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  • Effectiveness of intravenous acetaminophen for postoperative pain management in hip and knee arthroplasties: a population-based study

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Original article
Effectiveness of intravenous acetaminophen for postoperative pain management in hip and knee arthroplasties: a population-based study
  1. Ottokar Stundner1,
  2. Jashvant Poeran2,3,
  3. Hannah Noemi Ladenhauf4,
  4. Marc Moritz Berger1,
  5. Steven B Levy5,
  6. Nicole Zubizarreta2,3,
  7. Madhu Mazumdar2,
  8. Janis Bekeris1,6,
  9. Jiabin Liu6,
  10. Leesa M Galatz3,
  11. Calin S Moucha3 and
  12. Stavros Memtsoudis1,6,7
  1. 1 Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
  2. 2 Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  3. 3 Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  4. 4 Department of Pediatric and Adolescent Surgery, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
  5. 5 Department of Pharmacy, Mount Sinai St Luke's, Mount Sinai Health System, New York, New York, USA
  6. 6 Department of Anesthesiology, Hospital for Special Surgery, New York, New York, USA
  7. 7 Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
  1. Correspondence to Dr Jashvant Poeran, Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; jashvant.poeran{at}mountsinai.org

Abstract

Background and objectives The significance of intravenous over oral acetaminophen (APAP) as part of multimodal analgesic protocols is contested, particularly when considering its relatively high price and use in a surgical cohort such as total hip or knee arthroplasty (THA/TKA), which generally tolerates oral medications. This study aims to elucidate APAP’s effectiveness in a large, population-based patient sample.

Methods 1 039 647 THA/TKA procedures were sampled from the Premier Healthcare claims database 2011–2016. APAP use was categorized by intravenous/oral and use on the day of surgery, postoperative day 1 and thereafter. Outcomes were opioid utilization (in oral morphine equivalents), length and cost of hospitalization, and opioid-related adverse effects (respiratory, gastrointestinal, and naloxone use as a proxy). Mixed-effects models measured the associations between intravenous/oral APAP use and outcomes. Percent (%) change and 95% CIs are reported.

Results Overall, 23.6% (n=245 454) of patients received intravenous APAP; of these, 56.3% (n=138 180) received just one dose on the day of surgery. After adjustment for relevant covariates, particularly use of >1 dose of intravenous APAP (compared with no use) on postoperative day 1 was associated with −6.0% (CI −7.2% to −4.7%) reduced opioid utilization; this was −10.7% (CI −11.4% to -9.9%) for use of > 1 dose oral APAP on postoperative day 1. Further comparisons regarding other outcomes also favored oral (over intravenous) APAP.

Conclusions These results do not support the routine use of intravenous APAP in patients undergoing lower joint arthroplasty, especially since oral APAP shows more beneficial outcome patterns.

  • acute Pain
  • pain
  • postoperative
  • acetaminophen
  • arthroplasty
  • hip
  • arthroplasty
  • knee
  • analgesia

https://doi.org/10.1136/rapm-2018-100145

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    Footnotes

    • Contributors OS contributed to the generation of the research plan, helped interpret the analyzed data, and drafted the manuscript. JP contributed to the generation of the research plan, analyzed the data, and contributed to drafting the manuscript. HNL helped interpret the raw and analyzed data, and reviewed the manuscript. MMB contributed to the generation of the research plan, helped interpret the analyzed data, and assisted in drafting the manuscript. SBL provided field-specific guidance, helped to generate relevant variables, and interpret the analyzed data. NZ contributed to the generation of the research plan, helped in analyzing the data, and reviewed the manuscript. MM contributed to the generation of the research plan, provided senior statistical advisory, generated sensitivity analyses, audited the statistical methodology, and reviewed the manuscript. JB contributed to the generation of the research plan, helped in analyzing the data, and reviewed the manuscript. JL provided field-specific guidance, and helped to generate relevant variables and interpret the analyzed data. LMG contributed to analyzing the data and reviewed the manuscript. CSM provided senior field-specific guidance, helped analyze the data, and reviewed the manuscript. SM provided senior clinical advisory, assisted in the generation of the research plan, helped interpret the analyzed data, and assisted in drafting and reviewing the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval This retrospective cohort study was approved by the Mount Sinai Hospital Institutional Review Board (project #14–00647).

    • Provenance and peer review Not commissioned; externally peer reviewed.