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

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1 Feture Article Effect of Preopertive Intrvenous Methocrbmol nd Intrvenous Acetminophen on Opioid Use After Primry Totl Hip nd Knee Replcement THOMAS D. LOOKE, MD, PHD; CAMERON T. KLUTH, MBA bstrct Between 2010 nd 2011, periopertive pin protocol for primry totl hip nd knee replcement t one Florid medicl center replced preopertive orl nlgesics with intrvenous methocrbmol nd intrvenous cetminophen. This is retrospective cohort study of 300 ptients, with 150 ptients using the new pin protocol nd 150 ptients using 2008 pin protocol tht did not include these medictions. The 2 cohorts were similr in ptient gender, ge, nd body mss index. Opioid consumption ws evluted for period of 48 hours fter incision nd ws divided into 3 seprte time intervls, s well s totl 48-hour consumption. Men opite use decresed significntly from 2008 to 2011 in ll time intervls nd totl consumption ( mg to mg; P.01). Subgroup nlysis suggested tht chnges to the hip protocol were responsible for decresed opioid use in the operting room nd the postnesthesi cre unit, nd chnges to the knee protocol were responsible for decresed opioid use on the hospitl floor nd totl consumption. The difference between the 2 protocol groups ws not due to differences in individul surgeon prctice ptterns. Physicl therpy progress of knee flexion, verge wlking distnce, nd mximum wlking distnce were significntly improved. Hospitl dischrge ws shorter in the 2011 group ( dys in 2008 group nd dys in 2011 group). This study shows significnt improvement in ptient cre from 2008 to 2011 tht is t lest prtilly due to the chnge to the use of preopertive intrvenous methocrbmol nd intrvenous cetminophen. In the United Sttes, more thn 600,000 totl knee replcements nd 285,000 totl hip replcements re performed ech yer. 1,2 At Florid Hospitl, 4415 bed hospitl system with 22 cmpuses in centrl Florid, surgeons perform more thn 2100 primry totl hip nd knee replcements ech yer t the 7 cmpuses in the greter Orlndo re. Periopertive pin mngement protocols, which include orl nd prenterl nlgesics, regionl nesthetics, nd surgicl site injections, designed by physicins t the Florid Hospitl Winter Prk cmpus hve evolved over the pst severl yers. No stndrdized protocol existed prior to In 2006, the nesthesi deprtment offered regionl nesthesi to ll totl knee ptients. By mid-2008, nesthesiologists t Florid Hospitl Winter Prk offered every totl knee ptient femorl nerve sheth ctheter with The uthors re from the Florid Hospitl Deprtment of Anesthesiology nd Florid Hospitl, Winter Prk Division, Office of Orthopedic Reserch (TDL); nd from the University of Centrl Florid College of Medicine (CTK), Orlndo, Florid. Dr Looke received investigtor-initited study grnt support pid to his institution from Cdence Phrmceuticls, Inc., nd ws compensted by SLACK Incorported for his contribution to this mnuscript. Mr Kluth received trvel reimbursement from the University of Centrl Florid College of Medicine. The uthors thnk Gwen Certin nd Cecille Brocto for shring their extensive knowledge nd experience s certified pin nurses nd for providing their invluble ssistnce with dt collection; nd Dr Julie W. Pepe with Florid Hospitl Office of Reserch Administrtion for her biosttistics expertise. The uthors lso thnk the ledership tem t Florid Hospitl Winter Prk for providing equipment, office spce, nd logisticl support for this project. Correspondence should be ddressed to: Thoms D. Looke, MD, PhD, 4609 Jetty St, Orlndo, FL (tdlooke@hotmil.com). doi: / FEBRUARY 2013 Volume 36 Number 2 /SUPPLEMENT 25

2 Feture Article 48 hours of continuous regionl nesthesi for postopertive pin mngement. By 2010, the use of postopertive opioids fter totl knee surgery decresed significntly, nd ptient-controlled nlgesi delivery of intrvenous hydromorphone ws replced with nursing dministrtion of orl oxycodone plus cetminophen or intrvenous hydromorphone t ptient request only. In ddition, preopertive tretment with orl nlgesics ( surgeon-ordered combintion of 1 or more of celecoxib, oxycodone plus cetminophen, or pregblin) ws replced with intrvenous methocrbmol (Robxin Injection; Bxter Helthcre Corportion, Deerfield, Illinois). The gols with this mediction were to reduce orl loding preopertively nd reduce recovery room dischrge delys due to muscle spsm pin. At tht time, no reports existed on the effectiveness of intrvenous methocrbmol postopertively for totl joint surgery. Two studies of its use fter brest ugmenttion hd been performed, 3-5 but this mediction ws ignored by most of the nesthesi pin literture. 6 In 2011, intrvenous cetminophen (OFIRMEV; Cdence Phrmceuticls, Inc., Sn Diego, Cliforni) ws dded to the protocol. Physicins nd nursing stff hd necdotlly reported tht the combintion of intrvenous methocrbmol nd intrvenous cetminophen improved the erly postopertive recovery fter totl hip nd knee replcement. Although intrvenous cetminophen hd been studied for use in mjor orthopedic surgery, 7,8 it hd not been studied when dded to periopertive pin protocol tht included long cting peripherl regionl nesthetics nd other intrvenous djuncts. Our retrospective study compres cohort of ptients from 2011, who received preopertive intrvenous methocrbmol nd intrvenous cetminophen, with cohort of ptients using the 2008 pin protocol, who did not receive these medictions. The outcome mesures studied were opioid consumption, time to first opioid rescue, VAS pin scores, physicl therpy progress, nd hospitl dischrge times. This ws considered pilot study to determine if prospective, rndomized, controlled clinicl tril would likely show ny benefit from expnding the use of these 2 intrvenous medictions from 1 preopertive dose to regulr dosing for the first 48 hours. MATERIALS AND METHODS The Institutionl Review Bords of Florid Hospitl nd the University of Centrl Florid pproved this retrospective 2 cohort study with HIPAA nd informed consent wivers for 300 ptients. One hundred fifty ptients were included in the study group (using the 2011 protocol with preopertive intrvenous methocrbmol nd intrvenous cetminophen), nd 150 ptients in the control group (using the 2008 protocol without these 2 medictions). The ptient popultion ws identified from nesthesi billing records, including ll ptients from Florid Hospitl Winter Prk who hd primry unilterl totl knee rthroplsty (CPT 27447) or primry totl hip rthroplsty (CPT 27130) between Jnury 1, 2009, nd October 12, Ptients were grouped ccording to the periopertive pin protocol nd excluded ptients from the 2010 protocol who received intrvenous methocrbmol but not intrvenous cetminophen. Within ech protocol group, ptients were lso grouped first by surgeon (from gretest to lest surgicl volume), next by nesthesiologist (from gretest to lest volume), nd finlly by dte of surgery (in reverse chronologic order). Since the totl knee rthroplsty volume t Florid Hospitl Winter Prk (700 in 2011) is pproximtely twice tht of totl hip rthroplsty volume (375 in 2011), the tem decided, priori, to include 100 knees nd 50 hip ptients from ech protocol group. This mde it possible to limit the study to 2 surgeons performing knees (50 using the 2011 study protocol nd 50 using the 2008 control protocol ech) nd 2 surgeons performing hips (25 using the 2011 study protocol nd 25 using the 2008 control protocol ech). In totl, the study included ptients from 3 surgeons, becuse the second most prolific knee surgeon ws lso the second most prolific hip surgeon. More emphsis ws plced on limiting the number of surgeons rther thn nesthesiologists, becuse the number of ptient-cre items left to the discretion of the surgeon is greter thn those left to the discretion of the nesthesiologist. In ddition, the tem wnted to determine whether those items left to surgicl discretion, such s intropertive surgicl site injections nd periopertive nlgesic djunct selection, influenced primry outcome differences. Ptients were evluted from 2011 (study) nd 2008 (control) protocol groups in the order described bove nd included those ptients, between the ges of 18 nd 85, who hd n Americn Society of Anesthesiologists (ASA) physicl sttus of 1 to 3. Ptients were excluded if they hd chronic pin with ptient reported opioid use 1 month preopertively; hd tken centrlly cting muscle relxnts 24-hours preopertively; received regionl nesthesi procedure for postopertive pin control (other thn femorl nerve sheth ctheter for knees or fsci ilic block for hips); did not receive both of the study medictions; nd if there ws notble surgicl compliction s defined by the surgeon s opertive report. Dt ws collected for 300 ptients. During the dt nlysis phse, 1 totl hip ptient in the 2008 protocol group, whose opioid consumption exceeded 5 stndrd devitions bove the men, ws lso excluded from nlysis, bsed on history of chronic pin tht hd been missed in the initil ssessment. Thus, 299 ptients with primry totl knee or totl hip replcement were included in the study. For the study time periods, the surgicl incision ws defined s time zero. 26 ORTHOPEDICS Helio.com/Orthopedics

3 EFFECT OF METHOCARBAMOL AND ACETAMINOPHEN ON OPIOID USE AFTER THA AND TKA LOOKE & KLUTH Tble 1 Opite Equivlency Tble Used to Convert Opites Encountered During the Study to Hydromorphone Equivlents Opite Generic Nme Route Equivlent Dose Fentnyl Intrvenous 100 mcg Hydrocodone Orl 30 mg Hydromorphone Intrvenous 1.5 mg Hydromorphone Orl 7.5 mg Meperidine Intrvenous 75 mg Morphine Intrvenous 10 mg Morphine Orl 30 mg Oxycodone Orl 20 mg Propoxyphene Orl 150 mg All outcome dt for the first 48 hours fter surgicl incision ws plced into 1 of 10 distinct time periods: intropertive OR (incision time to time of dmission to the postnesthesi cre unit), postnesthesi cre unit PACU (recovery room dmission time to dischrge time), nd 8 6-hour hospitl FLOOR intervls with intervl 1 strting t PACU dischrge nd ending 6 hours fter incision time. Any opioids given prior to surgicl incision (preopertive or for induction of nesthesi) nd included in surgicl site injections were excluded. All dt were Tble 2 Demogrphics of Study Ptients Sex, No.(%) Age, y, BMI, ASA Clss No. (%) Group Femle Mle Men (SD) Men (SD) All 174 (58) 125 (42) 65.5 (9.8) 30.8(5.9) 23 (8) 190 (63) 86 (29) (56) 65 (44) 66.1 (9.4) 30.8(5.4) 5 (3) 95 (64) (60) 60 (40) 64.9 (10.3) 30.9(6.3) 18 (12) 95 (63) P vlue (33) 37 (25) Abbrevitions: ASA clss, Americn Society of Anesthesiology physicl sttus; BMI, body mss index. Meets criteri for signifi cnce t P<.05. obtined from electronic medicl records including scnned nesthesi nd nursing notes, dictted opertive reports, nd electroniclly entered nursing, phrmcy, nd physicl therpy notes. The primry study endpoint ws opioid consumption, which ws documented in the electronic medicl record, nd ll opioid mediction ws converted to hydromorphone equivlent milligrms (Tble 1). The secondry study endpoints were: VAS pin scores (recorded by nursing stff t regulr intervls nd prior to dministrtion of PRN opioids); rescue time (in minutes from incision to first request for opioid mediction); physicl therpy progress (rnge of motion fter totl knee in degrees of flexion nd extension, nd mbultion in feet fter both totl hip nd totl knee) recorded by physicl therpist once or twice dily; PACU dischrge time (in minutes from time of rrivl to the time tht PACU dischrge criteri ws met); nd hospitl dischrge time (in dys from time of incision to time officilly recorded s end of hospitl dmission). Sttisticl nlysis used chi-squre test for ech ctegoricl vrible (gender nd ASA clss) nd considered nonctegoricl vribles to be continuous. The tem then evluted nonctegoricl vribles using either prmetric or nonprmetric tests depending on whether the dt were found to be normlly or nonnormlly distributed. Prmetric tests included n independent 2-smple t test for the primry group (protocol) comprisons nd nlysis of vrince (ANOVA) for the multiple subgroup comprisons. The tem used Levene s test of equlity of error vrinces for the ANOVA comprisons to determine if the subgroup popultions hd comprble sttistics. A significnt Levene s test result mens tht subgroup popultions hve different chrcteristics nd thus ANOVA significnce vlues my not be vlid. The tem then pplied the Mnn-Whitney U test to evlute nonprmetric dt. RESULTS The ptients in the 2 protocol cohorts showed similr demogrphic dt for gender, ge, nd body mss index (BMI), but there ws significntly greter number of ASA 3 (nd fewer ASA 1) ptients in the 2008 protocol group (Tble 2). Four time intervls contined enough dt to be evluted for the primry outcome, opite consumption: OR, PACU, FLOOR, nd TOTAL (Tble 3). The FLOOR period combined the 8 6-hour Continued on pge 29 FEBRUARY 2013 Volume 36 Number 2/ SUPPLEMENT 27

4 Feture Article Tble 3 Opite Use by Time Period for Protocol nd Subgroup Group OR b PACU c FLOOR d TOTAL e Protocol group (.99) mg.56 (.80) mg 6.4 (2.7) mg 7.5 (3.4) mg (.49) mg.30 (.60) mg 5.6 (2.7) mg 6.1 (3.0) mg NP P vlue f Totl Hip Arthroplsty Only (1.20) mg 1.10 (.92) mg 6.6 (2.7) mg 8.9 (3.8) mg (.54) mg.54 (.79) mg 6.9 (3.3) mg 7.6 (3.6) mg NP P vlue f Totl Knee Arthroplsty Only (.65) mg.29 (.58) mg 6.3 (2.7) mg 6.8 (3.0) mg (46) mg.17 (.43) mg 5.0 (2.0) mg 5.3 (2.2) mg NP P vlue f Subgroup Anlysis by Surgery Type, Surgeon, nd Protocol Group THA, surgeon THA, surgeon ANOVA P vlues g Surgeon vs surgeon 2008 protocol vs 2011 protocol Surgeon influence on protocol TKA, surgeon TKA, surgeon ANOVA P vlues g Surgeon vs surgeon 2008 protocol vs 2011 protocol Surgeon influence on protocol 6.8 (3.2) mg 8.0 (4.0) mg 6.4 (2.3) mg 5.8 (1.7) mg h 5.3 (2.3) mg 4.5 (1.8) mg 7.3 (2.8) mg 5.5 (2.2) mg 10.0 (4.3) mg 8.9 (4.6) mg 7.9 (2.9) mg 6.3 (1.6) mg h 5.7 (2.5) mg 4.8 (2.1) mg 7.8 (3.1) mg 5.8 (2.3) mg Abbrevitions: ANOVA, nlysis of vrince; NP, nonprmetric; OR, operting room; PACU, postnesthesi cre unit; THA, totl hip rthroplsty; TKA, totl knee rthroplsty. Anlysis given s men (stndrd devition) in hydromorphone equivlent mg. b OR time period is defi ned s incision time to PACU dmission time. c PACU time period is defi ned s PACU dmission time to PACU dischrge time. d FLOOR time period is defi ned s PACU dischrge to 48 hours fter incision. e TOTAL time period is defi ned s incision time to 48 hours fter incision time. f NP P vlue refers to nonprmetric test of signifi cnce (Mnn-Whitney U test) with.05 considered signifi cnt, subgroup nlysis by surgeon only completed for FLOOR nd TOTAL time periods. g ANOVA P vlues for surgeon subgroup nlysis show tht for THA there ws sttisticlly significnt difference between the 2 surgeons but not the 2 protocol groups nd tht differences between the surgeons did not significntly influence nlysis of the protocol groups; for TKA, sttisticlly significnt differences were found between the surgeons nd the protocol groups but the surgeon differences did not significntly impct the protocol groups. h Levene s test of equlity of error vrinces ws positive when compring hip surgeons. Therefore, compring the hip surgeon popultions by ANOVA my not be vlid due to signifi cnt differences in the popultion chrcteristics in the 2 protocol groups h h 28 ORTHOPEDICS Helio.com/Orthopedics

5 EFFECT OF METHOCARBAMOL AND ACETAMINOPHEN ON OPIOID USE AFTER THA AND TKA LOOKE & KLUTH Opite Use in OR by Protocol Group 2008 Protocol (Blue) 2011 Protocol (Green) 2 1 Figure 1: Demonstrtion of skewed opite dt. The vst mjority of ptients receive no opite mediction in the operting room. The y-xis is opioid use in hydromorphone equivlent mg. The x-xis, lbeled Frequency, shows number of ptients receiving the mount of hydromorphone in the intervl shown with the bottom intervl (highest frequency) being the number of ptients receiving hydromorphone 0 to 0.2 mg. Figure 2: Opite usge by time intervl nd protocol group. OR is the time period in the operting room from time of incision to time of PACU dmission; PACU is time in postnesthesi cre unit from time of dmission to time of dischrge from PACU; FLOOR is the time period from PACU dischrge to 48 hours fter incision; nd TOTAL is the combined period from incision time to 48 hours fter incision. The height of the brs represents men with error line (stndrd devition) rising bove men demonstrting tht dt is not normlly distributed (skewed left). Mnn-Whitney U test P vlues shown bove ech time intervl. 3 Figure 3: FLOOR opite use by surgeon. Comprison of 2008 nd 2011 protocol groups opite use on the FLOOR (fter dischrge from PACU) broken down by surgeon. The height of the brs (error lines) represent men (stndrd devition) opite use in hydromorphone equivlent mg. Tble 4 gives ANOVA P vlues. For THA, Surgeon 1 nd 2 popultions hve different opite needs but the combined protocol groups re similr nd the differences between the surgeons did not significntly ffect protocol group chnges. For TKA, Surgeon 3 nd 2 popultions hve different opite needs, combined 2008 nd 2011 protocol groups hve different needs, but the difference between the surgeons did not impct the difference between the protocol groups. Continued from pge 27 FLOOR intervls (s described bove) into 1, necessry djustment due to spordic FLOOR dt. The TOTAL period combined ll dt for the 48-hour period strting with incision time. Our ptient popultion demonstrted non-normlly distributed opioid use tht ws hevily skewed to the left with the medin much greter thn the men in ll 4 Figure 4: Comprison of 2008 nd 2011 protocol groups totl opite use broken down by surgeon. The height of the brs (error lines) represent men (stndrd devition) opite use in hydromorphone equivlent mg. Tble 4 gives ANOVA P vlues. For THA, Surgeon 1 nd 2 popultions hve different opite needs but the combined protocol groups re similr nd the differences between the surgeons did not significntly ffect protocol group chnges. For TKA, Surgeon 3 nd 2 popultions hve different opite needs, combined 2008 nd 2011 protocol groups hve different needs, but the difference between the surgeons did not impct the difference between the protocol groups. time periods. Even with ptients in both protocol groups requiring miniml opioids in the OR nd PACU (Figure 1, for the OR), nonprmetric nlysis showed significnt reduction of opioid use in the 2011 protocol group in ll time periods (Figure 2). The results were lso nlyzed focusing on surgery type (hip or knee) nd surgeon (Tble 3). For surgery type, dt FEBRUARY 2013 Volume 36 Number 2/SUPPLEMENT proved dequte for ll time periods for both hip nd knee surgeries nd showed the sme skew to the left s the full protocol groups, necessitting nonprmetric pproch for this nlysis s well. The 2011 protocol group demonstrted significntly reduced opioid use in the OR nd PACU time periods fter hip surgery but not knee surgery. There ws significntly reduced opioid use on the FLOOR nd 29

6 Feture Article TOTAL in the knee surgery group but not the hip surgery group. Exmining the individul surgeons (identified only s surgeons 1, 2, nd 3), FLOOR nd TOTAL opite use were normlly distributed dt nd ANOVA ws used to determine if chnges in opioid use (FLOOR nd TO- TAL) from the 2008 protocol to the 2011 protocol could be ccounted for by those items left to surgeon discretion (Tble 3). All subgroups showed reduced opioid use from the 2008 protocol to the 2011 protocol, except for incresed FLOOR opioid use for surgeon 1, hip (Figures 3, 4). ANOVA nlysis showed tht differences in opioid use from the 2 protocols cnnot be ccounted for (sttisticlly) by differences mong the surgeons. This ssessment is tempered by positive Levene s test of equlity of error vrinces for the hip surgeon popultion groups. A positive Levene s test mens tht the 2 hip surgeon popultion groups hve such different sttisticl chrcteristics tht ANOVA my not be vlid. Exmining secondry outcomes (Tble 4), the verge pin intensity incresed significntly from the 2008 protocol to the 2011 protocol. Of the 10 time intervls of the study, only time intervl 5 (from 24 to 30 hours post-incision) hd enough dt points for seprte evlution. This showed no significnt difference between pin intensity scores in this time intervl. In ddition, no significnt differences in rescue time were found. All physicl therpy metrics, except for knee extension, improved in the 2011 protocol group. PACU dischrge times were unchnged. There ws pproximtely hlf-dy reduction in hospitl length of sty between the ptients in the 2008 nd 2011 protocols. DISCUSSION This retrospective cohort study showed tht ptient cre for primry hip nd knee replcement t Florid Hospitl Winter Prk improved from the 2008 protocol to the 2011 protocol. Opioid consumption decresed significntly, physicl therpy progress ccelerted, nd length of hospitl sty decresed. The study ws designed to isolte, s much s possible, the influence of dding single, preopertive dose of intrvenous methocrbmol nd intrvenous cetminophen on these outcomes. However, due to the retrospective nture of the study, it ws not possible to eliminte ll confounding vribles, including differences in ptient popultions, plnned chnges in the protocols other thn the study medictions, nd chnges in surgeon prctices. The 2008 protocol group hd significntly more ASA 3 ptients thn the 2011 group (33% vs 25%, P=.011). This fctor could possibly ccount for n incresed length of sty in the 2008 group. This 8% difference, lthough sttisticlly Tble 4 Secondry Outcome Vribles 2008 Protocol Group 2011 Protocol Group P Pin; ll periods b 4.9 (1.0) VAS 5.5 (1.2) VAS <.001 c Pin; period 5 b,d 5.4 (1.5) VAS 5.4 (1.8) VAS.846 Rescue time e 403 (332) min 440 (386) min.464 (NP) PT-extension f 3.8 (15.8 ) 3.5 (17.9 ).582 (NP) PT-flexion f 66 (21 ) 76 (17 ).001 (NP) c PT-wlk, 52 (55) ft 71 (83) ft.020 (NP) c verge g, h PT-wlk, 65 (76) ft 87 (95) ft.027 (NP) c mximum g, i PACU dischrge j 93 (41) min 88 (35) min.446 (NP) Hospitl dischrge k 4.0 (1.1) d 3.6 (1.0) d <.001 (NP) c Abbrevitions: NP, nonprmetric nlysis (required due to nonstndrd distribution of dt); PACU, postnesthesi cre unit; PRN, s needed; PT, physicl therpy; VAS, visul nlog scle. All vlues given s men (stndrd devition). b Pin mesured on stndrd VAS scle of 0-10 with only ordinl vlues reported. c Significnce stndrd of <.05 met. d Period 5 ws the FLOOR time period 24 to 30 hours fter incision. e Time from surgicl incision until first dose of ny PRN opite. f Vlues for knee extension nd flexion s reported in physicl therpy note. g Distnce reported in physicl therpy note. h Combintion of ll distnces reported for every ptient in the first 48 hours fter incision. i Mximum distnce wlked in the first 48 hours fter incision. j Time from PACU dmission until PACU dischrge criteri were met. k Time in dys from incision until ptient is officilly dischrged from hospitl. significnt, would not impct power nlysis or design future rndomized, controlled clinicl tril. In ddition to dding single, preopertive dose of intrvenous methocrbmol nd intrvenous cetminophen, other chnges to the periopertive pin protocols occurred from the 2008 group to the 2011 group, including type of nesthesi, spinl morphine, nd fsci ilic blocks. In the 2008 protocol group, 80% of the ptients received generl nesthesi (Tble 5). In the 2011 protocol, 80% of the ptients received spinl nesthesi. The expected result of spinl nesthesi is less or no pin in the erly postopertive period nd shift in opioid use from intropertive loding to post-pacu (FLOOR) dosing. The 30 ORTHOPEDICS Helio.com/Orthopedics

7 EFFECT OF METHOCARBAMOL AND ACETAMINOPHEN ON OPIOID USE AFTER THA AND TKA LOOKE & KLUTH Tble 5 Chnges in Intropertive Anesthesi Preference for Totl Hip Surgery Surgeon 1, No(%) Surgeon 2, No(%) Totl, No(%) No. GA Spinl Both b No. GA Spinl Both b (100) (60) (80) desired result is less time in the PACU djusting for indequte or excessive opite loding in the OR nd less opite use overll. The incresed use of spinl nesthesi from 2008 to 2011 certinly contributed to the significnt reduction in OR nd PACU opioid use in the totl hip subgroup (Tble 3) nd probbly to the slight (insignificnt) increse in opioid use on the floor. Overll, the TOTAL opite use fter hip surgery ws numericlly, (52) 16 (64) 16 (33) 6 (24) 6 (12) 25 5 (20) (36) 17 (68) 23 (92) 40 (80) 5 (20) 3 (12) 8 (16) Abbrevition: GA, generl nesthesi. Single injection of spinl nesthesi. b Ptient received both spinl nd GA. Reson for receiving both ws unspecified but could be filed or slow onset spinl or other ptient fctors, such s ptient preference, morbid obesity, or sleep pne). Tble 6 Use of Ptient-controlled Anlgesi Postopertively by Surgery Type, Surgeon, nd Protocol Group Procedure PCA No PCA PCA No PCA THA Surgeon 1 (n=49) Surgeon 2 (n=50) Totl, No.(%) 39 (80%) 10 (20%) 12 (24%) 38 (76%) TKA Surgeon 3 (n=100) Surgeon 2 (n=100) Totl, No.(%) 33 (33%) 67 (67%) All (n=299), No.(%) 72 (48%) 77 (52%) 12 (8%) 138 (92%) Abbrevitions: N, number of ptients; PCA, ptient-controlled nlgesi; THA, totl hip rthroplsty; TKA, totl knee rthroplsty. Numbers given in PCA columns represent the number of ptients with documented initition of PCA in nursing records; totls given s number (%). but not sttisticlly less (P=.074). In the 2008 totl hip protocol, 33% of ptients (ll from surgeon 2) lso received spinl morphine, but this incresed to 80% of ptients in the 2011 hip protocol (from both surgeons). The expected benefit is 6 to 12 hours of postopertive pin relief. None of the knee ptients received spinl morphine. Ultrsound-guided fsci ilic blocks were lso dded to ll ptients in the 2011 protocol for totl hip surgery, which my provide 12 hours of postopertive pin relief. We re not ble to determine if the incresed use of spinl morphine or fsci ilic blocks to the 2011 THA protocol contributed to the findings. It is possible tht sttisticlly significnt increse in FLOOR opioid use ws verted by these techniques. Other chnges in the use of ptientcontrolled nlgesi, preopertive orl nlgesics, nd surgicl site injections my hve influenced the results. Ten months fter inititing the 2008 protocol, most totl knee ptients who received spinl nesthesi nd femorl nerve ctheter controlled their postopertive pin with only PRN orl opioids. The ptientcontrolled nlgesi for totl knee surgery postopertively ws phsed out over the next yer. In the 2008 protocol group, 33% of ptients (who hd their surgery in 2009 nd erly 2010) received ptientcontrolled nlgesi, nd with the 2011 protocol, no ptients (except chronic pin ptients) received ptient-controlled nlgesi. This ws lso phsed out for totl hip ptients, with 80% receiving ptient-controlled nlgesis in the 2008 protocol group nd only 24% receiving ptient-controlled nlgesis in the 2011 protocol group (Tble 6). There ws significnt reduction in lte opite use (FLOOR nd TOTAL) nd concomitnt increse in verge pin scores (Tble 4). This my be relted to eliminting the ptient-controlled nlgesi. The presence of ptient-controlled nlgesi is n independent (second only to pin itself) driver of opioid consumption nd its elimintion will decrese opioid use without significntly chnging ptient stisfction. Thus, we were surprised to see 12% increse in pin scores nd re uncertin if the increse in verge pin scores from 4.9 to 5.5 is ccompnied with reduced ptient stisfction. In the 2008 protocol, both knee surgeons (surgeon 2 nd surgeon 3), routinely ordered preopertive nd postopertive orl nlgesics, including celecoxib nd FEBRUARY 2013 Volume 36 Number 2 /SUPPLEMENT 31

8 Feture Article combintion oxycodone-cetminophen tblet. In the 2011 protocol, both surgeons eliminted these medictions nd dded orl methocrbmol (500 mg 3 times dily) to the postopertive routine. This chnge my lso hve contributed to the lower opite use on the floor for totl knee surgery postopertively. Another vrible evluted ws intropertive surgicl site injections, s both totl knee surgeons routinely injected either the subcutneous tissues or the posterior cpsule. Surgeon 3 used the sme formul in both 2008 nd 2011: bupivcine 0.25% 50 ml, preservtive-free morphine 5 mg, nd ketorolc 30 mg. Surgeon 2 injected bupivcine 0.25% 50 ml nd preservtive-free morphine 5 mg in 2008 nd bupivcine 0.25% 50 ml lone in Subgroup nlysis focusing on the type of surgery subdivided by surgeon (Tble 3; Figures 3,4) reveled tht the opioid use group mens were significntly different (surgeon 1 compred with surgeon 2 for totl hip nd surgeon 3 compred with surgeon 2 for totl knee). The ANOVA test to determine if the surgeon differences were responsible for overll group chnges from 2008 protocol to 2011 protocol ws not significnt. Thus, the minor differences in surgeon prctice probbly influenced the opioid use, but did not ffect the outcome chnges nd were not confounding vribles. The study found no difference in PACU dischrge times but significnt decrese in hospitl length of sty. This my be relted to the difference in ASA grdes in the 2 groups, or possible chnge in rounding ptterns by the hospitlists. However, there ws no evidence other thn improved pin control to explin the decresed length of sty. There ws no chnge in physicl therpy prctice between the 2 cohorts nd improved pin control seems to be responsible for improvements in knee flexion nd wlking distnces. CONCLUSION This retrospective 2-cohort pilot study showed tht the ddition of preopertive intrvenous methocrbmol nd intrvenous cetminophen led to significnt improvements in the cre of ptients undergoing totl knee nd hip surgery t Florid Hospitl Winter Prk. The expnded use of these medictions postopertively for 48 hours should be studied in prospective, rndomized, controlled clinicl tril of totl hip nd knee ptients. Bsed on the dt of this study, in order to reduce opioid use by t lest 10%, reduce pin scores by t lest 10%, nd void confounding vribles, the proposed 2-rmed rndomized controlled tril would need 90 ptients in ech rm. This study is presently in the plnning stge. REFERENCES 1. Totl knee replcement. Americn Acdemy of Orthopedic Surgeons Web site. orthoinfo.os.org/topic.cfm?topic= Updted December Accessed October 20, Totl hip replcement. Americn Acdemy of Orthopedic Surgeons Web site. orthoinfo.os.org/topic.cfm?topic= Updted December Accessed October 20, Hidlgo DA, Pusic AL. The role of methocrbmol nd intercostl nerve blocks for pin mngement in brest ugmenttion. Aesthet Surg J. 2005; 25(6): Schneider MS. Methocrbmol: djunct therpy for pin mngement in brest ugmenttion. Aesthet Surg J. 2002; 22(4): Schneider MS. Pin reduction in brest ugmenttion using methocrbmol. Aesthetic Plst Surg. 1997; 21(1): White PF. The chnging role of non-opioid nlgesic techniques in the mngement of postopertive pin. Anesth Anlg. 2005; 101(5 Suppl):S Sintr RS, Jhr JS, Reynolds LW, Viscusi ER, Groudine SB, Pyen-Chmpenois C. Efficcy nd sfety of single nd repeted dministrtion of 1 grm intrvenous cetminophen injection (prcetmol) for pin mngement fter mjor orthopedic surgery. Anesthesiology. 2005; 102(4): Sintr RS, Jhr JS, Reynolds L, et l. Intrvenous cetminophen for pin fter mjor orthopedic surgery: n expnded nlysis. Pin Prct. 2012; 12(5): ORTHOPEDICS Helio.com/Orthopedics