Intravenous Acetaminophen Improves Outcomes after Transapical Transcatheter Aortic Valve Replacement

Abstract

Objective

Complications with opioid-based postoperative pain management have led to guideline recommendations for a multimodal analgesia strategy incorporating nonopioid agents. We evaluated the opioid-sparing effect of intravenous acetaminophen in patients undergoing transapical transcatheter aortic valve replacement.

Methods

A multimodal pain management strategy that incorporated intravenous acetaminophen was retrospectively evaluated in 43 patients undergoing transapical transcatheter aortic valve replacement between November 2012 and March 2014. Before intravenous acetaminophen formulary availability, 23 patients received standard postoperative pain management interventions including intravenous narcotics and oral narcotics/acetaminophen. After intravenous acetaminophen availability, 20 patients received intravenous acetaminophen (4 g/d, ≥4 doses) and supplemental intravenous and nonacetaminophen oral narcotics. Daily narcotic dose (standardized to morphine equivalents), drug cost, and hospital length of stay were compared between groups.

Results

Baseline characteristics were similar between intravenous acetaminophen (n = 20) and nonintravenous acetaminophen (n = 23) patients including the Society of Thoracic Surgery mortality risk (10.5% vs 9.0%, P = 0.3). The median number of intravenous acetaminophen doses was 6.5 (interquartile range = 4.0–18.5), with a median cost per patient of US $221 (interquartile range = $136–$629). Patients who received intravenous acetaminophen used significantly fewer morphine equivalents on postoperative day 0 compared with patients not receiving intravenous acetaminophen (22.5 vs 45.0 morphine equivalents, P = 0.03) and had a shorter median length of stay (5.0 vs 7.0 days, P = 0.007). After adjusting for the Society of Thoracic Surgery risk, intravenous acetaminophen continued to be associated with a reduction in median postoperative length of stay [−1.9 days (95% confidence interval = −0.9 to −8.2 days), P = 0.049].

Conclusions

In patients undergoing transapical transcatheter aortic valve replacement, a multimodal pain management strategy incorporating intravenous acetaminophen was associated with reductions in narcotic use on the day of surgery and overall length of stay.

Keywords

Intravenous acetaminophen Transapical transcatheter aortic valve replacement Multimodal analgesia Clinical outcomes Elderly

Get full access to this article

View all access options for this article.

References

American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116:248–273.

Barr

Fraser

Puntillo

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263–306.

Gandhi

Baratta

Heitz

Acute pain management in the postanesthesia care unit. Anesthesiol Clin. 2012;30:e1–e15.

Kessler

Shah

Gruschkus

Cost and quality implications of opioid-based postsurgical pain control using administrative claims data from a large health system: opioid-related adverse events and their impact on clinical and economic outcomes. Pharmacotherapy. 2013;33:383–391.

Pasero

Opioid-induced sedation and respiratory depression: evidence-based monitoring guidelines. J Perianesth Nurs. 2012;27:208–211.

The Joint Commission. Sentinel event alert issue 49: safe use of opioids in hospitals. Available at: https://www.jointcommission.org/sea_issue_49/. Published August 8, 2012. Accessed January 4, 2018.

Oderda

Said

Evans

Opioid-related adverse drug events in surgical hospitalizations: impact on costs and length of stay. Ann Pharmacother. 2007;41:400–406.

White

. Multimodal analgesia: its role in preventing postoperative pain. Curr Opin Investig Drugs. 2008;9:76–82.

10.

Jarzyna

Jungquist

Pasero

American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12:118–145.

11.

Wells

Pasero

McCaffery

Improving the quality of care through pain assessment and management. In: Hughes

, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ Publication No. 08–0043. Rockville, MD: Agency for Healthcare Research and Quality; 2008.

12.

The American Geriatrics Society. Pain management in the elderly. Available at: https://pogoe.org/sites/default/files/gsr/1_Pain_Management_In_The_Elderly.pdf. Accessed January 4, 2018.

13.

American Academy of Orthopaedic Surgeons. Management of hip fractures in the elderly: evidence-based clinical practice guideline. Available at: http://www.aaos.org/Research/guidelines/HipFxGuideline_rev.pdf. Published September 5, 2014. Accessed January 4, 2018.

14.

Feldman

Delaney

Ljungqvist

Carli

(Eds). The SAGES/ERAS^® Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery . New York, NY: Springer; 2015.

15.

Dowell

Haegerich

Chou

CDC guideline for prescribing opioids for chronic pain – United States, 2016. JAMA. 2016;315:1624–1645.

16.

U.S. Department of Health and Human Services. Addressing prescription drug abuse in the United States: current activities and future opportunities. Available at: https://www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf. Accessed January 4, 2018.

17.

U.S. Food and Drug Administration. Fact Sheet – FDA Opioids Action Plan. Available at: https://www.fda.gov/downloads/NewsEvents/Newsroom/FactSheets/UCM484743.pdf. Accessed January 4, 2018.

18.

American Society of Anesthesiologists. American Society of Anesthesiologists announces a committee to address opioid abuse and encourages co-prescribing of naloxone. Available at: https://www.asahq.org/about-asa/newsroom/news-releases/2016/03/american-society-of-anesthesiologists-announces-a-committee-to-address-opioid-abuse. Published March 31, 2016. Accessed January 4, 2018.

19.

Affordable Care Act. Available at: https://www.healthcare.gov/glossary/affordable-care-act/. Accessed January 4, 2018.

20.

Centers for Medicare and Medicaid. HCAHPS: Patients' Perspectives of Care Survey. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html. Accessed January 4, 2018.

21.

Arici

Gurbet

Türker

Preemptive analgesic effects of intravenous paracetamol in total abdominal hysterectomy. Agri. 2009;21:54–61.

22.

Looke

Kluth

. Effect of preoperative intravenous methocarbamol and intravenous acetaminophen on opioid use after primary total hip and knee replacement. Orthopedics. 2013;36:25–32.

23.

Atef

Fawaz

. Intravenous paracetamol is highly effective in pain treatment after tonsillectomy in adults. Eur Arch Otorhinolaryngol. 2008;265:351–355.

24.

Kemppainen

Kokki

Tuomilehto

Acetaminophen is highly effective in pain treatment after endoscopic sinus surgery. Laryngoscope. 2006;116:2125–2128.

25.

Sinatra

Jahr

Reynolds

Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery. Anesthesiology. 2005;102:822–831.

26.

Billings

IV Petracek

Roberts

II Pretorius

Perioperative intravenous acetaminophen attenuates lipid peroxidation in adults undergoing cardiopulmonary bypass: a randomized clinical trial. PLoS One. 2015;10:e0117625.

27.

Atallah

El-Gamal

Mageed

The efficacy of perioperative intravenous paracetamol in valve replacement. Egyptian J Intensive Care. 2010;15:17–25.

28.

Pettersson

Jakobsson

Owall

Intravenous acetaminophen reduced the use of opioids compared with oral administration after coronary artery bypass grafting. J Cardiothorac Vasc Anesth. 2005;19:306–309.

29.

Maheshwari

Boutary

Yun

Multimodal analgesia without routine parenteral narcotics for total hip arthroplasty. Clin Orthop Relat Res. 2006;453:231–238.

30.

Apfel

Jahr

Kelly

Effect of i.v. acetaminophen on total hip or knee replacement surgery: a case-matched evaluation of a national patient database. Am J Health Syst Pharm. 2015;72:1961–1968.

31.

Thiele

Rea

Turrentine

Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015;220:430–443.

32.

Shaffer

Pham

Woldman

Estimating the effect of intravenous acetaminophen for postoperative pain management on length of stay and inpatient hospital costs. Adv Ther. 2017;33:2211–2228.

33.

Cattabriga

Pacini

Lamazza

Intravenous paracetamol as adjunctive treatment for postoperative pain after cardiac surgery: a double blind randomized controlled trial. Eur J Cardiothorac Surg. 2007;32:527–531.

34.

Singla

Parulan

Samson

Plasma and cerebrospinal fluid pharmacokinetic parameters after single-dose administration of intravenous, oral, or rectal acetaminophen. Pain Pract. 2012;12:523–532.

35.

Berger

Berger-Gryllaki

Wiesel

Intestinal absorption in patients after cardiac surgery. Crit Care Med. 2000;28:2217–2223.

36.

Petring

Dawson

Blake

Normal postoperative gastric emptying after orthopaedic surgery with spinal anaesthesia and i.m. ketorolac as the first postoperative analgesic. Br J Anaesth. 1995;74:257–260.

37.

Kennedy

Tyers

Davey

. The influence of morphine on the absorption of paracetamol from various formulations in subjects in the supine position, as assessed by TDx measurement of salivary paracetamol concentrations. J Pharm Pharmacol. 2003;55:1345–1350.