Abstract
Introduction
Patients with pelvic and acetabular fractures often have considerable pain in the perioperative period. Regional anesthesia (RA) including peripheral nerve blocks and spinal analgesia may reduce pain. However, the real-world impact of these modalities on inpatient opioid consumption and outpatient opioid demand is largely unknown. The purpose of this study was to evaluate the impact of perioperative RA on inpatient opioid consumption and outpatient opioid demand.
Methods
This is a retrospective, observational review of inpatient opioid consumption and outpatient opioid demand in all patients ages 18 and older undergoing operative fixation of pelvic and acetabular fractures at a single Level, I trauma center from 7/1/2013–7/1/2018 (n = 205). Unadjusted and adjusted analyses were constructed to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand while controlling for age, sex, race, body mass index (BMI), smoking, chronic opioid use, ASA score, injury mechanism, additional injuries, open injury, and additional inpatient surgery.
Results
Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (12.6 estimated OE’s without RA vs 16.1 OE’s with RA from 48 to 72 h post-op, p < 0.05) but no significant differences at other timepoints (17.5 estimated OE’s without RA vs 16.8 OE’s with RA from 0 to 24 h post-op, 15.3 vs 17.1 from 24 to 48 h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA at discharge to 90 days post-op (and 156.8 vs 207.9 OE’s to 90 days, p < 0.05) but did not differ significantly before that time (121.5 OE’s without RA vs 123.9 with RA from discharge to two weeks, 145.2 vs 177.2 OE’s to 6 weeks, p > 0.05).
Discussion
In pelvis and acetabulum fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. Regional anesthesia may not be beneficial for these patients.
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References
Langford JR, Burgess AR, Liporace FA, Haidukewych GJ (2013) Pelvic fractures: part 1 Evaluation, classification, and resuscitation. J Am Acad Orthop Surg 21(8):448–457. https://doi.org/10.5435/JAAOS-21-08-448
Langford JR, Burgess AR, Liporace FA, Haidukewych GJ (2013) Pelvic fractures: part 2 Contemporary indications and techniques for definitive surgical management. J Am Acad Orthop Surg 21(8):458–468. https://doi.org/10.5435/JAAOS-21-08-458
Tornetta P 3rd (2001) Displaced acetabular fractures: indications for operative and nonoperative management. J Am Acad Orthop Surg 9(1):18–28. https://doi.org/10.5435/00124635-200101000-00003
Fritz A, Gericke L, Hoch A, Josten C, Osterhoff G (2020) Time-to-treatment is a risk factor for the development of pressure ulcers in elderly patients with fractures of the pelvis and acetabulum. Injury 51(2):352–356. https://doi.org/10.1016/j.injury.2019.12.007
Demetriades D, Karaiskakis M, Toutouzas K, Alo K, Velmahos G, Chan L (2002) Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes. J Am Coll Surg 195(1):1–10. https://doi.org/10.1016/s1072-7515(02)01197-3
Letournel É, Judet R (1993). Fractures of the Acetabulum. 2nd edn. Springer-Verlag
Rinne PP, Laitinen MK, Huttunen T, Kannus P, Mattila VM (2017) The incidence and trauma mechanisms of acetabular fractures: a nationwide study in Finland between 1997 and 2014. Injury 48(10):2157–2161. https://doi.org/10.1016/j.injury.2017.08.003
Tarabadkar N, Alton T, Gorbaty J, Nork S, Taitman L, Kleweno C (2018) Trends in orthopedic fracture and injury severity: a level i trauma center experience. Orthopedics 41(2):e211–e216. https://doi.org/10.3928/01477447-20180103-01
Marmor M, El Naga AN, Barker J, Matz J, Stergiadou S, Miclau T (2020) Management of pelvic ring injury patients with hemodynamic instability. Front Surg 7:588845. https://doi.org/10.3389/fsurg.2020.588845
Suzuki T, Shindo M, Soma K, Minehara H, Nakamura K, Uchino M, Itoman M (2007) Long-term functional outcome after unstable pelvic ring fracture. J Trauma 63(4):884–888. https://doi.org/10.1097/01.ta.0000235888.90489.fc
Lefaivre KA, Slobogean GP, Valeriote J, O’Brien PJ, Macadam SA (2012) Reporting and interpretation of the functional outcomes after the surgical treatment of disruptions of the pelvic ring: a systematic review. J Bone Joint Surg Br 94(4):549–555. https://doi.org/10.1302/0301-620X.94B4.27960
Gerbershagen HJ, Dagtekin O, Isenberg J, Martens N, Ozgur E, Krep H, Sabatowski R, Petzke F (2010) Chronic pain and disability after pelvic and acetabular fractures–assessment with the mainz pain staging system. J Trauma 69(1):128–136. https://doi.org/10.1097/TA.0b013e3181bbd703
Schafer SJ, Schafer LO, Anglen JO, Childers M (2000) Heterotopic ossification in rehabilitation patients who have had internal fixation of an acetabular fracture. J Rehabil Res Dev 37(4):389–393
Stibolt RD Jr, Patel HA, Huntley SR, Lehtonen EJ, Shah AB, Naranje SM (2018) Total hip arthroplasty for posttraumatic osteoarthritis following acetabular fracture: a systematic review of characteristics, outcomes, and complications. Chin J Traumatol 21(3):176–181. https://doi.org/10.1016/j.cjtee.2018.02.004
Kessler ER, Shah M, Gruschkus SK, Raju A (2013) 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 33(4):383–391. https://doi.org/10.1002/phar.1223
Gan TJ, Lubarsky DA, Flood EM, Thanh T, Mauskopf J, Mayne T, Chen C (2004) Patient preferences for acute pain treatment. Br J Anaesth 92(5):681–688. https://doi.org/10.1093/bja/aeh123
Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C, Schoelles KM (2010). Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev 2010 (1):CD006605. https://doi.org/10.1002/14651858.CD006605.pub2
Vakharia RM, Sabeh KG, Vakharia AM, Damodar DM, Law TY, Roche MW (2019) Comparison of implant related complications amongst patients with opioid use disorder and non-users following total knee arthroplasty. World J Orthop 10(3):137–144. https://doi.org/10.5312/wjo.v10.i3.137
Hah JM, Bateman BT, Ratliff J, Curtin C, Sun E (2017) Chronic opioid use after surgery: implications for perioperative management in the face of the opioid epidemic. Anesth Analg 125(5):1733–1740. https://doi.org/10.1213/ANE.0000000000002458
Weiss RJ, Montgomery SM, Stiller C-O, Wick MC, Jansson K-Å (2012) Long-term follow-up of opioid use in patients with acetabular fractures. Injury Extra 43(7):49–53. https://doi.org/10.1016/j.injury.2012.03.027
Cunningham D, LaRose M, Yoon RS, Gage MJ (2020) Factors associated with perioperative opioid demand in lower extremity fractures: does consumption vary by anatomic location? Injury. https://doi.org/10.1016/j.injury.2020.10.038
Cunningham DJ, LaRose MA, Gage MJ (2020) The impact of mental health and substance use on opioid demand after hip fracture surgery. J Am Acad Orthop Surg. https://doi.org/10.5435/JAAOS-D-20-00146
Cunningham D, LaRose M, Gage M (2020) The impact of substance use and abuse on opioid demand in lower extremity fracture surgery. J Orthop Trauma. https://doi.org/10.1097/BOT.0000000000001958
Cunningham DJ, LaRose MA, Klifto CS, Gage MJ (2020) Mental health and substance use affect perioperative opioid demand in upper extremity trauma surgery. J Shoulder Elbow Surg. https://doi.org/10.1016/j.jse.2020.06.024
Hedegaard H, Warner M, Minino AM (2017) Drug overdose deaths in the united states, 1999–2016. NCHS Data Brief 294:1–8
Hsu JR, Mir H, Wally MK, Seymour RB, Task OTAMP, F (2019) Clinical practice guidelines for pain management in acute musculoskeletal injury. J Orthop Trauma 33(5):e158–e182. https://doi.org/10.1097/BOT.0000000000001430
Manchikanti L, Helm S, 2nd, Fellows B, Janata JW, Pampati V, Grider JS, Boswell MV (2012) Opioid epidemic in the United States. Pain Physician 15 (3 Suppl):ES9–38
Morris BJ, Mir HR (2015) The opioid epidemic: impact on orthopaedic surgery. J Am Acad Orthop Surg 23(5):267–271. https://doi.org/10.5435/JAAOS-D-14-00163
Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SR (2011) Characteristics of opioid prescriptions in 2009. JAMA 305(13):1299–1301. https://doi.org/10.1001/jama.2011.401
Opioid prescription limits and policies by state. (2020). https://ballotpedia.org/Opioid_prescription_limits_and_policies_by_state. Accessed 5/25/2020 2020
Prevention CfDCa (2020) Understanding the Epidemic.
Services USDoHaH (2018) Strategy to Combat Opioid Abuse, Misuse, and Overdose.
Flanagan CD, Wysong EF, Ramey JS, Vallier HA (2018) Understanding the opioid epidemic: factors predictive of inpatient and postdischarge prescription opioid use after orthopaedic trauma. J Orthop Trauma 32(10):e408–e414. https://doi.org/10.1097/BOT.0000000000001256
Gadsden J, Warlick A (2015) Regional anesthesia for the trauma patient: improving patient outcomes. Local Reg Anesth 8:45–55. https://doi.org/10.2147/LRA.S55322
Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Cohen SR, Wu CL (2006) Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis Anesth Analg 102(1):248–257. https://doi.org/10.1213/01.ANE.0000181289.09675.7D
Gray A, Kehlet H, Bonnet F, Rawal N (2005) Predicting postoperative analgesia outcomes: NNT league tables or procedure-specific evidence? Br J Anaesth 94(6):710–714. https://doi.org/10.1093/bja/aei144
Strauss JE, O’Toole RV, Pollak AN (2012) Does supplemental epidural anesthesia improve outcomes of acetabular fracture surgery? J Orthop Trauma 26(2):67–72. https://doi.org/10.1097/BOT.0b013e31821cfc5b
Chelly JE, Casati A, Al-Samsam T, Coupe K, Criswell A, Tucker J (2003) Continuous lumbar plexus block for acute postoperative pain management after open reduction and internal fixation of acetabular fractures. J Orthop Trauma 17(5):362–367. https://doi.org/10.1097/00005131-200305000-00007
von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, Initiative S (2014) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg 12(12):1495–1499. https://doi.org/10.1016/j.ijsu.2014.07.013
National Center for Injury Prevention and Control CfDCaP (2018). CDC compilation of benzodiazepines, muscle relaxants, stimulants, zolpidem, and opioid analgesics with oral morphine milligram equivalent conversion factors.
Doyle DJ, Goyal A, Bansal P, Garmon EH (2021). American Society of Anesthesiologists Classification. In: StatPearls. Treasure Island (FL)
Prevention. CfDCa (2016) Definitions Relevant to the Clinical QI Opioid Measures. https://www.cdc.gov/drugoverdose/pdf/prescribing/CDC-DUIP-FactSheet-At-A-Glance_Opioid-Measures-508.pdf. Accessed 5/28 2020
Glynn AN, Quinn KM (2010) An introduction to the augmented inverse propensity weighted estimator. Polit Anal 18(1):36–56. https://doi.org/10.1093/pan/mpp036
Antonio Olmos PG (2015) A practical guide for using propensity score weighting in R. Pract Assess Res Eval 20:13
Aubrun F, Langeron O, Quesnel C, Coriat P, Riou B (2003) Relationships between measurement of pain using visual analog score and morphine requirements during postoperative intravenous morphine titration. Anesthesiology 98(6):1415–1421. https://doi.org/10.1097/00000542-200306000-00017
Nencini S, Ivanusic JJ (2016) The physiology of bone pain how much do we really know? Front Physiol 7:157. https://doi.org/10.3389/fphys.2016.00157
McGlone R, Sadhra K, Hamer DW, Pritty PE (1987) Femoral nerve block in the initial management of femoral shaft fractures. Arch Emerg Med 4(3):163–168. https://doi.org/10.1136/emj.4.3.163
Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH (2012) The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat 221(6):537–567. https://doi.org/10.1111/j.1469-7580.2012.01564.x
Gerhardt M, Johnson K, Atkinson R, Snow B, Shaw C, Brown A, Vangsness CT Jr (2012) Characterisation and classification of the neural anatomy in the human hip joint. Hip Int 22(1):75–81. https://doi.org/10.5301/HIP.2012.9042
Langworthy MJ, Sanzone AG (2018) Multimodal pain strategies including liposomal bupivacaine for isolated acetabular fracture surgery. J Orthop Trauma 32(Suppl 2):S11–S15. https://doi.org/10.1097/BOT.0000000000001228
Sort R, Brorson S, Gogenur I, Nielsen JK, Moller AM (2019) Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: an exploratory pilot study. Acta Anaesthesiol Scand 63(3):396–402. https://doi.org/10.1111/aas.13290
Dada O, Gonzalez Zacarias A, Ongaigui C, Echeverria-Villalobos M, Kushelev M, Bergese SD, Moran K (2019) Does rebound pain after peripheral nerve block for orthopedic surgery impact postoperative analgesia and opioid consumption? A narrative review. Int J Environ Res Public Health 16(18):3257. https://doi.org/10.3390/ijerph16183257
Henningsen MJ, Sort R, Moller AM, Herling SF (2018) Peripheral nerve block in ankle fracture surgery: a qualitative study of patients’ experiences. Anaesthesia 73(1):49–58. https://doi.org/10.1111/anae.14088
Kolarczyk LM, Williams BA (2011) Transient heat hyperalgesia during resolution of ropivacaine sciatic nerve block in the rat. Reg Anesth Pain Med 36(3):220–224. https://doi.org/10.1097/AAP.0b013e3182176f5a
Brummett CM, Amodeo FS, Janda AM, Padda AK, Lydic R (2010) Perineural dexmedetomidine provides an increased duration of analgesia to a thermal stimulus when compared with a systemic control in a rat sciatic nerve block. Reg Anesth Pain Med 35(5):427–431. https://doi.org/10.1097/AAP.0b013e3181ef4cf0
Brummett CM, Padda AK, Amodeo FS, Welch KB, Lydic R (2009) Perineural dexmedetomidine added to ropivacaine causes a dose-dependent increase in the duration of thermal antinociception in sciatic nerve block in rat. Anesthesiology 111(5):1111–1119. https://doi.org/10.1097/ALN.0b013e3181bbcc26
An K, Elkassabany NM, Liu J (2015) Dexamethasone as adjuvant to bupivacaine prolongs the duration of thermal antinociception and prevents bupivacaine-induced rebound hyperalgesia via regional mechanism in a mouse sciatic nerve block model. PLoS ONE 10(4):e0123459. https://doi.org/10.1371/journal.pone.0123459
Gordon SM, Chuang BP, Wang XM, Hamza MA, Rowan JS, Brahim JS, Dionne RA (2008) The differential effects of bupivacaine and lidocaine on prostaglandin E2 release, cyclooxygenase gene expression and pain in a clinical pain model. Anesth Analg 106 (1):321–327, table of contents. doi:https://doi.org/10.1213/01.ane.0000296474.79437.23
Kroin JS, Buvanendran A, Watts DE, Saha C, Tuman KJ (2006) Upregulation of cerebrospinal fluid and peripheral prostaglandin E2 in a rat postoperative pain model. Anesth Analg 103 (2):334–343, table of contents. doi:https://doi.org/10.1213/01.ane.0000223674.52364.5c
Goldstein RY, Montero N, Jain SK, Egol KA, Tejwani NC (2012) Efficacy of popliteal block in postoperative pain control after ankle fracture fixation: a prospective randomized study. J Orthop Trauma 26(10):557–561. https://doi.org/10.1097/BOT.0b013e3182638b25
Abdallah FW, Halpern SH, Aoyama K, Brull R (2015) Will the real benefits of single-shot interscalene block please stand up? a systematic review and meta-analysis. Anesth Analg 120(5):1114–1129. https://doi.org/10.1213/ANE.0000000000000688
Capdevila X, Pirat P, Bringuier S, Gaertner E, Singelyn F, Bernard N, Choquet O, Bouaziz H, Bonnet F, French Study Group on Continuous Peripheral Nerve B 2005 Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients Anesthesiology 103 5 1035 1045 https://doi.org/10.1097/00000542-200511000-00018
Williams BA, Bottegal MT, Kentor ML, Irrgang JJ, Williams JP (2007) Rebound pain scores as a function of femoral nerve block duration after anterior cruciate ligament reconstruction: retrospective analysis of a prospective, randomized clinical trial. Reg Anesth Pain Med 32(3):186–192. https://doi.org/10.1016/j.rapm.2006.10.011
Ding DY, Manoli A 3rd, Galos DK, Jain S, Tejwani NC (2015) Continuous popliteal sciatic nerve block versus single injection nerve block for ankle fracture surgery: a prospective randomized comparative trial. J Orthop Trauma 29(9):393–398. https://doi.org/10.1097/BOT.0000000000000374
Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH (2018). Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev. 6 (6):CD007105. doi:https://doi.org/10.1002/14651858.CD007105.pub4
Ladha KS, Patorno E, Liu J, Bateman BT (2016) Impact of perioperative epidural placement on postdischarge opioid use in patients undergoing abdominal surgery. Anesthesiology 124(2):396–403. https://doi.org/10.1097/ALN.0000000000000952
Sun EC, Bateman BT, Memtsoudis SG, Neuman MD, Mariano ER, Baker LC (2017) Lack of association between the use of nerve blockade and the risk of postoperative chronic opioid use among patients undergoing total knee arthroplasty: evidence from the marketscan database. Anesth Analg 125(3):999–1007. https://doi.org/10.1213/ANE.0000000000001943
Mueller KG, Memtsoudis SG, Mariano ER, Baker LC, Mackey S, Sun EC (2017) Lack of association between the use of nerve blockade and the risk of persistent opioid use among patients undergoing shoulder arthroplasty: evidence from the marketscan database. Anesth Analg 125(3):1014–1020. https://doi.org/10.1213/ANE.0000000000002031
Kehlet H, Jensen TS, Woolf CJ (2006) Persistent postsurgical pain: risk factors and prevention. Lancet 367(9522):1618–1625. https://doi.org/10.1016/S0140-6736(06)68700-X
Hsia HL, Takemoto S, van de Ven T, Pyati S, Buchheit T, Ray N, Wellman S, Kuo A, Wallace A, Raghunathan K (2018) Acute pain is associated with chronic opioid use after total knee arthroplasty. Reg Anesth Pain Med 43(7):705–711. https://doi.org/10.1097/AAP.0000000000000831
Dauphin A, Raymer KE, Stanton EB, Fuller HD (1997) Comparison of general anesthesia with and without lumbar epidural for total hip arthroplasty: effects of epidural block on hip arthroplasty. J Clin Anesth 9(3):200–203. https://doi.org/10.1016/s0952-8180(97)00035-4
Acan AE, Kilinc CY, Gultac E, Altiparmak B, Uysal AI, Aydogan NH (2020) Effects of different anesthesia techniques on intraoperative blood loss in acetabular fractures undergoing the modified stoppa approach. Ulus Travma Acil Cerrahi Derg 26(3):445–452. https://doi.org/10.14744/tjtes.2019.09294
Bendtsen TF, Pedersen EM, Haroutounian S, Soballe K, Moriggl B, Nikolajsen L, Hasselstrom JB, Fisker AK, Strid JM, Iversen B, Borglum J (2014) The suprasacral parallel shift vs lumbar plexus blockade with ultrasound guidance in healthy volunteers–a randomised controlled trial. Anaesthesia 69(11):1227–1240. https://doi.org/10.1111/anae.12753
Grass JA (2000) The role of epidural anesthesia and analgesia in postoperative outcome. Anesthesiol Clin North Am 18(2):407–428. https://doi.org/10.1016/s0889-8537(05)70170-x
Lumpkin MM (1998) FDA public health advisory. Anesthesiology 88(2):27A-28A. https://doi.org/10.1097/00000542-199802000-00001
Neal JM, Hebl JR, Gerancher JC, Hogan QH (2002) Brachial plexus anesthesia: essentials of our current understanding. Reg Anesth Pain Med 27(4):402–428. https://doi.org/10.1053/rapm.2002.34377
Moraca RJ, Sheldon DG, Thirlby RC (2003) The role of epidural anesthesia and analgesia in surgical practice. Ann Surg 238(5):663–673. https://doi.org/10.1097/01.sla.0000094300.36689.ad
Jeng CL, Torrillo TM, Rosenblatt MA (2010) Complications of peripheral nerve blocks. Br J Anaesth 105(Suppl 1):i97-107. https://doi.org/10.1093/bja/aeq273
Karunakar MA, Goulet JA, Mueller KL, Bedi A, Le TT (2005) Operative treatment of unstable pediatric pelvis and acetabular fractures. J Pediatr Orthop 25(1):34–38. https://doi.org/10.1097/00004694-200501000-00009
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Cunningham, D.J., Robinette, J.P., Paniagua, A.R. et al. Regional anesthesia does not decrease opioid demand in pelvis and acetabulum fracture surgery. Eur J Orthop Surg Traumatol 32, 1357–1370 (2022). https://doi.org/10.1007/s00590-021-03114-w
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DOI: https://doi.org/10.1007/s00590-021-03114-w