Is Scheduled Intravenous Acetaminophen Effective in the Pain Management Protocol of Geriatric Hip Fractures?

Alexander J Bollinger, Paul D Butler, Matthew S Nies, Debra L Sietsema, Clifford B Jones, Terrence J Endres, Alexander J Bollinger, Paul D Butler, Matthew S Nies, Debra L Sietsema, Clifford B Jones, Terrence J Endres

Abstract

Background: Hip fractures have significant effects on the geriatric population and the health care system. Prior studies have demonstrated both the safety of intravenous (IV) acetaminophen and its efficacy in decreasing perioperative narcotic consumption. The purpose of this study is to evaluate the effect of scheduled IV acetaminophen for perioperative pain control on length of hospital stay, pain level, narcotic use, rate of missed physical therapy (PT) sessions, adverse effects, and discharge disposition in geriatric patients with hip fractures.

Methods: A retrospective review was performed of all patients 65 years and older admitted to a level I trauma center, who received operative treatment for a hip fracture over a 2-year period. Demographic data, in-hospital variables, and outcome measures were analyzed. Three hundred thirty-six consecutive fractures in 332 patients met inclusion criteria. These patients were divided into 2 cohorts. Group 1 (169 fractures) consisted of patients treated before the initiation of a standardized IV acetaminophen perioperative pain control protocol, and group 2 (167 fractures) consisted of those treated after the protocol was initiated.

Results: Group 2 had a statistically significant shorter mean length of hospital stay (4.4 vs 3.8 days), lower mean pain score (4.2 vs 2.8), lower mean narcotic usage (41.3 vs 28.3 mg), lower rate of PT sessions missed (21.8% vs 10.4%), and higher likelihood of discharge home (7% vs 19%; P ≤ .001). Use of IV acetaminophen was also consistently and independently predictive of the same variables (P < .01).

Conclusion: The utilization of scheduled IV acetaminophen as part of a standardized pain management protocol for geriatric hip fractures resulted in shortened length of hospital stay, decreased pain levels and narcotic use, fewer missed PT sessions, and higher rate of discharge to home.

Level of evidence: Therapeutic level III.

Keywords: acetaminophen; geriatric hip fracture; length of stay; perioperative pain.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

    1. National Hospital Discharge Survey [database online]. Atlanta, GA: Center for Disease Control and Prevention/National Health Statistics Report, 2010 summary.
    1. Marks R, Allegrante J, Ronald-MacKenzie C, Lane JM. Hip fractures among the elderly: causes, consequences and control. Ageing Res Rev. 2003;2(1):57–93.
    1. Leibson C, Tosteson A, Gabriel S, Ransom JE, Melton LJ. Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc. 2002;50(10):1644–1650.
    1. Brainsky A, Glick H, Lydick E, et al. The economic cost of hip fractures in community-dwelling older adults: a prospective study. J Am Geriatr Soc. 1997;45(3):281–287.
    1. Hannan EL, Magaziner J, Wang JJ, et al. Mortality and locomotion 6 months after hospitalization for hip fracture: risk factors and risk-adjusted hospital outcomes. JAMA. 2001;285(21):2736–2742.
    1. Alegre-Lopez J, Cordero-Guevara J, Alonso-Valdivielso JL, Fernández-Melón J. Factors associated with mortality and functional disability after hip fracture: an inception cohort study. Osteoporos Int. 2005;16(7):729–736.
    1. Dwyer JG, Reynoso JF, Seevers GA, et al. Assessing preoperative frailty utilizing validated geriatric mortality calculators and their association with postoperative hip fracture mortality risk. Geriatr Orthop Surg Rehabil. 2014;5(3):109–115.
    1. Beaupre LA, Binder EF, Cameron ID, et al. Maximising functional recovery following hip fracture in frail seniors. Best Pract Res Clin Rheumatol. 2013;27(6):771–788.
    1. Cooper C, Cole ZA, Holroyd CR, et al. Secular trends in the incidence of hip and other osteoporotic fractures. Osteoporos Int. 2011;22(5):1277–1288.
    1. Hayes W, Myers E, Robinovitch S, Van Den Kroonenberg A, Courtney AC, McMahon TA. Etiology and prevention of age-related hip fractures. Bone. 1996;18(1 suppl):77–86.
    1. Schneider E, Guralnik J. The aging of America: impact on health care costs. JAMA. 1990;263(17):2335–2340.
    1. Morrison RS, Magaziner J, McLaughlin MA, et al. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103(3):303–311.
    1. Pasero CL, McCaffery M. Reluctance to order opioids in elders. Am J Nurs. 1997;97(9):20, 23.
    1. Duggleby W, Lander J. Cognitive status and postoperative pain: older adults. J Pain Symptom Manage. 1994;9(1):19–27.
    1. Gustafson Y, Berggren D, Brannstrom B, et al. Acute confusional states in elderly patients treated for femoral neck fracture. J Am Geriatr Soc. 1988;36(6):525–530.
    1. Givens JL, Sanft TB, Marcantonio ER. Functional recovery after hip fracture: the combined effects of depressive symptoms, cognitive impairment, and delirium. J Am Geriatr Soc. 2008;56(6):1075–1079.
    1. Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc. 2000;48(6):618–624.
    1. Lane JM. CORR Insights (R): Does early functional outcome predict 1-year mortality in elderly patients with hip fracture? Clin Orthop Relat Res. 2013;471(8):2711–013- 2995–6.
    1. Koval KJ, Skovron ML, Aharonoff GB, Meadows SE, Zuckerman JD. Ambulatory ability after hip fracture. A prospective study in geriatric patients. Clin Orthop Relat Res. 1995;(310):150–159.
    1. The Joint Commission. Sentinel Event Alert: Safe Use of Opioids in Hospitals. Oak Brook, IL: Joint Commission Resources; 2012;49:1–5.
    1. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. SAGE study group. Systematic assessment of geriatric drug use via epidemiology. JAMA. 1998;279(23):1877–1882.
    1. Cheville A, Chen A, Oster G, McGarry L, Narcessian E. A randomized trial of controlled-release oxycodone during inpatient rehabilitation following unilateral total knee arthroplasty. J Bone Joint Surg Am. 2001;83-A(4):572–576.
    1. Koppert W, Frotsch K, Huzurudin N, et al. The effects of paracetamol and parecoxib on kidney function in elderly patients undergoing orthopedic surgery. Anesth Analg. 2006;103(5):1170–1176.
    1. Jahr JS, Breitmeyer JB, Pan C, et al. Safety and efficacy of intravenous acetaminophen in the elderly after major orthopedic surgery: subset data analysis from 3, randomized, placebo-controlled trials. Am J Ther. 2012;19(2):66–75.
    1. Smith HS. Perioperative intravenous acetaminophen and NSAIDs. Pain Med. 2011;12(6):961–981.
    1. van der Westhuizen J, Kuo PY, Reed PW, et al. Randomised controlled trial comparing oral and intravenous paracetamol (acetaminophen) plasma levels when given as preoperative analgesia. Anaesth Intensive Care. 2011;39(2):242–246.
    1. Singla NK, Parulan C, Samson R, et al. Plasma and cerebrospinal fluid pharmacokinetic parameters after single-dose administration of intravenous, oral, or rectal acetaminophen. Pain Pract. 2012;12(7):523–532.
    1. Sinatra RS, Jahr JS, Reynolds LW, et al. Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery. Anesthesiology. 2005;102(4):822–831.
    1. Lachiewicz PF. The role of intravenous acetaminophen in multimodal pain protocols for perioperative orthopedic patients. Orthopedics. 2013;36(2 suppl):15–19.
    1. Looke TD, Kluth CT. Effect of preoperative intravenous methocarbamol and intravenous acetaminophen on opioid use after primary total hip and knee replacement. Orthopedics. 2013;36(2 suppl):25–32.
    1. Sinatra RS, Jahr JS, Reynolds L, et al. Intravenous acetaminophen for pain after major orthopedic surgery: an expanded analysis. Pain Pract. 2012;12(5):357–365.
    1. Tsang KS, Page J, Mackenney P. Can intravenous paracetamol reduce opioid use in preoperative hip fracture patients? Orthopedics. 2013;36(2 suppl):20–24.
    1. Abdulla S, Eckhardt R, Netter U, et al. Efficacy of three IV non-opioid-analgesics on opioid consumption for postoperative pain relief after total thyroidectomy: a randomised, double-blind trial. Middle East J Anesthesiol. 2012;21(4):543–552.
    1. American Medical Association. CPT® 2013 Professional. Chicago, IL: American Medical Association Press; 2013.
    1. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium - 2007: orthopaedic trauma association classification, database and outcomes committee. J Orthop Trauma. 2007;21(suppl 10): S1–S163.
    1. Knotkova H, Fine PG, Portenoy RK. Opioid rotation: the science and the limitations of the equianalgesic dose table. J Pain Symptom Manage. 2009;38(3):426–439.
    1. Collinge CA, McWilliam-Ross K, Beltran MJ, Weaver T. Measures of clinical outcome before, during, and after implementation of a comprehensive geriatric hip fracture program: is there a learning curve? J Orthop Trauma. 2013;27(12):672–676.
    1. Lau TW, Fang C, Leung F. The effectiveness of a geriatric hip fracture clinical pathway in reducing hospital and rehabilitation length of stay and improving short-term mortality rates. Geriatr Orthop Surg Rehabil. 2013;4(1):3–9.
    1. Berger MM, Berger-Gryllaki M, Wiesel PH, et al. Intestinal absorption in patients after cardiac surgery. Crit Care Med. 2000;28(7):2217–2223.
    1. Petring OU, Dawson PJ, Blake DW, et al. Normal postoperative gastric emptying after orthopaedic surgery with spinal anaesthesia and i.m. ketorolac as the first postoperative analgesic. Br J Anaesth. 1995;74(3):257–260.
    1. Simunovic N, Devereaux PJ, Sprague S, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010;182(15):1609–1616.
    1. Al-Ani AN, Samuelsson B, Tidermark J, et al. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am. 2008;90(7):1436–1442.
    1. Biber R, Singler K, Curschmann-Horter M, Wicklein S, Sieber C, Bail HJ. Implementation of a co-managed Geriatric Fracture Center reduces hospital stay and time-to-operation in elderly femoral neck fracture patients. Arch Orthop Trauma Surg. 2013;133(11):1527–1531.
    1. Rae HC, Harris IA, McEvoy L, Todorova T. Delay to surgery and mortality after hip fracture. ANZ J Surg. 2007;77(10):889–891.
    1. Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40(7):692–697.
    1. Carretta E, Bochicchio V, Rucci P, Fabbri G, Laus M, Fantini MP. Hip fracture: effectiveness of early surgery to prevent 30-day mortality. Int Orthop. 2011;35(3):419–424.
    1. Marcantonio ER, Flacker JM, Wright RJ, et al. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2001;49(5):516–522.
    1. Bjorkelund KB, Hommel A, Thorngren KG, Gustafson L, Larsson S, Lundberg D. Reducing delirium in elderly patients with hip fracture: a multi-factorial intervention study. Acta Anaesthesiol Scand. 2010;54(6):678–688.
    1. Chin RP, Ho CH, Cheung LP. Scheduled analgesic regimen improves rehabilitation after hip fracture surgery. Clin Orthop Relat Res. 2013;471(7):2349–2360.
    1. Dubljanin-Raspopovic E, Markovic-Denic L, Marinkovic J, Nedeljković U, Bumbaširević M. Does early functional outcome predict 1-year mortality in elderly patients with hip fracture? Clin Orthop Relat Res. 2013;471(8):2703–2710.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться