statistically significant improvement versus the historical control group (n = 66) in mean distance walked on discharge day (249.2 vs. 180.0 feet; unadjusted p = .025, adjusted p = .070), mean LOS (2.0 vs. 2.7 days; p < .001, p = .002), proportion of patients who used opioid rescue medication on postoperative day (POD) 1 (29.7% vs. 56.1%; p = .002, p = .003) and POD 2 (7.8% vs. 30.3%; p = .001, p = .003), mean cumulative area under the curve for pain score on POD 0 (127.6 vs. 292.5; p < .001, both), POD 1 (92.9 vs. 185.0; p < .001, both), and POD 2 (93.8 vs. 213.8; p = .006, both). Among a subgroup of patients with available financial information, mean hospital charges were lower in the experimental group ($43,794 [n = 24] vs. $48,010 [n = 66]; p < .001, both). Rates of all-cause 30 day readmission and AEs were not significantly different between groups. No falls occurred.

CONCLUSIONS

Infiltration at the surgical site with liposomal bupivacaine was associated with improved postsurgical outcomes when compared with traditional bupivacaine in patients undergoing THA.

Endogenous Opiates and Behavior: 2015

This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.