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Todays Hospitalist Special Report

IV Acetaminophen: The Hospitalists Perspective

Inpatient pain management is a necessary skill set for all physicians, but it is particularly

Darrell Harrington, MD

Chief,
Division of General
Internal Medicine
Harbor-UCLA
Medical Center
Los Angeles

PAnEl mEmbERS
CHAIR
Darrell Harrington, mD
Professor of Medicine
David Geffen School
of Medicine at UCLA
Chief, Division of
General Internal Medicine
Harbor-UCLA Medical Center
Los Angeles
FACUlTY
bruce Friedman, mD
Critical Care & Co-Director
JM Still Burn Center
Doctors Hospital
Augusta, Ga.
Richard V. Hausrod, mD
Chairman
Emergency Department
EMH Healthcare
Elyria, Ohio

Supported by

While opioid monotherapy has long been the primary approach to pain management in the inpatient
setting, the medical literature has documented numerous significant negative effects of opiate and
analgesic use in hospital-based practice. These negative effects include opioid addiction, gastrointestinal issues such as nausea and vomiting, constipation and ileus, and serious complications such
as respiratory depression and sedation, which increase the risk of respiratory failure, aspiration,
decreased mobility, and falls.1
Research also indicates that current pain management strategies often fail to adequately control patient pain. One study found that more than 80% of U.S. patients who have surgery report significant
postoperative pain.2 Data from another study indicate that fewer than half of postoperative patients
report receiving adequate pain relief.3
An alternative approach to pain management that has been gaining traction among physicians is a
multimodal analgesia strategy that incorporates not only opioids, but other classes of analgesics.4, 5,
6
By incorporating different classes of analgesic agents with unique pharmacologic and physiologic
actions, physicians can prescribe smaller doses of each agent, a strategy that helps reduce the
potential for drug-related adverse events.6
One element in such a multimodal approach to pain management is OFIRMEV, an intravenous
(IV) formulation of acetaminophen. IV acetaminophen was approved by the FDA in November 2010
for the management of mild to moderate pain, the management of moderate to severe pain with
adjunctive opioid analgesics, and the reduction of fever.7
While IV acetaminophen is relatively new in the U.S., the same formulation of IV acetaminophen has
been available in Europe since 2002 and was widely used in more than 60 countries before reaching
the U.S. market. As a result, a large body of literature exists supporting the role of IV acetaminophen
in the management of acute pain while reducing opioid use. This special report examines data regarding the use of IV acetaminophen, including its efficacy in controlling pain; its ability to reduce not
only the use of opioids, but also adverse effects such as post-operative nausea and vomiting; and
its effects on length of stay and patient satisfaction.

Efficacy of IV acetaminophen

Compared to oral acetaminophen, IV acetaminophen achieves a rapid elevation in plasma concentration and higher peak levels.8 The IV form achieves plasma levels rarely achieved by similar oral
doses of acetaminophen and produces 75% higher central nervous system (CNS) bioavailability
compared to the oral form.8 The analgesic effect peaks within one hour and lasts for four to six
hours.7
The efficacy of pain management therapies is of great interest to hospitalists for a variety of reasons.
As comanagers of postoperative patients, hospitalists are routinely faced with a variety of complications of pain management that include nausea and vomiting, respiratory depression, ileus, and constipation. In addition, studies have shown that postoperative pain is associated with poor outcomes,
such as increased time to ambulation, longer lengths of stay 9 and increased rates of complications

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To d a y s H o s p i t a l i s t

February 2013

19

Todays Hospitalist Special Report

brian Tyson, mD
Hospitalist
Critical Care Partners
Desert Regional
Medical Center
Palm Springs, Calif.

important for hospitalists working in the inpatient setting. Pain is so pervasive in the hospital setting
that it is sometimes referred to as the fifth vital sign, and a failure to manage pain has important
implications not only for hospitalists, but also for the hospitals where they practice. Hospitalists play
a critical role not only in comanaging postoperative patients, but they also manage a wide range
of conditions in which pain is prevalent, from pancreatitis to small bowel obstructions to sickle-cell
disease.

IV Acetaminophen: The Hospitalists Perspective

such as venous thromboembolism.10 Reducing length of stay in


postoperative patients is a major goal of many hospitalists, so
any alternative to opioids that can help accelerate discharge is
welcome.

scores for postoperative nausea/vomiting and sedation. The


authors concluded intravenous acetaminophen reduced the
use of opioids, extubation time, and opioid-related adverse effects after major surgery in the ICU.14

Clinical evidence demonstrates that IV acetaminophen has good


utility to treat inpatient postsurgical pain, even following total joint
arthroplasty, which is often associated with high pain scores.
Results from a 2005 study by Sinatra et al. demonstrate that IV
acetaminophen produces good quality analgesia even in this
moderate-to-severe pain model, reducing the consumption of
opioids and improving patient satisfaction.11 In that study, 101
postoperative orthopedic surgery patients were given either
1000 mg of IV acetaminophen or placebo every six hours for
24 hours. Patients were allowed to use a patient-controlled analgesia (PCA) pump with morphine for rescue analgesia if their
pain was inadequately controlled. Overall, there was a 33% decrease over 24 hours in the use of morphine among patients
who received IV acetaminophen.11 An expanded analysis of
those data also found that the sum of pain intensity over 24
hours highly favored IV acetaminophen.12

In addition, IV acetaminophen monotherapy appears to have


good utility in less painful procedures as well. In a study of
adults undergoing tonsillectomy, patients given IV acetaminophen received fewer opioids, and 71% of patients receiving IV
acetaminophen required no rescue analgesics. Patients given
IV acetaminophen experienced less pain, and they were less
likely to report insufficient pain relief.15
And in a study of patients who had undergone endoscopic
thyroidectomy, researchers found that subjects who received
IV acetaminophen reported significantly lower postoperative
pain scores than the control group, and fewer of those patients
needed rescue analgesics. Postoperative nausea and vomiting
were more frequent in the control group, but other side effects
such as sedation, confusion, and pruritus were similar in both
groups.16
Optimizing postoperative pain management is an important
goal for hospitalists involved in the management of surgical
patients. Specifically, the careful use of effective pain management therapies may lead to reduced postoperative complications and, ultimately, reduced morbidity and health care costs.

In another widely-cited 2010 study by Wininger and colleagues,


244 patients who had undergone abdominal laparoscopic surgery were divided into four groups and given either 1000 mg
of IV acetaminophen every six hours, 650 mg of IV acetaminophen every four hours, 100 mL of IV placebo every six hours,
or 65 mL of IV placebo every four hours. When researchers
compared differences in pain intensity, they found that patients
receiving IV acetaminophen reported significantly better scores.
Results showed that while both 1000 mg of IV acetaminophen
every six hours and 650 mg every four hours were effective,
only the 1000 mg dose produced a statistically significant difference in time to meaningful pain relief and total pain relief when
compared to the placebo group.13

While much of the literature examines the use of IV acetaminophen in postoperative patients, the drug also has been researched in several nonsurgical models. Many of these studies
pertain to pain in patients presenting to the emergency department (ED), which is another area where hospitalists serving as
consultants or staffing observation units are likely to encounter
acute pain.

A separate study of ICU patients following major abdominal or


pelvic surgery found that at 24 hours, patients who received IV
acetaminophen with IV meperidine had better pain scale and
visual analog scores than patients who received IV normal saline with IV meperidine. Patients receiving IV acetaminophen
also experienced a decrease in extubation time, and had lower

A study of 55 patients that compared IV acetaminophen 1000 mg


to IV morphine 10 mg in treating acute traumatic limb pain in the
ED found equivalent analgesic effect between the two therapies
at all time intervals. Although no differences in time to first use
of rescue medication were observed, patients given morphine
experienced significantly more adverse reactions.17 Similarly, two

Data from nonsurgical patients

IV AcetAmInoPHen DosIng InformAtIon*

Todays Hospitalist Special Report

Age group

Q4

Q6

max.
single dose

max. total
daily dose

Adults/adolescents >13 years


old and > 50 kg

650 mg

1,000 mg

1,000 mg

4,000 mg

Adults/adolescents >13 years


old and < 50 kg

12.5 mg

15 mg/kg

15 mg/kg up
(up to 750 mg)

75 mg/kg
(up to 3750 mg)

Children 2-12 years old

12.5 mg

15.5 mg/kg

15 mg/kg

* See reference 7 (OFIRMEV [acetaminophen] injection Prescribing Information).

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75 mg/kg

Todays Hospitalist special report

IV acetamInOPhen and reduced OPIOId cOnsumPtIOn


morphine usage over 24 hours after total hip/knee replacement 1
Placebo
57.4 mg
IV APAP
38.3 mg -33% difference
meperidine use after major abdominal surgery 2
Placebo
198 mg
IV APAP
77 mg
-61% difference
meperidine doses per group after adult tonselectomy 3
Placebo
82 doses
IV APAP
18 doses -78% difference
1. See reference 11.
2. See reference 14.
3. See reference 15.

other clinical trials found that IV acetaminophen was as effective


as IV or intramuscular (IM) ketorolac.18, 19
Another study of nearly 150 patients presenting to the ED with
suspected renal colic compared IV acetaminophen or morphine
to placebo. Researchers found that fewer patients receiving
IV acetaminophen required rescue medications at 30 minutes
(46%) than those receiving IV morphine at a dose of 0.1 mg/kg
(49%) or placebo (68%).20
While this study was not designed as a head-to-head trial, the
results are important for hospitalists because when physicians
are unable to adequately control a patients pain in a timely
manner, the threshold for admitting that patient may be lowered.
Thus, more effective pain control of patients in the ED might
reduce length of stay in the ED or, more importantly, prevent an
unnecessary admission.

Opioid reduction

Because opioids are associated with adverse drug events that


not only affect patient care but also increase costs, there has
been a call for physicians to embrace a multimodal pain approach whenever possible to minimize the use of opioids. The
American Society of Anesthesiologists (ASA) has strongly recommended the use of multimodal analgesia whenever possible
to reduce reliance on opioids in the perioperative setting. GuideIV acetamInOPhen and ImPrOVed PatIent satIsfactIOn
abdominal laparoscopy: good/excellent ratings at 24 hours 1
Placebo
70.3%
IV APAP
86.9%

total hip replacement: good/excellent ratings at 24 hours 3


Placebo
35.5%
IV APAP
80.0%
1. See reference 13.
2. See reference 11.
3. See reference 23.

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By introducing IV acetaminophen into pain management regimens, researchers have been able to reduce opioid consumption
in postsurgical patients in the ICU. In the previously mentioned
2010 study in the ICU in patients undergoing major abdominal
or pelvic surgery, patients given 1000 mg of IV acetaminophen
Q6h needed 61% less opioids than the control group.14 In the
2005 Sinatra study, patients who had undergone total hip or total
knee replacement surgery receiving IV acetaminophen 1000 mg
every 6 hours reduced morphine consumption by 48% over 6
hours and 33% over 24 hours.11 Two other studies examining total hip arthroplasty patients similarly found that total consumption
of morphine dropped by 53% and 63%.22, 23
Minimizing opioid use means decreasing the risk of sedation.
For hospitalists, however, particularly those treating postoperative patients, decreasing opioid use also means increasing the
ability of patients to participate in their care plans. Patients can
be more active in rehabilitation and wound management, better follow instructions, and more fully comprehend patient education efforts. Being pain-free is important, but if patients are
oversedated, their participation in their care may be impaired
or limited.
Hospitalists treating postoperative patients also may see another benefit of a drug like IV acetaminophen. Postsurgical
patients whose pain is better controlled, particularly those who
have undergone abdominal surgery, can take deeper breaths
and are less likely to develop atelectasis or pneumonia.
Reducing hospital-acquired conditions such as pneumonia is
not only a laudable patient safety goal, but is one that has the
attention of hospital administrators and hospitalists alike. Payers like Medicare have stopped paying for hospital-acquired
conditions such as pneumonia and pressure ulcers, giving both
physicians and hospitals a financial incentive to prevent complications associated with pain management.

Postoperative nausea and vomiting

Postoperative nausea and vomiting are associated with increased morbidity, including aspiration, and may prolong recovery and, ultimately, length of stay. Therefore, minimizing postoperative nausea and vomiting is an important pain management
goal in the postoperative setting.
While other strategies such as prokinetic agents and gastric pH
modifying agents are used, the most important strategy to reduce the risk of aspiration is the prevention of vomiting. The use
of narcotics, especially in narcotic-naive patients, is strongly associated with nausea and may lead to vomiting. Any opportunity
to address the symptoms of pain while reducing exposure to

Todays Hospitalist Special Report

total hip/knee replacement: good/excellent ratings at 24 hours 2


Placebo
23.1%
IV APAP
40.8%

lines issued by the ASAs Task Force on Acute Pain Management state that, unless contraindicated, patients should receive
an around-the-clock regimen of therapies that include acetaminophen.21 Unlike opioids, acetaminophen does not produce
sedation, respiratory depression, or ileus and constipation, and
it is not associated with a risk of substance abuse or misuse.

IV Acetaminophen: The Hospitalists Perspective

tions were higher after both the initial dose of IV acetaminophen


and the dose given at 24 hours compared with those in a placebo group. In addition, at 24 hours, significantly more patients
given IV acetaminophen rated their satisfaction as good or
One study designed to examine postoperative nausea and vomexcellent (40.8%) compared to patients in the placebo group
iting found that a single dose of IV acetaminophen was superior
(23.1%).11 In the Wininger study of patients who underwent abto placebo in decreasing the incidence of nausea (14.6% vs.
dominal laparoscopy, patients who received IV acetaminophen
33%) and vomiting (7.3% vs. 24.4%) during the first 24 hours
gave significantly better satisfaction evaluations than subjects
after surgery. Researchers also found differences between the
in the placebo group.13
IV acetaminophen and control groups in the number of doses
of analgesics required for rescue during that 24-hour period.24
Several other studies of IV acetaminophen in postsurgical pain
patients similarly showed that patients reported significantly
In two other studies that examined postoperative nausea and
higher satisfaction ratings when given the therapy than patients
vomiting, researchers found statistical differences between IV
in control groups. 30, 31, 32, 33
acetaminophen and placebo in both nausea and vomiting.25,
26
Several other studies have compared IV acetaminophen to Hospitalists know that patient satisfaction scores are increasmeperidine, tramadol, and morphine. One found reductions in ingly important in todays health care environment. Hospitals
nausea at all points in the study, and a reduction in vomiting at must collect and submit scores from the Hospital Consumer
the 30-minute timepoint when compared to tramadol alone.27 Assessment of Healthcare Providers and Systems (HCAHPS)
Another study showed differences between IV acetaminophen survey to receive their full Medicare payment, and the Centers
for Medicare & Medicaid Services (CMS) publishes patient
and morphine in the rates of nausea and vomiting.28
satisfaction scores from the HCAHPS survey on its Hospital
Length of stay, patient satisfaction
Compare Web site. Anything that hospitalists can do to improve
Hospitalists are very familiar with the importance of managing
patient satisfactionand, as a result, optimize patient satisfaclength of stay and reducing unnecessary health care costs. The
tion scores and reimbursementis welcome.
diagnosis-related group (DRG) reimbursement model currently
provides hospitals with a single fee for many conditions, re- It has been said that patient satisfaction equals patient experigardless of the number of days the patient stays in the hospital. ence, and this indeed is true. Patient experience in a hospital
Therefore, length of stay is a metric that can have serious rami- or health care system is defined to a large degree by patient
satisfaction. In the postoperative environment, a key element
fications for a hospitals finances.
of patient experience is pain management.
The current system of reimbursement gives hospitals an incentive to achieve two goals regarding patients in pain. The first
Conclusion
goal is to control patient pain more quickly, which allows paWhile opioid monotherapy is typically viewed as the gold stantients to begin eating, ambulating, and preparing for discharge
dard of pain management, downsides such as addiction, ileus,
more quickly. The second goal is to minimize side effects of
and respiration issues are well-known and well-documented in
pain therapy. Data from a number of studies have examined the
the medical literature. As a result, a movement is underway torole of IV acetaminophen in achieving both these goals.
ward a multimodal approach to pain management that incorpoIn a review of more than 350 patients who had undergone lapa- rates nonopioid analgesics to not only better manage pain, but
roscopic high anterior bowel resection, researchers compared reduce the adverse effects of opioids.
PCA morphine to IV acetaminophen combined with morphine,
An important component of this multimodal approach to pain
as well as to IV acetaminophen combined with morphine plus
management is IV acetaminophen. A wide body of research
a transverse abdominis plane block. Patients receiving IV acdemonstrates that IV acetaminophen not only effectively manetaminophen resumed a normal diet in a median of 12 hours;
ages patients pain but can help reduce the adverse effects of
patients receiving PCA morphine, by comparison, resumed a
opioid use. +
normal diet in a median of 36 hours. In this study, researchers
also found that patients receiving IV acetaminophen had a hosDISCLAIMER This special report is a summary of publicly
pital stay of three days compared to a median of five days for
available information and is not designed to be a comprepatients receiving PCA morphine.29
hensive clinical review of the subject. Todays Hospitalist
assumes no legal liability for the use of the material in this
Several studies have examined the effect that IV acetaminospecial report. Readers are directed to consult the primaphen can play in another important metric for hospitalists:
ry data sources cited in this article for more information.
patient satisfaction scores. In the previously mentioned 2005
Sinatra study of orthopedic patients, global satisfaction evalua-

Todays Hospitalist Special Report

agents that induce nausea will likely reduce the risk of vomiting
and consequently reduce the risk of aspiration pneumonia. A
formal study to address this has not been undertaken to date.

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Todays Hospitalist Special report

Case Study One

IV Acetaminophen for a Patient With Ileus


on Parenteral Nutrition and Mechanical Ventilation
BruCe FrIedM AN, MD
Critical Care & Co-Director, JM Still Burn Center
Doctors Hospital, Augusta, Ga.

fasciitis of the abdomen, which developed following a midline hernia repair and adnexal mass
removal. Her case was complicated by multiorgan dysfunction, and she arrived septic, requiring pressor support and mechanical ventilation. The patient also had a history of asthma,
hypertension, depression, and hypothyroidism.

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A 61-year-old morbidly obese woman presented at the burn center with necrotizing

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When the patient arrived at the burn center, she was on total parenteral nutrition and very sick.
Prior surgical intervention had resulted in paralytic ileus, resulting in prolonged nil-by-mouth
status. For pain management, she required 10 mg intravenous (IV) methadone every 12 hours,
a midazolam infusion of 4 mg/hr, and intermittent doses of morphine sulfate for breakthrough
pain. Once the patient was medically stabilized, she required debridement, which necessitated
a return to the operating room. Postoperatively, her Richmond Agitation-Sedation Scale (RASS)
score was 4, indicating deep sedation, which further complicated her ileus.

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Based on the above issues, the methadone and the midazolam drip were discontinued and
replaced with 1000 mg IV acetaminophen every six hours; morphine was provided for breakthrough pain. No other sedatives or analgesics were given to the patient.

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The patients variability in blood pressure improved, and enteral nutrition was initiated using
a postpyloric tube. IV acetaminophen allowed the pain management team to promptly wean
the patient from the ventilator as her narcotic requirement significantly decreased, resulting in
greater respiratory drive.

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Once the patient was taken off all narcotics and benzodiazepines, she showed a RASS score
of 0, which indicated that she was calm and alert without any complaints of pain. She required
morphine only during complex dressing changes, not for breakthrough pain. The patient
reached enteral nutrition goals 48 hours after IV acetaminophen was initiated. At that point,
parenteral nutrition was no longer required, and the patient encountered no further issues
with ileus.
While the patient required additional surgical procedures involving abdominal wound debridement and negative pressure wound therapy, she needed no additional narcotics for the
remainder of her hospitalization. IV acetaminophen was routinely continued for 32 days until
her discharge.

A major concern in this case was the potential for drug retention of lipid-soluble drugs such as
opioids and benzodiazepines because of the patients morbid obesity and associated disadvantageous pharmacokinetics. That could have potentially led to difficulty weaning from the
ventilator and prolonged sedation. Drugs such as IV acetaminophen allow decreased reliance
on opioid analgesics, thus potentially avoiding these kinds of issues. +

Todays Hospitalist Special Report

Once the patients ileus resolved, her premorbid problems with mood disorder resurfaced. At
that point, her RASS score vacillated between +1 and +2 secondary to anxiety. The burn center
team prescribed up to 1 mg alprazolam every 6 hours and later added 60 mg/day duloxetine.
The team was able to reduce her RASS score to 0 without adding any narcotics or analgesics.

5
1 7 F e b r u a r y y2 2 0 1 3 T o o d a ys s HH o p p ti a a i l si t t
Februar 013
Tday
9
oss i tl s

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IV Acetaminophen: The hospitalists Perspective

Case Study Two

IV Acetaminophen for Renal Colic


in the Emergency Department
RIChARD V. hAuSRoD, MD
Chairman, Emergency Department
EMH Healthcare, Elyria, Ohio

pain radiating to the lower groin. The patient had been experiencing symptoms for three hours,
and she rated her pain as severe, assigning it a score of 10 on a 10-point pain scale. Kidney
stones were the suspected cause of the patients symptoms, and a CT study confirmed the
presence of a 3-4 mm calcification in the proximal right ureter that was causing a moderate
obstructive uropathy. When asked about drug allergies, the patient noted she was morphineintolerant.

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A 59-year-old woman presented to the emergency department complaining of right flank

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Before the patient was sent for imaging, she was given intravenous (IV) normal saline for rehydration and two medications for pain: 1,000 mg of IV acetaminophen and 30 mg of IV ketorolac.
About two hours later, when reassessing her pain, the patient rated her pain as 5 on a 10-point
scale and was given 1 mg of IV hydromorphone. Ninety minutes later, the patient rated her pain
as 0 out of 10. The patient was discharged with an outpatient referral after a total door-to-door
time of about six hours.

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Inability to control pain and insufficient analgesia in the emergency room often leads to acute
hospital admission. When adequate pain relief can be achieved and no complicating factors
such as infection are present, patients can be managed conservatively as outpatients, eliminating the need for admission to the hospital.

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Patients presenting with renal colic are not unusual in the emergency department, but this case
serves as a useful example of the benefits of using nonnarcotics such as IV acetaminophen in
treating acute pain. While this patient reported an allergy to morphine, this was not the primary
reason that IV acetaminophen was ordered. My practice is to frequently order IV acetaminophen for patients presenting with renal colic and other conditions that involve intense pain for
several reasons.

Todays Hospitalist Special Report

In the emergency department, patient comfort is one of the key components of quality and
compassionate care, and a key goal of the emergency department staff is to make patients
comfortable as quickly and safely as possible. Following treatment with IV acetaminophen and
IV ketorolac and a small dose of IV hydromorphone, this patient left the emergency department
reporting 0 out of 10 pain and a patient satisfaction score of 5 on a 5-point scale. In my practice,
patients who receive IV acetaminophen tend to report improved patient satisfaction scores.
Patients who have received IV acetaminophen, either alone or in combination with other pain
medications, have demonstrated a greater reduction in pain scores and are often less likely to
require additional analgesia or repeat dosing. IV acetaminophen can also lead to a decreased
length of stay in the emergency department or hospital, increased patient and nurse satisfaction,
and a reduced need for opiates.
IV acetaminophen is associated with less bleeding risk than with NSAIDs and less respiratory
depression or altered sensorium than opioids. Unlike opioids, IV acetaminophen is not associated with addiction or drug-seeking behavior, which can complicate a patients stay in the
emergency department or hospital. IV acetaminophen has been a great addition to the pain
management armamentarium of the emergency physician. +

6
1 8 Februar y 2 0 1 3 To d a y s H o s p i t a l i s t
0

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Todays Hospitalist Special report

Case Study Three

IV acetaminophen for pain management


in orthopedic surgery patients
BrIan TySon, MD
Hospitalist, Critical Care Partners
Dessert Regional Medical Center, Palm Springs, Calif.

required two liters of oxygen per minute had been regularly using a combination of acetaminophen and oxycodone for knee pain for more than a year. He was referred by his primary care
physician to an orthopedic surgeon at a hospital where I worked previously. The patient was
relatively young and debilitated by knee osteoarthritis. At the recommendation of the orthopedic surgeon, he underwent total knee arthroplasty.

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a man in his mid-50s living with chronic obstructive pulmonary disease (COPD) that

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Because of his COPD and longtime narcotic use, the anesthesiologist used a spinal anesthesic technique with intrathecal morphine during the surgery.

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About 12 hours after surgery, the spinal anesthesia started to wear off and the patient complained of intense pain. Because of the risk of respiratory failure in patients with chronic
pulmonary disorder who take morphine, the surgical team was hesitant to administer systemic
opioids on top of the spinal narcotic. As a result, the patient was given 1000 mg IV acetaminophen and 30 mg IV ketorolac, and ice was applied to the affected knee.

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The patient did very well through the night. IV acetaminophen 1000 mg was continued every
six hours for a further 24 hours. The next morning, the patient was able to participate in physical therapy and did not experience any respiratory complications. The patient was successfully
discharged on postoperative Day 2.

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Without IV acetaminophen and ketorolac, the pain management approach taken for this patient would have been much different. He was in so much pain following surgery that systemic
opioids would have been required despite the intraspinal morphine precautions. That may well
have led to a delay in physical therapy and possible respiratory complications in this susceptible patient. And without IV acetaminophen, this patient may have required a more prolonged
stay in hospital.

Due to the positive experience in this patient and in others, the hospital has now protocolized
the use of IV acetaminophen for all orthopedic surgery patients. The first dose is administered
about 30 minutes before the end of surgery and then continued every 6 hours for 24 hours.
These patients typically have their first physical therapy session the morning after surgery and
then have a second session that afternoon. Many are able to have a third session on postoperative Day 2, and then are discharged home. Thus, patients who receive IV acetaminophen
not only tend to use less opiates, but they are more likely to start physical therapy right away,
which can lead to an earlier discharge. +
Todays Hospitalist Special Report

7
1 9 Februar y 2 0 1 3 To d a y s H o s p i t a l i s t
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IV Acetaminophen: The Hospitalists Perspective

18. Ko MJ, Lee JH, Cheong SH, Shin CM, Kim YJ, Choe YK, Lee
KM, Lim SH, Kim YH, Cho KR, Lee SE. Comparison of the effects of
acetaminophen to ketorolac when added to lidocaine for intravenous
regional anesthesia. Korean Journal Anesthesiol. 2010;58(4):357-361.
19. Lee SY, Lee WH, Lee EH, Han KC, Ko YK. The effects of
paracetamol, ketorolac, and paracetamol plus morphine on pain
control after thyroidectomy. Korean J Pain. 2010;23(2):124-130.
20. Bektas F, Eken C, Karadeniz O, Goksu E, Cubuk M, Cete Y.
Intravenous paracetamol or morphine for the treatment of renal
colic: a randomized, placebo-controlled trial. Ann Emerg Med.
2009;54(4):568-574.
21. American Society of Anesthesiologists. Practice guidelines for
acute pain management in the perioperative setting: an updated
report by the ASA Task Force on acute pain management. Anesthesiology. 2012;116(2):248-273.
22. Viscusi E, Royal M, Leclerc A, Fong L, Breitmeyer J. Pharmacokinetics, efficacy and safety of IV acetaminophen in the treatment of pain following total hip arthroplasty: results of a doubleblind, randomized, placebo-controlled, single-dose study. Poster
presented at the 24th Annual Meeting of the American Academy of
Pain Medicine; February 12-16, 2008; Orlando, FL.
23. Gimbel J, Royal M, Leclerc A, Smith H, Breitmeyer J. Efficacy
and safety of IV acetaminophen in the treatment of pain following
primary total hip arthroplasty: results of a double-blind, randomized,
placebo-controlled, multiple-dose, 24 hour study. Poster presented
at the 24th Annual Meeting of the American Academy of Pain Medicine; February 12-16, 2008; Orlando, FL.
24. Cok OY, Eker HE, Pelit A, Canturk S, Akin S, Aribogan A,
Arslan G. The effect of paracetamol on postoperative nausea
and vomiting during the first 24h after strabismus surgery: a
prospective, randomised, double-blind study. Eur J Anaesthesiol.
2011;28(12):836-841.
25. Arici S, Gurbet A, Turker G, Yavascaoglu B, Sahin S. Preemptive analgesic effects of intravenous paracetamol in total abdominal
hysterectomy. Agri. 2009;21(2):54-61.
26. Moon YE, Lee YK, Lee J, Moon DE. The effects of preoperative
intravenous acetaminophen in patients undergoing hysterectomy.
Arch Gynecol Obstet. 2011;284(6):1455-1460.
27. Khan ZU, Iqbal J, Saleh H, El Deek AM. Intravenous
paracetamol is as effective as morphine in knee arthroscopic day
surgery procedures. Pak J Med Sci. 2007;23(6):851-853.
28. Emir E, Serin S, Erbay RH, Sungurtekin H, Tomatir E. Tramadol
versus low dose tramadol-paracetamol for patient controlled analgesia during spinal vertebral surgery. Kaohsiung J Med Sci. 2010;
26(6):308-315.
29. Zafar N, Davies R, Greenslade GL, Dixon AR. The evolution of
analgesia in an accelerated recovery programme for resectional
laparoscopic colorectal surgery with anastomosis. Colorectal Dis.
2010;12(2):119-124.
30. Cakan T, Inan N, Culhaoglu S, Bakkal K, Basar H. Intravenous paracetamol improves quality of postoperative analgesia but
does not decrease narcotic requirements. J Neurosurg Anesthesiol.
2008;20:169-173.
31. Candiotti K, Singla N, Wininger S, Minkowitz, Breitmeyer J. A
randomized, double-blind, placebo-controlled, multi-center, parallelgroup, multiple-dose study of the efficacy and safety of intravenous
acetaminophen over 48 hours for the treatment of postoperative
pain after gynecologic surgery. Poster #13 at ASRA 2008, 33rd Annual Regional Anesthesia Meeting; May 1-4, 2008, Cancun, Mexico.
32. Hong JY, Won Han S, Kim WO, Kil HK. Fentanyl sparing effects
of combined ketorolac and acetaminophen for outpatient inguinal
hernia repair in children. J Urol. 2010;183(4):1551-1555.
33. Juhl GI, Norholt SE, Tonnessen E, HiesseProvost O, Jensen
RS. Analgesic efficacy and safety of intravenous paracetamol
(acetaminophen) administered as a 2 g starting dose following third
molar surgery. Eur J Pain. 2006;10:371-377.

Todays Hospitalist Special Report

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