Evaluation of an Intravenous Acetaminophen Protocol in the Emergency Department.

BACKGROUND: Acute pain is a leading reason for Emergency Department (ED) evaluation, accounting for nearly half of all ED visits. Therefore, providing effective non-opioid analgesics in the ED is critical. Oral acetaminophen (APAP) is commonly administered in the ED but is limited to patients tolerating oral intake. Intravenous (IV) APAP provides significant pain reduction parenterally. The purpose of this quality assessment project was to evaluate the frequency of opioid use in patients receiving IV APAP, the safety of IV APAP, and compliance with an ED IV APAP protocol. METHODS: This study included all patients who received IV APAP in the ED of a tertiary care, level I trauma center, during a three-month period. The protocol required ED patients to be NPO (nil per os), 18 years or older, and administered with a single 1000 mg dose. The adverse reactions within 24 hours post-IV APAP, ED length of stay (LOS), and opioid administration within four hours post-IV APAP were assessed. RESULTS: Ninety-four patients received IV APAP. All patients received a 1000 mg dose. One patient received more than one dose, but this patient had a 22-hour ED LOS. Two patients received oral medications within one hour of IV APAP (one received an antacid, and the other received carbamazepine and lamotrigine). An opioid was administered to 22 of the 94 (23.4%) patients during the four-hour protocol period. There were no reports of adverse reactions. CONCLUSIONS: The results show excellent compliance with the protocol. IV APAP was safe and well-tolerated. Notably, most patients did not receive an opioid within four hours of IV APAP. IV APAP can be safely and effectively utilized as an analgesic and lessen ED opioid use.

Efficacy and safety of intravenous acetaminophen (2 g/day) for reducing opioid consumption in Chinese adults after elective orthopedic surgery: A multicenter randomized controlled trial.

Background: Acetaminophen is an important component of a multimodal analgesia strategy to reduce opioid consumption and pain intensity after an orthopedic surgery. The opioid-sparing efficacy of intravenous acetaminophen has been established at a daily dose of 4 g. However, it is still unclear for the daily dose of 2 g of acetaminophen, which is recommended by the China Food and Drug Administration Center for Drug Evaluation, in terms of its efficacy and safety. Objectives: This study aimed to evaluate the efficacy and safety of intravenous acetaminophen at a daily dose of 2 g for reducing opioid consumption and pain intensity after orthopedic surgery. Methods: In this multicenter, randomized, double-blind, placebo-controlled phase III trial, 235 patients who underwent orthopedic surgery were randomly assigned to receive intravenous acetaminophen 500 mg every 6 h or placebo. Postoperative morphine consumption, pain intensity at rest and during movement, and adverse events were analysed. Results: For the mean (standard deviation) morphine consumption within 24 h after surgery, intravenous acetaminophen was superior to placebo both in the modified intention-to-treat analysis [8.7 (7.7) mg vs. 11.2 (9.2) mg] in the acetaminophen group and the placebo group, respectively. Difference in means: 2.5 mg; 95% confidence interval, 0.25 to 4.61; p = 0.030), and in the per-protocol analysis (8.3 (7.0) mg and 11.7 (9.9) mg in the acetaminophen group and the placebo group, respectively. Difference in means: 3.4 mg; 95% confidence interval: 1.05 to 5.77; p = 0.005). The two groups did not differ significantly in terms of pain intensity and adverse events. Conclusion: Our results suggest that intravenous acetaminophen at a daily dose of 2 g can reduce morphine consumption by Chinese adults within the first 24 h after orthopedic surgery, but the extent of reduction is not clinically relevant. Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT02811991].

Comparing the Efficacy and Side Effects of Intravenous Ibuprofen and Acetaminophen in Pain Control Following Laparoscopic Cholecystectomy.

BACKGROUND: The importance of using effective postoperative analgesia is widely accepted. Systemic opioids are the gold standard for reducing severe pain after surgery, but the side effects have limited the use of adequate doses. We aimed to evaluate the effect of adding intravenous acetaminophen and intravenous ibuprofen to fentanyl on patient-controlled analgesia. METHODS: In this randomized clinical trial study in Ardabil city hospital at 2019, 90 patients undergoing elective laparoscopic cholecystectomy were randomly divided into three groups. The control group (n=30) received normal saline, the acetaminophen group (n=30) received 1g intravenous acetaminophen, and the ibuprofen group (n=30) received 800 mg intravenous ibuprofen. All patients received a pain control by intravenous pump containing fentanyl (15µ/ml). The drugs were injected intravenously after surgery. Shoulder and abdominal pain scores, sedation rate, nausea and vomiting, satisfaction, and the doses of fentanyl and meperidine were recorded in SPSS software within 24 h after surgery. RESULTS: The mean abdominal pain scores in ibuprofen (3.02) and acetaminophen (2.89) groups were not significantly different (P=0.719) but were significantly lower than in the control group (5.10) (P<0.001). The severity of shoulder pain, nausea and vomiting, sedation, and fentanyl intake were not significantly different in the ibuprofen and acetaminophen groups but were significantly lower than in the control group. CONCLUSION: The use of both intravenous acetaminophen and ibuprofen in pain control after surgery can reduce the need for opioid use. Acetaminophen can also be a suitable alternative for postoperative pain control in patients that are unable to use NSAIDs.

National Intravenous Acetaminophen Use in Pediatric Inpatients From 2011-2016.

OBJECTIVE: To 1) determine current intravenous (IV) acetaminophen use in pediatric inpatients; and 2) determine the association between opioid medication duration when used with or without IV acetaminophen. METHODS: A retrospective analysis of pediatric inpatients exposed to IV acetaminophen from January 2011 to June 2016, using the national database Health Facts. RESULTS: Eighteen thousand one hundred ninety-seven (2.0%) of 893,293 pediatric inpatients received IV acetaminophen for a median of 14 doses per patient (IQR, 8-56). A greater proportion of IV acetaminophen patients were admitted to the intensive care unit (ICU) (14.8% vs 5.1%, p < 0.0001), received positive pressure ventilation (2.0% vs 1.5%, p < 0.0001), had a higher hospital mortality rate (0.9% vs 0.3%, p < 0.0001), and were operative (35.5% vs 12.8%, p < 0.001) than those not receiving IV acetaminophen. The most common operations associated with IV acetaminophen use were musculoskeletal and digestive system operations. Prescription of IV acetaminophen increased over time, both in prescription rates and number of per patient doses. Of the 18,197 patients prescribed IV acetaminophen, 16,241 (89.2%) also were prescribed opioids during their hospitalization. A multivariate analysis revealed patients prescribed both IV acetaminophen and opioids had a 54.8% increase in opioid duration as compared with patients who received opioids alone. CONCLUSIONS: This is the first study to assess IV acetaminophen prescription practices for pediatric inpatients. Intravenous acetaminophen prescription was greater in the non-operative pediatric inpatient population than operative patients. Intravenous acetaminophen prescription was associated with an increase in opioid duration as compared with patients who received opioids alone, suggesting that it is commonly used to supplement opioids for pain relief.

Post-operative pain control following arthroscopic rotator cuff repair: Intravenous acetaminophen versus interscalene brachial plexus block; A prospective randomized study.

BACKGROUND: With the increasing number of patients undergoing arthroscopic rotator cuff repair (ARCR), postoperative pain control in these patients has become an important issue. We investigated and compared post-operative pain relief with intravenous acetaminophen (IA) and interscalene brachial plexus block (IBPB) after ARCR. METHODS: This prospective study involved 66 consecutive patients who underwent ARCR in 2019-2020 at our hospital. Overall, 23 and 43 shoulders were assigned to the IA and IBPB groups, respectively. We evaluated the visual analog scale (VAS) pain scores at rest, during activity, and at night for the first 72 h postoperatively. We compared the results statistically between the groups. A p-value <0.05 was considered statistically significant. RESULTS: VAS scores for night pain in the IBPB group were significantly lower than those in the IA group for the first 24 h postoperatively (p = 0.017). In contrast, the same scores were significantly lower in the IA group than in the IBPB group at 72 h postoperatively (p = 0.024). Other scores were not significantly different between the groups. CONCLUSIONS: IBPB provides superior night pain control during the first 24 h postoperatively, and IA provides superior night pain control at 72 h postoperatively. However, there were no significant differences in other pain scores between the two groups.

Randomized control trial of intravenous acetaminophen for reduction of intrapartum maternal fever.

BACKGROUND: Intravenous acetaminophen reaches a higher mean peak plasma concentration than oral acetaminophen in a shorter period of time. The favorable pharmacokinetics of intravenous acetaminophen may be beneficial for treating intrapartum maternal fever. OBJECTIVE: The primary objective was to compare intravenous and oral acetaminophen in time to defervescence (temperature <38°C). The secondary objective was to compare intravenous and oral acetaminophen in the percentage of participants being afebrile and percent reduction in maternal temperature 30 minutes after administration of first dose. Other outcomes evaluated were histopathological placental findings; neonatal outcomes; oxidative stress; and levels of RANTES, interferon-δ, interleukin 1ß, interleukin 2, interleukin 4, interleukin 6, interleukin 8, interleukin 10, interleukin 13, and tumor necrosis factor-α in maternal and neonatal blood. STUDY DESIGN: This was a randomized, comparator-controlled, double-dummy, double-blind clinical trial. At the onset of intrapartum fever ≥38°C, patients ≥36 weeks' gestation were either randomized to the control or experimental study arm. Patients in the control arm received 1000 mg of oral acetaminophen capsules and an intravenous placebo resembling intravenous acetaminophen. Patients randomized to the experimental arm received 1000 mg of intravenous acetaminophen and oral placebo capsules resembling acetaminophen. Maternal temperatures and fetal heart rates were recorded at consecutive intervals following administration of the first dose of acetaminophen. Maternal blood, collected at the onset of fever and after delivery, and neonatal cord blood collected at delivery were evaluated for oxidative stress (glutathione levels), levels of RANTES and cytokines (interferon-δ, interleukin 1ß, interleukin 2, interleukin 4, interleukin 6, interleukin 8, interleukin 10, interleukin 13, and tumor necrosis factor-α). Placentas were collected for pathologic review. A P value of <.05 was considered statically significant. RESULTS: A total of 121 patients (55 in the intravenous and 66 in the oral group) were recruited from December 1, 2016, to February 28, 2018. Patient demographics and intrapartum factors were similar between both arms. The intravenous group showed a mean time of 54.86 minutes (95% confidence interval, 20.57-39.43) to defervescence vs 52.58 minutes (95% confidence interval, 16.58-43.42) in the oral group (P=.71). In addition, intravenous and oral acetaminophen showed similar results in percentage of patients being afebrile and percent reduction in maternal temperature 30 minutes after administration of the first dose. Histopathological findings, neonatal outcomes, oxidative stress markers, and RANTES and cytokine levels were not statistically significant between intravenous and oral acetaminophen groups. CONCLUSION: Intravenous acetaminophen did not demonstrate a higher efficacy than oral acetaminophen in treating intrapartum maternal fever. Select patients may benefit from intravenous acetaminophen for treatment of intrapartum fever, including those who cannot tolerate oral medication.

Effectiveness of scheduled intravenous acetaminophen in the postoperative pain management of video-assisted thoracic surgery.

PURPOSE: The scheduled administration of intravenous acetaminophen (scheduled-IV-AcA) is one of the more effective multimodal analgesic approaches for postoperative pain in abdominal/orthopedic surgeries. However, there is little evidence concerning scheduled-IV-AcA after general thoracic surgery, especially when limited to video-assisted thoracoscopic surgery (VATS). We investigated the efficacy of scheduled-IV-AcA administration in patients after undergoing VATS. METHODS: Ninety-nine patients who underwent VATS lobectomy or segmentectomy via an 8-cm access window and 1 camera port were retrospectively reviewed by categorizing them into groups either with scheduled-IV-AcA (Group AcA: n = 29) or without it (Group non-AcA: n = 70). Group AcA received 1 g of IV-AcA every 6 h from the end of the operation until the end of POD2. Postoperative pain was measured using a numeric rating scale (NRS) three times per day until discharge. RESULTS: NRS scores were significantly lower in Group AcA with motion (on POD1 to the first point of POD2) than in Group non-AcA. Group non-AcA was also more likely to use additional analgesics than Group AcA (39% vs. 17%, p = 0.058). CONCLUSIONS: Scheduled-IV-AcA administration is a safe and effective multimodal analgesic approach in patients undergoing VATS pulmonary resection via an 8-cm access window.

Opioid-Sparing Effect of Liposomal Bupivacaine and Intravenous Acetaminophen in Colorectal Surgery.

BACKGROUND: This study evaluated the opioid-sparing effect of liposomal bupivacaine and intravenous acetaminophen in colorectal surgery. MATERIALS AND METHODS: This study was a retrospective, 2 × 2 factorial cohort conducted at an academic medical center from May 2016 to February 2018. Patients undergoing open or minimally invasive colorectal resection were included. Exclusion criteria were age <18 y, surgery after second hospital day, ostomy, and allergy to acetaminophen, opioids, or bupivacaine. Intraoperative liposomal bupivacaine and intravenous acetaminophen administration within 18 h after surgery were evaluated. The primary outcome was intravenous morphine milligram equivalents administered within 24 h after surgery. A linear regression model adjusted for American Society of Anesthesiologists score, enhanced recovery after surgery management, open surgery, opioid use before surgery, and height was used for the primary analysis. RESULTS: Among 486 included patients, 193 received both liposomal bupivacaine and intravenous acetaminophen, 93 received liposomal bupivacaine only, 104 received intravenous acetaminophen only, and 96 did not receive either. On average, patients received 21 (SD = 31) morphine equivalents over 24 h. Intraoperative liposomal bupivacaine was associated with a reduction of morphine equivalents (adjusted change -11, 95% CI -17 to -6), but intravenous acetaminophen was not (2, 95% CI -3 to 7). Intraoperative liposomal bupivacaine was associated with a reduction of length of stay (adjusted change = -1.2 d, 95% CI -2.1 to -0.3), but intravenous acetaminophen was not (adjusted change = 1.5 d, 95% CI 0.7 to 2.2). CONCLUSIONS: Liposomal bupivacaine was associated with a significant reduction of opioid use within 24 h after colorectal surgery, but intravenous acetaminophen was not.

Opioid-free multimodal analgesia pathway to decrease opioid utilization after cesarean delivery.

AIM: To evaluate an opioid-free multimodal analgesic pathway (MAP) to decrease opioid utilization after cesarean delivery (CD) compared to historic data of our institution prior to using MAP for pain management (pre-MAP). METHODS: The MAP was implemented in three phases from September 2018 to August 2019. Patients received 1000 mg intravenous (IV) acetaminophen with 30 mg IV ketorolac at 0 (arrival time at recovery room), 6, 12 and 18 h of postoperative course. On the 2nd and the 3rd postoperative days, patients were monitored for pain every 6 h by Numeric Pain Intensity Scale (0 = no pain to 10 = severe pain) and administered 600 mg oral ibuprofen for a pain score between 0 and 4, 600 mg oral ibuprofen and/or 650 mg oral acetaminophen for a pain score between 5-6, 1000 mg IV acetaminophen and/or 30 mg of IV or intramuscular ketorolac for a pain score between 7 and 10. Five milligrams of oral oxycodone was reserved for rescue if all protocol options were exhausted. Patients were discharged with 600 mg oral ibuprofen without opioid prescription. Likert surveys measuring patient satisfaction of pain control were administered during phase 3. RESULTS: Inpatient and outpatient opioid consumption rates were significantly decreased from 45%, 18% to 23.8%, 8.5% after MAP implementation (P-value <0.001). More than 90% of patients reported that their pain was well controlled and willing to request the same regimen for a future CD. CONCLUSION: MAP Implementation after CD significantly reduced inpatient and outpatient opioid consumption compared to pre-MAP results while maintaining high patients' satisfaction with pain control.

Effect of preoperative intravenous vs oral acetaminophen on postoperative opioid consumption in an enhanced recovery after surgery (ERAS) program in patients undergoing open gynecologic oncology surgery.

OBJECTIVE: Both intravenous (IV) and oral acetaminophen provide effective opioid-sparing analgesia after surgery when used as part of a multimodal preemptive pain management strategy. The purpose of this study was to compare postoperative opioid consumption in patients undergoing open gynecologic oncology surgery who received preoperative IV vs oral acetaminophen within an enhanced recovery after surgery (ERAS) program. METHODS: Retrospective data were collected on consecutive patients undergoing open gynecologic oncology surgery from May 1, 2016 to February 28, 2018 in patients receiving either 1 g IV or oral acetaminophen preoperatively. Patients were given a preoperative multimodal analgesia regimen including acetaminophen, celecoxib, pregabalin and tramadol. The primary outcomes were morphine equivalent daily doses (MEDD) on postoperative days (POD) 0 and 1. Secondary outcomes included highest patient-reported pain score in the post-anesthesia care unit (PACU) and intraoperative MEDD. Regression models adjusted by matched pairs were fit to estimate the average treatment effect of IV vs oral acetaminophen on MEDD. RESULTS: Of 353 patients, 178 (50.4%) received IV acetaminophen and 175 (49.6%) received oral acetaminophen. When balancing across the matched samples, there was no difference in postoperative MEDD for POD 0 between the IV and oral acetaminophen groups (Beta = -1.11; 95% CI: -4.83 to 2.60; p = 0.56). On POD 1, there was no difference between the IV and oral groups (Beta = 2.24; 95% CI: -2.76 to 7.25; p = 0.38). CONCLUSIONS: There was no difference in postoperative opioid consumption between patients receiving preoperative IV or oral acetaminophen within an ERAS program for patients undergoing open gynecologic oncology surgery.

A Quality Improvement Initiative to Decrease Inappropriate Intravenous Acetaminophen Use at an Academic Medical Center.

Background: Following availability in the United States in 2011, intravenous acetaminophen (IV APAP) was added to many hospital formularies for multimodal pain control. In 2014, the price of IV APAP increased from $12/g to $33/g and became a top 10 medication expenditure at our institution. Objective: To promote appropriate IV APAP prescribing and reduce costs. Design, Setting, Participants: Quality improvement project at a 562-bed academic medical center involving all inpatient admissions from 2010 to 2017. Interventions: Using Plan-Do-Study-Act (PDSA) methodology, our Pharmacy & Therapeutics (P&T) committee aimed to reduce inappropriate use of IV APAP by refinement of restriction criteria, development of clinical decision support in the electronic medical record, education of clinical staff on appropriate use, and empowerment of hospital pharmacists to enforce restrictions. Measurements: Monthly IV APAP utilization and spending were assessed using statistical process control charts. Balancing measures included monthly usage of IV opioid, IV ketorolac, and oral ibuprofen. Results: Five PDSA cycles were conducted during the study period. Monthly spending on IV APAP decreased from the highest average of $56 038 per month to $5822 per month at study conclusion. Interventions resulted in an 80% annual cost savings, or an approximate savings of $600 000 per year. Usage of IV opioids, IV ketorolac, and oral ibuprofen showed no major changes during the study period. Conclusions: IV APAP can be restricted in a safe and cost effective manner without concomitant increase in IV opioid use.

Effect of scheduled intravenous acetaminophen on postoperative nausea and vomiting in patients undergoing laparoscopic gynecologic surgery.

PURPOSE: The aim of this study was to assess the effect of scheduled intravenous acetaminophen (SIVA) on the incidence of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic gynecologic surgery (LGS). METHODS: This retrospective observational study identified consecutive patients who underwent LGS at our institution from January to November of 2017 and were managed with either our hospital's old protocol (Group H) or a new protocol using SIVA (Group S). Primary outcomes included the incidences of PONV and the amount of additional antiemetic required in the postoperative period. The secondary outcomes included the pain score on postoperative day 1, the requirement for additional analgesic medications, and the length of hospitalization (LOH). RESULTS: Patients in Group S had significantly lower incidences of PONV from postoperative days 0 to 1 and required significantly less antiemetics or tramadol than those in Group H (P = 0.0085). Patients at a low risk for PONV in Group S had significantly lower incidences of PONV than those in Group H (P = 0.0129). Further, the amount of additional tramadol required was lower in Group S than in Group H (P = 0.0021). CONCLUSION: Introduction of SIVA into the postoperative pain management protocol of LGS may reduce the incidence of PONV and the amount of adjunctive antiemetic medication required from postoperative days 0 to 1. In patients undergoing LGS, PONV prophylaxis using antiemetics should be prescribed depending on PONV risk profile; however, SIVA prophylaxis can be used in all patients regardless of PONV risk profile.

Effectiveness of intravenous acetaminophen for postoperative pain management in shoulder arthroplasties: A population-based study.

BACKGROUND: Intravenous acetaminophen (IV APAP) is an option in multimodal postoperative analgesia. Prior trials focus on hip and knee arthroplasties, whereas large-scale data on utilization and effectiveness in shoulder arthroplasties are lacking. METHODS: Data on 67,494 (452 hospitals) partial/total shoulder arthroplasties were extracted from the Premier claims database (2011-2016). Patients were categorized by receipt and dosage of IV APAP. Multilevel models measured associations between IV APAP and opioid utilization (in oral morphine equivalents), length/cost of stay and opioid-related complications. Effect estimates (adjusted % change) with 95% confidence intervals (CIs) are reported. RESULTS: IV APAP was used in 17.7% (n = 11,949) of patients with an increasing utilization trend. Most patients received only one dose on the day of surgery (69.5%; n = 8308). When adjusting for relevant covariates, IV APAP was not associated with meaningful effects on outcomes. Specifically, its use (versus no use) was not associated with decreased (but rather somewhat increased) opioid utilization: + 5.4% (CI 3.6-7.1%; P < 0.05). CONCLUSION: In this first large-scale study that assesses IV APAP in shoulder arthroplasties, IV APAP use was not associated with decreased opioid utilization or the length/cost of stay. These results do not support routine use of IV APAP in this cohort, especially given its high cost. THE TRANSLATIONAL POTENTIAL FOR THIS ARTICLE: Multimodal pain control to assist in reducing the opioid pain medications are seen as a route to improved postoperative patient outcomes, better pain control and expedited hospital discharge. Acetaminophen plays a significant role in these protocols in many institutions, but it is not established if this expensive IV formulation is superior to the oral formulation. This study evaluates the use and effectiveness of IV acetaminophen following shoulder arthroplasty at a large number of institutions.

Intraoperative Single-Dose Intravenous Acetaminophen for Postoperative Analgesia After Skin Laser Irradiation Surgery in Paediatric Patients: A Small Prospective Study.

OBJECTIVE: Acetaminophen is an analgesic that shows efficacy in postoperative pain relief in children. Many drugs such as opioids, non-steroidal anti-inflammatory drugs, and/or acetaminophen have been used in paediatric skin laser irradiation surgery for postoperative pain relief. However, acetaminophen has some advantages over opioids, and opioids are being used less often. We aimed to demonstrate the effectiveness of intravenous (IV) acetaminophen during surgery for postoperative pain in paediatric skin laser irradiation. METHODS: The present study is a small, prospective, double-blinded, randomized controlled trial. Paediatric patients (1-12 years old with an American Society of Anesthesiologists physical Status I and II), scheduled for skin laser irradiation for a nevus or haemangioma between October 2014 and April 2016 were randomized into the acetaminophen (n=9) and placebo (saline, n=8) groups. The observational face scale (FS) and the Behavioural Observational Pain Scale (BOPS) scores were recorded on emergence from anaesthesia, and 1, 2, and 4 hr post-surgery. RESULTS: Patient characteristics were not significantly different except with regard to the irradiation area and surgery time. The observational FS and BOPS scores of the acetaminophen group were lower than those of the placebo group; median (minimum-maximum) at each recording time: 1 (0-2) - 0 (0-2) - 0 (0-1) - 0 (0-2) vs. 2 (0-4) - 0 (0-2) - 0 (0-2) - 0 (0-1) and 1 (0-3) - 1 (0-3) - 1 (0-2) - 0 (0-1) vs. 2 (0-4) - 3 (0-5) - 1 (0-4) - 0 (0-3), p=0.07 and p=0.003, respectively. No differences in post-surgical analgesic use or adverse events were observed. CONCLUSION: In this study, we showed that the IV acetaminophen group had lower observational FS and BOPS scores in the early postoperative period; however, further studies including a large number of patients are required to confirm our findings.

Reduction of Postoperative Pain by Addition of Intravenous Acetaminophen after Total Hip Arthroplasty: A Retrospective Cohort Study.

We evaluated the analgesic effects of multimodal pain control in which intravenous acetaminophen (IV APAP) was added to the standard protocol for Japanese patients who had undergone a total hip arthroplasty (THA). We performed a retrospective cohort study of 180 patients aged 66.4±10.5 years (30% male) who had undergone a THA (Oct. 2014 to Feb. 2015) at our hospital. The control patients were administered the standard analgesic protocol: flurbiprofen axetil as a continuous intravenous infusion and oral celecoxib (NAPAP; n=109). The patients in the new analgesic protocol group received IV APAP in addition to the standard analgesic protocol (APAP; n=71). The primary outcome was the maximum value of postoperative pain the patients reported on a numerical rating scale (NRS) during the first 24 h post-surgery. A univariate analysis and multivariate analyses adjusted for age, sex, the stage of hip osteoarthritis, preoperative pain, and surgical time showed that the maximum postoperative pain NRS scores during the first 24 h after surgery was significantly lower when the APAP protocol was used. The addition of IV APAP to the current standard multimodal analgesia protocol for Japanese patients who have undergone a THA may decrease the patients' postoperative pain.

Comparison of the postoperative analgesic efficacies of intravenous acetaminophen and fascia iliaca compartment block in hip fracture surgery: A randomised controlled trial.

BACKGROUND: Managing pain during movement after hip fracture surgery is important for achieving earlier hip mobilisation and for preventing postoperative complications. In the present study, we tested the hypothesis that the fascia iliaca compartment block (FICB) would improve postoperative pain on movement compared with intravenous acetaminophen. METHODS: In this prospective, randomised, controlled, parallel trial, patients were assigned to either the intravenous acetaminophen or the ultrasound-guided FICB group. Visual analog scale (VAS) pain scores were evaluated at 6, 9, 12, 18, 24 h, 2 days, and 7 days postoperatively. The primary outcome was VAS scores on movement at 24 h after surgery. The secondary outcomes were VAS scores on movement at the other time points, VAS scores at rest, the total number of rescue analgesics required and incidence of delirium during the first 24 h postoperatively, potential drug or block-related complications, and the time to first standing. RESULTS: VAS scores on movement at 24 h after surgery were significantly lower in the FICB group than in the intravenous acetaminophen group [median (the 25th to 75th percentiles), 20 (10-30) vs 40 (30-53); P < 0.01]. The VAS scores on movement at any other time point and the scores at rest at 12 h after surgery were also significantly lower in the FICB group than in the intravenous acetaminophen group. The two groups did not differ in terms of the total number of rescue analgesics required or the incidence of delirium during the first 24 h postoperatively; complications; or the time to first standing. CONCLUSIONS: FICB improved postoperative pain on movement compared with intravenous acetaminophen without increasing the complication rate. However, the total number of rescue analgesics required and the time to first standing were not significantly different between the two groups.

Intravenous acetaminophen vs saline in perioperative analgesia with laparoscopic hysterectomy.

BACKGROUND: Opioids are effective for the treatment of postoperative pain but can cause nausea and are associated with dependency with long-term use. Nonopioid medications such as acetaminophen offer the promise of decreasing these nondesirable effects while still providing patient comfort. OBJECTIVE: The purpose of this study was to compare intravenous acetaminophen with placebo and to evaluate postoperative pain control and opioid usage after laparoscopic hysterectomy. STUDY DESIGN: We conducted a prospective double-blind randomized study with 183 patients who were assigned randomly (1:1) to receive acetaminophen or placebo (Canadian Task Force Design Classification I). Patients received either 1000 mg of acetaminophen (n=91) or a placebo of saline solution (n=92) at the time of induction of anesthesia and a repeat dose 6 hours later. Both groups self-reported pain and nausea levels preoperatively and at 2, 4, 6, 12, and 24 hours after extubation with the use of a visual analog scale with a score of 0 for no pain to 10 for highest level of pain. Patients self-reported pain, nausea, and postoperative oral opiates that were taken after discharge. All opiates were converted to milligram equivalents of oral morphine for standardization. RESULTS: There were no significant differences in generalized abdominal pain at any time point postoperatively that included 2 hours (placebo 3.6±2.5 vs acetaminophen 4.4±2.5; P=.07) and up to 24 hours (placebo 3.3±2.4 vs acetaminophen 3.6±2.5; P=.28). Similar results were observed for nausea scores. There were no differences in opioid consumption at any time point including intraoperatively (placebo 4.4±3.9 vs acetaminophen 3.3±4.0; P=.06), post anesthesia care unit (placebo 10.5±10.3 vs acetaminophen 9.7±10.3; P=.59), and up to 24 hours after surgery (placebo 1.4±2.0 vs acetaminophen 1.6±2.1; P=.61). There were no differences in demographics or surgical data between groups. CONCLUSION: There was no difference between acetaminophen and placebo groups in postoperative pain, satisfaction scores, or opioid requirements. Given the relatively high cost ($23.20 per dose in our study), lack of benefit, and available oral alternatives, our results do not support routine use during hysterectomy.

Scheduled Intravenous Acetaminophen for Postoperative Management of Patients Who Had Thoracoscopic Esophagectomy for Esophageal Cancer.

BACKGROUND/AIM: The aim of this study was to assess the effects of scheduled intravenous acetaminophen for postoperative management of patients who underwent thoracoscopic esophagectomy for esophageal cancer. PATIENTS AND METHODS: The records of 56 consecutive patients who underwent thoracoscopic esophagectomy in the prone position for esophageal cancer were reviewed. For postoperative pain control, twenty-eight patients underwent the scheduled intravenous acetaminophen (SIVA group), whereas the other 28 were managed with intravenous flurbiprofen (Control group). The perioperative outcomes of the two groups were compared. RESULTS: The incidence of pneumonia and the total numerical rating scale of postoperative pain level were significantly lower in the SIVA group than in the Control group (3.6% vs. 25.0%; p=0.022, 40 vs. 93; p=0.027). Patients' fever on the third day after surgery in the SIVA group was significantly lower than in the Control group (36.9°C vs. 37.2°C; p=0.029). However, the incidence of anastomotic leakage, laryngeal nerve palsy, the changes of postoperative C-reactive protein level, and the duration of hospital stay were not different between the two groups. CONCLUSION: Scheduled intravenous acetaminophen after thoracoscopic esophagectomy in patients with esophageal cancer was a useful strategy in reducing the incidence of postoperative pneumonia.

Efficacy of Intravenous Acetaminophen in Length of Stay and Postoperative Pain Control in Laparoscopic Roux-en-Y Gastric Bypass Surgery Patients.

Background: Opiate-based pain medications may incur adverse effects following bariatric surgery. The aim of this study was to evaluate the efficacy of intravenous Acetaminophen (IVAPAP) on length of stay (LOS) after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Methods: This was a prospective, double-blind, randomized controlled trial conducted from October 2011 to March 2014 at a 416-bed teaching hospital. Eighty-nine total patients were included (control group, n = 45; treatment group, n = 44). Patients were administered either 1000 mg of IVAPAP or placebo every 6 h beginning preoperatively and continuing for four doses. LOS, total narcotic consumption, pain and nausea scores, time to return of flatus (ROF), and postoperative rescue pain medication used were measured during the first 24 h after surgery. Results: LOS was significantly decreased in the treatment group compared with control (2.72 days vs. 3.18 days; p = 0.03). There was significant reduction in time to ROF (1.87 days vs. 2.24 days; p = 0.04). Pain was significantly decreased in the first 2 postoperative hours in the treatment group (p = 0.02). Total opioid consumption, postoperative nausea scores, and use of rescue pain medications were not affected. Conclusions: The use of IVAPAP significantly decreases LOS following LRYGB, improves acute postoperative pain control, and mediates quicker return of bowel function.

Effectiveness of Novel Adjuncts in Pain Management Following Total Knee Arthroplasty: A Randomized Clinical Trial.

BACKGROUND: Total knee arthroplasty (TKA) can be associated with significant pain which can negatively impact outcomes. Multiple strategies have been employed to reduce pain. The aim of this study is to compare the effectiveness of 3 different pain management modalities after TKA that included (1) our standardized knee injection cocktail and oral acetaminophen, (2) liposomal bupivacaine periarticular injection and oral acetaminophen, and (3) our standardized knee injection cocktail and intravenous (IV) acetaminophen. METHODS: A prospective randomized clinical trial was conducted with 3 perioperative pain management regimes: oral acetaminophen and our standardized knee injection cocktail (standard group), oral acetaminophen and liposomal bupivacaine periarticular injection (LB group), and IV acetaminophen and our standardized knee injection cocktail (IVA group). Primary outcome measures included visual analog scale, total morphine equivalents, and the opioid-related symptoms distress scale at 24 and 48 hours postoperatively. RESULTS: There were no significant differences on visual analog scale/opioid-related symptoms distress scale scores 24 hours after surgery. The LB group required significantly more narcotics (total morphine equivalents) than the standard (P = .025) and IVA groups (P = .032). No significant differences were observed on any of the outcomes measured at 48 hours after surgery. CONCLUSION: Our data suggest that there is no added benefit in the routine use of IV acetaminophen or liposomal bupivacaine after TKA.