RESUMO
BACKGROUND: This study compares the use of liposomal bupivacaine (Exparel) versus ropivacaine in adductor canal blocks (ACB) before total knee arthroplasties (TKAs). METHODS: From the months of April 2020 to September 2021, 147 patients undergoing unilateral primary TKA were asked to participate in this prospective, double-blinded randomized controlled trial. Each patient received an iPACK block utilizing ropivacaine and was additionally randomized to receive an ACB with Exparel or Ropivacaine. For each patient, demographic information, inpatient hospital information, postoperative opioid use, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire scores were collected. RESULTS: Overall, 100 patients were included (50 in each cohort). The Exparel group had a lower hospital length of stay compared to the Control group (36.3 vs 49.7 hours, P < .01). Patients in the Exparel group reported an increased amount of Numerical Rating Scale pain score improvement at all postoperative timepoints. These patients also used a lower amount of inpatient opioids (40.9 vs 47.3 MME/d, P = .04) but a similar amount of outpatient opioids (33.4 vs 32.1 MME/d, P = .351). Finally, the Exparel group had increased improvements in all WOMAC subscores and total scores at most timepoints compared to the Control group (P < .05). CONCLUSION: Exparel peripheral regional nerve blocks lead to decreases in pain levels, shorter hospital lengths of stay, inpatient opioid usage, and improved WOMAC scores. Exparel can be safely used in ACB blocks before TKA to help in controlling postoperative pain and decrease length of stay.
Assuntos
Artroplastia do Joelho , Analgésicos Opioides/uso terapêutico , Anestésicos Locais , Bupivacaína , Humanos , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Estudos Prospectivos , RopivacainaRESUMO
INTRODUCTION: Based on preoperative and perioperative risk factors that have been found to correlate with the development of acute kidney injury (AKI), our institution developed a protocol aimed at managing and improving outcomes in all elective THA and TKA patients. This article highlights the continued success and growth of our protocol aimed at decreasing AKI and hypotension in elective total joint arthroplasty patients. METHOD: A multidisciplinary team comprising orthopaedic surgeons, nephrologists, anesthesiologists, cardiologists, and internal medicine hospitalists created a comprehensive protocol aimed at decreasing complications after elective joint arthroplasty and improving clinical outcomes across multiple hospitals. Patient demographics, hospital length of stay, readmission rates, mortality, and postoperative AKI and hypotension incidences were recorded and compared between preprotocol phase I (initial protocol implementation) and phase II (protocol expansion across 10 hospitals) patient cohorts. RESULTS: Overall, 3,222 patients over 56 months and 10 hospitals were included. Our phase II AKI rate (0.6%) was significantly lower than our preprotocol rate (6.2%, P < 0.01) and statistically similar to our phase I rate (1.2%, P = 0.61). Our hypotension rate in phase II (6.8%) was significantly lower than our preprotocol rate (12.7%, P < 0.01) but statistically similar to our phase I rate (5.9%, P = 0.40). Furthermore, a significant decrease was observed in hospital length of stay (P < 0.01) over time, but no difference was observed in readmission (P = 0.59) and mortality rates (P = 1.00) over time. DISCUSSION: This protocol-driven interventional study provides a detailed and successful multidisciplinary method to manage and decrease rates of AKI and hypotension in a large patient cohort across multiple hospital centers.
Assuntos
Injúria Renal Aguda , Artroplastia de Quadril , Artroplastia do Joelho , Hipotensão , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/prevenção & controle , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Humanos , Hipotensão/epidemiologia , Hipotensão/etiologia , Hipotensão/prevenção & controle , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Fatores de RiscoRESUMO
STUDY DESIGN: Retrospective chart review. OBJECTIVE: The aim of this study was to ascertain whether the presence of structural thoracic deformities affects outcomes of permanent SCS placement. SUMMARY OF BACKGROUND DATA: Neural modulation via spinal cord stimulators (SCSs) has become an accepted treatment option for various chronic pain syndromes. In most cases, the surgeon desires accurate midline positioning of the paddle lead, allowing for flexibility of unilateral or bilateral coverage of pain patterns. Structural spinal deformities (scoliosis or kyphosis) often result from coronal, sagittal, and rotatory deformity that can make midline placement more difficult. METHODS: Between 2013 and 2017, two-hundred forty-one charts of patients who underwent permanent SCS placement at our suburban hospital were reviewed. Demographic information, numerical rating system (NRS) pain scores, Oswestry Disability Index (ODI) scores, and opioid medication usage were recorded at baseline and after permanent stimulator placement. Thoracic scoliosis and kyphosis angles were measured using spinal radiographs. The effect of each structural deformity on NRS, ODI, and narcotic medication usage changes from baseline was analyzed. RESULTS: Overall, 100 patients were included in our cohort. Fifty-six patients had measured thoracic spinal deformities (38% with scoliosis, 31% with kyphosis). There was no significant difference in NRS scores, ODI scores, or narcotic usage change between patients with scoliosis and those without (Pâ=â0.66, Pâ=â0.57, Pâ=â0.75) or patients with kyphosis and those without (Pâ=â0.51, Pâ=â0.31, Pâ=â0.63). Bivariate linear regression analysis showed that scoliotic and kyphotic angles were not significant predictors of NRS (Pâ=â0.39, Pâ=â0.13), ODI (Pâ=â0.45, Pâ=â0.07), and opioid usage (Pâ=â0.70, Pâ=â0.90) change, with multivariate regression analyses confirming these findings. CONCLUSION: SCSs can be effective options for treating lumbar back pain and radiculopathy. Our study suggests that the presence of mild structural deformities does not adversely affect outcomes of permanent SCS placement and as such should not preclude this population from benefiting from such therapies.Level of Evidence: 4.
Assuntos
Terapia por Estimulação Elétrica , Cifose/complicações , Manejo da Dor , Escoliose/complicações , Medula Espinal , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Cifose/cirurgia , Masculino , Pessoa de Meia-Idade , Dor/epidemiologia , Radiculopatia , Radiografia , Estudos Retrospectivos , Escoliose/cirurgia , Coluna Vertebral/cirurgia , Resultado do TratamentoRESUMO
STUDY DESIGN: A retrospective chart review. OBJECTIVE: The aim of this study was to address and characterize the differences between pain relief obtained from the "trial" versus permanent stimulator in the acute postoperative period (less than 6 weeks). SUMMARY OF BACKGROUND DATA: After a short stimulator trial (typically less than 7 days), patients who report at least a 50% relief are set up for permanent spinal cord stimulator (SCS) placement. The literature has shown that a subset of patients develop tolerance to these stimulating therapies, often resulting in reduced efficacy of symptom relief as early as 2 years post-permanent implantation. METHODS: Between the years of 2013 and 2017, 241 patient charts who underwent a successful trial and had a subsequent permanent SCS placed by a fellowship-trained surgeon through an open incision were reviewed. For each patient, demographic information, numerical rating system (NRS) pain scores, Oswestry Disability Index (ODI) scores, and opioid medication usage were recorded and stratified by time-period (before trial, after trial and before permanent placement, and after permanent SCS placement). RESULTS: Of the 100 included patients, 60 were female; 60 patients had previous failed lumbar surgery (53%). Placement of trial stimulator (medianâ=â4) decreased pain scores significantly more than permanent spinal cord stimulator did (medianâ=â2) (Pâ=â0.00). No significant difference was seen in ODI score difference between trial and initial scores (medianâ=â4) and final and initial scores (medianâ=â6) (Pâ=â0.64). Finally, a significantly higher decrease in pain medication usage was seen after trial initiation (medianâ=â0) versus after permanent spinal cord stimulator placement (medianâ=â0) (Pâ=â0.028). Twenty-two patients (22%) had reported complications, with 15 complaining of prolonged surgical site pain. CONCLUSION: Discrepancies observed in symptom alleviation between percutaneous trials and permanent placement in the acute 6-week postop period can have a significant effect on patient perceived outcomes. Understanding these issues will help in providing preoperative counseling and managing postoperative expectations. LEVEL OF EVIDENCE: 4.
Assuntos
Dor nas Costas/terapia , Dor Crônica/terapia , Manejo da Dor/métodos , Medição da Dor/métodos , Estimulação da Medula Espinal/métodos , Adulto , Idoso , Dor nas Costas/diagnóstico , Dor Crônica/diagnóstico , Terapia por Estimulação Elétrica/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: When critically analyzing our hospital system's rate of hypotension and acute kidney injury (AKI) after total joint arthroplasty, our incidence rates (14.54%, 6.02%) were much higher than our peers (7.17%, 2.03%) and national rates (2.0%, 3.3%). We present a multi-disciplinary management intervention that aimed to decrease overall complication rates. METHOD: A multi-disciplinary team implemented a protocol at our suburban hospital to limit complication rates after joint replacement surgery. Hypotension, AKI, length of stay (LOS), re-admission rates, and mortality rates were compared before the protocol was implemented, after protocol implementation, and after protocol integration into our EMR (electronic medical record). RESULTS: In total, 1233 patients over 36 months were followed. Hypotension rates after protocol implementation into EMR (group 3) were significantly lower than rates before the protocol (group 1) (P = .002), with rates after protocol implementation without EMR (group 2) trending toward a significant decrease from group 1 (P = .064). AKI rates in group 3 were significantly lower than group 1 (P = .000) and group 2 (P = .006). No difference was seen in hypotension rates between group 2 and 3 (P = .792) or AKI rates between group 1 and 2 (P = .533). Finally, no significant difference was seen between groups in LOS (P = .560), re-admission rates (P = .378), and mortality rates (all 0.0%). CONCLUSION: By implementing a comprehensive electronic protocol consisting of pre-operative risk stratification, multi-disciplinary medical optimization, and an evolving post-operative management plan, significant decreases in hypotension and AKI can be seen.
Assuntos
Injúria Renal Aguda/prevenção & controle , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Hipotensão/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Injúria Renal Aguda/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos Clínicos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVE: This study aims to determine the groups of patients who are at risk for noncompliance and misunderstanding of their pain regimen. DESIGN: Survey-based cohort study. SETTING: Suburban Level-I trauma center. PATIENTS/PARTICIPANTS: A total of 171 patients between the ages of 18-89 years who underwent surgical fixation of fractures involving the pelvis, long bones, or periarticular regions of the knee, ankle, elbow, and wrist. MAIN OUTCOME MEASUREMENTS: Patients who cannot accurately reproduce their prescribed pain medication list and patients who modify this pain medication regimen were analyzed by age, employment status, income level, education level, time between surgery and follow-up, and whether pain interfered with activities of daily living. RESULTS: Overall, 147 patients completed the survey. Seventy percent (n = 114) of patients could not accurately reproduce their pain medication regimen, regardless of age, employment status, income level, education level, time between surgery and follow-up, and whether pain interfered with activities of daily living. Patients (61.2%; n = 90), regardless of the 6 aforementioned demographic factors, also admitted to modifying their pain medication regimen with non-prescribed medications, with 55.8% (n = 82) of patients adding over-the-counter medications to surgeon-prescribed narcotic medications. CONCLUSIONS: Misunderstanding and noncompliance of surgeon-prescribed pain regimens are prevalent across all patient demographics. Knowledge of the potential effects these augmentative medications can have on fracture healing and any drug-drug interactions that may arise is an important aspect of patient postoperative care. Surgeons must be wary of these trends and screen for any unintended side effects a patient's pain regimen may have. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Atividades Cotidianas/psicologia , Analgésicos/administração & dosagem , Adesão à Medicação/psicologia , Adesão à Medicação/estatística & dados numéricos , Procedimentos Ortopédicos/psicologia , Dor Pós-Operatória/psicologia , Dor Pós-Operatória/terapia , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Compreensão , Escolaridade , Emprego/psicologia , Emprego/estatística & dados numéricos , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Renda/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Procedimentos Ortopédicos/estatística & dados numéricos , Dor Pós-Operatória/epidemiologia , Pennsylvania/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Autoadministração/psicologia , Autoadministração/estatística & dados numéricos , Adulto JovemRESUMO
OBJECTIVE: In light of the recent uptrend in the prescription of opioids, this study seeks to identify patterns of opioid misuse among orthopaedic postoperative patients and principal external sources in obtaining these medications. DESIGN: Ten-month survey-based study. SETTING: Two Level I trauma centers (urban and suburban). PATIENTS/PARTICIPANTS: Two hundred seven patients between the ages of 18 and 89 years who underwent surgical fixation of fractures involving the pelvis, long bones, or periarticular regions of the knee, ankle, elbow, and wrist. MAIN OUTCOME MEASUREMENTS: Patients who believed they were undermedicated, used prescribed opioids at higher than recommended doses, and took extra opioids in addition to their prescribed analgesics were analyzed by age, employment, income, education, controlled substance use, pain interference with activities of daily living, and anatomic surgical site. RESULTS: One hundred eighty-two patients completed the survey; 19.2% of patients (n = 35) felt undermedicated [unemployed (P < 0.05), low income (P < 0.05), and self-reported controlled substance users (P < 0.05)]; 12.6% of patients (n = 23) admitted to using pain medications at a higher dose than prescribed [unemployed (P < 0.05), lower income (P < 0.05), nonhigh school graduates (P < 0.05), and previous controlled substance users (P < 0.05)]; 9.3% (n = 17) admitted to using external opioids [unemployed patients (P < 0.05) and self-reported controlled substance users (P < 0.05)]. Major sources of extraneous opioids include family/friends (n = 5) and other doctors (n = 4). CONCLUSION: Unemployed and lower-income patients were significantly more likely to believe that their surgeon was not prescribing them enough pain medications as well as use their prescribed opioid medications at a higher than recommended dose compared with their employed counterparts with higher incomes. Unemployed patients were also significantly more likely to use additional opioid analgesics in addition to those prescribed to them by their primary surgeon. Surgeon awareness of a patient's socioeconomic background and associated risk of opioid misuse is crucial to prescribe the safest most effective pain regimen. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.