Effect of Preoperative Intravenous Methocarbamol and Intravenous Acetaminophen on Opioid Use After Primary Total Hip and Knee Replacement

 
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Effect of Preoperative Intravenous Methocarbamol and Intravenous Acetaminophen on Opioid Use After Primary Total Hip and Knee Replacement
■ Feature Article

Effect of Preoperative Intravenous
Methocarbamol and Intravenous
Acetaminophen on Opioid Use After
Primary Total Hip and Knee Replacement
THOMAS D. LOOKE, MD, PHD; CAMERON T. KLUTH, MBA

                                                                                            gical site injections, designed by physi-
    abstract                                                                                cians at the Florida Hospital Winter Park
                                                                                            campus have evolved over the past sever-
    Between 2010 and 2011, a perioperative pain protocol for primary total hip and          al years. No standardized protocol exist-
    knee replacement at one Florida medical center replaced preoperative oral an-           ed prior to 2006. In 2006, the anesthesia
    algesics with intravenous methocarbamol and intravenous acetaminophen. This             department offered regional anesthesia
    is a retrospective cohort study of 300 patients, with 150 patients using the new        to all total knee patients. By mid-2008,
    pain protocol and 150 patients using a 2008 pain protocol that did not include          anesthesiologists at Florida Hospital
    these medications. The 2 cohorts were similar in patient gender, age, and body          Winter Park offered every total knee pa-
    mass index. Opioid consumption was evaluated for a period of 48 hours after             tient a femoral nerve sheath catheter with
    incision and was divided into 3 separate time intervals, as well as total 48-hour
    consumption. Mean opiate use decreased significantly from 2008 to 2011 in
    all time intervals and total consumption (7.5⫾3.4 mg to 6.1⫾3.0 mg; P⬍.01).                  The authors are from the Florida Hospital De-
                                                                                            partment of Anesthesiology and Florida Hospital,
    Subgroup analysis suggested that changes to the hip protocol were responsible           Winter Park Division, Office of Orthopedic Research
    for decreased opioid use in the operating room and the postanesthesia care unit,        (TDL); and from the University of Central Florida
    and changes to the knee protocol were responsible for decreased opioid use on           College of Medicine (CTK), Orlando, Florida.
    the hospital floor and total consumption. The difference between the 2 protocol              Dr Looke received investigator-initiated study
                                                                                            grant support paid to his institution from Cadence
    groups was not due to differences in individual surgeon practice patterns. Physical     Pharmaceuticals, Inc., and was compensated by
    therapy progress of knee flexion, average walking distance, and maximum walk-           SLACK Incorporated for his contribution to this
    ing distance were significantly improved. Hospital discharge was shorter in the         manuscript. Mr Kluth received travel reimburse-
    2011 group (4.0⫾1.1 days in 2008 group and 3.6⫾1.0 days in 2011 group). This            ment from the University of Central Florida College
                                                                                            of Medicine.
    study shows significant improvement in patient care from 2008 to 2011 that is at             The authors thank Gwen Certain and Cecille
    least partially due to the change to the use of preoperative intravenous methocar-      Brocato for sharing their extensive knowledge and
    bamol and intravenous acetaminophen.                                                    experience as certified pain nurses and for providing
                                                                                            their invaluable assistance with data collection; and
                                                                                            Dr Julie W. Pepe with Florida Hospital Office of Re-
                                                                                            search Administration for her biostatistics expertise.

I
    n the United States, more than             perform more than 2100 primary total hip     The authors also thank the leadership team at Flor-
    600,000 total knee replacements and        and knee replacements each year at the       ida Hospital Winter Park for providing equipment,
    285,000 total hip replacements are         7 campuses in the greater Orlando area.      office space, and logistical support for this project.
                                                                                                 Correspondence should be addressed to: Thom-
performed each year.1,2 At Florida Hos-        Perioperative pain management proto-         as D. Looke, MD, PhD, 4609 Jetty St, Orlando, FL
pital, a 4415 bed hospital system with         cols, which include oral and parenteral      32817 (tdlooke@hotmail.com).
22 campuses in central Florida, surgeons       analgesics, regional anesthetics, and sur-        doi: 10.3928/01477447-20130122-54

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Effect of Preoperative Intravenous Methocarbamol and Intravenous Acetaminophen on Opioid Use After Primary Total Hip and Knee Replacement
■ Feature Article

48 hours of continuous regional anesthe-       opioid rescue, VAS pain scores, physical       and 50 using the 2008 control protocol
sia for postoperative pain management.         therapy progress, and hospital discharge       each) and 2 surgeons performing hips
By 2010, the use of postoperative opioids      times. This was considered a pilot study       (25 using the 2011 study protocol and 25
after total knee surgery decreased signifi-    to determine if a prospective, random-         using the 2008 control protocol each). In
cantly, and patient-controlled analgesia       ized, controlled clinical trial would likely   total, the study included patients from 3
delivery of intravenous hydromorphone          show any benefit from expanding the use        surgeons, because the second most pro-
was replaced with nursing administration       of these 2 intravenous medications from        lific knee surgeon was also the second
of oral oxycodone plus acetaminophen           1 preoperative dose to regular dosing for      most prolific hip surgeon. More empha-
or intravenous hydromorphone at patient        the first 48 hours.                            sis was placed on limiting the number of
request only. In addition, preoperative                                                       surgeons rather than anesthesiologists,
treatment with oral analgesics (a sur-         MATERIALS AND METHODS                          because the number of patient-care items
geon-ordered combination of 1 or more              The Institutional Review Boards of         left to the discretion of the surgeon is
of celecoxib, oxycodone plus acetamino-        Florida Hospital and the University of         greater than those left to the discretion
phen, or pregabalin) was replaced with         Central Florida approved this retrospec-       of the anesthesiologist. In addition, the
intravenous methocarbamol (Robaxin In-         tive 2 cohort study with HIPAA and in-         team wanted to determine whether those
jection; Baxter Healthcare Corporation,        formed consent waivers for 300 patients.       items left to surgical discretion, such as
Deerfield, Illinois). The goals with this      One hundred fifty patients were included       intraoperative surgical site injections and
medication were to reduce oral loading         in the study group (using the 2011 proto-      perioperative analgesic adjunct selection,
preoperatively and reduce recovery room        col with preoperative intravenous metho-       influenced primary outcome differences.
discharge delays due to muscle spasm           carbamol and intravenous acetamino-                Patients were evaluated from 2011
pain. At that time, no reports existed on      phen), and 150 patients in the control         (study) and 2008 (control) protocol
the effectiveness of intravenous metho-        group (using the 2008 protocol without         groups in the order described above and
carbamol postoperatively for total joint       these 2 medications). The patient popula-      included those patients, between the ages
surgery. Two studies of its use after breast   tion was identified from anesthesia bill-      of 18 and 85, who had an American Soci-
augmentation had been performed,3-5 but        ing records, including all patients from       ety of Anesthesiologists (ASA) physical
this medication was ignored by most of         Florida Hospital Winter Park who had           status of 1 to 3. Patients were excluded
the anesthesia pain literature.6               primary unilateral total knee arthroplasty     if they had chronic pain with patient
    In 2011, intravenous acetaminophen         (CPT 27447) or primary total hip arthro-       reported opioid use 1 month preopera-
(OFIRMEV; Cadence Pharmaceuticals,             plasty (CPT 27130) between January 1,          tively; had taken centrally acting muscle
Inc., San Diego, California) was added to      2009, and October 12, 2011. Patients           relaxants 24-hours preoperatively; re-
the protocol. Physicians and nursing staff     were grouped according to the periopera-       ceived a regional anesthesia procedure
had anecdotally reported that the combi-       tive pain protocol and excluded patients       for postoperative pain control (other than
nation of intravenous methocarbamol and        from the 2010 protocol who received in-        a femoral nerve sheath catheter for knees
intravenous acetaminophen improved the         travenous methocarbamol but not intra-         or fascia iliaca block for hips); did not
early postoperative recovery after total       venous acetaminophen.                          receive both of the study medications;
hip and knee replacement. Although in-             Within each protocol group, patients       and if there was a notable surgical com-
travenous acetaminophen had been stud-         were also grouped first by surgeon (from       plication as defined by the surgeon’s op-
ied for use in major orthopedic surgery,7,8    greatest to least surgical volume), next       erative report. Data was collected for 300
it had not been studied when added to a        by anesthesiologist (from greatest to          patients. During the data analysis phase,
perioperative pain protocol that included      least volume), and finally by date of          1 total hip patient in the 2008 protocol
long acting peripheral regional anesthet-      surgery (in reverse chronologic order).        group, whose opioid consumption ex-
ics and other intravenous adjuncts.            Since the total knee arthroplasty volume       ceeded 5 standard deviations above the
    Our retrospective study compares a co-     at Florida Hospital Winter Park (700 in        mean, was also excluded from analysis,
hort of patients from 2011, who received       2011) is approximately twice that of total     based on a history of chronic pain that
preoperative intravenous methocarbamol         hip arthroplasty volume (375 in 2011),         had been missed in the initial assessment.
and intravenous acetaminophen, with a          the team decided, a priori, to include         Thus, 299 patients with a primary total
cohort of patients using the 2008 pain         100 knees and 50 hip patients from each        knee or total hip replacement were in-
protocol, who did not receive these med-       protocol group. This made it possible to       cluded in the study.
ications. The outcome measures studied         limit the study to 2 surgeons performing           For the study time periods, the sur-
were opioid consumption, time to first         knees (50 using the 2011 study protocol        gical incision was defined as time zero.

26                                                                                            ORTHOPEDICS | Healio.com/Orthopedics
Effect of Preoperative Intravenous Methocarbamol and Intravenous Acetaminophen on Opioid Use After Primary Total Hip and Knee Replacement
EFFECT OF METHOCARBAMOL AND ACETAMINOPHEN ON OPIOID USE AFTER THA AND TKA | LOOKE & KLUTH

                                                                                                    time (in minutes from incision to first
                                              Table 1                                               request for opioid medication); physical
         Opiate Equivalency Table Used to Convert Opiates Encountered                               therapy progress (range of motion after
                During the Study to Hydromorphone Equivalents                                       total knee in degrees of flexion and ex-
                                                                                                    tension, and ambulation in feet after both
   Opiate Generic Name                     Route                        Equivalent Dose             total hip and total knee) recorded by a
   Fentanyl                             Intravenous                        100 mcg                  physical therapist once or twice daily;
   Hydrocodone                             Oral                             30 mg                   PACU discharge time (in minutes from
   Hydromorphone                        Intravenous                         1.5 mg                  time of arrival to the time that PACU
   Hydromorphone                           Oral                             7.5 mg                  discharge criteria was met); and hospital
                                                                                                    discharge time (in days from time of inci-
   Meperidine                           Intravenous                         75 mg
                                                                                                    sion to time officially recorded as end of
   Morphine                             Intravenous                         10 mg
                                                                                                    hospital admission).
   Morphine                                Oral                             30 mg
                                                                                                       Statistical analysis used a chi-square
   Oxycodone                               Oral                             20 mg                   test for each categorical variable (gender
   Propoxyphene                            Oral                            150 mg                   and ASA class) and considered noncat-
                                                                                                    egorical variables to be continuous. The
                                                                                                    team then evaluated noncategorical vari-
                                                                                                    ables using either parametric or nonpara-
                                              Table 2
                                                                                                    metric tests depending on whether the
                             Demographics of Study Patients                                         data were found to be normally or non-
                                                                                                    normally distributed. Parametric tests
                      Sex, No.(%)                                           ASA Class No. (%)
                                             Age, y,        BMI,                                    included an independent 2-sample t test
   Group           Female        Male       Mean (SD)      Mean (SD)         1        2       3     for the primary group (protocol) compar-
   All             174 (58)    125 (42)     65.5 (9.8)      30.8(5.9)      23 (8)    190      86    isons and analysis of variance (ANOVA)
                                                                                     (63)    (29)
                                                                                                    for the multiple subgroup comparisons.
   2008            84 (56)     65 (44)      66.1 (9.4)      30.8(5.4)      5 (3)      95      49    The team used Levene’s test of equality
                                                                                     (64)    (33)
                                                                                                    of error variances for the ANOVA com-
   2011            90 (60)     60 (40)      64.9 (10.3)     30.9(6.3)        18       95      37
                                                                            (12)     (63)    (25)   parisons to determine if the subgroup
   P value                .559                 .276           .959                   .011a
                                                                                                    populations had comparable statistics.
                                                                                                    A significant Levene’s test result means
  Abbreviations: ASA class, American Society of Anesthesiology physical status; BMI, body mass
  index.                                                                                            that subgroup populations have different
  a
   Meets criteria for significance at P
Effect of Preoperative Intravenous Methocarbamol and Intravenous Acetaminophen on Opioid Use After Primary Total Hip and Knee Replacement
■ Feature Article

                                                                            Table 3
                                        Opiate Use by Time Period for Protocol and Subgroupa

     Group                                                              ORb                    PACUc                FLOORd                  TOTALe
     Protocol group
      2008                                                          .53 (.99) mg            .56 (.80) mg          6.4 (2.7) mg            7.5 (3.4) mg
      2011                                                          .16 (.49) mg            .30 (.60) mg          5.6 (2.7) mg            6.1 (3.0) mg
      NP P valuef                                                       .000                    .002                  .003                    .000
     Total Hip Arthroplasty Only
      2008                                                        1.24 (1.20) mg           1.10 (.92) mg          6.6 (2.7) mg            8.9 (3.8) mg
      2011                                                          .19 (.54) mg            .54 (.79) mg          6.9 (3.3) mg            7.6 (3.6) mg
                   f
      NP P value                                                        .000                    .001                  .978                    .074
     Total Knee Arthroplasty Only
      2008                                                          .18 (.65) mg            .29 (.58) mg          6.3 (2.7) mg            6.8 (3.0) mg
      2011                                                          .15 (46) mg             .17 (.43) mg          5.0 (2.0) mg            5.3 (2.2) mg
                   f
      NP P value                                                        .572                    .179                  .000                    .000
     Subgroup Analysis by Surgery Type, Surgeon, and Protocol Group
      THA, surgeon 1
        2008                                                                                                      6.8 (3.2) mg           10.0 (4.3) mg
        2011                                                                                                      8.0 (4.0) mg            8.9 (4.6) mg
      THA, surgeon 2
        2008                                                                                                      6.4 (2.3) mg            7.9 (2.9) mg
        2011                                                                                                      5.8 (1.7) mg            6.3 (1.6) mg
      ANOVA P valuesg
        Surgeon vs surgeon                                                                                             .024                    .002
        2008 protocol vs 2011 protocol                                                                                 .604                    .067
        Surgeon influence on protocol                                                                                 .143h                   .717h
      TKA, surgeon 3
        2008                                                                                                      5.3 (2.3) mg            5.7 (2.5) mg
        2011                                                                                                      4.5 (1.8) mg            4.8 (2.1) mg
      TKA, surgeon 2
        2008                                                                                                      7.3 (2.8) mg            7.8 (3.1) mg
        2011                                                                                                      5.5 (2.2) mg            5.8 (2.3) mg
      ANOVA P valuesg
        Surgeon vs surgeon                                                                                             .000                    .000
        2008 protocol vs 2011 protocol                                                                                 .000                    .000
        Surgeon influence on protocol                                                                                 .146h                   .134h

  Abbreviations: ANOVA, analysis of variance; NP, nonparametric; OR, operating room; PACU, postanesthesia care unit; THA, total hip arthroplasty;
  TKA, total knee arthroplasty.
  a
    Analysis given as mean (standard deviation) in hydromorphone equivalent mg.
  b
    OR time period is defined as incision time to PACU admission time.
  c
    PACU time period is defined as PACU admission time to PACU discharge time.
  d
    FLOOR time period is defined as PACU discharge to 48 hours after incision.
  e
    TOTAL time period is defined as incision time to 48 hours after incision time.
  f
   NP P value refers to nonparametric test of significance (Mann-Whitney U test) with .05 considered significant, subgroup analysis by surgeon only
  completed for FLOOR and TOTAL time periods.
  g
    ANOVA P values for surgeon subgroup analysis show that for THA there was a statistically significant difference between the 2 surgeons but not the 2
  protocol groups and that differences between the surgeons did not significantly influence analysis of the protocol groups; for TKA, statistically significant
  differences were found between the surgeons and the protocol groups but the surgeon differences did not significantly impact the protocol groups.
  h
    Levene’s test of equality of error variances was positive when comparing hip surgeons. Therefore, comparing the hip surgeon populations by ANOVA
  may not be valid due to significant differences in the population characteristics in the 2 protocol groups.

28                                                                                                           ORTHOPEDICS | Healio.com/Orthopedics
EFFECT OF METHOCARBAMOL AND ACETAMINOPHEN ON OPIOID USE AFTER THA AND TKA | LOOKE & KLUTH

                             Opiate Use in OR by Protocol Group
                2008 Protocol (Blue)                  2011 Protocol (Green)

                                                                                                                                                                         2
                                                                                         Figure 2: Opiate usage by time interval and protocol group. OR is the time period in
                                                                                 1       the operating room from time of incision to time of PACU admission; PACU is time
Figure 1: Demonstration of skewed opiate data. The vast majority of patients             in postanesthesia care unit from time of admission to time of discharge from PACU;
receive no opiate medication in the operating room. The y-axis is opioid use in          FLOOR is the time period from PACU discharge to 48 hours after incision; and TO-
hydromorphone equivalent mg. The x-axis, labeled Frequency, shows number                 TAL is the combined period from incision time to 48 hours after incision. The height
of patients receiving the amount of hydromorphone in the interval shown with             of the bars represents mean with error line (standard deviation) rising above mean
the bottom interval (highest frequency) being the number of patients receiving           demonstrating that data is not normally distributed (skewed left). Mann-Whitney U
hydromorphone 0 to 0.2 mg.                                                               test P values shown above each time interval.

                                                                                 3                                                                                       4
Figure 3: FLOOR opiate use by surgeon. Comparison of 2008 and 2011 protocol              Figure 4: Comparison of 2008 and 2011 protocol groups total opiate use broken
groups opiate use on the FLOOR (after discharge from PACU) broken down by                down by surgeon. The height of the bars (error lines) represent mean (standard
surgeon. The height of the bars (error lines) represent mean (standard deviation)        deviation) opiate use in hydromorphone equivalent mg. Table 4 gives ANOVA P
opiate use in hydromorphone equivalent mg. Table 4 gives ANOVA P values. For             values. For THA, Surgeon 1 and 2 populations have different opiate needs but the
THA, Surgeon 1 and 2 populations have different opiate needs but the combined            combined protocol groups are similar and the differences between the surgeons
protocol groups are similar and the differences between the surgeons did not             did not significantly affect protocol group changes. For TKA, Surgeon 3 and 2 popu-
significantly affect protocol group changes. For TKA, Surgeon 3 and 2 popula-            lations have different opiate needs, combined 2008 and 2011 protocol groups have
tions have different opiate needs, combined 2008 and 2011 protocol groups have           different needs, but the difference between the surgeons did not impact the differ-
different needs, but the difference between the surgeons did not impact the dif-         ence between the protocol groups.
ference between the protocol groups.

Continued from page 27                                            time periods. Even with patients in both           proved adequate for all time periods for
FLOOR intervals (as described above)                              protocol groups requiring minimal opi-             both hip and knee surgeries and showed
into 1, a necessary adjustment due to spo-                        oids in the OR and PACU (Figure 1, for             the same skew to the left as the full pro-
radic FLOOR data. The TOTAL period                                the OR), nonparametric analysis showed             tocol groups, necessitating a nonparamet-
combined all data for the 48-hour period                          significant reduction of opioid use in the         ric approach for this analysis as well. The
starting with incision time.                                      2011 protocol group in all time periods            2011 protocol group demonstrated signifi-
   Our patient population demonstrated a                          (Figure 2).                                        cantly reduced opioid use in the OR and
non-normally distributed opioid use that                             The results were also analyzed focus-           PACU time periods after hip surgery but
was heavily skewed to the left with the                           ing on surgery type (hip or knee) and              not knee surgery. There was significantly
median much greater than the mean in all                          surgeon (Table 3). For surgery type, data          reduced opioid use on the FLOOR and

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■ Feature Article

TOTAL in the knee surgery group but not
the hip surgery group. Examining the in-                                                       Table 4

dividual surgeons (identified only as sur-                                   Secondary Outcome Variablesa
geons 1, 2, and 3), FLOOR and TOTAL
opiate use were normally distributed data                                    2008 Protocol               2011 Protocol
                                                                                Group                       Group                        P
and ANOVA was used to determine if
changes in opioid use (FLOOR and TO-
                                                  Pain; all periods   b
                                                                              4.9 (1.0) VAS              5.5 (1.2) VAS
EFFECT OF METHOCARBAMOL AND ACETAMINOPHEN ON OPIOID USE AFTER THA AND TKA | LOOKE & KLUTH

                                                                                                             surgery, which may provide 12 hours of
                                                      Table 5                                                postoperative pain relief. We are not able
     Changes in Intraoperative Anesthesia Preference for Total Hip Surgery                                   to determine if the increased use of spi-
                                                                                                             nal morphine or fascia iliaca blocks to
                                     2008                                           2011                     the 2011 THA protocol contributed to the
                                                  a              b
                 No.         GA          Spinal          Both        No.     GA        Spinala      Bothb    findings. It is possible that a statistically
   Surgeon        24          24            0              0         25      13           17           5     significant increase in FLOOR opioid
   1, No(%)                 (100)                                           (52)         (68)        (20)    use was averted by these techniques.
   Surgeon        25         15             16              6        25      5            23           3         Other changes in the use of patient-
   2, No(%)                 (60)           (64)           (24)              (20)         (92)        (12)
                                                                                                             controlled analgesia, preoperative oral
   Total,         49         39             16              6        50      18           40           8     analgesics, and surgical site injections
   No(%)                    (80)           (33)           (12)              (36)         (80)        (16)
                                                                                                             may have influenced the results. Ten
  Abbreviation: GA, general anesthesia.                                                                      months after initiating the 2008 protocol,
  a
   Single injection of spinal anesthesia.
  b
    Patient received both spinal and GA. Reason for receiving both was unspecified but could be failed or    most total knee patients who received spi-
  slow onset spinal or other patient factors, such as patient preference, morbid obesity, or sleep apnea).   nal anesthesia and a femoral nerve cath-
                                                                                                             eter controlled their postoperative pain
                                                                                                             with only PRN oral opioids. The patient-
                                                      Table 6                                                controlled analgesia for total knee sur-
                 Use of Patient-controlled Analgesia Postoperatively                                         gery postoperatively was phased out over
                                                                                                             the next year. In the 2008 protocol group,
                   by Surgery Type, Surgeon, and Protocol Group
                                                                                                             33% of patients (who had their surgery in
                                                           2008                          2011                2009 and early 2010) received a patient-
   Procedure                                 PCAa               No PCA       PCA            No PCA           controlled analgesia, and with the 2011
                                                                                                             protocol, no patients (except chronic pain
   THA
                                                                                                             patients) received a patient-controlled
     Surgeon 1 (n=49)                        14                 10           12             13
                                                                                                             analgesia. This was also phased out for
     Surgeon 2 (n=50)                        25                 0            0              25
                                                                                                             total hip patients, with 80% receiving
     Total, No.(%)                           39 (80%)           10 (20%)     12 (24%)       38 (76%)         patient-controlled analgesias in the 2008
   TKA                                                                                                       protocol group and only 24% receiving
     Surgeon 3 (n=100)                       12                 38           0              50               patient-controlled analgesias in the 2011
     Surgeon 2 (n=100)                       21                 29           0              50               protocol group (Table 6). There was a
     Total, No.(%)                           33 (33%)           67 (67%)     0              100              significant reduction in late opiate use
   All (n=299), No.(%)                       72 (48%)           77 (52%)     12 (8%)        138 (92%)        (FLOOR and TOTAL) and a concomitant
                                                                                                             increase in average pain scores (Table 4).
  Abbreviations: N, number of patients; PCA, patient-controlled analgesia; THA, total hip arthroplasty;
  TKA, total knee arthroplasty.                                                                              This may be related to eliminating the
  a
   Numbers given in PCA columns represent the number of patients with documented initiation of a PCA         patient-controlled analgesia. The pres-
  in nursing records; totals given as number (%).                                                            ence of a patient-controlled analgesia is
                                                                                                             an independent (second only to pain it-
                                                                                                             self) driver of opioid consumption and
desired result is less time in the PACU                    but not statistically less (P=.074). In the       its elimination will decrease opioid use
adjusting for inadequate or excessive                      2008 total hip protocol, 33% of patients          without significantly changing patient
opiate loading in the OR and less opiate                   (all from surgeon 2) also received spinal         satisfaction. Thus, we were surprised to
use overall. The increased use of spinal                   morphine, but this increased to 80% of            see a 12% increase in pain scores and are
anesthesia from 2008 to 2011 certainly                     patients in the 2011 hip protocol (from           uncertain if the increase in average pain
contributed to the significant reduction in                both surgeons). The expected benefit is 6         scores from 4.9 to 5.5 is accompanied
OR and PACU opioid use in the total hip                    to 12 hours of postoperative pain relief.         with reduced patient satisfaction.
subgroup (Table 3) and probably to the                     None of the knee patients received spi-               In the 2008 protocol, both knee sur-
slight (insignificant) increase in opioid                  nal morphine. Ultrasound-guided fascia            geons (surgeon 2 and surgeon 3), routinely
use on the floor. Overall, the TOTAL opi-                  iliaca blocks were also added to all pa-          ordered preoperative and postoperative
ate use after hip surgery was numerically,                 tients in the 2011 protocol for total hip         oral analgesics, including celecoxib and a

FEBRUARY 2013 | Volume 36 • Number 2/SUPPLEMENT                                                                                                       31
■ Feature Article

combination oxycodone-acetaminophen                 The study found no difference in PACU      REFERENCES
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the type of surgery subdivided by surgeon       provements in the care of patients under-           101(5 Suppl):S5-22.
(Table 3; Figures 3,4) revealed that the opi-   going total knee and hip surgery at Florida    7.   Sinatra RS, Jahr JS, Reynolds LW, Viscusi
oid use group means were significantly dif-     Hospital Winter Park. The expanded use              ER, Groudine SB, Payen-Champenois C.
                                                                                                    Efficacy and safety of single and repeated
ferent (surgeon 1 compared with surgeon 2       of these medications postoperatively for
                                                                                                    administration of 1 gram intravenous acet-
for total hip and surgeon 3 compared with       48 hours should be studied in a prospec-            aminophen injection (paracetamol) for pain
surgeon 2 for total knee). The ANOVA test       tive, randomized, controlled clinical trial         management after major orthopedic surgery.
                                                                                                    Anesthesiology. 2005; 102(4):822-831.
to determine if the surgeon differences         of total hip and knee patients. Based on
                                                                                               8.   Sinatra RS, Jahr JS, Reynolds L, et al. Intra-
were responsible for overall group changes      the data of this study, in order to reduce          venous acetaminophen for pain after major
from 2008 protocol to 2011 protocol was         opioid use by at least 10%, reduce pain             orthopedic surgery: an expanded analysis.
not significant. Thus, the minor differences    scores by at least 10%, and avoid con-              Pain Pract. 2012; 12(5):357-365.
in surgeon practice probably influenced         founding variables, the proposed 2-armed
the opioid use, but did not affect the out-     randomized controlled trial would need
come changes and were not confounding           90 patients in each arm. This study is pres-
variables.                                      ently in the planning stage.

32                                                                                             ORTHOPEDICS | Healio.com/Orthopedics
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