Reduced length of stay and hospitalization costs among inpatient hysterectomy patients with postoperative pain management including IV versus oral acetaminophen

Effectiveness of oral vs intravenous acetaminophen on pain management following total joint arthroplasty: A systematic review and meta-analysis

BACKGROUND

In the management of postoperative pain following total joint arthroplasty (TJA), the use of nonsteroidal anti-inflammatory drugs, including acetaminophen, plays a key role in alleviating pain. However, the comparison between intravenous and oral acetaminophen administration in patients undergoing full joint replacement surgery remains controversial.

AIM

To assess the effectiveness of intravenous and oral acetaminophen in alleviating pain and supporting rehabilitation following TJA.

METHODS

PubMed, Embase and the Cochrane Library were comprehensively searched to identify cohort studies. The effects of intravenous and oral acetaminophen for managing pain and supporting rehabilitation following TJA were analysed using randomized controlled trials. PRISMA guidelines were followed. The effectiveness of the administration routes was compared based on visual analogue scale (VAS) scores at 24 and 48 h, total morphine usage within 24 h, and total duration of hospital stay.

RESULTS

The meta-analysis included seven studies comparing intravenous acetaminophen groups and oral acetaminophen groups. The results demonstrated that oral acetaminophen was comparable to intravenous acetaminophen with regard to VAS scores at 24 h and 48 h (P = 0.76 and 0.08, respectively). The difference in total morphine use between the two groups was not significant (P = 0.22). However, the total hospital stay duration of the intravenous acetaminophen groups was significantly reduced compared to the oral acetaminophen groups (P = 0.0005), showing significant advantages in optimizing postoperative recovery and shortening hospitalisation time.

CONCLUSION

After TJA surgery, intravenous injection of acetaminophen can shorten hospitalisation time and is suitable for rapid analgesia, Oral administration has become the preferred choice for mild cases due to its convenience and economy, providing a basis for clinical drug selection.

Robotic-assisted hysterectomy for benign gynecologic disease in the United States: in-hospital use of opioid and non-opioid analgesics

To compare the in-hospital opioid and non-opioid analgesic use among women who underwent robotic-assisted hysterectomy (RH) vs. open (OH), vaginal (VH), or laparoscopic hysterectomy (LH). Records of women in the United States who underwent hysterectomy for benign gynecologic disease were extracted from the Premier Healthcare Database (2013-2019). Propensity score methods were used to create three 1:1 matched cohorts stratified in inpatients [RH vs. OH (N = 16,821 pairs), RH vs. VH (N = 6149), RH vs. LH (N = 11,250)] and outpatients [RH vs. OH (N = 3139), RH vs. VH (N = 29,954), RH vs. LH (N = 85,040)]. Opioid doses were converted to morphine milligram equivalents (MME). Within matched cohorts, opioid and non-opioid analgesic use was compared. On the day of surgery, the percentage of patients who received opioids differed only for outpatients who underwent RH vs. LH or VH (maximum difference = 1%; p < 0.001). RH was associated with lower total doses of opioids in all matched cohorts (each p < 0.001), with the largest difference observed between RH and OH: median (IQR) of 47.5 (25.0-90.0) vs. 82.5 (36.0-137.0) MME among inpatients and 39.3 (19.5-66.0) vs. 60.0 (35.0-113.3) among outpatients. After the day of surgery, fewer inpatients who underwent RH received opioids vs. OH (78.7 vs. 87.5%; p < 0.001) or LH (78.6 vs. 80.6%; p < 0.001). The median MME was lower for RH (15.0; 7.5-33.5) versus OH (22.5; 15.0-55.0; p < 0.001). Minor differences were observed for non-opioid analgesics. RH was associated with lower in-hospital opioid use than OH, whereas the same magnitude of difference was not observed for RH vs. LH or VH.

Age-Related Variations in Postoperative Pain Intensity across 10 Surgical Procedures: A Retrospective Study of Five Hospitals in South Korea

Age-related differences in pain perception have been reported in various contexts; however, their impact on postoperative pain intensity remains poorly understood, especially across different surgical procedures. Data from five hospitals were retrospectively analyzed, encompassing patients who underwent 10 distinct surgical procedures. Numeric rating scale scores were used to assess the worst postoperative pain intensity during the 24 h after surgery. The multivariate linear regression model analyzed the relationship between age and pain intensity. Subgroup analyses were performed according to sex and patient-controlled analgesia (PCA). This study included 41,187 patients. Among the surgeries studied, lumbar spine fusion (β = -0.155, p < 0.001) consistently and significantly exhibited a decrease in worst postoperative pain with increasing age. Similar trends were observed in cholecystectomy (β = -0.029, p < 0.001) and several other surgeries; however, the results were inconsistent across all analyses. Surgeries with higher percentages of PCA administration had lower median worst-pain scores. In conclusion, age may affect postoperative pain intensity after specific surgeries; however, a comprehensive understanding of the complex interplay between age, surgical intervention, and pain intensity is required. Pain management strategies should consider various factors, including age-related variations.

Healthcare Resource Utilization After Surgical Treatment of Cancer: Value of Minimally Invasive Surgery

Background

As the US healthcare system moves towards value-based care, hospitals have increased efforts to improve quality and reduce unnecessary resource use. Surgery is one of the most resource-intensive areas of healthcare and we aim to compare health resource utilization between open and minimally invasive cancer procedures.

Methods

We retrospectively analyzed cancer patients who underwent colon resection, rectal resection, lobectomy, or radical nephrectomy within the Premier hospital database between 2014 and 2019. Study outcomes included length of stay (LOS), discharge status, reoperation, and 30-day readmission. The open surgical approach was compared to minimally invasive approach (MIS), with subgroup analysis of laparoscopic/video-assisted thoracoscopic surgery (LAP/VATS) and robotic (RS) approaches, using inverse probability of treatment weighting.

Results

MIS patients had shorter LOS compared to open approach: − 1.87 days for lobectomy, − 1.34 days for colon resection, − 0.47 days for rectal resection, and − 1.21 days for radical nephrectomy (all p < .001). All MIS procedures except for rectal resection are associated with higher discharge to home rates and lower reoperation and readmission rates. Within MIS, robotic approach was further associated with shorter LOS than LAP/VATS: − 0.13 days for lobectomy, − 0.28 days for colon resection, − 0.67 days for rectal resection, and − 0.33 days for radical nephrectomy (all p < .05) and with equivalent readmission rates.

Conclusion

Our data demonstrate a significant shorter LOS, higher discharge to home rate, and lower rates of reoperation and readmission for MIS as compared to open procedures in patients with lung, kidney, and colorectal cancer. Patients who underwent robotic procedures had further reductions in LOS compare to laparoscopic/video-assisted thoracoscopic approach, while the reductions in LOS did not lead to increased rates of readmission.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09189-8.

Paracetamol for multimodal analgesia

Pain and related disability remain a major social and therapeutic problem. Comorbidities and therapies increase drug interactions and side effects making pain management more compounded especially in the elderly who are the fastest-growing pain population. Multimodal analgesia consists of using two or more drugs and/or techniques that target different sites of pain, increasing the level of analgesia and decreasing adverse events from treatment. Paracetamol enhances multimodal analgesia in experimental and clinical pain states. Strong preclinical evidence supports that paracetamol has additive and synergistic interactions with anti-inflammatory, opioid and anti-neuropathic drugs in rodent models of nociceptive and neuropathic pain. Clinical studies in young and adult elderly patients confirm the utility of paracetamol in multimodal, non-opioid or opioid-sparing, therapies for the treatment of acute and chronic pain.

Comparison of Cranioplasty Techniques Following Translabyrinthine Surgery: Implications for Postoperative Pain and Opioid Usage

OBJECTIVE

To assess differences in postoperative pain, opioid usage, and surgical outcomes between cranioplasty using abdominal fat graft (AFG) versus hydroxyapatite cement (HAC) following translabyrinthine surgery.

STUDY DESIGN

Retrospective case control.

SETTING

Tertiary referral center.

PATIENTS

Sixty translabyrinthine procedures were evaluated, including 30 consecutive HAC patients and 30 matched AFG patients. Patients were matched by age, gender, body mass index, and tumor size.

INTERVENTION

Cranioplasty using HAC or AFG following translabyrinthine resection of vestibular schwannoma.

MAIN OUTCOME MEASURES

Postoperative patient pain ratings, narcotic usage, inpatient length of stay, and complication rates.

RESULTS

Patients who underwent HAC cranioplasty had lower postoperative pain scores on several measures (p < 0.05) and less postoperative narcotic usage (mean difference of 36.7 morphine equivalents, p = 0.0025) when compared to those that underwent AFG closure. HAC cranioplasty patients had shorter average length of hospital stay (2.2 vs 3.4 days, p = 0.0441). Postoperative cerebrospinal fluid leaks (one in HAC group, two in AFG group) and skin reactions in AFG closure patients (n = 1) were infrequent.

CONCLUSION

HAC cranioplasty is a safe technique comparable to AFG closure following translabyrinthine surgery which can decrease postoperative pain, narcotic usage, and hospital length of stay.

Cost-effectiveness of Tamoxifen, Aromatase Inhibitor, and Switch Therapy (Adjuvant Endocrine Therapy) for Breast Cancer in Hormone Receptor Positive Postmenopausal Women in India

Background

Breast cancer is the leading cause of cancer among women in India. Treatment with hormone therapy reduces recurrence. We undertook this cost-effectiveness study to ascertain the treatment option offering the best value for money.

Methods

The lifetime costs and health outcomes of using tamoxifen, AI and switch therapy were measured in a cohort of 50-year-old women with HR-positive early stage breast cancer. A Markov model of disease was developed using a societal perspective with a lifetime study horizon. Local, contralateral, and distant recurrence were modelled along with treatment related adverse effects. Primary data collected to obtain estimates of out-of-pocket expenditure (OOPE) and utility weights. Both health system cost and OOPE were included. The future costs and consequences were discounted at 3%. A probabilistic sensitivity analysis was used.

Results

The lifetime cost of hormone therapy with tamoxifen, AI and switch therapy was to be ₹1,472,037 (I$ 68,947), ₹1,306,794 (I$ 61,208) and ₹1,281,811 (I$ 60,038). The QALYs lived per patient receiving tamoxifen, AI and switch were 13.12, 13.42 and 13.32. tamoxifen was found to be more expensive and less effective. As compared to switch therapy, AI for five years incurred an incremental cost of ₹259,792 (I$12,168) per QALY gained. At the willingness to pay equals to per capita GDP of India, there is 55% probability of AI therapy to be cost-effective compared to switch therapy.

Conclusion

In postmenopausal women with HR-positive early-stage breast cancer, switch therapy is recommended for use on the basis of cost-effectiveness.

Surgical site infection after open and laparoscopic surgery in children: a systematic review and meta-analysis

Surgical site infections (SSIs) are the most common healthcare-associated infections in patients undergoing surgery. Various randomised control trials (RCTs) indicate that laparoscopic procedures can be associated with better outcomes compared to open procedures. However, how open versus laparoscopic approaches compare across various paediatric procedures with respect to SSI rate remains poorly defined. In this review, we examined RCTs that directly compare SSI rates after open versus laparoscopic operations for appendicitis, gastro-esophageal reflux, inguinal hernia, and pyloric stenosis. MEDLINE, Embase, and Web of Science were searched for RCTs comparing four types of open versus laparoscopic operations in children. The operations included appendectomy, fundoplication for gastro-esophageal reflux, inguinal hernia repair, or pyloromyotomy. 364 records were identified and screened, 54 full-text articles were assessed for eligibility, and 17 RCTs were included in the analysis. SSI rate was the primary outcome. Operative time and length of stay (LOS) were the secondary outcomes. A meta-analysis was conducted using RevMan 5.4 software. Laparoscopic appendectomy had a lower SSI rate than open appendectomy (odds ratio of 2.22 [1.19, 4.15] p = 0.01). Laparoscopic fundoplication for gastro-esophageal reflux, inguinal hernia repair, or pyloromyotomy for pyloric stenosis were not associated with lower SSI rate compared to open surgery. Operative time was shorter in open fundoplication (- 71.22 min [- 89.79,  - 52.65] p < 0.00001) than laparoscopic fundoplication. There was no significant difference in operative time of any of the other procedures. There was no significant difference in LOS between open and laparoscopic procedures for all types of operations analysed. Based on the findings of this review, it is recommended to utilise the laparoscopic approach over the open approach to reduce SSI risk in paediatric appendectomy.

Opioid-free multimodal analgesia pathway to decrease opioid utilization after cesarean delivery

AIM

To evaluate an opioid-free multimodal analgesic pathway (MAP) to decrease opioid utilization after cesarean delivery (CD) compared to historic data of our institution prior to using MAP for pain management (pre-MAP).

METHODS

The MAP was implemented in three phases from September 2018 to August 2019. Patients received 1000 mg intravenous (IV) acetaminophen with 30 mg IV ketorolac at 0 (arrival time at recovery room), 6, 12 and 18 h of postoperative course. On the 2nd and the 3rd postoperative days, patients were monitored for pain every 6 h by Numeric Pain Intensity Scale (0 = no pain to 10 = severe pain) and administered 600 mg oral ibuprofen for a pain score between 0 and 4, 600 mg oral ibuprofen and/or 650 mg oral acetaminophen for a pain score between 5-6, 1000 mg IV acetaminophen and/or 30 mg of IV or intramuscular ketorolac for a pain score between 7 and 10. Five milligrams of oral oxycodone was reserved for rescue if all protocol options were exhausted. Patients were discharged with 600 mg oral ibuprofen without opioid prescription. Likert surveys measuring patient satisfaction of pain control were administered during phase 3.

RESULTS

Inpatient and outpatient opioid consumption rates were significantly decreased from 45%, 18% to 23.8%, 8.5% after MAP implementation (P-value <0.001). More than 90% of patients reported that their pain was well controlled and willing to request the same regimen for a future CD.

CONCLUSION

MAP Implementation after CD significantly reduced inpatient and outpatient opioid consumption compared to pre-MAP results while maintaining high patients' satisfaction with pain control.

Preoperative Intravenous Versus Oral Acetaminophen in Outpatient Surgery: A Double-Blinded, Randomized Control Trial

PURPOSE

Preoperative acetaminophen is recognized as an effective part of the multimodal approach to perioperative pain management. The present study, conducted between April 12, 2018 and February 14, 2019, examined whether there are differences in patient-reported pain, postoperative opioid consumption, negative opioid effects, length of postanesthesia care unit stay, and patient satisfaction with pain control between patients who receive intravenous (IV) acetaminophen and patients who receive oral acetaminophen.

DESIGN

This double-blinded, randomized controlled trial was conducted among 120 patients undergoing outpatient surgery.

METHODS

Patients were randomized to receive preoperatively either intravenous (IV) acetaminophen (and oral placebo) or oral acetaminophen (and IV placebo). Results were analyzed using SPSS statistical software; statistical analyses consisted of Mann-Whitney U test, independent samples t test, and χ² test. In all analyses, a P value less than .05 was considered significant.

FINDINGS

There were no significant differences in any outcome measures based on the route of acetaminophen administration.

CONCLUSIONS

The findings of the present study support the practice of administering oral acetaminophen, as opposed to IV acetaminophen, preoperatively as part of the multimodal approach to manage postoperative pain in patients able to tolerate preoperative oral medications.

Effects of Low Intraperitoneal Pressure on Quality of Postoperative Recovery after Laparoscopic Surgery for Genital Prolapse in Elderly Patients Aged 75 Years or Older

STUDY OBJECTIVE

Previous clinical trials for laparoscopic surgery have included few elderly patients aged ≥75 years. We aimed to evaluate the quality of postoperative recovery after laparoscopic surgery using low intraperitoneal pressure (IPP) (6 mm Hg) and warmed, humidified carbon dioxide gas for genital prolapse in elderly patients aged ≥75 years.

DESIGN

Prospective consecutive case series.

SETTING

University hospital.

PATIENTS

Consecutive patients (n = 30) aged ≥75 years planning to undergo laparoscopic surgery for genital prolapse by the same surgeon were recruited from October 2016 through December 2019.

INTERVENTIONS

Laparoscopic promontofixation for the treatment of genital prolapse was performed using low IPP and warmed, humidified carbon dioxide gas. When a promontory could not be easily identified, laparoscopic pectopexy was alternatively performed.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the Quality of Recovery-40 (QoR-40) score at 24 hours postoperatively. The secondary outcomes were postoperative pain using a 100-mm visual analog scale and the length of hospital stay after surgery (LHSS). For the global QoR-40 score and for 4 dimensions of the QoR-40, "emotional state," "physical comfort," "psychologic support," and "pain," no differences were observed between the baseline score and the score at 24 hours. The score for the "physical independence" dimension at 24 hours was significantly lower than the baseline score (p <.001). No patient had visual analog scale pain scores >30 out of 100 at 12 hours or later. LHSS was <48 hours in 22 patients (73.3%) and <72 hours in 8 patients (26.7%). Multivariable analysis showed that the odds of an LHSS >48 hours were more than 8 times higher in patients who were discharged from the operating room in the afternoon compared with those with a morning discharge.

CONCLUSION

The use of a low IPP is feasible, safe, and has clinical benefits for elderly patients aged ≥75 years who undergo laparoscopic surgery for genital prolapse.

Intravenous Versus Oral Acetaminophen in Outpatient Cystoscopy Procedures: Retrospective Comparison of Postoperative Opioid Requirements and Analgesia Scores

PURPOSE

To assess if the choice of acetaminophen formulation (intravenous vs oral) when administered preoperatively for ambulatory cystoscopy procedures is associated with differences in anesthetic outcomes.

METHODS

Medical records of adult patients undergoing ambulatory cystoscopy procedures at an outpatient procedural center from July 1, 2014, through November 30, 2017, were abstracted. The association between anesthetic outcomes (severe pain, rescue opioids, postoperative nausea, and vomiting) and acetaminophen formulation was assessed. Propensity-adjusted analyses were performed using inverse probability of treatment weighting to account for potential confounders.

RESULTS

During the study time frame, there were 611 intravenous and 2955 oral acetaminophen administrations for cystoscopy procedures. Postoperative bladder spasms were a major contributor to severe pain and complicated 1036 cases, with similar rates between intravenous (N = 183, 29.9%) and oral (N = 853, 28.9%) formulations, P = .625. After adjusting for bladder spasms, intravenous acetaminophen was associated with longer anesthesia recovery (estimate 5.2 [95% CI 0.5-9.9] minutes, P = .030), use of rescue opioids (odds ratio 1.33 [1.07-1.66], P = .012), and postoperative nausea and vomiting (1.40 [1.02-1.93], P = .037), but not severe pain (1.07 [0.81-1.40], P = .640).

CONCLUSION

Preoperative intravenous acetaminophen compared to oral acetaminophen for ambulatory cystoscopy procedures was not associated with better anesthetic outcomes. Bladder spasms were a major contributor to postoperative pain.

Intravenous versus oral paracetamol in a UK ambulance service: a case control study

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.

Using Electronic Health Record Activity to Represent Interdisciplinary Care Teams and Examining their Contribution to Hospital Length of Stay

Modeling variance in patient outcomes using medical claims and other forms of aggregated administrative data may ignore significant contributions associated with providers who are not recorded in billing transactions. We examined the association between interdisciplinary provider factors and length of stay (LOS) for 1,099 lumbar spine surgery patients. Interdisciplinary provider "dose" (number of providers/case), "workload" (care of other patients), and "activity" factors were defined and generated. Hierarchical Regression models were used to test the impact of these provider factors controlling for the effect of socio-demographic and clinical factors. Interdisciplinary provider factors explained 12% of additional variance in LOS. EHR-based interdisciplinary care team representations hold promise in contributing to our understanding of health care delivery and quality. Keywords: interdisciplinary care, nursing documentation, workload, length of stay, electronic health records (EHR).

Preemptive Oral Compared With Intravenous Acetaminophen for Postoperative Pain After Robotic-Assisted Laparoscopic Hysterectomy: A Randomized Controlled Trial

OBJECTIVE

To compare pain after robotic-assisted laparoscopic hysterectomy when giving preoperative oral compared with intravenous acetaminophen.

METHODS

This double-blind randomized trial included women undergoing robotic-assisted laparoscopic hysterectomy for benign indications. Participants received either acetaminophen 1 g orally then normal saline 100 mL intravenously before surgery, or a placebo orally then acetaminophen 1 g intravenously. The primary outcome measured was difference in pain between the groups 2 hours postoperatively. A sample size of 74 participants (37/group) was needed to achieve 80% power to detect noninferiority using a one-sided, two-sample t-test with an alpha of 0.025 and a noninferiority margin of 10 mm.

RESULTS

From April 2016 through August 2017, 77 patients were enrolled, with 75 participants included in the final analysis. Characteristics were similar between groups. No difference in average pain score was noted 2 hours after surgery, nor at any of the measured time points. Average scores for the oral and intravenous group, respectively, at 2 hours were 35 and 36 mm (P=.86), at 4 hours 36 and 37 mm (P=.96), and at 24 hours 35 and 36 mm (P=.79). Thirty-eight percent of participants in the oral group and 19% of participants in the intravenous group experienced nausea (P=.12). The oral group used 9.7 morphine equivalents in the recovery room, and the intravenous group used 9.5 morphine equivalents (P=.9). The oral group requested analgesia in 45 minutes on average, and the intravenous group requested analgesia in 43 minutes (P=.79).

CONCLUSION

No difference in pain was observed 2 hours postoperatively when comparing preoperative administration of oral compared with intravenous acetaminophen. Given the ease of administration and lower cost of oral dosing, this study supports the oral route as part of the enhanced recovery after surgery protocol for minimally invasive gynecologic surgery.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03391284.